MI Peer Response due 1-11-23

MI Peer Response due 1-11-23

Instructions:

400 words for each2 peer response total of 800 words.

Look at your course colleagues’ responses. 

· From your advanced practice mindset reflect on a discussion you would like to have with two of your course colleagues about their responses.

· Post a response individually to each of them that expresses your advanced practice nursing role perspective of the data represented in their response.

· In each response add statistical data regarding MI to include population group impacted, preventative measures to include primary secondary and tertiary prevention for MI. Include at least 4 new references.

Use scholarly resources relevant to your advanced practice nursing role to support the key elements of the peer discussions you construct. [For example – if you are a nurse educator (clinical or academic) what are your thoughts about their ability to follow task instructions for constructing the assignment, etc.?; if you a nurse leader what are your thoughts about the success of their application of a process improvement model, etc.?; if you are a nurse practitioner what are your observations about the non-conventional modality presented in the schemata, can you locate any evidence or the foundational basic sciences that support the modality, etc?

Please be sure to validate your opinions and ideas with citations and references in APA format.

1. Peers posting

Unit 1 Discussion – Initial post

Case Study:  Mr. T is at higher risk for cardiac disease. He presents with a BMI of 38.4, elevated blood pressure, high cholesterol, a family history of early age heart attack and stroke, hypertension, and is African American. African Americans suffer from cardiac diseases greater than any other ethnicity (American Heart Association, 2023). Also of note is his position as a corporate manager, which may be associated with higher stress levels which have been shown to impact heart health negatively (American Heart Association, 2020). Mr. T also drinks alcohol but does not indicate quantity.

Explain the progressive pathophysiologic relationship between an MI and the development of left ventricular (LV) failure.

A myocardial infarction (MI) occurs when the oxygen supply to the heart tissue is insufficient due to compromised circulation related to sclerotic vessels, clots, or significant blood loss (McCance & Huether, 2019). When heart tissue is damaged following an MI, the structure of the heart can be altered with scar tissue or necrosis, affecting the contractility of the heart and its ability to pump blood to the body. The left ventricle receives oxygenated blood from the pulmonary veins and pumps that blood out to the arteries. When the left ventricle cannot pump efficiently, blood begins to back up in the pulmonary vessels leading to fluid build-up in the lungs that manifests as shortness of breath and crackles in the lung bases on auscultation.

What factors affect the severity of LV failure?

Several factors can contribute to the severity of left heart failure. Initially, severity is determined by the extent of damage to the heart. The more extensive the damage to the cardiac tissue, the less productive the heart will be. The presence of coronary artery disease and hypertension can increase severity as well as comorbidities like diabetes and lung and kidney disease (McCance & Huether, 2019). When perfusion pressure decreases, the kidneys respond through the renin-angiotensin-aldosterone system, which causes increases in blood volume and vasoconstriction, ultimately increasing the workload on the heart and exacerbating heart failure (McCance & Huether, 2019). Other important considerations are age, obesity, and lifestyle choices such as smoking, poor diet, and alcohol consumption (McCance & Huether, 2019). Chronic alcohol consumption has been shown to hasten atherosclerosis and increase blood pressure, increasing workload and adding resistance that the heart must pump against (Fernández-Solà, 2020).

Document the manifestations and management of clients with deep vein thrombosis.

Deep vein thrombosis (DVT) is a serious condition that can happen to anyone (Centers for Disease Control and Prevention [CDC], 2022). The most common symptoms of DVT are pain, swelling, tenderness, redness, and warmth, most often in the lower leg and pelvis; however, it should be noted that half of all cases are symptomatic (CDC, 2022). Acute treatment of DVT involves the use of anticoagulants such as Heparin or Warfarin and the use of a compression stocking during the day for at least two years (NHS Inform, 2022). Prevention is key, though, and patients should be educated on the importance of physical activity, maintaining a healthy weight, avoiding sitting for long periods, and wearing loose-fitting clothing (CDC, 2022).

Submit a summary of some of the things you learned from this video. 

The video reviewed the common pathologies of the cardiovascular system and areas to focus on, such as understanding hypertension, primary and secondary, and how it affects functioning and causes and exacerbates conditions like congestive heart failure.

Reference

s

American Heart Association. (2023). African Americans and heart disease, stroke. 

https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/african-americans-and-heart-disease-stroke
Links to an external site.

American Heart Association. (2020, February 4). Chronic stress can cause heart trouble. 

https://www.heart.org/en/news/2020/02/04/chronic-stress-can-cause-heart-trouble#:~:text=Stress%20may%20lead%20to%20high,cardiovascular%20events%2C%22%20Schiffrin%20said.
Links to an external site.

Centers for Disease Control and Prevention. (2022, June 14). What is venous thromboembolism? 

https://www.cdc.gov/ncbddd/dvt/facts.html
Links to an external site.

Fernández-Solà, J. (2020). The effects of ethanol on the heart: Alcoholic cardiomyopathy. Nutrients, 12(2), 572. 

https://doi.org/10.3390/nu12020572
Links to an external site.

McCance, K., & Huether, S. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier. 

https://ambassadored.vitalsource.com/books/9780323583473
Links to an external site.

Zhan, C., Shi, M., Wu, R., He, H., Liu, X., & Shen, B. (2019). Mirkb: A myocardial infarction risk knowledge base. Database, 2019. 

https://doi.org/10.1093/database/baz125

2. Peers posting

Case study 1 Discussion – Myocardial Infarction   

Explain the progressive pathophysiologic relationship between an MI and the development of left ventricular (LV) failure.

To better understand and explain the progressive pathophysiologic relationship between an MI and the development of left ventricular failure, we must first speak about the pathophysiology of a myocardial infarction which is also more commonly known to the public as a heart attack.

A myocardial infarction occurs when “a pathophysiologic continuum impairs the pumping ability of the heart by depriving the heart muscle of blood-borne oxygen and nutrients.” (McCance & Huether, 2019) therefore a portion of the heart muscle dies because the blocked artery stops oxygen-rich blood from reaching the heart muscle, leading to cell death. Depending on the severity and the duration of those muscles being deprived of blood, the consequences of a MI can be devastating as it can weaken the heart muscle, and this is how it can lead to the development of left ventricular (LV) failure. It is important to remind that the left ventricle is the main pumping chamber of the heart, if the muscle has been weakened due to a MI, the left ventricle will then be unable to pump enough blood to meet the body’s needs. If left untreated, the left ventricle will start to hypertrophy because it will “serve as a compensatory mechanism and can help maintain cardiac output, but long-term can inhibit relaxation of the myocardium leading to impaired cardiac filling and decrease left ventricular output.” (Chaine & Alvey, 2022).

What factors affect the severity of LV failure?

Several factors can affect the severity of left ventricular (LV) failure, first as expressed previously the severity of the MI is a major factor as a larger MI is more likely to cause more damage to the heart muscle, leading to more severe LV failure. Factors may also vary depending on individuals, for example, hypertension management is one of the most important factors in the severity of the development of LV failure, as “it contributes to endothelial injury, a key step in atherogenesis and causes myocardial hypertrophy, which increases myocardial demand for coronary flow.” (McCance & Huether, 2019). Individuals that might be non-compliant with their blood pressure medications may also be at higher risk of developing severe LV failure. Like most heart conditions, there are modifiable factors that can be changed to minimize risks such as dieting, exercising, etc. However, old age and genetics can play a role in the development of severe failure LV failure as well.

Document the manifestations and management of clients with deep vein thrombosis.

Deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, most commonly in the leg area, however, it can also develop in the arms (CDC, 2022). As nurses, we strive to recognize DVT with the following symptoms: the affected leg becomes swollen due to the accumulation of fluid caused by the clot-blocking flow. Patients experience pain in the leg, especially upon movement of the leg. Redness and warmth are also important signs of a DVT as the skin on the affected leg may become red or discolored and may feel warm to the touch due to increased blood flow to the area (CDC, 2022). It is important to also mention that about half of patients with DVT do not show any signs or symptoms (CDC, 2022). 

Management of patients with DVT is very important because “chronic venous insufficiency, post-thrombotic syndrome (PTS) and pulmonary embolism (PE) are the main complications of DVT” (El-Menyar et.al, 2017).  Anticoagulation medications and compression stockings are the first lines of treatment for DVT.

Submit a summary of some of the things you learned from this video. 

The video highlighted different cardiac functions and conditions and their management, such as hypertension and its role in how it affects cardiac function in general. It also explained the main difference between primary and secondary hypertension. The video was very informative and a great alternative to learning about different cardiac conditions rather than trying to read a book.

Reference

Chahine, J., & Alvey, H. (2022, January). Left ventricular failure – StatPearls – NCBI Bookshelf. National Library of Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK537098/

Centers for Disease Control and Prevention. (2022, June 9). What is venous thromboembolism? Centers for Disease Control and Prevention. 
https://www.cdc.gov/ncbddd/dvt/facts.html
Links to an external site.

El-Menyar, A., Asim, M., Jabbour, G., & Al-Thani, H. (2017). Clinical implications of the anatomical variation of deep venous thrombosis. Phlebology: The Journal of Venous Disease, 33(2), 97–106. 

https://doi.org/10.1177/0268355516687863
Links to an external site.

 Links to an external site.

McCance, K., & Huether, S. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.  

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RN ADULT MEDICAL SURGICAL NURSING I

RN Adult Medical Surgical Nursing
REVIEW MODULE EDITION 11.0

Contributors
Honey C. Holman, MSN, RN

Debborah Williams, MSN, RN

Sheryl Sommer, PhD, RN, CNE

Janean Johnson, MSN, RN, CNE

Brenda S. Ball, MEd, BSN, RN

LaKeisha Wheless, MSN, RN

Peggy Leehy, MSN, RN

Terri Lemon, DNP, MSN, RN

Consultants
Greta Lucinda Baldwin Mason, MSN, RN

Christi Blair, DNP, RN

Tracey Bousquet, BSN, RN

Valerie S. Eschiti, PhD, RN,
AHN-BC, CHTP, CTN-A

Penny Fauber, PhD, MS, BSN, RN

Sara Hoffmann, MSN, RN

Tomekia Luckett, PhD, RN

Donna Russo, RN, MSN, CCRN, CNE

Melanie P. Schrader, PhD, RN

INTELLECTUAL PROPERTY NOTICE
ATI Nursing is a division of Assessment Technologies Institute®, LLC.

Copyright © 2019 Assessment Technologies Institute, LLC. All rights reserved.

The reproduction of this work in any electronic, mechanical or other means, now known or hereafter

invented, is forbidden without the written permission of Assessment Technologies Institute, LLC. All of the

content in this publication, including, for example, the cover, all of the page headers, images, illustrations,

graphics, and text, are subject to trademark, service mark, trade dress, copyright, and/or other intellectual

property rights or licenses held by Assessment Technologies Institute, LLC, one of its affiliates, or by

third parties who have licensed their materials to Assessment Technologies Institute, LLC.

dawni
Stamp

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II CONTENT MASTERY SERIES

IMPORTANT NOTICE TO THE READER
Assessment Technologies Institute, LLC, is the publisher of this publication. The content of this publication is for

informational and educational purposes only and may be modified or updated by the publisher at any time. This

publication is not providing medical advice and is not intended to be a substitute for professional medical advice,

diagnosis, or treatment. The publisher has designed this publication to provide accurate information regarding the

subject matter covered; however, the publisher is not responsible for errors, omissions, or for any outcomes related to

the use of the contents of this book and makes no guarantee and assumes no responsibility or liability for the use of the

products and procedures described or the correctness, sufficiency, or completeness of stated information, opinions, or

recommendations. The publisher does not recommend or endorse any specific tests, providers, products, procedures,

processes, opinions, or other information that may be mentioned in this publication. Treatments and side effects described

in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect

that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by

the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice,

and government regulations often change the accepted standard in this field. When consideration is being given to use

of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the

drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations

on dose, precautions, and contraindications and determining the appropriate usage for the product. Any references

in this book to procedures to be employed when rendering emergency care to the sick and injured are provided solely

as a general guide. Other or additional safety measures may be required under particular circumstances. This book

is not intended as a statement of the standards of care required in any particular situation, because circumstances

and a patient’s physical condition can vary widely from one emergency to another. Nor is it intended that this book

shall in any way advise personnel concerning legal authority to perform the activities or procedures discussed. Such

specific determination should be made only with the aid of legal counsel. Some images in this book feature models.

These models do not necessarily endorse, represent, or participate in the activities represented in the images. THE

PUBLISHER MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, WITH

RESPECT TO THE CONTENT HEREIN. THIS PUBLICATION IS PROVIDED AS-IS, AND THE PUBLISHER AND ITS AFFILIATES

SHALL NOT BE LIABLE FOR ANY ACTUAL, INCIDENTAL, SPECIAL, CONSEQUENTIAL, PUNITIVE, OR EXEMPLARY

DAMAGES RESULTING, IN WHOLE OR IN PART, FROM THE READER’S USE OF, OR RELIANCE UPON, SUCH CONTENT.

Director of content review: Kristen Lawler

Director of development: Derek Prater

Project management: Tiffany Pavlik, Shannon Tierney

Coordination of content review: Honey C. Holman, Debborah Williams

Copy editing: Kelly Von Lunen, Bethany Phillips, Kya Rodgers

Layout: Spring Lenox, Maureen Bradshaw, Bethany Phillips

Illustrations: Randi Hardy, Marley Starcev

Online media: Brant Stacy, Ron Hanson, Britney Fuller, Barry Wilson

Cover design: Jason Buck

Interior book design: Spring Lenox

07/24/15 April 9, 2019 11:12 AM rm_rn_2019_ams_FRONT-MATTER

RN ADULT MEDICAL SURGICAL NURSING User’s GUide III

User’s Guide
Welcome to the Assessment Technologies Institute® RN
Adult Medical Surgical Nursing Review Module Edition
11.0. The mission of ATI’s Content Mastery Series® Review
Modules is to provide user-friendly compendiums of
nursing knowledge that will:

● Help you locate important information quickly.
● Assist in your learning efforts.
● Provide exercises for applying your nursing knowledge.
● Facilitate your entry into the nursing profession as a

newly licensed nurse.

This newest edition of the Review Modules has been
redesigned to optimize your learning experience. We’ve
fit more content into less space and have done so in a
way that will make it even easier for you to find and
understand the information you need.

ORGANIZATION
This Review Module is organized into units covering the
foundations of nursing care (Unit 1), body systems and
physiological processes (Units 2 to 13), and perioperative
nursing care (Unit 14). Chapters within these units
conform to one of three organizing principles for
presenting the content.

● Nursing concepts
● Procedures
● System disorders

Nursing concepts chapters begin with an overview
describing the central concept and its relevance to nursing.
Subordinate themes are covered in outline form to
demonstrate relationships and present the information in
a clear, succinct manner.

Procedures chapters include an overview describing
the procedure(s) covered in the chapter. These
chapters provide nursing knowledge relevant to each
procedure, including indications, nursing considerations,
interpretation of findings, and complications.

System disorders chapters include an overview describing
the disorder(s) and/or disease process. These chapters
address assessments, including risk factors, expected
findings, laboratory tests, and diagnostic procedures.
Next, you will focus on patient-centered care, including
nursing care, medications, therapeutic procedures,
interprofessional care, and client education. Finally, you
will find complications related to the disorder, along with
nursing actions in response to those complications.

ACTIVE LEARNING SCENARIOS
AND APPLICATION EXERCISES

Each chapter includes opportunities for you to test your
knowledge and to practice applying that knowledge. Active
Learning Scenario exercises pose a nursing scenario
and then direct you to use an ATI Active Learning
Template (included at the back of this book) to record
the important knowledge a nurse should apply to the
scenario. An example is then provided to which you can
compare your completed Active Learning Template. The
Application Exercises include NCLEX-style questions, such
as multiple-choice and multiple-select items, providing
you with opportunities to practice answering the kinds of
questions you might expect to see on ATI assessments or
the NCLEX. After the Application Exercises, an answer key
is provided, along with rationales.

NCLEX® CONNECTIONS
To prepare for the NCLEX-RN, it is important to
understand how the content in this Review Module
is connected to the NCLEX-RN test plan. You can find
information on the detailed test plan at the National
Council of State Boards of Nursing’s website, www.ncsbn.
org. When reviewing content in this Review Module,
regularly ask yourself, “How does this content fit into
the test plan, and what types of questions related to this
content should I expect?”

To help you in this process, we’ve included NCLEX
Connections at the beginning of each unit and with each
question in the Application Exercises Answer Keys. The
NCLEX Connections at the beginning of each unit point
out areas of the detailed test plan that relate to the content
within that unit. The NCLEX Connections attached to the
Application Exercises Answer Keys demonstrate how each
exercise fits within the detailed content outline.
These NCLEX Connections will help you understand how
the detailed content outline is organized, starting with
major client needs categories and subcategories and
followed by related content areas and tasks. The major
client needs categories are:

● Safe and Effective Care Environment
◯ Management of Care
◯ Safety and Infection Control

● Health Promotion and Maintenance
● Psychosocial Integrity
● Physiological Integrity

◯ Basic Care and Comfort
◯ Pharmacological and Parenteral Therapies
◯ Reduction of Risk Potential
◯ Physiological Adaptation

An NCLEX Connection might, for example, alert you that
content within a unit is related to:

● Reduction of Risk Potential
◯ Diagnostic Tests

■ Monitor the results of diagnostic testing and
intervene as needed.

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IV User’s GUide CONTENT MASTERY SERIES

QSEN COMPETENCIES
As you use the Review Modules, you will note the
integration of the Quality and Safety Education for
Nurses (QSEN) competencies throughout the chapters.
These competencies are integral components of the
curriculum of many nursing programs in the United States
and prepare you to provide safe, high-quality care as a
newly licensed nurse. Icons appear to draw your attention
to the six QSEN competencies.

Safety: The minimization of risk factors that could
cause injury or harm while promoting quality care
and maintaining a secure environment for clients, self,
and others.

Patient-Centered Care: The provision of caring and
compassionate, culturally sensitive care that addresses
clients’ physiological, psychological, sociological, spiritual,
and cultural needs, preferences, and values.

Evidence-Based Practice: The use of current knowledge
from research and other credible sources, on which to base
clinical judgment and client care.

Informatics: The use of information technology as a
communication and information-gathering tool that
supports clinical decision-making and scientifically based
nursing practice.

Quality Improvement: Care related and organizational
processes that involve the development and
implementation of a plan to improve health care services
and better meet clients’ needs.

Teamwork and Collaboration: The delivery of client care
in partnership with multidisciplinary members of the
health care team to achieve continuity of care and positive
client outcomes.

ICONS
Icons are used throughout the Review Module to draw
your attention to particular areas. Keep an eye out for
these icons.

This icon is used for NCLEX Connections.

This icon indicates gerontological considerations,
or knowledge specific to the care of older
adult clients.

This icon is used for content related to safety
and is a QSEN competency. When you see this
icon, take note of safety concerns or steps that
nurses can take to ensure client safety and a
safe environment.

This icon is a QSEN competency that indicates
the importance of a holistic approach to
providing care.

This icon, a QSEN competency, points out the
integration of research into clinical practice.

This icon is a QSEN competency and highlights
the use of information technology to support
nursing practice.

This icon is used to focus on the QSEN
competency of integrating planning processes to
meet clients’ needs.

This icon highlights the QSEN competency of care
delivery using an interprofessional approach.

This icon appears at the top-right of pages
and indicates availability of an online media
supplement, such as a graphic, animation, or
video. If you have an electronic copy of the
Review Module, this icon will appear alongside
clickable links to media supplements. If you have
a hard copy version of the Review Module, visit
www.atitesting.com for details on how to access
these features.

FEEDBACK
ATI welcomes feedback regarding this Review Module.
Please provide comments to comments@atitesting.com.

As needed updates to the Review Modules are identified,
changes to the text are made for subsequent printings
of the book and for subsequent releases of the electronic
version. For the printed books, print runs are based
on when existing stock is depleted. For the electronic
versions, a number of factors influence the update
schedule. As such, ATI encourages faculty and students to
refer to the Review Module addendums for information on
what updates have been made. These addendums, which
are available in the Help/FAQs on the student site and the
Resources/eBooks & Active Learning on the faculty site,
are updated regularly and always include the most current
information on updates to the Review Modules.

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RN ADULT MEDICAL SURGICAL NURSING TABLe OF CONTeNTs V

Table of Contents

NCLEX® Connections 1

UNIT 1 Foundations of Nursing Care for
Adult Clients 3

CHAPTER 1 Health, Wellness, and Illness 3

CHAPTER 2 Emergency Nursing Principles and Management 7

NCLEX® Connections 15

UNIT 2 Neurologic Disorders 17
SECTION: Diagnostic and Therapeutic Procedures 17

CHAPTER 3 Neurologic Diagnostic Procedures 17

CHAPTER 4 Pain Management 25

SECTION: Central Nervous System Disorders 31

CHAPTER 5 Meningitis 31

CHAPTER 6 Seizures and Epilepsy 35

CHAPTER 7 Parkinson’s Disease 41

CHAPTER 8 Alzheimer’s Disease 47

CHAPTER 9 Brain Tumors 53

CHAPTER 10 Multiple Sclerosis 59

CHAPTER 11 Headaches 63

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VI TABLe OF CONTeNTs CONTENT MASTERY SERIES

SECTION: Sensory Disorders 67

CHAPTER 12 Disorders of the Eye 67

CHAPTER 13 Middle and Inner Ear Disorders 73

SECTION: Neurologic Emergencies 81

CHAPTER 14 Head Injury 81

CHAPTER 15 Stroke 87

CHAPTER 16 Spinal Cord Injury 95

NCLEX® Connections 103

UNIT 3 Respiratory Disorders 105
SECTION: Diagnostic and Therapeutic Procedures 105

CHAPTER 17 Respiratory Diagnostic Procedures 105

CHAPTER 18 Chest Tube Insertion and Monitoring 111

CHAPTER 19 Respiratory Management and Mechanical Ventilation 115

SECTION: Respiratory System Disorders 125

CHAPTER 20 Acute Respiratory Disorders 125

CHAPTER 21 Asthma 133

CHAPTER 22 Chronic Obstructive Pulmonary Disease 137

CHAPTER 23 Tuberculosis 143

SECTION: Respiratory Emergencies 149

CHAPTER 24 Pulmonary Embolism 149

CHAPTER 25 Pneumothorax, Hemothorax, and Flail Chest 155

CHAPTER 26 Respiratory Failure 161

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RN ADULT MEDICAL SURGICAL NURSING TABLe OF CONTeNTs VII

NCLEX® Connections 167

UNIT 4 Cardiovascular Disorders 169
SECTION: Diagnostic and Therapeutic Procedures 169

CHAPTER 27 Cardiovascular Diagnostic and Therapeutic Procedures 169

CHAPTER 28 Electrocardiography and Dysrhythmia Monitoring 179

CHAPTER 29 Pacemakers and Implantable Cardioverter/Defibrillators 185

CHAPTER 30 Invasive Cardiovascular Procedures 191

SECTION: Cardiac Disorders 199

CHAPTER 31 Angina and Myocardial Infarction 199

CHAPTER 32 Heart Failure and Pulmonary Edema 205

CHAPTER 33 Valvular Heart Disease 213

CHAPTER 34 Inflammatory Disorders 219

SECTION: Vascular Disorders 223

CHAPTER 35 Peripheral Vascular Diseases 223

CHAPTER 36 Hypertension 233

CHAPTER 37 Hemodynamic Shock 239

CHAPTER 38 Aneurysms 247

NCLEX® Connections 253

UNIT 5 Hematologic Disorders 255
SECTION: Diagnostic and Therapeutic Procedures 255

CHAPTER 39 Hematologic Diagnostic Procedures 255

CHAPTER 40 Blood and Blood Product Transfusions 259

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VIII TABLe OF CONTeNTs CONTENT MASTERY SERIES

SECTION: Hematologic Disorders 265

CHAPTER 41 Anemias 265

CHAPTER 42 Coagulation Disorders 271

NCLEX® Connections 275

UNIT 6 Fluid/Electrolyte/Acid‑Base Imbalances 277
CHAPTER 43 Fluid Imbalances 277

CHAPTER 44 Electrolyte Imbalances 283

Sodium imbalances 283

Potassium imbalances 285

Other electrolyte imbalances 288

CHAPTER 45 Acid‑Base Imbalances 293

NCLEX® Connections 299

UNIT 7 Gastrointestinal Disorders 301
SECTION: Diagnostic and Therapeutic Procedures 301

CHAPTER 46 Gastrointestinal Diagnostic Procedures 301

CHAPTER 47 Gastrointestinal Therapeutic Procedures 309

SECTION: Upper Gastrointestinal Disorders 319

CHAPTER 48 Esophageal Disorders 319

CHAPTER 49 Peptic Ulcer Disease 327

CHAPTER 50 Acute and Chronic Gastritis 333

SECTION: Lower Gastrointestinal Disorders 339

CHAPTER 51 Noninflammatory Bowel Disorders 339

CHAPTER 52 Inflammatory Bowel Disease 347

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RN ADULT MEDICAL SURGICAL NURSING TABLe OF CONTeNTs IX

SECTION: Gallbladder and Pancreas Disorders 355

CHAPTER 53 Cholecystitis and Cholelithiasis 355

CHAPTER 54 Pancreatitis 359

SECTION: Liver Disorders 365

CHAPTER 55 Hepatitis and Cirrhosis 365

NCLEX® Connections 373

UNIT 8 Renal Disorders 375
SECTION: Diagnostic and Therapeutic Procedures 375

CHAPTER 56 Renal Diagnostic Procedures 375

CHAPTER 57 Hemodialysis and Peritoneal Dialysis 379

CHAPTER 58 Kidney Transplant 385

SECTION: Renal System Disorders 391

CHAPTER 59 Polycystic Kidney Disease, Acute Kidney Injury, and Chronic Kidney Disease 391

CHAPTER 60 Infections of the Renal and Urinary System 399

CHAPTER 61 Renal Calculi 407

NCLEX® Connections 413

UNIT 9 Reproductive Disorders 415
SECTION: Female Reproductive Disorders 415

CHAPTER 62 Diagnostic and Therapeutic Procedures for Female Reproductive Disorders 415

CHAPTER 63 Female Physiologic Processes 423

CHAPTER 64 Disorders of Female Reproductive Tissue 429

SECTION: Male Reproductive Disorders 435

CHAPTER 65 Diagnostic Procedures for Male Reproductive Disorders 435

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X TABLe OF CONTeNTs CONTENT MASTERY SERIES

CHAPTER 66 Benign Prostatic Hyperplasia, Erectile Dysfunction, and Prostatitis 439

NCLEX® Connections 445

UNIT 10 Musculoskeletal Disorders 447
SECTION: Diagnostic and Therapeutic Procedures 447

CHAPTER 67 Musculoskeletal Diagnostic Procedures 447

CHAPTER 68 Arthroplasty 453

CHAPTER 69 Amputations 459

SECTION: Musculoskeletal Disorders 463

CHAPTER 70 Osteoporosis 463

CHAPTER 71 Musculoskeletal Trauma 469

CHAPTER 72 Osteoarthritis and Low‑Back Pain 479

NCLEX® Connections 487

UNIT 11 Integumentary Disorders 489
SECTION: Diagnostic and Therapeutic Procedures 489

CHAPTER 73 Integumentary Diagnostic Procedures 489

SECTION: Integumentary Disorders 493

CHAPTER 74 Skin Disorders 493

CHAPTER 75 Burns 499

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RN ADULT MEDICAL SURGICAL NURSING TABLe OF CONTeNTs XI

NCLEX® Connections 509

UNIT 12 Endocrine Disorders 511
SECTION: Diagnostic and Therapeutic Procedures 511

CHAPTER 76 Endocrine Diagnostic Procedures 511

SECTION: Pituitary Disorders 519

CHAPTER 77 Pituitary Disorders 519

SECTION: Thyroid Disorders 525

CHAPTER 78 Hyperthyroidism 525

CHAPTER 79 Hypothyroidism 531

SECTION: Adrenal Disorders 535

CHAPTER 80 Cushing’s Disease/Syndrome 535

CHAPTER 81 Addison’s Disease and Acute Adrenal Insufficiency (Addisonian Crisis) 541

SECTION: Diabetes Mellitus 545

CHAPTER 82 Diabetes Mellitus Management 545

CHAPTER 83 Complications of Diabetes Mellitus 555

NCLEX® Connections 559

UNIT 13 Immune System and
Connective Tissue Disorders 561
SECTION: Diagnostic and Therapeutic Procedures 561

CHAPTER 84 Immune and Infectious Disorders Diagnostic Procedures 561

CHAPTER 85 Immunizations 565

SECTION: Immune Disorders 571

CHAPTER 86 HIV/AIDS 571

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XII TABLe OF CONTeNTs CONTENT MASTERY SERIES

SECTION: Connective Tissue Disorders 577

CHAPTER 87 Lupus Erythematosus, Gout, and Fibromyalgia 577

CHAPTER 88 Rheumatoid Arthritis 585

SECTION: Cancer‑Related Disorders 591

CHAPTER 89 General Principles of Cancer 591

CHAPTER 90 Cancer Screening and Diagnostic Procedures 597

CHAPTER 91 Cancer Treatment Options 601

CHAPTER 92 Cancer Disorders 611

CHAPTER 93 Pain Management for Clients Who Have Cancer 645

NCLEX® Connections 651

UNIT 14 Nursing Care of Perioperative Clients 653
CHAPTER 94 Anesthesia and Moderate Sedation 653

Anesthesia 653

Moderate sedation 656

CHAPTER 95 Preoperative Nursing Care 659

CHAPTER 96 Postoperative Nursing Care 665

Active Learning Templates A1
Basic Concept A1

Diagnostic Procedure A3

Growth and Development A5

Medication A7

Nursing Skill A9

System Disorder A11

Therapeutic Procedure A13

Concept Analysis A15

07/24/15 April 9, 2019 11:12 AM rm_rn_2019_ams_unit1

RN ADULT MEDICAL SURGICAL NURSING NCLeX® CONNeCTiONs 1

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Health Promotion and Maintenance
HEALTH PROMOTION/DISEASE PREVENTION
Identify risk factors for disease/illness.

Educate the client on actions to promote/
maintain health and prevent disease.

HEALTH SCREENING: Apply knowledge of
pathophysiology to health screening.

Physiological Adaptation
HEMODYNAMICS: Intervene to improve
the client’s cardiovascular status.

ILLNESS MANAGEMENT: Educate client about managing illness.

MEDICAL EMERGENCIES: Apply knowledge of pathophysiology
when caring for a client experiencing a medical emergency.

07/24/15 April 9, 2019 11:12 AM rm_rn_2019_ams_unit1

2 NCLeX® CONNeCTiONs CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 1 HeALTH, WeLLNess, ANd iLLNess 3

UNIT 1 FOUNDATIONS OF NURSING
CARE FOR ADULT CLIENTS

CHAPTER 1 Health, Wellness,
and Illness

Health and wellness combine to form a state
of optimal physical functioning and a feeling
of emotional and social contentment. Wellness
involves the ability to adapt emotionally
and physically to a changing state of health
and environment.

illness is an altered level of functioning in
response to a disease process. disease is
a condition that results in the physiological
alteration in the composition of the body.

Nurses must understand the variables affecting
health, wellness, and illness, and how they relate
to clients’ individual perceptions of health needs.

Health and wellness
The level of health and wellness is unique to each
individual and relative to the individual’s usual state of
functioning. For example, a person who has rheumatoid
arthritis, a strong support system, and positive outlook
might consider himself healthy while functioning at an
optimal level with minimal pain.

VARIABLES
● Modifiable: Can be changed, such as smoking,

nutrition, access to health education, sexual practices,
and exercise

● Non-modifiable: Cannot be changed, such as sex, age,
developmental level, and genetic traits

ASPECTS OF HEALTH AND WELLNESS
● Physical: Able to perform activities of daily living
● Emotional: Adapts to stress; expresses and

identifies emotions
● Social: Interacts successfully with others
● Intellectual: Effectively learns and disseminates

information
● Spiritual: Adopts a belief that provides meaning to life
● Occupational: Balances occupational activities with

leisure time
● Environmental: Creates measures to improve standards

of living and quality of life

ENVIRONMENT
● A client’s state of health and wellness is constantly

changing and adapting to a continually fluctuating
external and internal environment.

● THE EXTERNAL ENVIRONMENT
◯ Social: Crime vs. safety, poverty vs. prosperity, peace
vs. social unrest, and presence vs. absence of support
from social networks

◯ Physical: Access to health care, sanitation, availability
of clean water, and geographic location

● THE INTERNAL ENVIRONMENT includes cumulative
life experiences, cultural and spiritual beliefs, age,
developmental stage, gender, emotional factors, and
perception of physical functioning.

DESIRED OUTCOMES
● Desired outcomes are to obtain and maintain optimal

state of wellness and function through access to
and use of health promotion, wellness, and illness
prevention strategies.

● Health and wellness can be achieved through health
education and positive action (stress management,
smoking cessation, weight loss, immunizations, seeking
health care).

ILLNESS‑WELLNESS CONTINUUM
The Illness-Wellness Continuum is an assessment tool
used to measure the level of wellness to premature death.

● It can be useful as an assessment guide or tool to set
goals and find ways to improve a client’s state of health
or to have the client return to a previous state of health,
which can include an illness within optimal wellness.
The health care professional can assist the client to see
where he is at on the continuum and seek ways to move
toward optimal wellness.

● At the center of the continuum is the client’s normal
state of health.

● The range of wellness to illness runs from optimal
wellness to severe illness.

● The degree of wellness is relative to the usual state of
wellness for a client and is achieved through awareness,
education, and personal growth.

Illness
● Illness is the impairment of a client’s physical, social,

emotional, spiritual, developmental, or intellectual
functioning.

● Illness encompasses the effects of a disease on a client.
However, illness and disease are not synonymous.

Response to illness can be influenced by:
● Degree of physical changes as a result of a

disease process.
● Perceptions by self and others of the illness, which can

be influenced by various reliable and unreliable sources
of information (friends, magazines, TV, internet).

● Cultural values and beliefs.
● Denial or fear of illness.
● Social demands, time constraints, economic resources,

and health care access.

CHAPTER 1

4 CHAPTER 1 HeALTH, WeLLNess, ANd iLLNess CONTENT MASTERY SERIES

HEALTH PROMOTION AND
DISEASE PREVENTION

Use health education and awareness to reduce risk factors
and promote health care.

HeALTH/WeLLNess AssessMeNT
● Physical assessment
● Evaluating health perceptions
● Identifying risks to health/wellness
● Identifying access to health care

Identifying obstacles to compliance and adherence:
● Perceptions of illness: awareness of the severity of

the illness
● Confidence in the provider
● Belief in the prescribed therapy

◯ A client who has had a negative experience with
the health care system might not trust the provider
and might not follow the advice or comply with the
treatment prescribed.

◯ Cultural or religious beliefs might not align with the
prescribed treatment.

● Availability of support systems
● Family role and function: One family member might be

the family caregiver but neglect caring for herself.
● Financial restrictions that can lead to prioritized

health care
◯ Prescription medication costs
◯ A parent might seek medical care for children, but not
for herself

NUrsiNG CAre
Evaluate the health needs of a client and create strategies
to meet those needs.

iNTerVeNTiONs
● Provide resources to strengthen coping abilities.
● Identify and encourage use of support systems during

times of illness and stress.
● Identify obstacles to health and wellness and create

strategies to reduce these obstacles.
● Identify ways to reduce health risks and

improve compliance.
● Develop health education methods to improve health

awareness and reduce health risks.

Application Exercises

1. A nurse is caring for a client who has a new
diagnosis of type 2 diabetes mellitus and reports
difficulty following the diet and remembering
to take the prescribed medication. Which of the
following actions should the nurse take to promote
client compliance? (select all that apply.)

A. Ask the dietitian to assist with meal planning.

B. Contact the client’s support system.

C. Assess for age‑related cognitive awareness.

d. encourage the use of a daily medication dispenser.

e. Provide educational materials for home use.

2. A nurse in a health care clinic is evaluating the level of
wellness for clients using the illness‑wellness continuum
tool. The nurse should identify which of the following
clients as being at the center of the continuum?

A. A college student who has influenza

B. An older adult who has a new diagnosis
of type 2 diabetes mellitus

C. A new mother who has a urinary tract infection

d. A young male client who has a long history
of well‑controlled rheumatoid arthritis

3. A nurse is evaluating clients at a health fair for
modifiable variables affecting health and wellness.
The nurse should identify which of the following
variables as modifiable? (select all that apply.)

A. smoking on social occasions

B. BMi of 28

C. Alopecia

d. Trisomy 21

e. History of reflux

4. A nurse is caring for a client who was just informed
of a new diagnosis of breast cancer. The nurse
evaluates the client’s response. Which of the
following statements by the client reflects a lack
of understanding of an illness perspective?

A. “i have no family history of breast cancer.”

B. “i need a second opinion. There is no lump.”

C. “i am glad we live in the city near
several large hospitals.”

d. “i will schedule surgery next
week, over the holidays.”

Active Learning Scenario

A nurse in a clinic is caring for a client who continues
to smoke despite numerous attempts to quit and
has a family history of cardiovascular disease. What
nursing interventions should the nurse use to meet the
health needs of this client? Use the ATi Active Learning
Template: Basic Concept to complete this item.

RELATED CONTENT: include one
statement identifying the goal.

UNDERLYING PRINCIPLES: include one statement
regarding health promotion and disease prevention.

NURSING INTERVENTIONS: include a minimum of four.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 1 HeALTH, WeLLNess, ANd iLLNess 5

Application Exercises Key

1. A. CORRECT: The nurse provides resources to strengthen
coping abilities by asking the dietitian to assist the client with
meal planning. This will improve client compliance.

B. CORRECT: With the client’s consent, the nurse can
contact members of the client’s support system and
encourage the client to use this support during times
of illness and stress to improve compliance.

C. Assessing the client for age‑related cognitive
awareness is important but it is not an appropriate
intervention that enhances the client’s compliance.

d. CORRECT: The nurse encourages the use of a daily
medication dispenser to reduce health risks and
improve medication compliance by the client.

e. CORRECT: The nurse provides educational
materials to the client to improve health awareness
and reduce health risks after discharge.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

2. A. The client who has influenza is measured on the
continuum by the level of health to illness in
comparison to the norm for the client.

B. The client who is newly diagnosed with type 2 diabetes
mellitus is measured by the level of health to illness
in comparison to the norm for the client.

C. The client who has a urinary tract infection is measured
on the continuum by the level of health to illness
in comparison to the norm for the client.

d. CORRECT: The client who has well‑controlled rheumatoid
arthritis is measured at the center of the continuum,
which is the client’s normal state of health.

NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions

3. A. CORRECT: The nurse identifies smoking as a
modifiable variable that a client can change. The nurse
should provide the client with educational materials
and information on smoking cessation.

B. CORRECT: The nurse identifies a BMi of 28 as a
modifiable variable that a client can change. The nurse
should provide the client with educational materials and
information on weight reduction and exercising.

C. The nurse identifies alopecia as a non‑modifiable
variable because alopecia is a genetic disorder.

d. The nurse identifies Trisomy 21 as a non‑modifiable
variable because Trisomy 21 is genetic in origin.

e. CORRECT: The nurse identifies reflux as a modifiable variable
that a client can change. The nurse should provide the client
with step‑by‑step educational information about treatment.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

4. A. The client’s lack of a family history of cancer can influence
the client’s response to the new diagnosis, but it does not
reflect a lack of understanding of an illness perspective.

B. CORRECT: The client’s statement of denial reflects a
lack of understanding of the illness perspective and can
influence the client’s acceptance of the diagnosis.

C. Access to health care resources can influence the client’s
response to the new diagnosis, but it does not reflect
a lack of understanding of an illness perspective.

d. Time constraints can influence a client’s response
to the diagnosis, but it does not reflect a lack of
understanding of an illness perspective.

NCLEX® Connection: Health Promotion and Maintenance,
Health Screening

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT: identifying obstacles
for compliance and adherence

UNDERLYING PRINCIPLES: Health promotion and
disease prevention are influenced by many factors that
a nurse should address for a client’s success.

NURSING INTERVENTIONS
● Provide the client with resources to strengthen coping abilities.
● encourage use of support systems (family, support group).
● identify ways to improve compliance.
● develop health education methods to reduce health risks.
● identify the client’s obstacles to health and wellness.
● Create strategies to reduce the client’s obstacles.

NCLEX® Connection: Health Promotion and Maintenance,
High Risk Behaviors

6 CHAPTER 1 HeALTH, WeLLNess, ANd iLLNess CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT 7

UNIT 1 FOUNDATIONS OF NURSING
CARE FOR ADULT CLIENTS

CHAPTER 2 Emergency Nursing
Principles and
Management

emergency nursing principles are the guidelines
that nurses follow to assess and manage
emergency situations for a client or multiple clients.

Nurses must have the ability to identify emergent
situations and rapidly assess and intervene
when life‑threatening conditions exist. emergent
conditions are common to all nursing environments.

emergency nursing principles: triage, primary
survey, the ABCde principle, poisoning, rapid
response team, cardiac emergency, and
postresuscitation.

emergency departments often implement the
five‑level system of triage: resuscitation (level
one), emergent (level two), urgent (level three),
less urgent (level four), and nonurgent (level five).
Time and experience are required for the nurse
to become an effective member of the triage
team. The nurse, provider, and other members
of the health care team work together in the
triage area to determine the needs of the client.

resuscitation triage requires immediate
treatment to prevent death.

Nonurgent is a non‑life‑threatening condition
requiring simple evaluation and care management.

PRIMARY SURVEY
● A primary survey is a rapid assessment of

life-threatening conditions.
● The primary survey should be completed systematically

so life-threatening conditions are not missed.
● Standard precautions—gloves, gowns, eye protection,

face masks, and shoe covers—must be worn to prevent
contamination with bodily fluids.

● The ABCDE principle guides the primary survey.

ABCDE PRINCIPLE

AirWAy/CerViCAL sPiNe
● This is the most important step in performing the

primary survey. If a patent airway is not established,
subsequent steps of the primary survey are futile. As a
result of hypoxia, brain injury or death will occur within
3 to 5 min if the airway is not patent.

● If a client is awake and responsive, the airway is open.
● If a client’s ability to maintain an airway is lost, it is

important to inspect for blood, broken teeth, vomitus,
or other foreign materials in the airway that can cause
an obstruction.

● If the client is unresponsive without suspicion of
trauma, the airway should be opened with a head-tilt/
chin-lift maneuver.

◯ Do NOT perform this technique on clients who have a
potential cervical spine injury.

◯ To perform the head-tilt/chin-lift maneuver, the nurse
should assume a position at the head of the client,
place one hand on his forehead, and place the other
hand underneath the client’s chin. His head should be
tilted while his chin is lifted upward and forward.
This maneuver lifts the tongue away from the
laryngopharynx and provides for a patent airway.

● If the client is unresponsive with suspicion of trauma,
the airway should be opened with a modified jaw
thrust maneuver.

◯ The nurse should assume a position at the head of
the client and place both hands on either side of the
client’s head. Locate the connection between the
maxilla and the mandible. Lift the jaw superiorly
while maintaining alignment of the cervical spine.

● Once the airway is opened, it should be inspected for
blood, broken teeth, vomitus, and secretions. If present,
obstructions should be cleared with suction or a
finger-sweep method if the object is clearly visible.

● The open airway can be maintained with
airway adjuncts, such as an oropharyngeal or
nasopharyngeal airway.

● A bag valve mask with a 100% oxygen source is
indicated for clients who need additional support during
resuscitation until an advanced airway is established.

● A nonrebreather mask with 100% oxygen source is
indicated for clients who are spontaneously breathing.

BreATHiNG
Once a patent airway is achieved, the nurse should assess
for the presence and effectiveness of breathing.

BREATHING ASSESSMENT
● Auscultation of breath sounds
● Observation of chest expansion and respiratory effort
● Notation of rate and depth of respirations
● Identification of chest trauma
● Assessment of tracheal position
● Assessment for jugular vein distention

If a client is not breathing or is breathing inadequately ,
manual ventilation should be performed by a bag valve
mask with supplemental oxygen or mouth-to-mask
ventilation until a bag valve mask can be obtained.

CHAPTER 2

8 CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT CONTENT MASTERY SERIES

CirCULATiON
● Once adequate ventilation is accomplished, circulation

is assessed.
● Nurses should assess heart rate, blood pressure,

peripheral pulses, and capillary refill for
adequate perfusion.

● Nurses should consider cardiac arrest, myocardial
dysfunction, and hemorrhage as precursors to shock and
leading to ineffective circulation.

● Shock can develop if circulation is compromised. Shock
is the body’s response to inadequate tissue perfusion
and oxygenation. It manifests with an increased heart
rate and hypotension and can result in tissue ischemia
and necrosis.

NURSING ACTIONS
● Interventions for restoring effective circulation:

◯ Perform CPR.
◯ Assess for external bleeding.
◯ Hemorrhage control: Apply direct pressure to visible,
significant external bleeding.

◯ Obtain IV access using large-bore IV catheters
inserted into the antecubital fossa of both arms,
unless there is obvious injury to the extremity.

◯ Infuse isotonic IV fluids such as lactated Ringer’s and
0.9% sodium chloride, and/or blood products.

● Interventions to alleviate shock
◯ Administer oxygen.
◯ Apply pressure to obvious bleeding.
◯ Elevate lower extremities to shunt blood to
vital organs.

◯ Administer IV fluids and blood products.
◯ Monitor vital signs.
◯ Remain with the client, and provide reassurance and
support for anxiety.

disABiLiTy
Disability is a quick assessment to determine the client’s
level of consciousness.

● The AVPU mnemonic is useful. (2.1)
● The Glasgow Coma Scale is another widely-used

method. (2.2)
● Neurologic assessment must be repeated at frequent

intervals to ensure immediate response to any change.

FrOsTBiTe
● Skin condition which occurs after prolonged exposure to

freezing temperatures.
● Extent of injury to exposed skin may not be evident

for at least 24 hr after injury and is categorized as
superficial (first degree), partial thickness (second
degree), or full thickness (third and fourth degree).

◯ 1st degree: Least severe form. Only superficial
layers of exposed skin are affected with hyperemia
and edema.

◯ 2nd degree: Blisters cover the exposed skin areas
causing necrotic tissue death and swelling.

◯ 3rd degree: Extensive edema and blisters to the
affected skin which does not blanch. Affected areas
will be treated by debridement of damaged tissue.

◯ 4th degree: The affected area completely lacks blood
supply and is considered full thickness necrosis of
skin with potential progression to gangrene. The
extent of the gangrene may require amputation of
affected areas.

NURSING ACTIONS
● Clients require rewarming. Bathing affected areas in

warm bath (104º to 108º F [40º to 42º C]) will improve
blood circulation and promote healing of damaged
tissue. This rewarming process can increase pain as
circulation improves to affected areas of skin.

● Administer tetanus toxoid IM vaccine to prevent
complications related to growth of tetanus in wounds.

eXPOsUre
● The nurse removes the client’s clothing for a complete

physical assessment. The nurse might need to cut off
the client’s clothing to accomplish this task.

● Clothing is always removed during a resuscitation
situation to assess for additional injuries or those
related to chemical and thermal burns involving
the clothing.

● The nurse should preserve items of evidence (clothing,
bullets, drugs, weapons).

● Hypothermia is a primary concern. Hypothermia occurs
when the client’s core temperature is 35° C (95° F) or less.

● Victims of trauma are at risk for hypothermia due to
exposure, unwarmed oxygen, and cold IV fluids.

● Hypothermia can lead to eventual coma, hypoxemia,
and acidosis.

2.1 AVPU mnemonic

A Alert
V Responsive to voice
P Responsive to pain
U Unresponsive

2.2 Glasgow Coma Scale

EYE‑OPENING
RESPONSE
spontaneous 4
To voice 3
To pain 2
None 1

VERBAL RESPONSE
Oriented 5
Confused 4
inappropriate words 3
incomprehensible sounds 2
None 1

MOTOR RESPONSE
Obeys commands 6
Localizes pain 5
Withdraws 4
Flexion 3
extension 2
None 1

A low score of 3 indicates a client who is totally unresponsive, and a high
score of 15 indicates a client who is within normal limits neurologically.

+ +

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT 9

To prevent hypothermia:
● Remove wet clothing from the client.
● Cover the client with warm blankets.
● Increase the temperature of the room.
● Use a heat lamp to provide additional warmth.
● Infuse warmed IV fluids.

HeAT eXHAUsTiON
● Heat exhaustion occurs after prolonged exposure to

elevated temperatures and causes excessive diaphoresis
and tachycardia leading to dehydration.

● Clients must receive rapid treatment for the dehydration
and low sodium to prevent developing heat stroke.

HeAT sTrOKe
Heat stroke is a medical emergency and clients must
receive immediate treatment to prevent death.

MANIFESTATIONS
● Elevated temperature (greater than 40° C [104° F])
● Lack of perspiration
● Low blood pressure
● Increased heart rate
● Decreased urinary output
● Alterations in mental status
● Abnormal blood potassium or sodium levels

NURSING ACTIONS
● Priority is to assess using ABCDE.
● Administer oxygen as needed.
● Insert large-gauge IV catheter for rapid intravenous

administration of 0.9% sodium chloride.
● Client can require indwelling urinary catheter.
● Apply ice packs and cooling blankets.

To prevent hyperthermia
● Wear lightweight, loose-fitting clothing.
● Avoid excessive sun exposure.
● Stay indoors with fans or air conditioning when outside

temperatures are elevated.
● Limit consumption of alcohol and caffeine.
● Apply sunscreen of at least 30 SPF.
● If overheated, take a cool water shower or bath.

POisONiNG
Poisoning is exposure to a toxic agent.

● Medications, illicit drugs, ingestion of a toxic agent
● Environmental (pollutants, snake and spider bites)

Poisoning is considered a medical emergency and
requires rapid management therapy.

● Obtain a client history to identify the toxic agent.
● Implement supportive care.
● Determine type of poison.
● Prevent further absorption of the toxin.
● Extract or remove the poison.
● Administer antidotes when necessary.
● A snakebite from a venomous snake is a

medical emergency.
◯ Children ages 1 to 9 are at highest risk for snakebites.
◯ The nurse should be familiar with indigenous snakes
in the community.

◯ Generally, ice, tourniquets, heparin, and
corticosteroids are contraindicated in the first 6 to
8 hr after the bite.

◯ Antivenom based on the type and severity of a snake
bite is most effective if administered within 4 to 12 hr.

Interventions to manage the clinical status of the client
exposed to or who ingested a toxic agent:

● Provide measures for respiratory support (oxygen,
airway management, mechanical ventilation).

● Monitor compromised circulation (resulting from excess
perspiration, vomiting, diarrhea).

● Restore fluids with IV fluid therapy.
● Monitor blood pressure, cardiac monitoring, ECG.
● Assess for tissue edema every 15 to 30 min if bitten by a

snake or spider.
● Administer opioid medications for pain due to snake or

spider bite.
● Monitor ABGs, blood glucose levels, coagulation profile.
● For ingested poison, three procedures are available:

activated charcoal, gastric lavage (if done within 1 hr
of ingestion), and aspiration. Syrup of ipecac is no
longer recommended.

● Administer diazepam if seizures occur.
● Reverse heroin and other opiate toxicity with naloxone.
● Implement dialysis and an exchange blood transfusion

as a nonpharmacologic technique to remove
toxic agents.

2.3 Common causes
of pulseless
electrical activity

5 H’s
Hypovolemia
Hypoxia
Hydrogen ion
accumulation,
resulting in
acidosis
Hyperkalemia
or hypokalemia
Hypothermia

5 T’s
Toxins
(accidental or
deliberate drug
overdose)
Tamponade
(cardiac)
Tension
pneumothorax
Thrombosis
(coronary)
Thrombosis
(pulmonary)

2.4 Receptor sites and responses

Alpha1
Activation of receptors in arterioles of
skin, viscera and mucous membranes,
and veins lead to vasoconstriction

Beta1
Heart stimulation leads to increased
heart rate, increased myocardial
contractility, and increased
rate of conduction through the
atrioventricular (AV) node.
Activation of receptors in the kidney
leads to the release of renin.

Beta2
Bronchial stimulation leads
to bronchodilation.
Activation of receptors in uterine
smooth muscle causes relaxation.
Activation of receptors in the liver causes
a breakdown of glycogen into glucose.
skeletal muscle receptor activation
leads to muscle contraction,
which can lead to tremors.

Dopamine
Activation of receptors in the kidney
cause the renal blood vessels to dilate.

10 CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT CONTENT MASTERY SERIES

RAPID RESPONSE TEAM
● The team is a group of critical care experts (ICU nurse,

respiratory therapist, critical care provider,
hospitalist).

● Responds to an emergency call from nurses or family
members when a client exhibits indications of a
rapid decline.

● Provides early recognition and response before a
respiratory or cardiac arrest or stroke occurs.

● Policies and procedures are established in a health
care setting.

● Training for personnel is provided about criteria for
calling for assistance when a client’s condition changes
toward a crisis situation.

● SBAR (Situation, Background, Assessment,
Recommendation) communication techniques are used
for contacting the team and documentation of event.

● Implement follow-up, education, and sharing of
information (debriefing) for participants after the call.

● Discuss information to identify system failures (not
recognizing a crisis, lack of adequate communication,
failure in the plan of care).

● Retrieve more information at www.ihi.org.

CARDIAC EMERGENCY
Cardiac arrest: the sudden cessation of cardiac function
caused most commonly by ventricular fibrillation or
ventricular asystole.

Ventricular fibrillation (VF): a fluttering of the ventricles
causing loss of consciousness, pulselessness, and no
breathing. This requires collaborative care to defibrillate
immediately using ACLS protocol.

Pulseless ventricular tachycardia (VT): an irritable firing of
ectopic ventricular beats at a rate of 140 to 180/min. The client
over time will become unconscious and deteriorate into VF.

Ventricular asystole: a complete absence of electrical
activity and ventricular movement of the heart. The client
is in complete cardiac arrest and requires implementation
of BLS and ACLS protocol.

Pulseless electrical activity (PEA): a rhythm that appears
to have electrical activity but is not sufficient to stimulate
effective cardiac contractions and requires implementation
of BLS and ACLS protocol.

Emergency nurse certifications
● Basic Life Support (BLS), Advanced Cardiac Life Support

(ACLS), and Pediatric Advanced Life Support (PALS) are
certifications required for nurses practicing in United
States emergency departments.

● BLS involves a hands-on approach for assessment
and management to restore airway, breathing,
and circulation.

● ACLS builds on the BLS assessment and management
skills to include advanced concepts.

◯ Cardiac monitoring for specific resuscitation rhythms
◯ Invasive airway management
◯ Electrical therapies (defibrillation or cardioversion)
◯ Obtaining IV access
◯ Administration of IV antidysrhythmic medications
◯ Management of the client postresuscitation

● PALS is built on the BLS protocol for neonatal and
pediatric assessment and management skills to include
advanced concepts for resuscitation of children.

● Certification courses are based on evidence-based
practice management theory, and the basic concepts and
techniques for cardiopulmonary
resuscitation (CPR).

● Current BLS and ACLS guidelines are available from the
American Heart Association (AHA) at www.heart.org.

AHA ACLs PrOTOCOLs
VF or pulseless VT

● Initiate the CPR components of BLS.
● Defibrillate according to BLS guidelines.
● Establish IV access.
● Administer IV antidysrhythmic medications,

such as epinephrine or vasopressin, according to
ACLS guidelines.

● Consider the following medications:
◯ Amiodarone hydrochloride
◯ Lidocaine hydrochloride
◯ Magnesium sulfate

2.5 Food interactions

MAOIs promote the release of norepinephrine from
sympathetic nerves and thereby prolong and intensify the
effects of epinephrine and can cause hypertensive crisis.

NURSING INTERVENTIONS: Avoid the use of
MAOis in clients who are receiving epinephrine.

Tricyclic antidepressants block the uptake of epinephrine,
which will prolong and intensify the effects of epinephrine.
NURSING INTERVENTIONS: Clients
taking these medications concurrently can
need a lower dose of epinephrine.

General anesthetics can cause the heart
to become hypersensitive to the effects of
epinephrine, which leads to dysrhythmias.

NURSING INTERVENTIONS
Perform continuous eCG monitoring.
Notify the provider if the client experiences chest
pain, dysrhythmias, or an elevated heart rate.

Beta‑adrenergic blocking agents, such as
propranolol, block the action at beta receptors.

NURSING INTERVENTIONS: Propranolol may
be used to treat chest pain, hypertension,
myocardial infarction, and dysrhythmias.

Diuretics promote the beneficial effect of dopamine.

NURSING INTERVENTIONS: Monitor
for therapeutic effects.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT 11

2.6 Emergency medications

RECEPTORS
PHARMACOLOGICAL
ACTION THERAPEUTIC USE ADVERSE EFFECTS NURSING ACTIONS

Epinephrine

Alpha1 Vasoconstriction

slows absorption of
local anesthetics
Manages superficial
bleeding
reduces congestion
of nasal mucosa
increases blood
pressure

Vasoconstriction
from activation of
alpha1 receptors in
the heart can lead to
hypertensive crisis.

Provide continuous cardiac monitoring.
report changes in vital
signs to the provider.

Beta1

increases heart rate
strengthens myocardial
contractility
increases rate of
conduction through
the AV node

Treatment of
AV block and
cardiac arrest

Beta1 receptor activation
in the heart can cause
dysrhythmias. Beta1
receptor activation also
increases the workload
of the heart and oxygen
demand, leading to the
development of angina.

Provide continuous cardiac monitoring.
Monitor closely for dysrhythmias,
change in heart rate, and chest pain.
Monitor for hyperglycemia in clients
who have diabetes mellitus.
Notify the provider if the client
experiences dysrhythmias, an
elevated heart rate, or chest
pain, and treat per protocol.Beta2 Bronchodilation Asthma

The activation of beta2
receptors in the liver
and skeletal muscles can
cause hyperglycemia
from the breakdown
of glycogen.

Dopamine

dopamine

Low dose – dopamine
(2 to 5 mcg/kg/min)
renal blood
vessel dilation

shock
Heart failure
Acute kidney injury

Beta1

Moderate dose
– dopamine
(5 to 10 mcg/kg/min)
renal blood
vessel dilation
increases:

● Heart rate
● Myocardial contractility
● rate of conduction
through the AV node

● Blood pressure

Beta1 receptor activation
in the heart can cause
dysrhythmias. Beta1
receptor activation also
increases the workload
of the heart and oxygen
demand, leading to the
development of angina.

Provide continuous cardiac monitoring.
Monitor closely for dysrhythmias,
change in heart rate, and chest pain.
Notify the provider of manifestations
of dysrhythmias, elevated heart rate,
and chest pain, and treat per protocol.
Monitor for urinary output
less than 30 mL/hr.
do not confuse dopamine
with dobutamine.

Beta1

Alpha1

High dose – dopamine
(greater than
10 mcg/kg/min)
renal blood vessel
vasoconstriction
increases:

● Heart rate
● Myocardial contractility
● rate of conduction
through the AV node

● Blood pressure
● Vasoconstriction

Necrosis can occur from
extravasation due to high
doses of dopamine.

infuse dopamine into the central
line. Monitor the iV site carefully.
discontinue the infusion at first
indication of irritation.

Dobutamine

Beta1

increases:
● Heart rate
● Myocardial contractility
● rate of conduction
through the AV node

Heart failure increased heart rate

Provide continuous cardiac monitoring.
report changes in vital
signs to the provider.
Monitor for urinary output
less than 30 mL/hr.
do not confuse dobutamine
with dopamine.

12 CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT CONTENT MASTERY SERIES

Pulseless electrical activity (PEA)
● Initiate the CPR components of BLS.
● If shockable rhythm, defibrillate according to

BLS guidelines.
● Establish IV access.
● Consider the most common causes. (2.3)
● Administer epinephrine 1 mg IV push every 3 to 5 min.
● Asystole

◯ Initiate the CPR components of BLS.
◯ Establish IV access.
◯ Give epinephrine 1 mg IV push every 3 to 5 min.
◯ Consider reversible causes.
◯ Asystole is often the final rhythm as the electrical
and mechanical activity of the heart has stopped.
The provider should consider ceasing resuscitation if
asystole persists.

POsTresUsCiTATiON
PHARMACOLOGICAL MANAGEMENT

● Medication therapy following a successful cardiac arrest
includes IV medications that cause a catecholamine
adrenergic agonist’s effect.

● Catecholamine adrenergic agonists cannot be taken by
the oral route, do not cross the blood-brain barrier, and
have a short duration of action.

● Medications include epinephrine, dopamine,
and dobutamine.

● These medications respond to an identifiable receptor
and produce specific effects.

CONTRAINDICATIONS/PRECAUTIONS
● Pregnancy Risk Category C: epinephrine, dopamine,

dobutamine.
● These medications are contraindicated in clients who

have tachydysrhythmias and ventricular fibrillation.
● Use cautiously in clients who have hyperthyroidism,

angina, history of myocardial infarction, hypertension,
and diabetes mellitus.

NURSING ACTIONS
● Administer medications by continuous IV infusion.
● Use IV pump to control infusion.
● Titrate dosage based on blood pressure response and/or

heart rate response. (These medications affect heart rate
and blood pressure.)

● Stop the infusion at the first indication of infiltration.
Extravasation can be treated with a local injection of an
alpha-adrenergic blocking agent, such as phentolamine.

● Assess/monitor for chest pain. Notify the provider if the
client experiences chest pain.

● Provide continuous ECG monitoring. Notify the provider
if the client experiences tachycardia or dysrhythmias.

Application Exercises

1. A nurse on a medical‑surgical unit is caring for a
group of clients. The nurse should notify the rapid
response team for which of the following clients?

A. Client who has a pressure injury of the right
heel whose blood glucose is 300 mg/dL

B. Client who reports right calf pain
and shortness of breath

C. Client who has blood on a pressure dressing in the
femoral area following a cardiac catheterization

d. Client who has dark red coloration of
left toes and absent pedal pulse

2. A nurse is caring for a client who has ingested a
toxic agent. Which of the following actions should
the nurse plan to take? (select all that apply.)

A. induce vomiting.

B. instill activated charcoal.

C. Perform a gastric lavage with aspiration.

d. Administer syrup of ipecac.

e. infuse iV fluids.

3. A nurse in the emergency department is
caring for a client who fell through the ice on
a pond and is unresponsive and breathing
slowly. Which of the following actions should
the nurse take? (select all that apply.)

A. remove wet clothing.

B. Maintain normal room temperature.

C. Apply warm blankets.

d. Use a rapid rewarming water of 40º
to 42º C (104º to 108º F).

e. infuse warmed iV fluids.

4. A nurse in the emergency department is assessing a
client who is unresponsive. The client’s partner states,
“He was pulling weeds in the yard and slumped
to the ground.” Which of the following techniques
should the nurse use to open the client’s airway?

A. Head‑tilt, chin‑lift

B. Modified jaw thrust

C. Hyperextension of the head

d. Flexion of the head

5. A nurse is reviewing the common emergency
management protocol for clients who have asystole.
Which of the following actions should the nurse
plan to take during this cardiac emergency?

A. Perform defibrillation.

B. Prepare for transcutaneous pacing.

C. Administer iV epinephrine.

d. elevate the client’s lower extremities.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 22 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNTeMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT 13

Active Learning Scenario

A nurse in the emergency department (ed) is implementing
triage using the five‑level system. Use the ATi Active
Learning Template: Basic Concept to complete this item.

RELATED CONTENT: identify the five
levels of the ed triage system.

UNDERLYING PRINCIPLES: define
each of the five triage levels.

NURSING INTERVENTIONS: describe a client who
meets the criteria for each of the five triage levels.

Application Exercises Key

1. A. The nurse should notify the provider. The
situation does not indicate the beginning of a
rapid decline in the client’s condition.

B. CORRECT: The nurse should identify that the client
is at risk for respiratory arrest due to a possible
embolism. The nurse should call the rapid response
team because the manifestations can indicate the
beginning of a rapid decline in the client’s condition.

C. This assessment does not indicate the beginning
of a rapid decline in the client’s condition at this
time. The nurse should reassess the client and
notify the provider if the bleeding increases.

d. The nurse should notify the provider. The
situation does not indicate the beginning of a
rapid decline in the client’s condition.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

2. A. Vomiting places the client at risk for aspiration.
B. CORRECT: This is an appropriate action by the nurse

because activated charcoal adsorbs toxic substances,
and the charcoal does not pass into the bloodstream.

C. CORRECT: This is an appropriate action by the
nurse because gastric lavage with aspiration
removes the toxic substance when the instilled fluid
is suctioned from the gastrointestinal tract.

d. Administering syrup of ipecac is not recommended
because it induces vomiting, which increases
the client’s risk for aspiration.

e. CORRECT: This is an appropriate action by the
nurse because intravenous fluids help dilute the
toxic substances in the bloodstream and promote
elimination from the body through the kidneys.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

3. A. CORRECT: This is an appropriate action by the
nurse because the body temperature can rise more
quickly when heat is applied to dry skin.

B. The nurse should increase the temperature of the room to
help return the client to a normal body temperature.

C. CORRECT: This is an appropriate action by the nurse
because the client’s body temperature can rise more
quickly when warm blankets are applied.

d. CORRECT: This is an appropriate action by the nurse because
the client’s body temperature can rise more quickly when a
rapid rewarming bath water of 40º to 42º C (104º to 108º F)
is used to warm the client’s body and preserve tissues.

e. CORRECT: This is an appropriate action by the nurse
because the client’s body temperature can rise more
quickly when warmed iV fluids are infused.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

4. A. CORRECT: The nurse should open the client’s
airway by the head‑tilt, chin‑lift because the client is
unresponsive without suspicion of trauma.

B. The nurse should not open the client’s airway with the
modified jaw thrust because this method is used for a client
who is unresponsive with suspected traumatic neck injury.

C. The nurse should not open the client’s airway with
hyperextension of the head because hyperextension of
the head can close off the airway and cause injury.

d. The nurse should not open the client’s airway
with flexion of the head because flexion of
the head does not open the airway.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

5. A. defibrillation is not indicated for asystole, because this
is not considered a shockable cardiac rhythm.

B. Transcutaneous pacing is not indicated
for the treatment of asystole.

C. CORRECT: Administering epinephrine during
asystole is an appropriate action by the nurse
because it increases heart rate, improves cardiac
output, and promotes bronchodilation.

d. elevating the client’s lower extremities is indicated for the
treatment of a client who is in shock, rather than asystole.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

14 CHAPTER 22 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNTeMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT CONTENT MASTERY SERIES

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT
● resuscitation
● emergent
● Urgent
● Less Urgent
● Nonurgent

UNDERLYING PRINCIPLES
● resuscitation: The client needs immediate treatment to prevent death.
● emergent: The client requires time sensitive treatment for a problem that has the potential to become a life or limb‑threatening situation.
● Urgent: The client requires treatment but the situation is not life‑threatening.
● Less Urgent: The client is able to wait for a period of time without immediate treatment.
● Nonurgent: The client requires simple evaluation and minor management of care.

NURSING INTERVENTIONS
● resuscitation: A client who is experiencing cardiac arrest, stroke, pulmonary emboli, or drug overdose.
● emergent: A client who has sustained a traumatic amputation, head or neck injury, snake or spider bite.
● Urgent: A client who has a kidney stone, gallbladder colic, or fracture.
● Less Urgent: A client who has a bladder infection, laceration, or infected toe.
● Nonurgent: A client who has a rash, minor cut, or backache.

NCLEX® Connection: Physiological Adaptation, Medical Emergencies

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RN ADULT MEDICAL SURGICAL NURSING NCLeX® CONNeCTiONs 15

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Basic Care and Comfort
NON-PHARMACOLOGICAL COMFORT INTERVENTIONS:
Provide non-pharmacological comfort measures.

MOBILITY/IMMOBILITY: Assess the client for
mobility, gait, strength, and motor skills.

NUTRITION AND ORAL HYDRATION
Evaluate client intake and output and intervene as needed.

Evaluate the impact of disease/illness on nutritional status of a client.

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS: Apply knowledge of
nursing procedures, pathophysiology and psychomotor skills
when caring for a client with an alteration in body systems.

ILLNESS MANAGEMENT: Implement interventions
to manage the client’s recovery from an illness.

Pharmacological and Parenteral Therapies
ADVERSE EFFECTS/CONTRAINDICATIONS/
SIDE EFFECTS/INTERACTIONS
Assess the client for actual or potential side effects
and adverse effects of medications.

Apply knowledge of nursing procedures and psychomotor skills
when caring for a client with potential for complications.

EXPECTED ACTIONS/OUTCOMES: Evaluate

CLIENT RESPONSE TO MEDICATION.

PHARMACOLOGICAL PAIN MANAGEMENT
Assess client need for administration of a PRN pain medication.

Administer medications for pain management.

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16 NCLeX® CONNeCTiONs CONTENT MASTERY SERIES

Reduction of Risk Potential
DIAGNOSTIC TESTS: Compare client diagnostic
findings with pretest results.

POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC TESTS/
TREATMENTS/PROCEDURES: Use precautions to prevent injury
and/or complications associated with a procedure or diagnosis.

THERAPEUTIC PROCEDURES: Apply knowledge of related
nursing procedures and psychomotor skills when caring
for clients undergoing therapeutic procedures.

Safety and Infection Control
STANDARD PRECAUTIONS/TRANSMISSION-BASED PRECAUTIONS/
SURGICAL ASEPSIS: Apply principles of infection control.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres 17

UNIT 2 NEUROLOGIC DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 3 Neurologic
Diagnostic
Procedures

Neurologic assessment and diagnostic
procedures are used to evaluate neurologic
function by testing indicators such as mental
status, motor functioning, electrical activity, and
intracranial pressure.

Neurologic assessment and diagnostic
procedures that nurses should be
knowledgeable about include cerebral
angiography, cerebral computed tomography
(CT) scan, electroencephalography (eeG),
Glasgow Coma scale (GCs), intracranial pressure
monitoring, lumbar puncture (spinal tap),
magnetic resonance imaging (Mri), positron
emission tomography (PeT), single‑photon
emission computed tomography (sPeCT), and
radiography (x‑ray).

Cerebral angiography
Cerebral angiography provides visualization of the
cerebral blood vessels.

● Digital subtraction angiography hides the bones and
tissues from the images, providing x-rays with only the
vessels apparent.

● The procedure detects defects, narrowing, or obstruction
of arteries or blood vessels in the brain.

● The procedure is performed within the radiology
department because iodine-based contrast dye is
injected into an artery during the procedure.

INDICATIONS
Cerebral angiography is used to assess the blood flow to
and within the brain, identify aneurysms, and define the
vascularity of tumors (useful for surgical planning). It is
also used therapeutically to inject medications that treat
blood clots or to administer chemotherapy.

CONSIDERATIONS

PrePrOCedUre
If the client is pregnant, a determination of the risks to
the fetus versus the benefits of the information obtained
by this procedure should be made.

NURSING ACTIONS
● Instruct the client to refrain from consuming food or

fluids for 4 to 6 hr prior to the procedure.
● Assess for history of allergies.
● Any history of bleeding or taking anticoagulant

medication requires additional considerations and
additional monitoring to ensure clotting after the
procedure.

● Assess BUN and blood creatinine to determine the
kidney’s ability to excrete the dye.

● Ensure that the client is not wearing any jewelry.
● A mild sedative for relaxation is occasionally

administered prior to and during the procedure, and vital
signs are continuously monitored during the procedure.

CLIENT EDUCATION
● The head will be immobilized during the procedure, and

it is important to remain still.
● Void immediately prior to the procedure.
● Following dye injection, it is common to experience a

metallic taste and feel a sensation of warmth behind the
eyes, and over the face, jaw, tongue, and lips.

iNTrAPrOCedUre
● The client is placed on a radiography table, where the

client’s head is secured.
● A catheter is placed into an artery (usually in the groin

or the neck), dye is injected, and x-ray pictures are taken.
● Once all pictures are taken, the catheter is removed and

an arterial closure device is used or pressure is held over
the artery to control bleeding by thrombus formation
sealing the artery.

POsTPrOCedUre
NURSING ACTIONS

● Closely monitor the area to ensure that clotting occurs.
● Movements are restricted depending on the type of

procedure used to seal the artery to prevent rebleeding
at the catheter site.

● Place an ice pack on the insertion site.

COMPLICATIONS
There is a risk for bleeding or hematoma formation at the
entry site.

NURSING ACTIONS
● Check the insertion site frequently.
● Check the affected extremity distal to the puncture

site for adequate circulation (color, temperature, pulses,
capillary refill).

● If bleeding occurs, apply pressure over the artery and
notify the provider.

CHAPTER 3

18 CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres CONTENT MASTERY SERIES

Cerebral computed
tomography scan

A CT scan provides cross-sectional images of the cranial
cavity. A contrast medium can be used to enhance
the images.

INDICATIONS
CT scanning can be used to identify tumors and
infarctions, detect abnormalities, monitor response to
treatment, and guide needles used for biopsies.

CONSIDERATIONS

PrePrOCedUre
If the client is pregnant, a determination of the risks to
the fetus versus the benefits of the information obtained
by this procedure should be made.

NURSING ACTIONS
● If contrast media and/or sedation is expected:

◯ Instruct the client to refrain from consuming food or
fluids for at least 4 hr prior to the procedure.

◯ Assess for allergy to shellfish or iodine, which would
require the use of a different contrast media.

◯ Assess BUN and creatinine because contrast media is
excreted by the kidneys.

● Because this procedure is performed with the client in
a supine position, placing pillows in the small of the
client’s back can assist in preventing back pain. The
head must be secured to prevent unnecessary movement
during the procedure.

● Ensure that the client’s jewelry is removed prior to this
procedure. In general, clients wear a hospital gown to
prevent any metals from interfering with the x-rays.

iNTrAPrOCedUre
● The client must lie supine with the head stabilized

during the procedure.
● Although CT scanning is painless, sedation can

be provided.

POsTPrOCedUre
NURSING ACTIONS

● There is no follow-up care associated with a CT scan.
● If contrast media is injected, monitor for allergic

reaction and changes in kidney function.
● If sedation is administered, monitor the client

until stable.

Electroencephalography
An EEG is a noninvasive procedure that assesses the
electrical activity of the brain and is used to determine
abnormalities in brain wave patterns. An EEG provides
information about the ability of the brain to function and
highlights areas of abnormality.

INDICATIONS
EEGs are most commonly performed to identify and
determine seizure activity, but they are also useful for
detecting sleep disorders and behavioral changes.

CONSIDERATIONS

PrePrOCedUre
NURSING ACTIONS: Review medications with the
provider to determine if they should be continued prior to
this procedure.

CLIENT EDUCATION
● Wash the hair to eliminate all oils, gels, and sprays.
● Stay awake prior to the test. Being sleep-deprived

provides cranial stress, increasing the possibility of
abnormal electrical activity, such as seizure potentials,
occurring during the procedure.

● To stimulate electrical activity during the test, you
might be exposed to bright flashing lights, or asked to
hyperventilate for 3 to 4 min.

● Avoid taking any stimulant or sedative medication 12 to
24 hr prior to the procedure.

iNTrAPrOCedUre
● The procedure generally takes 45 to 120 min.
● There are no risks associated with this procedure.
● With the client resting in a chair or lying in bed, small

electrodes are placed on the scalp and connected to a
brain wave machine or computer.

● Electrical signals produced by the brain are recorded by
the machine or computer in the form of wavy lines. This
documents brain activity.

● Notations are made when stimuli are presented or when
sleep occurs. (Flashes of light or pictures can be used
during the procedure to assess the client’s response
to stimuli.)

POsTPrOCedUre
CLIENT EDUCATION: Resume your normal activities
and routine.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres 19

Glasgow Coma Scale
This assessment concentrates on neurologic function
and is useful to determine the level of consciousness and
monitor response to treatment. The Glasgow Coma Scale is
reported as a number that allows providers to immediately
determine if neurologic changes have occurred.

INDICATIONS
GCS scores are helpful in determining changes in the
level of consciousness for clients who have head injuries,
space-occupying lesions or cerebral infarctions, and
encephalitis. This is important because complications
related to neurologic injuries can occur rapidly and require
immediate treatment.

CONSIDERATIONS
GCS scores are calculated by using appropriate stimuli (a
painful stimulus can be necessary) and then assessing the
client’s response in three areas.

● Eye opening (E): The best eye response, with responses
ranging from 4 to 1

◯ 4 = Eye opening occurs spontaneously.
◯ 3 = Eye opening occurs secondary to sound.
◯ 2 = Eye opening occurs secondary to pain.
◯ 1 = Eye opening does not occur.

● Verbal (V): The best verbal response, with responses
ranging from 5 to 1

◯ 5 = Conversation is coherent and oriented.
◯ 4 = Conversation is incoherent and disoriented.
◯ 3 = Words are spoken, but inappropriately.
◯ 2 = Sounds are made, but no words.
◯ 1 = Vocalization does not occur.

● Motor (M): The best motor response, with responses
ranging from 6 to 1

◯ 6 = Commands are followed.
◯ 5 = Local reaction to pain occurs.
◯ 4 = General withdrawal from pain.
◯ 3 = Decorticate posture (adduction of arms, flexion of
elbows and wrists) is present.

◯ 2 = Decerebrate posture (abduction of arms, extension
of elbows and wrists) is present.

◯ 1 = Motor response does not occur.
Responses within each subscale are added, with the
total score quantitatively describing the client’s level of
consciousness. E + V + M = Total GCS

● In critical situations, where head injury is present and
close monitoring is required, subscale results may also
be documented. Thus, a GCS may be reported as either
a single number, indicating the sum of the subscales
(3 to 15), or as 3 numbers, one from each subscale result,
and the total (E3 V3 M4 = GCS 10). This allows providers
to determine specific neurologic function.

● Intubation limits the ability to use GCS summed scores.
If intubation is present, the GCS may be reported as
two scores, with modification noted. This is generally
reported by totaling the eye and motor score, and
recording it with a “t”, such as “GCS 5t” (with the t
representing the intubation tube).

INTERPRETATION OF FINDINGS
● The best possible GCS score is 15. In general, total scores

of the GCS correlate with the degree or level of coma.
● A score less than 8 is associated with severe head injury

and coma.
● A score of 9 to 12 indicates a moderate head injury.
● A score greater than 13 is associated with minor

head trauma.

Intracranial pressure
monitoring

An intracranial pressure (ICP) monitor is a device inserted
into the cranial cavity that records pressure and is
connected to a monitor that shows a picture of the
pressure waveforms.

● Monitoring ICP facilitates continual assessment and is
more precise than vague manifestations.

● The insertion procedure is performed by a neurosurgeon
in the operating room, emergency department, or
critical care unit. This procedure is rarely used unless
the client is comatose, so there is minimal need for pain
medication and preprocedural client teaching.

Three basic types of ICP monitoring systems
● Intraventricular catheter (also called a

ventriculostomy): A fluid-filled catheter is inserted into
the anterior horn of the lateral ventricles (most often
on the right side) through a burr hole. The catheter is
connected to a sterile drainage system with a three-way
stopcock that allows simultaneous drainage of
cerebrospinal fluid (CSF) and monitoring of pressures by
a transducer connected to a bedside monitor.

● Subarachnoid screw or bolt: A hollow, threaded screw
or bolt is placed into the subarachnoid space through a
twist-drill burr hole in the front of the skull, behind the
hairline. The bolt is connected by fluid-filled tubing to
a transducer leveled at the approximate location of the
lateral ventricles.

● Epidural or subdural sensor: A fiber-optic sensor
is inserted into the epidural space through a burr
hole. The fiber-optic device measures changes in the
amount of light reflected from a pressure-sensitive
diaphragm in the catheter tip. The cable is connected
to a precalibrated monitor that displays the numerical
value of ICP. This method of monitoring is noninvasive
because the device does not penetrate the dura.

INDICATIONS
● ICP monitoring is useful for early identification and

treatment of increased intracranial pressure. Clients
who are comatose or have GCS scores of 8 or lower are
candidates for ICP monitoring.

● Manifestations of increased ICP include severe headache,
deteriorating level of consciousness, restlessness,
irritability, dilated or pinpoint pupils, slowness to
react, alteration in breathing pattern (Cheyne-Stokes
respirations, central neurologic hyperventilation,
apnea), deterioration in motor function, and abnormal
posturing (decerebrate, decorticate, flaccidity).

20 CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres CONTENT MASTERY SERIES

CONSIDERATIONS

PrePrOCedUre
The head is shaved around the insertion location. The site
is then cleansed with an antibacterial solution.

iNTrAPrOCedUre
● Local anesthetic can be used to numb the area if the

client’s GCS indicates some level of consciousness
(GCS 8 to 11).

● Insertion and care of any ICP monitoring device
requires surgical aseptic technique to reduce the risk for
CNS infection.

POsTPrOCedUre
NURSING ACTIONS

● Maintain system integrity at all times.
System contamination can cause serious,
life-threatening infection.

● Inspect the insertion site at least every 24 hr for redness,
swelling, and drainage. Change the sterile dressing
covering the access site per facility protocol.

● ICP monitoring equipment must be balanced and
recalibrated per facility protocols.

● After the insertion procedure, observe ICP waveforms,
noting the pattern of waveforms and monitoring for
increased ICP (a sustained elevation of pressure greater
than 15 mm Hg).

● Assess the client’s clinical status and monitor routine
and neurologic vital signs every hour as needed.

INTERPRETATION OF FINDINGS
Normal ICP is 10 to 15 mm Hg. Persistent elevation of ICP
minimizes cerebral circulation, which will result in brain
death if not treated urgently.

COMPLICATIONS
The insertion and maintenance of an ICP monitoring
system can cause infection and bleeding.

NURSING ACTIONS
● Follow strict surgical aseptic technique.
● Perform sterile dressing changes per facility protocol.
● Keep drainage systems closed.
● Limit monitoring to 3 to 5 days.
● Irrigate the system only as needed to maintain patency.

Lumbar puncture (spinal tap)
A lumbar puncture is a procedure during which a small
amount of CSF is withdrawn from the spinal canal and
then analyzed to determine its constituents.

INDICATIONS
This procedure is used to detect the presence of some
diseases (multiple sclerosis, syphilis, meningitis),
infection, and malignancies. A lumbar puncture may also
be used to reduce CSF pressure, instill a contrast medium
or air for diagnostic tests, or administer medication or
chemotherapy directly to spinal fluid.

CONSIDERATIONS

PrePrOCedUre
The risks versus benefits of a lumbar puncture should be
discussed with the client prior to this procedure.

● A lumbar puncture can be associated with rare but
serious complications, such as brain herniation,
especially when performed in the presence of
increased ICP.

● Lumbar punctures for clients who have bleeding
disorders or who are taking anticoagulants can result in
bleeding that compresses the spinal cord.

NURSING ACTIONS
● Ensure that all of the client’s jewelry is removed and

that the client is wearing only a hospital gown.
● Instruct the client to void prior to the procedure.
● Clients should be positioned to stretch the spinal

canal. This can be done by having the client assume a
“cannonball” position while on one side. (3.1)

iNTrAPrOCedUre
● The area of the needle insertion is cleansed, and a local

anesthetic is injected.
● The needle is inserted and the CSF is withdrawn, after

which the needle is removed.
● A manometer can be used to determine the opening

pressure of the spinal cord, which is useful if increased
pressure is a consideration.

POsTPrOCedUre
CSF is sent to the pathology department for analysis.

● NURSING ACTIONS: Monitor the puncture site. The
client should remain lying for several hours to ensure
that the site clots and to decrease the risk of a
post-lumbar puncture headache, caused by
CSF leakage.

● CLIENT EDUCATION: Normal activities may be resumed
after prescribed bed rest is complete as long as in
stable condition.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres 21

COMPLICATIONS
If clotting does not occur to seal the dura puncture site,
CSF can leak, resulting in a headache and increasing the
potential for infection.

NURSING ACTIONS
● Encourage the client to lie flat in bed. Provide fluids for

hydration, and administer pain medication.
● Prepare the client for an epidural blood patch to seal the

hole in the dura if the headache persists.

Magnetic resonance
imaging scan

An MRI scan of the head provides cross-sectional images
of the cranial cavity. A contrast medium may be used to
enhance the images.

● Unlike CT scans, MRI images are obtained using
magnets, thus the consequences associated with
radiation are avoided. This makes this procedure safer
for women who are pregnant.

● The use of magnets precludes the ability to scan a client
who has an artificial device (pacemakers, surgical clips,
intravenous access port).

! Use Mri‑approved equipment to monitor
vital signs and provide ventilator/oxygen
assistance to clients undergoing Mri scans.

INDICATIONS
● MRI scans are used to detect abnormalities, monitor

response to treatment, and guide needles used
for biopsies.

● MRIs are capable of discriminating soft tissue from
tumor or bone. This makes the MRI scan effective in
determining tumor size and blood vessel location.

CONSIDERATIONS

PrePrOCedUre
NURSING ACTIONS

● Remove any transdermal patches with a foil backing, as
these can cause burn injuries.

● Ensure that the client’s jewelry is removed prior to this
procedure. The client should wear a hospital gown to
prevent any metals from interfering with the magnet.

● If sedation is expected, the client should refrain from
food or fluids for 4 to 8 hr prior to the procedure.

● Determine if the client has a history of claustrophobia,
and explain the tight space and noise.

● Ask the client about any implants containing metal
(pacemaker, orthopedic joints, artificial heart valves,
intrauterine devices, aneurysm clips).

● Ensure all people who will be in the scanning area while
the magnet is on remove all jewelry, electronics, and
phones to prevent damage to themselves or the magnet.

● Place pillows in the small of the client’s back to prevent
back pain from lying supine. The head must be secured
to prevent unnecessary movement during the procedure.

iNTrAPrOCedUre
● Ensure the client remains supine with the

head stabilized.
● MRI scanning is noisy, and earplugs or sedation may

be provided.

POsTPrOCedUre
NURSING ACTIONS

● If contrast media is injected, monitor the site to
ensure that clotting has occurred and monitor for any
indications of an allergic reaction.

● If sedation is administered, monitor the client
until stable.

3.1 Lumbar puncture positioning

3.2 Lumbar puncture

22 CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres CONTENT MASTERY SERIES

PET and SPECT scans
Positron emission tomography and single-photon
emission computed tomography scans are nuclear
medicine procedures that produce three-dimensional
images of the head. These images can be static (depicting
vessels) or functional (depicting brain activity).

● A glucose-based tracer is injected into the blood stream
prior to the PET scan. This initiates regional metabolic
activity, which is then documented by the PET scanner.
A radioisotope is used for SPECT scanning.

● A CT scan may be performed after a PET/SPECT scan, as
this provides information regarding brain activity and
pathological location (brain injury, death, neoplasm).

INDICATIONS
A PET/SPECT scan captures regional metabolic processes,
which is most useful in determining tumor activity and/or
response to treatment. PET/SPECT scans are also able
to determine the presence of dementia, indicated by the
inability of the brain to respond to the tracer.

CONSIDERATIONS

PrePrOCedUre
PET/SPECT scans use radiation, thus the risks and benefits
to a client who might be pregnant must be discussed.

NURSING ACTIONS: Assess for a history of diabetes
mellitus. While this condition does not preclude a
PET/SPECT scan, alterations in the client’s medications
can be necessary to avoid hyperglycemia or hypoglycemia
before and after this procedure.

iNTrAPrOCedUre
● While the pictures are being obtained, the client must

lie flat with the head restrained.
● This procedure is not painful and sedation is

rarely necessary.

POsTPrOCedUre
NURSING ACTIONS

● If radioisotopes are used, assess for allergic reaction.
● There is no follow-up care after a PET/SPECT scan.
● Because the tracer is glucose-based and short-acting

(less than 2 hr), it is broken down within the body as a
sugar, not excreted.

Radiography (x‑ray)
● An x-ray uses electromagnetic radiation to capture

images of the internal structures of an individual.
● A structure’s image is light or dark relative to the

amount of radiation the tissue absorbs. The image is
recorded on a radiograph, which is a black-and-white
image that is held up to light for visualization. Some are
recorded digitally and available immediately.

INDICATIONS
X-ray examinations of the skull and spine can reveal
fractures, curvatures, bone erosion and dislocation, and
possible soft tissue calcification, all of which can damage
the nervous system.

CONSIDERATIONS

PrePrOCedUre
NURSING ACTIONS

● There is no specific preprocedure protocol for x-rays
that do not use contrast. X-rays are often the first
diagnostic tool used after an injury (such as rule out
cervical fracture in head trauma).

● Determine whether the client is pregnant.
● Ensure that the client’s jewelry is removed and that no

clothes cover the area.
CLIENT EDUCATION: Explain that the amount of radiation
used in contemporary x-ray machines is very small.

iNTrAPrOCedUre
The procedure is quick, but the client is to remain still
during the procedure.

POsTPrOCedUre
NURSING ACTIONS: No postprocedure care is required.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres 23

Application Exercises

1. A nurse is caring for a client who is postprocedure
following lumbar puncture and reports a throbbing
headache when sitting upright. Which of the following
actions should the nurse take? (select all that apply.)

A. Use the Glasgow Coma scale
when assessing the client.

B. Assist the client to a supine position.

C. Administer an opioid medication.

d. encourage the client to increase fluid intake.

e. instruct the client to perform deep
breathing and coughing exercises.

2. A nurse is caring for a client who experienced a
traumatic head injury and has an intraventricular
catheter (ventriculostomy) for iCP monitoring. The
nurse should monitor the client for which of the
following complications related to the ventriculostomy?

A. Headache

B. infection

C. Aphasia

d. Hypertension

3. A nurse is assessing a client for changes in the level
of consciousness using the Glasgow Coma scale
(GCs). The client opens his eyes when spoken to,
speaks incoherently, and moves his extremities
when pain is applied. Which of the following
GCs scores should the nurse document?

A. e2 + V3 + M5 = 10

B. e3 + V4 + M4 = 11

C. e4 + V5 + M6 = 15

d. e2 + V2 + M4 = 8

4. A nurse is developing a plan of care for a client
who is scheduled for cerebral angiography
with contrast media. Which of the following
statements by the client should the nurse report
to the provider? (select all that apply.)

A. “i think i might be pregnant.”

B. “i take warfarin.”

C. “i take antihypertensive medication.”

d. “i am allergic to shrimp.”

e. “i ate a light breakfast this morning.”

5. A nurse is providing education to a client who
is to undergo an electroencephalogram (eeG)
the next day. Which of the following information
should the nurse include in the teaching?

A. “do not wash your hair the
morning of the procedure.”

B. “Try to stay awake most of the night
prior to the procedure.”

C. “The procedure will take
approximately 15 minutes.”

d. “you will need to lie flat for 4 hours
after the procedure.”

Active Learning Scenario

A nurse is developing a plan of care for a client who is
scheduled for a magnetic resonance imaging (Mri) scan
with contrast media. What should the nurse include in
the plan of care? Use the ATi Active Learning Template:
diagnostic Procedure to complete this item.

PROCEDURE NAME: define this diagnostic test.

NURSING INTERVENTIONS (PRE, INTRA, POST):
identify three preprocedure actions, one intraprocedure
action, and one postprocedure action.

24 CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres CONTENT MASTERY SERIES

Application Exercises Key

1. A. The Glasgow Coma scale is used to assess a
client’s level of consciousness and is not necessary
following a lumbar puncture.

B. CORRECT: The nurse should assist the client
to a supine position, which can relieve a
headache following a lumbar puncture.

C. CORRECT: The nurse should administer an opioid
medication for a client’s report of headache pain.

d. CORRECT: The nurse should encourage an increased
fluid intake to maintain a positive fluid balance, which
can relieve a headache following a lumbar puncture.

e. Coughing can increase iCP, which can result in
an increase in the client’s headache.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

2. A. The nurse should monitor a client who has increased
iCP for a headache, but a headache does not indicate a
complication directly related to the ventriculostomy.

B. CORRECT: The nurse should monitor a client who has a
ventriculostomy for infection, which is a complication.
The nurse should use strict asepsis to avoid this
life‑threatening condition, which can result in meningitis.

C. The nurse should monitor a client who has increased
iCP for aphasia related to the head injury, but this not a
complication directly related to the ventriculostomy.

d. The nurse should monitor a client who has increased
iCP for hypertension, but this is not a complication
directly related to the ventriculostomy.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

3. A. The calculation is incorrect. e2 represents eyes opening
secondary to pain, V3 represents verbal response with
words spoken inappropriately, and M5 represents
motor response to pain with a local reaction.

B. CORRECT: The client’s score is calculated correctly,
indicating moderate head injury. e3 represents opening
eyes secondary to voice stimulation, V4 represents verbal
conversation that is incoherent and disoriented, and M4
represents motor response as a general withdrawal to pain.

C. The client’s score is calculated incorrectly. e4 represents
eyes opening spontaneously, V5 represents verbal
conversation as coherent and oriented, and M6
indicates a client is able to follow commands.

d. The client’s score is calculated incorrectly. e2 represents eyes
opening secondary to pain, V2 represents verbal response
by the client making sounds but speaking no words, and M4
is a motor response with a general withdrawal to pain.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

4. A. CORRECT: The nurse should report the client’s statement
of possible pregnancy to the provider because the
contrast media can place the fetus at risk.

B. CORRECT: The nurse should report that the
client is taking warfarin to the provider due to the
potential for bleeding following angiography.

C. There is no contraindication related to cerebral angiography
for a client who is taking antihypertensive medication.

d. CORRECT: The nurse should report a client’s report of
allergy to shrimp, which is a shellfish, to the provider due
to a potential allergic reaction to the contrast media.

e. CORRECT: The nurse should report a client’s intake
of food to the provider since the client should remain
NPO for 4 to 6 hr prior to the procedure.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

5. A. The nurse should teach the client to wash her hair on
the morning of the procedure to remove oils, gels, and
sprays, which can affect the eeG readings.

B. CORRECT: The nurse should teach the client to remain
awake most of the night to provide cranial stress and
increase the possibility of abnormal electrical activity.

C. The nurse should teach the client that the
procedure will take approximately 1 hr.

d. The nurse should teach the client that normal activity
can resume immediately following the procedure.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

PROCEDURE NAME: Magnetic resonance imaging (Mri) scan relies on magnetic field to take multiple images of the body.

NURSING INTERVENTIONS (PRE, INTRA, POST)
● Preprocedure

◯ remove all client jewelry.
◯ determine if the client has claustrophobia.
◯ Question the client concerning implants containing metal.
◯ Question the client regarding allergies.

● intraprocedure: stabilize the client’s head
● Postprocedure: Monitor for allergic reaction to the contrast media used during the Mri.

NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 4 PAiN MANAGeMeNT 25

UNIT 2 NEUROLOGIC DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 4 Pain Management
effective pain management includes the use of
pharmacological and nonpharmacological pain
management therapies.

Clients have a right to adequate assessment and
management of pain. Nurses are accountable
for the assessment of pain. Professional
organizations and The Joint Commission have
mandates requiring pain assessment and
management. The nurse’s role is that of an
advocate, member of the health care team, and
educator for effective pain management.

Nurses have a priority responsibility for the
continual assessment of the client’s pain level and
to provide individualized interventions. depending
on the setting and route of analgesia administration,
the nurse might need to reassess pain 10 to 60 min
after administering medication.

Assessment challenges can occur with clients
who have cognitive impairment, who speak
a different language than the nurse, or who
receive prescribed mechanical ventilation.

PHYSIOLOGY
● Nociceptive pain involves transduction, transmission,

perception, and modulation of impulses generated by
nociceptors located throughout the body.

● Stimuli following tissue damage from cuts, burns,
tumor growth, or chemicals trigger these nociceptors to
send a message to the nervous system.

● Neuropathic pain is caused by changes in the peripheral
or central nervous system.

◯ Peripheral sensitization, changes in ion channels,
and neuroplasticity are peripheral nervous system
changes that contribute to neuropathic pain.
Neuroplasticity occurs when nerve endings are
damaged and reorganized in an abnormal manner.

◯ Central nervous system changes that lead to
neuropathic pain include an increase in the
excitability of central neurons, an increase in the
release of and binding of neurotransmitters, and
reorganization of nerves following injury, all of which
alter or increase pain sensations.

ASSESSMENT
Pain is whatever the person experiencing it says it is, and
it exists whenever the person says it does. The client’s
report of pain is the most reliable diagnostic measure of
pain. Self-report using standardized pain scales is useful
for clients over the age of 7 years. Specialized pain scales
are available for use with younger children and other
clients who are unable to self-report pain. There are a
variety of pain scales that feature images, numbers,
intensity indicators, and descriptive words, and in various
languages.

● Assess and document pain (the fifth vital sign)
according to the client’s condition and agency
guidelines. (4.1)

● Use a focused assessment to obtain subjective data. (4.2)

CHAPTER 4

4.1 Pain categories

Acute pain
Acute pain is protective,
temporary, usually
self‑limiting, and resolves
with tissue healing.
Physiological responses
(sympathetic nervous
system) are fight‑or‑flight
responses (tachycardia,
hypertension, anxiety,
diaphoresis, muscle tension).
Behavioral responses
include grimacing, moaning,
flinching, and guarding.
The nurse should be aware
that a client not exhibiting
physiological or behavioral
responses does not mean
that pain is absent.
interventions include treatment
of the underlying problem.
surgical incisions and wounds
from injury produce acute pain.

Chronic pain
Chronic pain is not protective.
it is ongoing or recurs
frequently, lasting longer
than 3 months and persisting
beyond tissue healing.
Physiological responses do
not usually increase vital signs.
The client’s vital signs can
actually be lower than normal
in response to chronic pain.
Clients can have depression,
fatigue, decreased level of
functioning, or disability.
Chronic pain might not have
a known cause, and it might
not respond to interventions.
Chronic pain can be classified
as chronic cancer pain or
chronic noncancer pain.
The pain associated with
osteoarthritis and neuropathy
are examples of chronic pain.

Nociceptive pain
Nociceptive pain arises from
damage to or inflammation
of tissue other than that
of the peripheral and
central nervous systems.
Nociceptive pain is the
result of activation of normal
processing of painful stimuli.
it is usually throbbing,
aching, and localized.
This pain is managed
using opioids and non‑
opioid medications.

TYPES OF NOCICEPTIVE PAIN
somatic: in bones,
joints, muscles, skin, or
connective tissues.
Visceral: in internal organs
such as the stomach or
intestines. it can cause referred
pain in other body locations
separate from the stimulus.

Neuropathic pain
Neuropathic pain arises
from abnormal or
damaged pain nerves.
it differs from nociceptive
pain as it is the abnormal
processing of painful stimuli.
it includes phantom limb
pain, pain below the level
of a spinal cord injury, and
diabetic neuropathy.
Neuropathic pain is
usually intense, shooting,
burning, or described as
“pins and needles.”
This pain typically is
managed using adjuvant
medications (antidepressants,
antispasmodic agents,
skeletal muscle relaxants).

26 CHAPTER 4 PAiN MANAGeMeNT CONTENT MASTERY SERIES

TyPes OF PAiN
Pain is categorized by duration (acute or chronic) or by
pathology (nociceptive or neuropathic).

● Clients can experience mixed pain that is difficult to
categorize. Conditions that cause mixed pain include
fibromyalgia, HIV, and Lyme disease.

● Breakthrough pain occurs when a client experiences an
exacerbation of acute pain. Clients who have chronic
conditions can experience episodes of breakthrough
pain requiring additional pain relief measures.

risK FACTOrs
Risk factors for undertreatment of pain

● Cultural and societal attitudes
● Lack of knowledge
● Fear of addiction
● Exaggerated fear of respiratory depression

Populations at risk for undertreatment of pain
● Infants
● Children
● Older adults
● Clients who have substance use disorder

Causes of acute and chronic pain
● Trauma
● Surgery
● Cancer (tumor invasion, nerve compression, bone

metastases, associated infections, immobility)
● Arthritis
● Fibromyalgia
● Neuropathy
● Diagnostic or treatment procedures (injection,

intubation, radiation)

Factors that affect the pain experience
● Age

◯ Infants cannot verbalize or understand their pain.
◯ Older adult clients can have multiple pathologies that
cause pain and limit function.

● Fatigue can increase sensitivity to pain.
● Genetic sensitivity can increase or decrease

pain tolerance.
● Cognitive function: Clients who are cognitively impaired

might not be able to report pain or report it accurately.
● Prior experiences can increase or decrease sensitivity

depending on whether clients obtained adequate relief.
● Anxiety and fear can increase sensitivity to pain.
● Support systems can decrease sensitivity to pain.
● Culture can influence how clients express pain or the

meaning they give to pain.

4.2 Focused pain assessment

Location
USE ANATOMICAL TERMINOLOGY AND
LANDMARKS TO DESCRIBE LOCATION.
Ask: “Where is your pain?”
Ask: “Does it radiate anywhere else?”
Ask clients to point to the location.

Quality
QUALITY REFERS TO HOW THE PAIN FEELS:
sharp, dull, aching, burning, stabbing, pounding,
throbbing, shooting, gnawing, tender, heavy, tight,
tiring, exhausting, sickening, terrifying, torturing,
nagging, annoying, intense, or unbearable.
Ask: “What does the pain feel like?” Give more than two
choices (“Is the pain throbbing, burning, or stabbing?”).

Measures
INTENSITY, STRENGTH, AND SEVERITY ARE
“MEASURES” OF THE PAIN. Use visual analog
scales (description scale, number rating scale)
to measure pain, monitor pain, and evaluate
the effectiveness of interventions.
Ask: “How much pain do you have now?”
Ask: “What is the worst/best the pain has been?”
Ask: “Rate your pain on a scale of 0 to 10.”

Timing
ONSET, DURATION, FREQUENCY.
Ask: “When did it start?”
Ask: “How long does it last?”
Ask: “How often does it occur?”
Ask: “Is it constant or intermittent?”

Setting
HOW THE PAIN AFFECTS DAILY LIFE OR HOW
ACTIVITIES OF DAILY LIVING (ADLS) AFFECT THE PAIN.
Ask: “Where are you when the symptoms occur?”
Ask: “What are you doing when the symptoms occur?”
Ask: “How does the pain affect your sleep?”
Ask: “How does the pain affect your
ability to work and do your job?”

Associated manifestations
DOCUMENT ASSOCIATED MANIFESTATIONS:
fatigue, depression, nausea, anxiety.
Ask: “What other symptoms do you have
when you are feeling pain?”

Aggravating/relieving factors
Ask: “What makes the pain better?”
Ask: “What makes the pain worse?”
Ask: “Are you currently taking any prescription,
herbal, or over‑the‑counter medications?”

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 4 PAiN MANAGeMeNT 27

eXPeCTed FiNdiNGs
● Behaviors complement self-report and assist in pain

assessment of nonverbal clients.
◯ Facial expressions (grimacing, wrinkled forehead),

body movements (restlessness, pacing, guarding)
◯ Moaning, crying
◯ Decreased attention span

● Blood pressure, pulse, and respiratory rate can
temporarily increase with acute pain. Eventually,
increases in vital signs will stabilize despite the
persistence of pain. Therefore, physiologic indicators
might not be an accurate measure of pain over time.

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Incorporate pharmacological and nonpharmacological

strategies into the plan of care. Consider the client’s
preferences. Discuss the use of complementary and
alternative practices.

● Assist the client to set a pain-relief or comfort-function
goal and refer back to the goal when planning or
evaluating pain interventions.

● Determine the client’s need for scheduled analgesia,
such as for chronic or postoperative pain.

● Plan to premedicate the client prior to painful
procedures (repositioning, wound care, invasive
diagnostic testing).

● Refer to dosage charts that describe equianalgesia to
compare the potency levels of various pain medications.

NONPHArMACOLOGiCAL
PAiN MANAGeMeNT

● Nonpharmacological pain strategies help to improve
coping by relieving stress associated with pain.
These strategies can assist clients in reducing the
amount of pharmacological interventions for pain
and are particularly helpful when clients cannot take
pain medication.

● Clients might choose nonpharmacological
complementary and alternative measures to
manage pain.

◯ Mind-body practices (yoga,
chiropractic manipulation)

◯ Cognitive approaches (meditation, distraction)
◯ Natural products (herbs, oils)

PHArMACOLOGiCAL iNTerVeNTiONs
Analgesics are the mainstay for relieving pain. The
parenteral route is best for immediate, short-term
relief of acute pain. The oral route is better for chronic,
nonfluctuating pain.

● Treatment tools, such as the WHO analgesic ladder,
suggest administering non-opioid analgesics first,
progressing through weak opioids to stronger ones to
manage pain.

● Expect to administer IV analgesia immediately
postoperatively, and to transition clients to oral
medication as pain is managed properly through the
postoperative period.

● When transitioning clients from IV to oral analgesia, a
larger dose is required for oral dosing because the full
dose of medication does not reach the bloodstream.

● Clients experiencing acute pain receive doses that are
gradually titrated down until they can be comfortable
without medication, or at a minimal dose.

● The three classes of analgesics are non-opioids, opioids,
and adjuvants.

Non-opioid analgesics
Non-opioid analgesics are appropriate for treating mild
to moderate pain, and are often added to opioids for
treatment for more intense pain. Non-opioid analgesics
also have antipyretic and anti-inflammatory properties.

● Non-opioid analgesics are often prescribed following
painful procedures.

● Acetaminophen is most often used, alone or in
combination with other mediations.

◯ Ensure the total amount of acetaminophen a client
consumes daily does not exceed 4 g for clients 50 kg
(110 lb) or greater.

◯ It is safe to administer acetaminophen concurrently
with NSAIDS (ibuprofen, aspirin, celecoxib,
naproxen) ketorolac, because the medications act in
different ways.

28 CHAPTER 4 PAiN MANAGeMeNT CONTENT MASTERY SERIES

Opioid analgesics
Opioid analgesics are appropriate for treating moderate
to severe pain. The term “narcotic” is not synonymous
with opioid analgesics. Narcotics can also refer to illegal
substances such as cocaine.

● Opioid analgesics for moderate pain include tramadol,
hydrocodone, and codeine.

● Hydromorphone, fentanyl, morphine, oxycodone, or
methadone are effects for more severe pain. Morphine
is the opioid most used and other opioid effects are
compared to the effects of morphine.

● Meperidine is no longer recommended for use except in
rare conditions at low doses.

● Check opioid formulations carefully to determine
whether a short-acting or modified release (extended
release) dose is indicated.

● For many opioids, the dose can be titrated upward
progressively until the client experiences pain relief;
however, upward titration increases the risk for
adverse effects.

● Opioids are available in transdermal, transmucosal, and
buccal routes.

● It is essential to monitor and intervene for adverse
effects of opioid use.

◯ Constipation: Use a preventative approach (monitoring
of bowel movements, fluids, fiber intake, exercise,
stool softeners, stimulant laxatives, enemas).

◯ Orthostatic hypotension: Advise clients to sit or lie
down if lightheadedness or dizziness occur. Instruct
clients to avoid sudden changes in position by slowly
moving from a lying to a sitting or standing position.
Provide assistance with ambulation.

◯ Urinary retention: Monitor I&O, assess for distention,
administer bethanechol, and catheterize.

◯ Nausea/vomiting: Administer antiemetics,
advise clients to lie still and move slowly, and
eliminate odors.

◯ Sedation: Monitor level of consciousness and take
safety precautions. Sedation usually precedes
respiratory depression.

◯ Respiratory depression: Monitor respiratory rate prior
to and following administration of opioids. Initial
treatment of respiratory depression and sedation is
generally a reduction in opioid dose. If necessary,
administer naloxone to reverse opioid effects.

Adjuvant analgesics
Adjuvant analgesics, or coanalgesics, enhance the effects
of non-opioids, help alleviate other manifestations that
aggravate pain (depression, seizures, inflammation), and
are useful for treating neuropathic pain.

● Adjuvant medications include the following.
◯ Anticonvulsants: carbamazepine
◯ Antianxiety agents: diazepam
◯ Tricyclic antidepressants: amitriptyline
◯ Antihistamine: hydroxyzine
◯ Glucocorticoids: dexamethasone
◯ Antiemetics: ondansetron
◯ Anesthetics: Ketamine

Patient-controlled analgesia (PCA)
PCA is a medication delivery system that allows clients to
self-administer safe doses of opioids.

● Small, frequent dosing ensures consistent plasma levels.
● Clients have less lag time between identified need and

delivery of medication, which increases their sense
of control and can decrease the amount of medication
they need.

● Morphine and hydromorphone are typical opioids for
PCA delivery.

● Clients should let the nurse know if using the pump
does not control the pain.

● To prevent inadvertent overdosing, the client is the only
person who should push the PCA button.

Other pain management strategies
● Implantable pain pumps
● Medication injections and short-term infusions

◯ Local infusion into a wound
◯ Regional infusion to block a group of nerves
(epidural infusions)

● Stimulation of the brain and spinal cord
● Nerve ablation and cryoablation procedures

Chronic pain interventions
● Strategies specific for relieving chronic pain include the

above interventions, plus:
◯ Administering long-acting or controlled-release
opioid analgesics (including the transdermal route).

◯ Administering analgesics around the clock
rather than PRN.

◯ Referral to accredited pain management center, which
offer a holistic approach to pain management.

◯ Referral to palliative or hospice treatment centers as
indicated, based on the case of pain.

COMPLICATIONS
● Undertreatment of pain is a serious complication and

can lead to increased anxiety with acute pain and
depression with chronic pain. Assess clients for pain
frequently, and intervene as appropriate.

● Sedation, respiratory depression, and coma can occur as
a result of overdosing. Sedation always precedes
respiratory depression.

◯ Identify high-risk clients (older adult clients).
◯ Carefully titrate doses while closely monitoring
respiratory status.

◯ Stop the opioid and give the antagonist naloxone if
respiratory rate is below 8/min and shallow, or the
client is difficult to arouse.

◯ The nurse should closely monitor the client following
administration of naloxone. The duration of the
certain opioids can last longer than the effectiveness
of the naloxone creating a need for additional doses.

◯ Identify the cause of sedation.
◯ Use a sedation scale in addition to a pain rating scale
to assess pain, especially when administering opioids.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 4 PAiN MANAGeMeNT 29

Application Exercises

1. A nurse is caring for a client who is experiencing
mild acute pain after spraining an ankle.
Which of the following analgesics should
the nurse expect to administer?

A. Ketorolac

B. Ketamine

C. Meperidine

d. Methadone

2. A nurse at a clinic is talking with a client who has
cancer and takes extended‑release opioids twice
daily. The client reports an increase in localized,
achy pain over the last few days. How should
the nurse document this increase in pain?

A. Phantom limb pain

B. Mixed pain

C. Breakthrough pain

d. Neuropathic pain

3. A nurse is caring for a client who is receiving
morphine via a patient‑controlled analgesia (PCA)
infusion device after abdominal surgery. Which
of the following client statements indicates that
the client understands how to use the device?

A. “i’ll wait to use the device until
it’s absolutely necessary.”

B. “i’ll be careful about pushing the button
so i don’t get an overdose.”

C. “i should tell the nurse if the pain doesn’t
stop after i use this device.”

d. “i will ask my son to push the dose
button when i am sleeping.”

4. A nurse is discussing pain assessment with a
newly licensed nurse. Which of the following
information should the nurse include?

A. Most clients exaggerate their level of pain.

B. Pain must have an identifiable source
to justify the use of opioids.

C. Objective data are essential in assessing pain.

d. Pain is whatever the client says it is.

5. A nurse is monitoring a client who is receiving
opioid analgesia. Which of the following findings
should the nurse identify as adverse effects of
opioid analgesics? (select all that apply.)

A. Urinary incontinence

B. diarrhea

C. Bradypnea

d. Orthostatic hypotension

e. Nausea

Active Learning Scenario

A nurse on a medical‑surgical unit is reviewing with a
group of newly licensed nurses the various types of pain
the clients on the unit have. Use the ATi Active Learning
Template: Basic Concept to complete this item.

UNDERLYING PRINCIPLES: List the four different
types of pain, their definitions, and characteristics.

30 CHAPTER 4 PAiN MANAGeMeNT CONTENT MASTERY SERIES

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

UNDERLYING PRINCIPLES

Acute pain
● definition: Protective, temporary, usually
self‑limiting, resolves with tissue healing

● Physiological responses: Tachycardia, hypertension,
anxiety, diaphoresis, muscle tension

● Behavioral responses: Grimacing, moaning, flinching, guarding

Chronic pain
● definition: Not protective; ongoing or recurs frequently,
lasts longer than 3 months, persists beyond tissue healing,
can be chronic cancer pain or chronic noncancer pain

● Physiological responses: No change in vital signs, depression,
fatigue, decreased level of functioning, disability

Nociceptive pain
● definition: Arises from damage to or inflammation of tissue
other than that of the peripheral and central nervous
systems, is usually throbbing, aching, localized; pain typically
responds to opioids and non‑opioid medications

● Types of nociceptive pain
◯ somatic: in bones, joints, muscles, skin, or connective tissues
◯ Visceral: in internal organs such as the stomach
or intestines, can cause referred pain

Neuropathic pain
● definition: Arises from abnormal or damaged pain nerves (phantom
limb pain, pain below the level of a spinal cord injury, diabetic
neuropathy), usually intense, shooting, burning, or “pins and needles”

● Physiological responses to adjuvant medications (antidepressants,
antispasmodic agents, skeletal muscle relaxants)

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

Application Exercises Key

1. A. CORRECT: Ketorolac is in the NsAid category
and is useful for anti‑inflammatory effects in
managing minor pain following a sprain.

B. Ketamine is an anesthetic agent that is often used as an
adjuvant medication for treating neuropathic pain.

C. Meperidine is not recommended for regular use
due to adverse effects of the medication.

d. Methadone is effective for treating severe pain.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

2. A. Phantom limb pain is pain that is perceived to be initiated
from a part of the body that is no longer present.

B. Mixed pain is pain that is difficult to define,
for conditions such as fibromyalgia.

C. CORRECT: Breakthrough pain is an acute exacerbation of
pain beyond the level the client typically experiences.

d. Neuropathic pain sensations are described as
burning, shooting, or pins and needles.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

3. A. The client may use the device when he begins to feel pain.
it will help prevent unnecessary worsening of the pain
and more doses of analgesia to provide relief.

B. A feature of PCA devices is the timing control or
lockout mechanism, which enforces a preset minimum
interval between medication doses. This safety feature
is one means of preventing an overdose because
the client cannot self‑administer another dose of
medication until that time interval has passed.

C. CORRECT: The nurse should identify that PCA is a method
of delivering pain medication through an electronic infusion
device that allows the client to self‑administer pain medication
on an as‑needed basis. if the client is not achieving adequate
pain control, he should let the nurse know so that she can
initiate a reevaluation of the client’s pain management plan.

d. The client is the only one who should operate the
PCA pump. in situations where the client is not
able to do so, the provider may authorize a nurse
or a family member to operate the pump.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

4. A. A misconception about pain is that clients
exaggerate their pain level.

B. Clients can have pain without being
able to identify the source.

C. Objective data are not always present
when clients have pain.

d. CORRECT: The nurse should identify that pain
is a subjective experience, and the client is the
best source of information about it.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

5. A. Urinary retention, not urinary incontinence, is a
common adverse effect of opioid analgesia.

B. Constipation, not diarrhea, is a common
adverse effect of opioid analgesia.

C. CORRECT: respiratory depression, which causes
respiratory rates to drop to dangerously low levels, is
a common adverse effect of opioid analgesia.

d. CORRECT: dizziness or lightheadedness when changing
positions is a common adverse effect of opioid analgesia.

e. CORRECT: Nausea and vomiting are common
adverse effects of opioid analgesia.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Expected Actions/Outcomes

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 5 MeNiNGiTis 31

UNIT 2 NEUROLOGIC DISORDERS
SECTION: CENTRAL NERVOUS SYSTEM DISORDERS

CHAPTER 5 Meningitis
Meningitis is an inflammation of the meninges,
which are the membranes that protect the brain
and spinal cord.

Viral, or aseptic, meningitis is the most common
form of meningitis and commonly resolves
without treatment. Fungal meningitis is common
in clients who have Aids. Bacterial (or septic)
meningitis is a contagious infection with a high
mortality rate. The prognosis depends on how
quickly care is initiated.

There are three vaccines for different pathogens
that cause bacterial meningitis. One is available
for high‑risk populations, such as residential
college students.

HEALTH PROMOTION AND
DISEASE PREVENTION

Haemophilus influenzae type b (Hib) vaccine
Ensure infants receive vaccine for bacterial meningitis
on schedule. A series of four doses is recommended
beginning at 2 months of age, with the final dose at 12 to
15 months.

Pneumococcal polysaccharide vaccine (PPSV)
Though primarily intended to prevent respiratory
infection, this immunization also decreases the
risk for CNS infections. Vaccinate adults who are
immunocompromised, have a chronic disease, smoke
cigarettes, or live in a long-term care facility. Follow CDC
guidelines for reimmunization. Give one dose to adults
older than 65 who have not previously been immunized
nor have history of disease.

Meningococcal vaccine (MCV4) (Neisseria meningitidis)
Ensure that adolescents receive the vaccine on schedule
and prior to living in a residential setting in college.
Individuals in other communal living conditions (such
as military) also should be immunized. An initial dose is
recommended for healthy children between the ages of 11
to 12, with a booster administered at age 16.

ASSESSMENT

risK FACTOrs
Viral meningitis

● Viral illnesses (mumps, measles, herpes, arboviruses
[West Nile]).

● There is no vaccine against viral meningitis.

Fungal meningitis: Fulminant fungal-based infection of
the sinuses are from the organism Cryptococcus neoformans.

Bacterial meningitis: Bacterial-based infections (otitis
media, pneumonia, sinusitis) in which the infectious
micro-organism is Neisseria meningitidis, Streptococcus
pneumoniae, or Haemophilus influenzae.

Immunosuppression

Direct contamination of spinal fluid

Invasive procedures, skull fracture, or
penetrating wound

Environment: Overcrowded living conditions.

eXPeCTed FiNdiNGs
SUBJECTIVE DATA

● Excruciating, constant headache
● Nuchal rigidity (stiff neck)
● Photophobia (sensitivity to light)

OBJECTIVE DATA: Physical Assessment Findings
● Fever and chills
● Nausea and vomiting
● Altered level of consciousness (confusion, disorientation,

lethargy, difficulty arousing, coma)
● Positive Kernig’s sign (resistance and pain with

extension of the client’s leg from a flexed position)
● Positive Brudzinski’s sign (flexion of the knees and hips

occurring with deliberate flexion of the client’s neck)
● Hyperactive deep tendon reflexes
● Tachycardia
● Seizures
● Red macular rash (meningococcal meningitis)
● Restlessness, irritability

LABOrATOry TesTs
● Urine, throat, nose, and blood culture and sensitivity:

Culture and sensitivity of various body fluids identify
possible infectious bacteria and an appropriate broad-
spectrum antibiotic. Not definitive for meningitis but
can guide initial selection of antimicrobial.

● CBC: Elevated WBC count

CHAPTER 5

32 CHAPTER 5 MeNiNGiTis CONTENT MASTERY SERIES

diAGNOsTiC PrOCedUres
Cerebrospinal fluid (CSF) analysis

● CSF analysis is the most definitive diagnostic procedure.
CSF is collected during a lumbar puncture performed by
the provider.

● Results indicative of meningitis
◯ Appearance of CSF: cloudy (bacterial) or clear (viral)
◯ Elevated WBC
◯ Elevated protein
◯ Decreased glucose (bacterial)
◯ Elevated CSF pressure

● Counterimmunoelectrophoresis (CIE) can be done on
CSF to determine whether the infectious agent is viral
or protozoa. This diagnostic study is also indicated if
the client received antibiotics before CSF was collected.

CT scan and MRI: A CT scan or an MRI can be performed
to identify increased intracranial pressure (ICP) and/or
an abscess.

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Isolate the client as soon as meningitis is suspected.
● Maintain isolation precautions per hospital policy.

◯ Initiate droplet precautions, which require a private
room. Continue droplet precautions until antibiotics
have been administered for 24 hr and oral and nasal
secretions are no longer infectious. Clients who have
bacterial meningitis might need to remain on droplet
precautions continuously.

◯ Standard precautions are implemented for all clients
who have meningitis.

● Implement fever-reduction measures, such as a cooling
blanket, if necessary.

● Report meningococcal infections to the public
health department.

● Decrease environmental stimuli.
● Provide a quiet environment.
● Minimize exposure to bright light (natural and electric).
● Maintain bed rest with the head of the bed

elevated to 30°.
● Monitor for increased ICP.
● Tell the client to avoid coughing and sneezing, which

increase ICP.
● Maintain client safety, such as seizure precautions.
● Replace fluid and electrolytes as indicated by

laboratory values.
● Older adult clients are at an increased risk for secondary

complications, such as pneumonia.
● Monitor vital signs to assess for septic shock.

MediCATiONs
● Ceftriaxone or cefotaxime in combination with

vancomycin: Antibiotics given until culture and
sensitivity results are available. Effective for
bacterial infections.

● Phenytoin: Anticonvulsants given if ICP increases or
client experiences a seizure.

● Acetaminophen, ibuprofen: Analgesics for headache
and/or fever. Non-opioid to avoid masking changes in
the level of consciousness.

● Ciprofloxacin, rifampin, or ceftriaxone: Prophylactic
antibiotics given to individuals in close contact with
the client.

COMPLICATIONS

Increased ICP

Meningitis can cause ICP to increase, possibly to the point
of brain herniation.

NURSING ACTIONS
● Monitor for indications of increasing ICP (decreased

level of consciousness, pupillary changes, impaired
extraocular movements).

● Provide interventions to reduce ICP (positioning with
head of the bed elevation at 30° and avoidance of
coughing and straining).

● Mannitol can be administered via IV.

SIADH

SIADH can be a complication of meningitis due to
abnormal stimulation to the hypothalamic area of
the brain, causing excess secretion of antidiuretic
hormone (vasopressin).

NURSING ACTIONS
● Monitor for manifestations (dilute blood,

concentrated urine).
● Provide interventions, such as the administration of

demeclocycline and restriction of fluid.
● Monitor the client’s weight daily.

Septic emboli
● Septic emboli can form during meningitis and travel to

other parts of the body, particularly the hands, but can
occur in the feet as well.

● Development of gangrene can necessitate an amputation.
● Septic emboli can lead to disseminated intravascular

coagulation or stroke.

NURSING ACTIONS
● Monitor circulatory status of extremities and

coagulation studies.
● Report any alterations immediately to the provider.

Online Image: Gangrenous Toe

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 5 MeNiNGiTis 33

Application Exercises

1. A nurse is assessing a client who reports severe
headache and a stiff neck. The nurse’s assessment
reveals positive Kernig’s and Brudzinski’s signs. Which
of the following actions should the nurse perform first?

A. Administer antibiotics.

B. implement droplet precautions.

C. initiate iV access.

d. decrease bright lights.

2. A nurse is assessing for the presence of Brudzinski’s
sign in a client who has suspected meningitis. Which
of the following actions should the nurse take when
performing this technique? (select all that apply.)

A. Place client in supine position.

B. Flex client’s hip and knee.

C. Place hands behind the client’s neck.

d. Bend client’s head toward chest.

e. straighten the client’s flexed leg at the knee.

3. A nurse is planning care for a client who has
meningitis and is at risk for increased intracranial
pressure (iCP). Which of the following actions should
the nurse plan to take? (select all that apply.)

A. implement seizure precautions.

B. Perform neurologic checks four times a day.

C. Administer morphine for the report
of neck and generalized pain.

d. Turn off room lights and television.

e. Monitor for impaired extraocular movements.

F. encourage the client to cough frequently.

4. A nurse is reviewing the use of the meningococcal
vaccine (MCV4) for the prevention of meningitis
with a newly licensed nurse. Which of the following
information should the nurse include?

A. The vaccine is indicated to reduce
the risk of respiratory infection.

B. The vaccine is administered in
a series of four doses.

C. The vaccine is recommended for
adolescents before starting college.

d. The vaccine is initially given at 2 months of age.

5. A nurse is planning care for a client who has bacterial
meningitis. Which of the following actions should the
nurse include in the plan of care? (select all that apply.)

A. Monitor for bradycardia.

B. Provide an emesis basin at the bedside.

C. Administer antipyretic medication.

d. Perform a skin assessment.

e. Keep the head of the bed flat.

Active Learning Scenario

A nurse is reviewing the plan of care for a client who
has bacterial meningitis. Use the ATi Active Learning
Template: system disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS):
define bacterial meningitis.

MEDICATIONS: identify three medications, their
actions, and the reason for administration.

COMPLICATIONS: describe two complications of meningitis.

34 CHAPTER 5 MeNiNGiTis CONTENT MASTERY SERIES

Application Exercises Key

1. A. The nurse should administer antibiotics to
stop the micro‑organisms from multiplying,
but this is not the priority action.

B. CORRECT: When using the urgent vs. nonurgent approach
to care, the nurse determines the priority action is to
initiate droplet precautions when meningitis is suspected
to prevent spread of the disease to others.

C. The nurse should initiate iV access to allow iV medication
and fluid administration, but this is not the priority action.

d. The nurse should decrease bright lights because of the
client’s sensitivity to light, but this is not the priority action.

NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission‑Based Precautions/Surgical Asepsis

2. A. CORRECT: The nurse should place the client in supine
position when assessing for Brudzinski’s sign.

B. The nurse should flex the client’s hip and knee
when assessing for Kernig’s sign.

C. CORRECT: The nurse should place her hands behind
the client’s neck when assessing for Brudzinski’s
sign, in order to flex the client’s neck.

d. CORRECT: The nurse should bend the client’s head
toward the chest when assessing for Brudzinski’s sign.

e. The nurse should straighten the client’s flexed leg
at the knee when assessing for Kernig’s sign.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

3. A. CORRECT: The client is at risk for seizures due to possible
increased iCP. Therefore, the nurse should implement seizure
precautions to reduce the client’s risk for injury.

B. The nurse should perform neurologic checks at least
every 2 hr for a client who is at risk for increased iCP.

C. The nurse should avoid administering opioids to a
client who is at risk for increased iCP. Opioids can mask
changes in the client’s level of consciousness.

d. CORRECT: The nurse should turn off room lights and the
television because they can increase neuron stimulation and
cause a seizure when a client is at risk for increased iCP.

e. CORRECT: The nurse should monitor for impaired extraocular
movements because this finding can indicate increased iCP.

F. The nurse should instruct the client to avoid coughing
because this action can cause increased iCP.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. A. The pneumococcal vaccine is primarily indicated to
reduce the risk of respiratory infection. However,
it also reduces the risk of CNs infection.

B. The HiB vaccine is administered to infants
in a series of four doses.

C. CORRECT: The nurse should identify that the
meningococcal vaccine is recommended for adolescents
prior to starting college due to the increased risk
for infection in communal living facilities.

d. The initial dose of the HiB vaccine is recommended
for infants at 2 months of age.

NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission‑Based Precautions/Surgical Asepsis

5. A. The nurse should plan to monitor for tachycardia
when a client has meningitis.

B. CORRECT: The nurse should provide an emesis
basin at the bedside because the client who has
meningitis can have nausea and vomiting.

C. CORRECT: The nurse should plan to administer antipyretic
medication for fever to a client who has meningitis.

d. CORRECT: The nurse should perform a skin assessment
to determine whether the client has a red macular
rash associated with meningococcal meningitis.

e. The nurse should elevate the head of the client’s
bed 30° to promote venous drainage from
the head and prevent increased iCP.

NCLEX® Connection: Physiological Adaptation,
Illness Management

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): Bacterial meningitis is a
bacterial infection that causes an inflammation of the meninges,
the membranes that protect the brain and spinal cord.

MEDICATIONS
● Ceftriaxone with vancocin: antibiotics
administered to treat the infection.

● Acetaminophen: an antipyretic used to treat a fever.
● Phenytoin: an anticonvulsant given to prevent the client
from experiencing a seizure when at risk of iCP.

COMPLICATIONS
● increased iCP, which can lead to seizures, coma, and death.
● syndrome of inappropriate antidiuretic hormone (siAdH),
which is due to pressure from inflammation abnormally
stimulating the hypothalamus, causing increased
secretion of antidiuretic hormone (vasopressin).

● septic emboli can occur as a result of meningitis.
This complication can lead to disseminated
intravascular coagulation, stroke, or gangrene.

NCLEX® Connection: Physiological Adaptation, Illness
Management

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 6 seizUres ANd ePiLePsy 35

UNIT 2 NEUROLOGIC DISORDERS
SECTION: CENTRAL NERVOUS SYSTEM DISORDERS

CHAPTER 6 Seizures and
Epilepsy

seizures are an abrupt, abnormal, excessive, and
uncontrolled electrical discharge of neurons
within the brain that can cause alterations in the
level of consciousness and/or changes in motor
and sensory ability and/or behavior.

epilepsy is the term used to define chronic
recurring abnormal brain electrical activity
resulting in two or more seizures. seizures
resulting from identifiable causes, such
as substance withdrawal or fever, are not
considered epilepsy.

The international Classification of epileptic
seizures uses three broad categories to describe
seizures: generalized, partial, and unclassified.

ASSESSMENT

risK FACTOrs
● Genetic predisposition: Absence seizures are more

common in children and tend to occur in families.
● Acute febrile state: Particularly among infants and

children younger than 2 years old.
● Head trauma: Can be early or late onset (up to
9 months), and incidence is increased when the head
trauma includes a skull fracture.

● Cerebral edema: Especially when it occurs acutely and
seizure activity tends to disappear when the edema is
successfully treated.

● Abrupt cessation of antiepileptic drugs (AEDs): As a
rebound activity.

● Infection: If intracranial, a result of increased
intracranial pressure; if systemic, a result of the
persistent febrile state.

● Metabolic disorder: A result of insufficient or excessive
chemicals within the brain, such as occurring with
hypoglycemia or hyponatremia.

● Exposure to toxins: Especially those associated with
pesticides, carbon monoxide, and lead poisoning.

● Stroke: Most likely to occur within the first
24 hr following a stroke as a result of increased
intracranial pressure.

● Heart disease: Common cause of new-onset seizures in
older adults.

● Brain tumor: If benign, seizures caused by the increased
bulk associated with the tumor; if malignant, associated
with the ability of the brain tissue to function.

● Hypoxia: Results in a decreased oxygen level of the
brain; necessary for neuronal activity.

● Acute substance withdrawal: Dehydration accompanies
withdrawal, creating a toxic level of the substance
in the body.

● Fluid and electrolyte imbalances: Results in abnormal
levels of nutrients required for neuronal function.

● With older adult clients, increased seizure incidence is
associated with cerebrovascular diseases.

TRIGGERING FACTORS
● Increased physical activity
● Excessive stress
● Hyperventilation
● Overwhelming fatigue
● Acute alcohol ingestion
● Excessive caffeine intake
● Exposure to flashing lights
● Substances such as cocaine, aerosols, and inhaled

glue products

eXPeCTed FiNdiNGs
Generalized seizures
Generalized seizure involves both cerebral hemispheres.
Generalized seizures can begin with an aura (alteration in
vision, smell, hearing, or emotional feeling).
Clients can experience five types of generalized seizures.

● Tonic-clonic seizure
◯ A tonic-clonic seizure begins for only a few seconds
with a tonic episode (stiffening of muscles) and loss
of consciousness.

◯ A 1- to 2-min clonic episode (rhythmic jerking of the
extremities) follows the tonic episode.

◯ Breathing can stop during the tonic phase and become
irregular during the clonic phase.

◯ Cyanosis can accompany breathing irregularities.
◯ Biting of the cheek or tongue can occur during
clonic phase.

◯ Incontinence can also accompany a
tonic-clonic seizure.

◯ During the postictal phase, a period of confusion and
sleepiness follows the seizure.

● Tonic seizure
◯ Only the tonic phase is experienced.
◯ Clients suddenly lose consciousness and experience
sudden increased muscle tone, loss of consciousness,
and autonomic manifestations (arrhythmia, apnea,
vomiting, incontinence, salivation).

◯ Tonic seizures generally last less than 30 seconds, but
some sources indicate they can last several minutes.

● Clonic seizure
◯ Only the clonic phase is experienced.
◯ The seizure lasts several minutes.
◯ During this type of seizure, the muscles contract
and relax.

CHAPTER 6

36 CHAPTER 6 seizUres ANd ePiLePsy CONTENT MASTERY SERIES

● Myoclonic seizure
◯ Myoclonic seizures consist of brief jerking or
stiffening of the extremities, which can be
symmetrical or asymmetrical.

◯ This type of seizure lasts for seconds.
● Atonic or akinetic seizure

◯ Atonic or akinetic seizures are characterized by a few
seconds in which muscle tone is lost.

◯ The seizure is followed by a period of confusion.
◯ The loss of muscle tone frequently results in falling.

Partial or focal/local seizure
Partial or focal/local seizure involves only one cerebral
hemisphere.
Clients can experience two types of partial seizures.

● Complex partial seizure
◯ Complex partial seizures have associated automatisms
(behaviors that the client is unaware of, such as lip
smacking or picking at clothes).

◯ The seizure can cause a loss of consciousness or
blackout for several minutes.

◯ Amnesia can occur immediately prior to and after
the seizure.

● Simple partial seizure
◯ Consciousness is maintained throughout simple

partial seizures.
◯ Seizure activity can consist of unusual sensations,
a sense of déjà vu, autonomic abnormalities such
as changes in heart rate and abnormal flushing,
unilateral abnormal extremity movements, pain, or
offensive smell.

Unclassified or idiopathic seizures
Unclassified or idiopathic seizures do not fit into other
categories. These types of seizures account for half of all
seizure activity and occur for no known reason.

LABOrATOry TesTs
Tests should include alcohol and illicit substance levels,
HIV testing, and, if suspected, screen for the presence of
excessive toxins.

diAGNOsTiC PrOCedUres
● Electroencephalogram (EEG) records electrical activity

and can identify the origin of seizure activity.
● Magnetic resonance imaging (MRI), computed

tomography (CT) imaging/computed axial tomography
(CAT) scan, positron emission tomography (PET) scan,
cerebrospinal fluid (CSF) analysis, and skull x-ray can be
used to identify or rule out potential causes of seizures.

PATIENT‑CENTERED CARE

NUrsiNG CAre
During a seizure

● Protect the client’s privacy and the client from injury
(move furniture away, hold head in lap if on the floor).

● Position the client to provide a patent airway.
● Be prepared to suction oral secretions.
● Turn the client to the side to decrease the risk

of aspiration.
● Loosen restrictive clothing.
● Do not attempt to restrain the client.
● Do not attempt to open the jaw or insert airway during

seizure activity (can damage teeth, lips, and tongue).
● Do not use padded tongue blades.
● Document onset and duration of seizure and findings

(level of consciousness, apnea, cyanosis, motor activity,
incontinence) prior to, during, and following the seizure.

After a seizure
● This is the postictal phase of the seizure episode.
● Maintain the client in a side-lying position to prevent

aspiration and to facilitate drainage of oral secretions.
● Check vital signs.
● Assess for injuries.
● Perform neurological checks.
● Allow the client to rest if necessary.
● Reorient and calm the client, who might be agitated

or confused.
● Determine if client experienced an aura, which can

indicate the origin of seizure in the brain.
● Try to determine possible trigger (such as fatigue).

MediCATiONs
● Administer prescribed antiepileptic drugs (AEDs), such

as phenytoin.
● Initial goal is to control seizure activity using one

medication. If the chosen medication is not effective,
either the dose is increased, or another medication is
added or substituted.

● Therapeutic levels are determined by blood tests. These
are performed on a routine schedule to ensure
compliance and effectiveness of the medication.

● Allergic reactions to these medications are rare, yet can
occur immediately or late in therapy. If the client is
allergic, another medication may be substituted.

CLIENT EDUCATION
● Take medications at the same time every day to enhance

effectiveness.
● The potential to develop tolerance to antiseizure

medications over time is called drug decline. This can
lead to an increase in seizures. Some clients develop
sensitivity with age. If drug decline or sensitivity occurs,
clients will need blood levels drawn frequently and
medication dosages adjusted.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 6 seizUres ANd ePiLePsy 37

● Be aware of adverse effects and interactions with food or
other medications. These are specific to the medication.

● Some antiepileptic medications cause oral gum
overgrowth. Routine oral hygiene and dental visits can
minimize this adverse effect.

● When using phenytoin, specific instructions should
include avoidance of oral contraceptives, as this
medication decreases their effectiveness. Warfarin
should also not be given with this medication, as
phenytoin can decrease absorption and increase
metabolism of oral anticoagulants.

iNTerPrOFessiONAL CAre
● Initiate a social services referral to aid in obtaining

medications if cost will affect the client’s ability to
adhere to the medication routine.

● If employment is affected by seizure activity,
refer to social agencies for financial support and
vocational evaluation.

● If seizure activity affects a school-age child’s
performance in the classroom, this condition should
be reported to the disability office, which can develop
specialized interventions or facilitate an Individualized
Education Program (IEP).

● Discrimination on the basis of epilepsy is illegal in
all states.

THerAPeUTiC PrOCedUres
Vagal nerve stimulation and conventional surgical
procedures can be helpful for clients whose seizures are
not controlled with medication therapy.

Vagal nerve stimulator
● Vagal nerve stimulation is indicated for treatment of
partial seizures.

● The vagal nerve stimulator is a device implanted into
the left chest wall and connected to an electrode placed
on the left vagus nerve.

● This procedure is performed under general anesthesia.
● The device is then programmed to administer
intermittent stimulation of the brain via stimulation of
the vagal nerve, at a rate specific to the client’s needs.

CLIENT EDUCATION
● In addition to routine stimulation, the client may
initiate vagal nerve stimulation by holding a magnet
over the implantable device, at the onset of seizure
activity. This either aborts the seizure, or lessens
its severity.

● Avoid diagnostic procedures, such as MRI, ultrasound
diathermy, and the use of microwave ovens and
shortwave radios.

Conventional surgical procedures
● Conventional surgical procedures are available for

clients who experience partial or generalized seizures.
● Prior to surgery, AEDs are discontinued and the specific

area of the seizure activity is identified through the use
of EEG monitoring. Surgically implanted electrodes can
also be used.

● The affected area of the brain can be excised if it is
determined that vital brain function will not be affected.

◯ An intracarotid amobarbital (Wada) test can help
determine if language or memory would be affected.

◯ Neuropsychological testing can help determine if
visuospatial function, memory, language, or cognitive
function would be affected.

● Partial corpus callosotomy can be used for clients who
are not candidates for conventional surgical procedures.
The procedure resects the corpus callosum, preventing
neuronal discharges across hemispheres and reduces the
severity and frequency of seizures.

● These procedures have associated morbidities, including
infection, loss of cerebral function, and a lack of success
in preventing seizures.

NURSING ACTIONS
● Provide client education regarding seizure management.

◯ Importance of monitoring AED levels and maintaining
therapeutic medication levels

◯ Possible medication interactions (decreased
effectiveness of oral contraceptives)

● Encourage the client to wear a medical identification tag
at all times.

● Instruct clients who have a history of seizures to
research state driving laws. Some states restrict or limit
driving for individuals who have a recent history
of seizures.

6.1 Vagal nerve stimulator

38 CHAPTER 6 seizUres ANd ePiLePsy CONTENT MASTERY SERIES

COMPLICATIONS

Status epilepticus

This is repeated seizure activity within a 30-min time
frame or a single prolonged seizure lasting more than
5 min. The complications associated with this condition
are related to decreased oxygen levels, inability of the
brain to return to normal functioning, and continued
assault on neuronal tissue. This acute condition requires
immediate treatment to prevent permanent loss of
brain function and death.
The usual causes are substance withdrawal, sudden
withdrawal from AEDs, head injury, cerebral edema,
infection, and metabolic disturbances.

NURSING ACTIONS
● Maintain an airway, provide oxygen, establish IV access,

perform ECG monitoring, and monitor pulse oximetry
and ABG results.

● Administer diazepam or lorazepam IV push followed by
IV phenytoin or fosphenytoin.

Active Learning Scenario

A nurse is planning care for a client who is experiencing
status epilepticus. What concepts should the nurse
include in the plan of care? Use the ATi Active Learning
Template: Basic Concept to complete this item.

RELATED CONTENT: define the condition.

UNDERLYING PRINCIPLES: describe four possible causes.

NURSING INTERVENTIONS: describe five
actions the nurse should plan to take.

Application Exercises

1. A nurse is assessing a client who has a seizure
disorder. The client tells the nurse, “i am about
to have a seizure.” Which of the following actions
should the nurse implement? (select all that apply.)

A. Provide privacy.

B. ease the client to the floor if standing.

C. Move furniture away from the client.

d. Loosen the client’s clothing.

e. Protect the client’s head with padding.

F. restrain the client.

2. A nurse is caring for a client who just experienced
a generalized seizure. Which of the following
actions should the nurse perform first?

A. Keep the client in a side‑lying position.

B. document the duration of the seizure.

C. reorient the client to the environment.

d. Provide client hygiene.

3. A nurse is providing discharge instructions to a client
who has a prescription for phenytoin. Which of the
following information should the nurse include?

A. Consider taking an antacid when
on this medication.

B. Watch for receding gums when
taking the medication.

C. Take the medication at the same time every day.

d. Provide a urine sample to determine
therapeutic levels of the medication.

4. A nurse is reviewing trigger factors that can
cause seizures with a client who has a new
diagnosis of generalized seizures. Which of
the following information should the nurse
include in this review? (select all that apply.)

A. Avoid overwhelming fatigue.

B. remove caffeinated products from the diet.

C. Limit looking at flashing lights.

d. Perform aerobic exercise.

e. Limit episodes of hypoventilation.

F. Use of aerosol hairspray is recommended.

5. A nurse is completing discharge teaching to a client
who has seizures and received a vagal nerve stimulator
to decrease seizure activity. Which of the following
statements should the nurse include in the teaching?

A. “it is safe to use microwaves that
are 1,200 watts or less.” .

B. “you should avoid the use of CT
scans with contrast.”.

C. “you should place a magnet over the implantable
device when you feel an aura occurring.”

d. “it is recommended that you use ultrasound
diathermy for pain management.”

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 6 seizUres ANd ePiLePsy 39

Application Exercises Key

1. A. CORRECT: The nurse should implement privacy
to minimize the client’s embarrassment.

B. CORRECT: The nurse should ease the client to
the floor to prevent falling and injury.

C. CORRECT: The nurse should move the furniture
away from the client to prevent injury.

d. CORRECT: The nurse should loosen the client’s
clothing to minimize restriction of movement.

e. CORRECT: The nurse should protect the client’s head
from injury by placing the client’s head in her lap or using
a pillow or blanket under the head during a seizure.

F. The nurse should not restrain the client. restraint can
increase the client’s risk for injury or more seizure activity.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

2. A. CORRECT: The greatest risk to the client is aspiration during
the postictal phase. Therefore, the priority intervention is
to keep the client in a side‑lying position so secretions can
drain from the mouth keeping the airway patent.

B. The nurse should document the duration of the
seizure in the client’s medical record, but there is
another action that the nurse should take first.

C. The nurse should reorient the client to the environment
because the client can feel confused, but there is
another action that the nurse should take first.

d. The nurse should provide client hygiene if the client
experienced incontinence during the seizure, but there
is another action that the nurse should take first.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

3. A. The nurse does not need to instruct the client to
consider taking an antacid, because phenytoin does
not cause any gastrointestinal adverse effects.

B. The nurse should instruct the client that phenytoin
causes overgrowth of the gums.

C. CORRECT: The nurse should instruct the
client to take phenytoin at the same time
every day to enhance effectiveness.

d. The nurse should instruct the client to have periodic blood
tests to determine the therapeutic level of phenytoin.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. A. CORRECT: The nurse should instruct the client to avoid
overwhelming fatigue, which can trigger a seizure by
stimulating abnormal electrical neuron activity.

B. CORRECT: The nurse should instruct the client to remove
caffeinated products from the diet, which can trigger a
seizure by stimulating abnormal electrical neuron activity.

C. CORRECT: The nurse should instruct the client to refrain
from looking at flashing lights, which can trigger a seizure
by stimulating abnormal electrical neuron activity.

d. The nurse should instruct the client to avoid vigorous physical
activity, which can help to avoid triggering a seizure.

e. The nurse should instruct the client to limit excess
hyperventilation, which can trigger a seizure by
stimulating abnormal electrical neuron activity.

F. The nurse should instruct the client to avoid using
aerosol hairspray, which can trigger a seizure by
stimulating abnormal electrical neuron activity.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

5. A. The nurse should instruct the client to avoid using
a microwave, regardless of wattage, which can
affect the function of the stimulator.

B. The nurse should instruct the client to avoid Mris,
which can affect the function of the stimulator.

C. CORRECT: The nurse should instruct the client to
hold a magnet over the implantable device when an
aura occurs so as to decrease seizure activity.

d. The nurse should instruct the client to avoid the use of
ultrasound diathermy for pain management because
of its effect on the function of the stimulator.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT: status epilepticus is repeated
seizure activity within a 30‑min time frame or a single
prolonged seizure lasting more than 5 min.

UNDERLYING PRINCIPLES
● substance withdrawal
● Withdrawal from antiepileptic medication
● infection
● Head injury
● Cerebral edema
● Metabolic disturbances

NURSING INTERVENTIONS
● Maintain a patent airway.
● Perform eCG monitoring.
● review ABG results.
● establish iV access.
● Provide oxygen.
● Monitor pulse oximetry.
● Administer lorazepam or diazepam.
● Administer phenytoin or fosphenytoin.

NCLEX® Connection: Physiological Adaptation, Alterations in
Body Systems

40 CHAPTER 6 seizUres ANd ePiLePsy CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 7 PArKiNsON’s diseAse 41

UNIT 2 NEUROLOGIC DISORDERS
SECTION: CENTRAL NERVOUS SYSTEM DISORDERS

CHAPTER 7 Parkinson’s Disease
Parkinson’s disease (Pd) is a progressively
debilitating disease that grossly affects motor
function. it is characterized by four primary
findings: tremor, muscle rigidity, bradykinesia
(slow movement), and postural instability. These
findings occur due to overstimulation of the
basal ganglia by acetylcholine.

The secretion of dopamine and acetylcholine
in the body produce inhibitory and excitatory
effects on the muscles respectively.

Overstimulation of the basal ganglia by
acetylcholine occurs because degeneration of the
substantia nigra results in decreased dopamine
production. This allows acetylcholine to dominate,
making smooth, controlled movements difficult.

Treatment of Pd focuses on increasing the
amount of dopamine or decreasing the amount
of acetylcholine in a client’s brain.

ASSESSMENT

risK FACTOrs
● Onset of findings between age 40 to 70
● More common in males
● Genetic predisposition
● Exposure to environmental toxins and chemical solvents
● Chronic use of antipsychotic medication

eXPeCTed FiNdiNGs
● Report of fatigue
● Report of decreased manual dexterity over time

PHYSICAL ASSESSMENT FINDINGS
● Stooped posture
● Slow, shuffling, and propulsive gait
● Slow, monotonous speech
● Tremors/pill-rolling tremor of the fingers
● Muscle rigidity (rhythmic interruption,

mildly restrictive, total resistance to movement)
● Bradykinesia/akinesia
● Masklike expression
● Autonomic findings (orthostatic hypotension,

flushing, diaphoresis)
● Difficulty chewing and swallowing

◯ Drooling
◯ Dysarthria
◯ Progressive difficulty with ADLs
◯ Mood swings
◯ Cognitive impairment (dementia)

LABOrATOry TesTs
● There are no definitive diagnostic procedures.
● Diagnosis is made based on manifestations, their

progression, and by ruling out other diseases. (7.1)

CHAPTER 7 Online Video: Assessment Findings with
Parkinson’s Disease

7.1 The five stages of Parkinson’s disease involvement

As Parkinson’s disease is a progressive disease, there are five stages of involvement.

STAGE I: Unilateral
shaking or tremor
of one limb.

STAGE II: Bilateral limb
involvement occurs,
making walking and
balance difficult.
Masklike face; slow,
shuffling gait.

STAGE III: Physical
movements slow
down significantly,
affecting walking more.
Postural instability.

STAGE IV: Tremors
can decrease but
akinesia and rigidity
make day‑to‑day
tasks difficult.

STAGE V: Client
unable to stand or
walk, is dependent
for all care, and might
exhibit dementia.

42 CHAPTER 7 PArKiNsON’s diseAse CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Administer medications at prescribed times. Monitor

medication effectiveness, and make recommendations for
changes in dosage and time of administration to provide
best coverage.

● Monitor swallowing, and maintain adequate nutrition and
weight. Consult speech and language therapist to assess
swallowing if the client demonstrates a risk for choking.

◯ Consult the client’s dietitian for appropriate diet, which
often includes semisolid foods and thickened liquids.

◯ Document the client’s weight at least weekly.
◯ Keep a diet intake log.
◯ Encourage fluids and document intake.
◯ Provide smaller, more frequent meals.
◯ Sit the client upright to eat or drink.
◯ Consult with an occupational therapist for adaptive
eating devices.

◯ Evaluate the need for high-calorie, high-protein
supplements to maintain the client’s weight.

● Maintain client mobility for as long as possible.
◯ Encourage exercise, such as yoga (can also improve
mental status).

◯ Encourage use of assistive devices as
disease progresses.

◯ Encourage range-of-motion (ROM) exercises.
◯ Teach the client to stop occasionally when walking to
slow down speed and reduce risk for injury.

◯ Pace activities by providing rest periods.
◯ Assist with ADLs as needed (hygiene, dressing).

● Promote client communication for as long as possible.
◯ Teach the client facial muscle strengthening exercises.
◯ Encourage the client to speak slowly and to

pause frequently.
◯ Use alternate forms of communication as appropriate.
◯ Refer the client to a speech-language pathologist.

● Monitor mental and cognitive status.
◯ Observe for manifestations of depression
and dementia.

◯ Provide a safe environment (no throw rugs, encourage
the use of an electric razor).

◯ Assess personal and family coping with the client’s
chronic, degenerative disease.

◯ Provide a list of community resources (support
groups) to the client and family.

◯ Refer the client to a social worker or case manager as
condition advances (financial issues, long-term home
care, and respite care).

MediCATiONs
● Can take several weeks of use before improvement of

manifestations is seen.
● While the client is taking a combination of medications,

maintenance of therapeutic medication levels is
necessary for adequate control.

Dopaminergics
● When given orally, medications such as levodopa

are converted to dopamine in the brain, increasing
dopamine levels in the basal ganglia.

● Dopaminergics may be combined with carbidopa to
decrease peripheral metabolism of levodopa, requiring a
smaller dose to make the same amount available to the
brain. Adverse effects are subsequently less.

● Due to medication tolerance and metabolism, the
dosage, form of medication, and administration times
must be adjusted to avoid periods of poor mobility.

NURSING ACTIONS: Monitor for the “wearing-off”
phenomenon and dyskinesias (problems with movement),
which can indicate the need to adjust the dosage or time
of administration or the need for a medication holiday.

Dopamine agonists

Dopamine agonists (bromocriptine, ropinirole,
pramipexole) activate release of dopamine. May be used in
conjunction with a dopaminergic for better results.

NURSING ACTIONS: Monitor for orthostatic hypotension,
dyskinesias, and hallucinations.

Anticholinergics

Anticholinergics, such as benztropine and trihexyphenidyl,
help control tremors and rigidity.

NURSING ACTIONS: Monitor for anticholinergic
effects (dry mouth, constipation, urinary retention,
acute confusion).

Catechol O‑methyltransferase (COMT) inhibitors

COMT inhibitors, such as entacapone, decrease the
breakdown of levodopa, making more available to the
brain as dopamine. Can be used in conjunction with a
dopaminergic and dopamine agonist for better results.

NURSING ACTIONS
● Monitor for dyskinesia/hyperkinesia when used

with levodopa.
● Assess for diarrhea.
● Dark urine is a normal finding.

Monoamine oxidase type B (MAO‑B) inhibitors

MAO-B inhibitors, such as selegiline and rasagiline,
inhibit monoamine oxidase type B activity and
increase dopamine levels. They reduce the wearing-off
phenomenon when administered concurrently
with levodopa.

NURSING ACTIONS: Severe reactions can occur
when these medications are administered with
sympathomimetics, meperidine, and fluoxetine.

CLIENT EDUCATION: Avoid foods high in tyramine, which
can cause hypertensive crisis.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 7 PArKiNsON’s diseAse 43

Antivirals

Antivirals, such as amantadine, stimulate release of
dopamine and prevent its reuptake.

NURSING ACTIONS
● Monitor for discoloration of the skin that subsides when

amantadine is discontinued.
● Client might experience anxiety, confusion, and

anticholinergic effects.

THerAPeUTiC PrOCedUres

Stereotactic pallidotomy or thalamotomy
● Strict eligibility criteria generally includes those who

have not responded to other therapies.
● Stereotactic pallidotomy and thalamotomy causes the

destruction of a small portion of the brain within the
globus pallidus or thalamus through the use of brain
imaging and electrical stimulation.

● Target area is identified with a CT scan or an MRI.
● Mild electrical stimulation is provided through a burr

hole to a target area.
● Client is assessed for a decrease in tremors and

muscle rigidity.
● When a decrease is elicited, a temporary lesion is

formed and the client is reassessed.
● If symptomatic relief is demonstrated (such as

alleviation of tremors and rigidity), a permanent
lesion is made.

NURSING ACTIONS: Assess for a neurologic impairment
and brain hemorrhage postoperatively.

Deep brain stimulation
● An electrode is implanted in the thalamus.
● A current is delivered through a small pulse generator

implanted under the skin of the upper chest. Electrical
stimulation from deep rain stimulation impulses
decreases tremors and involuntary movements, and can
decrease medications required to control PD.

NURSING ACTIONS: Monitor for infection, brain
hemorrhage, or stroke-like findings.

iNTerPrOFessiONAL CAre
● Because PD is a degenerative neurologic disorder,

long-term treatment and care must be accommodated.
● During the later stages of the disorder, the client needs

referrals to and support from disciplines such as speech
therapists, occupational therapists, physical therapists,
and social service/case management.

COMPLICATIONS

Aspiration pneumonia

As PD advances in severity, alterations in chewing and
swallowing worsen, increasing the risk for aspiration.

NURSING ACTIONS
● Use swallowing precautions to decrease the risk for

aspiration.
● Develop an individual dietary plan based on the speech

therapist’s recommendations.
● Have a nurse in attendance when the client is eating.
● Encourage the client to eat slowly and chew thoroughly

before swallowing.
● Feed the client in an upright position and have suction

equipment on standby.
● Evaluate need for enteral feedings to maintain weight

and prevent aspiration as PD progresses.

Altered cognition (dementia, memory deficits)

Clients in advanced stages of PD can exhibit altered
cognition in the form of dementia and memory loss.

NURSING ACTIONS
● Acknowledge the client’s feelings.
● Provide for a safe environment.
● Develop a comprehensive plan of care with the family,

client, and interprofessional team.

44 CHAPTER 7 PArKiNsON’s diseAse CONTENT MASTERY SERIES

Application Exercises

1. A nurse is caring for a client who displays
manifestations of stage iii Parkinson’s disease. Which
of the following actions should the nurse include?

A. recommend a community support group.

B. integrate a daily exercise routine.

C. Provide a walker for ambulation.

d. Perform AdLs for the client.

2. A nurse is developing a plan of care for the
nutritional needs of a client who has stage iV
Parkinson’s disease. Which of the following actions
should the nurse include? (select all that apply.)

A. Provide three large balanced meals daily.

B. record diet and fluid intake daily.

C. document weight every other week.

d. Offer cold fluids such as milkshakes.

e. Offer nutritional supplements between meals.

3. A nurse is reinforcing teaching with a client
who has Parkinson’s disease and has a new
prescription for bromocriptine. Which of the
following instructions should the nurse include?

A. rise slowly when standing.

B. expect urine to become dark‑colored.

C. Avoid foods containing tyramine.

d. report any skin discoloration.

4. A nurse is assessing a client for manifestations
of Parkinson’s disease. Which of the following
are expected findings? (select all that apply.)

A. decreased vision

B. Pill‑rolling tremor of the fingers

C. shuffling gait

d. drooling

e. Bilateral ankle edema

F. Lack of facial expression

5. A nurse is caring for a client who has Parkinson’s
disease and is starting to display bradykinesia. Which
of the following is an appropriate action by the nurse?

A. Teach the client to walk more
quickly when ambulating.

B. Complete passive range‑of‑motion exercises daily.

C. Place the client on a low‑protein, low‑calorie diet.

d. Give the client extra time to perform activities.

Active Learning Scenario

A nurse is preparing a plan of care for a client who has a
new diagnosis of Parkinson’s disease. What should the nurse
include in the plan of care? Use the ATi Active Learning
Template: system disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS):
define Parkinson’s disease.

COMPLICATIONS: identify four.

NURSING CARE: describe six nursing actions.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 7 PArKiNsON’s diseAse 45

Application Exercises Key

1. A. The client/family should be involved in a community
support group at the onset of the disease process
to enhance coping mechanisms.

B. The client should perform daily exercises with the
onset of the disease process to promote mobility
and independence for as long as possible.

C. CORRECT: The client should use a walker for ambulation
in stage iii of Parkinson’s disease because movement
slows down significantly and gait disturbances occur.

d. The client loses the ability to perform AdLs during stage
V of Parkinson’s disease and is dependent on others for
care at that time. during earlier stages, the client should
be encouraged to remain as independent as possible.

NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention

2. A. Plan to provide small, frequent meals during the
day to maintain adequate nutrition.

B. CORRECT: record the client’s diet and fluid
intake daily to assess for dietary needs and to
maintain adequate nutrition and hydration.

C. document the client’s weight weekly to identify weight
loss and intervene to maintain the client’s weight.

d. CORRECT: Provide cold fluids such as milkshakes. Thick
and cold fluids are tolerated easier by the client.

e. CORRECT: Offer nutritional supplements between
meals to maintain the client’s weight.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

3. A. CORRECT: Orthostatic hypotension is a common adverse
effect of bromocriptine, a dopamine receptor agonist.
Therefore, rising slowly when standing up will decrease
the risk of dizziness and lightheadedness.

B. The client should expect urine to turn dark when taking
entacapone, a COMT inhibitor. dark urine is not an
expected finding when taking bromocriptine.

C. The client should avoid tyramine in the diet
when taking selegiline, a monoamine type B
inhibitor. However, bromocriptine does not
interact with foods that contain tyramine.

d. skin discoloration is an adverse effect of
amantadine, an anti‑viral medication. However, it
is not an adverse effect of bromocriptine.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

4. A. decreased vision is not an expected finding
in a client who has Pd.

B. CORRECT: The client who has Pd can manifest
pill‑rolling tremors of the fingers due to
overstimulation of the basal ganglia by acetylcholine,
making controlled movement difficult.

C. CORRECT: The client who has Pd can manifest shuffling
gait because of overstimulation of the basal ganglia by
acetylcholine, making controlled movement difficult.

d. CORRECT: The client who has Pd can manifest
drooling because of overstimulation of the basal
ganglia by acetylcholine, making the controlled
movement of swallowing secretions difficult.

e. Bilateral ankle edema is not an expected finding in
a client who has Pd, but can be an adverse effect
of certain medications used for treatment.

F. CORRECT: The client who has Pd can manifest a lack of facial
expressions due to overstimulation of the basal ganglia by
acetylcholine, making controlled movement difficult.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

5. A. The client who has Pd develops a propulsive gait and
tends to walk increasingly rapidly. The client should be
reminded to stop occasionally when walking to prevent
a propulsive gait and decrease the risk for falls.

B. encourage active, not passive, range‑of‑motion
exercises to promote mobility in the client who
has Pd and is displaying bradykinesia.

C. The client who has Pd often requires high‑calorie,
high‑protein supplements between meals in
order to maintain adequate weight.

d. CORRECT: Bradykinesia is abnormally slowed
movement and is seen in clients who have Pd. The
client should be given extra time to perform activities
and should be encouraged to remain active.

NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): Parkinson’s disease is a debilitating condition that progresses to complete dependent care. The disease involves
a decrease in dopamine production and an increase in secretion of acetylcholine, causing resting tremor, slowed movement, and muscular rigidity.

COMPLICATIONS
● Aspiration due to pharyngeal muscle involvement making swallowing difficult
● Orthostatic hypotension, slow movement, and muscle rigidity
● Change in speech pattern: slow, monotonous speech
● Altered emotional changes that can include depression and fear

NURSING CARE
● Add thickener to liquids to prevent aspiration.
● Consult with a dietitian about appropriate diet.
● encourage periods of rest between activities.
● Allow adequate time to rise slowly from a sitting to standing position.
● encourage slower speech when expressing thoughts.
● Observe for manifestations of depression and dementia.

NCLEX® Connection: Physiological Adaptation, Illness Management

46 CHAPTER 7 PArKiNsON’s diseAse CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 8 ALzHeiMer’s diseAse 47

UNIT 2 NEUROLOGIC DISORDERS
SECTION: CENTRAL NERVOUS SYSTEM DISORDERS

CHAPTER 8 Alzheimer’s Disease
Alzheimer’s disease (Ad) is a nonreversible type
of dementia that progressively develops over
many years. A framework made up of seven
stages has been designed to categorize the
disease and its manifestations. The framework is
based on three general stages: early stage, mid
stage, and late stage.

dementia is defined as multiple cognitive
deficits that impair memory and can affect
language, motor skills, and/or abstract thinking.
The percentage of dementia attributable to Ad
ranges from 60% to 90%.

The mean duration of survival after diagnosis is
approximately 10 years, but some people can
live with the disease for up to 20 years.

Ad is most likely to occur in clients in their 60s
and 70s. However, it can be diagnosed as early as
40. Age, sex, and genetics, are known risk factors
for Ad, which usually occurs after the age of 65.

Ad is characterized by memory loss, problems
with judgment, and changes in personality. As the
disease progresses, severe physical decline occurs
along with deteriorating cognitive functions.

sTAGes OF ALzHeiMer’s diseAse
The progression of Alzheimer’s disease can be different for
each client. While there is no universal scale for the stages
and manifestations, the following is an example of one
scale.

Mild Alzheimer’s (early stage)
● Memory lapses
● Losing or misplacing items
● Difficulty concentrating and organizing
● Unable to remember material just read
● Still able to perform ADLs
● Short-term memory loss noticeable to close relations
● Trouble remembering names when introduced to

new people
● Greater difficulty performing tasks in a worse setting

Moderate Alzheimer’s (middle stage)
● Forgetting events of one’s own history
● Difficulty performing tasks that require planning and

organizing (paying bills, managing money)
● Difficulty with complex mental arithmetic
● Personality and behavioral changes: appearing

withdrawn or subdued, especially in social or mentally
challenging situations; compulsive; repetitive actions

● Changes in sleep patterns
● Can wander and get lost
● Can be incontinent
● Clinical findings that are noticeable to others

Severe Alzheimer’s (late stage)
● Losing ability to converse with others
● Assistance required for ADLs
● Incontinence
● Losing awareness of one’s environment
● Progressing difficulty with physical abilities (walking,

sitting, and eventually swallowing)
● Eventually losses all ability to move; can develop stupor

and coma
● Death frequently related to choking or infection
● Vulnerable to infection, especially pneumonia, which

may become lethal

ASSESSMENT
Mini Mental State Examination (MMSE), set test using
FACT, Short Blessed Test, or Clock Drawing Test is used.

risK FACTOrs
● Advanced age
● Chemical imbalances
● Family history of AD or Down syndrome
● Genetic predisposition, apolipoprotein E
● Environmental agents (herpes virus, metal, or

toxic waste)
● Previous head injury
● Sex (female)
● Ethnicity/race (African American and Hispanic people

are at an increased risk for the development of AD
than non-Hispanic white people due to the APOE and
ABCA7 genes)

eXPeCTed FiNdiNGs
The progression of Alzheimer’s disease can be different for
each client. There is no universal scale for the stages and
manifestations.
FOR MORE INFORMATION, SEE MENTAL HEALTH CHAPTER 17:

NEUROCOGNITIVE DISORDERS

CHAPTER 8

48 CHAPTER 8 ALzHeiMer’s diseAse CONTENT MASTERY SERIES

LABOrATOry TesTs
● No specific lab test can definitively diagnose AD.
● Several lab tests can rule out other causes of dementia.
● A genetic test for the presence of apolipoprotein can

determine if there is an increased risk of AD, but it does
not specifically diagnose AD. The presence of the protein
increases the likelihood that dementia is due to AD.

diAGNOsTiC PrOCedUres
● There is no definitive diagnostic procedure, except brain

tissue examination upon death.
● Magnetic resonance imaging (MRI), computed

tomography (CT) imaging/computed axial tomography
(CAT) scan, positron emission tomography (PET) scan,
and electroencephalogram (EEG) may be performed to
rule out other possible causes of findings.

● A lumbar puncture may be performed for laboratory
testing of cerebral spinal fluid for soluble beta protein
precursor (sBPP). Beta amyloid protein normally assists
in growth and protection of nerve cells. The presence of
low levels of sBPP supports the diagnosis of AD.

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Assess cognitive status, memory, judgment, and

personality changes.
● Initiate bowel and bladder program based on a

set schedule.
● Encourage the client and family to participate in an AD

support group.
● Provide a safe environment.

◯ Frequent monitoring/visual checks.
◯ Keep client from stairs, elevators, exits.
◯ Remove or secure dangerous items in the
client’s environment.

● Provide frequent walks to reduce wandering.
● Maintain a sleeping schedule, and monitor for irregular

sleeping patterns.
● Provide verbal and nonverbal ways to communicate with

the client.
● Offer snacks or finger foods if the client is unable to sit

for long periods of time.
● Check skin weekly for breakdown.

8.1 Alzheimer’s disease stages and manifestations

Mild Alzheimer’s
(early stage)
NO APPARENT MANIFESTATION

● Normal function
● Manifestation: No memory problems.

STAGE 2: Forgetfulness
● (Can be normal age‑related changes
or very early manifestations of Ad)

● Manifestations
◯ Forgetfulness, especially of everyday
objects (eyeglasses or wallet).

◯ No memory problems evident to
provider, friends, or coworkers.

STAGE 3: Mild Cognitive decline
● (Problems with memory or concentration
can be measurable in clinical testing or
during a detailed medical interview)

● Mild cognitive deficits, including losing
or misplacing important objects.

● Manifestations
◯ decreased ability to plan.
◯ short‑term memory loss
noticeable to close relatives.

◯ decreased attention span.
◯ difficulty remembering
words or names.

◯ difficulty in social or work situations.
◯ Can get lost when driving.

Moderate Alzheimer’s
(middle stage)
STAGE 4: Mild to moderate
Cognitive decline

● Medical interview will detect
clear‑cut deficiencies.

● Manifestations
◯ Personality changes: appearing
withdrawn or subdued,
especially in social or mentally
challenging situations.

◯ Obvious memory loss.
◯ Limited knowledge and memory
of recent occasions, current
events, or personal history.

◯ difficulty performing tasks that
require planning and organizing
(paying bills or managing money).

◯ difficulty with complex
mental arithmetic.

◯ depression and social
withdrawal can occur.

STAGE 5: Moderate cognitive decline
● Manifestations

◯ increasing cognitive deficits emerge.
◯ inability to recall important details
such as address, telephone
number, or schools attended, but
memory of information about
self and family remains intact.

◯ Assistance with AdLs
becomes necessary.

◯ disorientation and confusion
as to time and place.

Severe Alzheimer’s
(late stage)
STAGE 6: Moderate to severe
cognitive decline

● Manifestations
◯ Memory difficulties continue to worsen.
◯ Loss of awareness of recent
events and surroundings.

◯ Can recall own name, but unable
to recall personal history.

◯ significant personality changes are
evident (delusions, hallucinations,
and compulsive behaviors).

◯ Wandering behavior.
◯ requires assistance with AdLs such
as dressing, toileting, and grooming.

◯ Normal sleep/wake cycle is disrupted.
◯ increased episodes of urinary
and fecal incontinence.

STAGE 7: severe cognitive decline
● Manifestations

◯ Ability to respond to environment,
speak, and control movement is lost.

◯ Unrecognizable speech.
◯ General urinary incontinence.
◯ inability to eat without assistance
and impaired swallowing.

◯ Gradual loss of all ability to
move extremities (ataxia).

Refer to Review Module: Mental Health: Chapter 17: Neurocognitive Disorders on Alzheimer’s Disease.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 8 ALzHeiMer’s diseAse 49

● Provide cognitive stimulation.
◯ Offer varied environmental stimulations (walks,
music, craft activities).

◯ Keep a structured environment and introduce change
gradually (client’s daily routine or a room change).

◯ Use a calendar to assist with orientation.
◯ Use short directions when explaining an activity or
care the client needs, such as a bath.

◯ Be consistent and repetitive.
◯ Use therapeutic touch.

● Provide memory training.
◯ Reminisce with the client about the past.
◯ Use memory techniques, such as making lists and
rehearsing.

◯ Stimulate memory by repeating the client’s
last statement.

● Avoid overstimulation. (Keep noise and clutter to a
minimum, and avoid crowds.)

● Promote consistency by placing commonly used objects
in the same location and using a routine schedule.

◯ Reality orientation (early stages)
◯ Easily viewed clock and single-day calendar
◯ Pictures of family and pets
◯ Frequent reorientation to time, place, and person

● Validation therapy (later stages)
◯ Acknowledge the client’s feelings.
◯ Don’t argue with the client; this will lead to the client

becoming upset.
◯ Reinforce and use repetitive actions or ideas cautiously.

● Promote self-care as long as possible. Assist with
activities of daily living as appropriate.

● Speak directly to the client in short, concise sentences.
● Reduce agitation. (Use calm, redirecting statements.

Provide a diversion.)
● Provide a routine toileting schedule.

MediCATiONs
● Most medications for clients who have dementia

attempt to target behavioral and emotional problems
(anxiety, agitation, combativeness, depression).

● These medications include antipsychotics,
antidepressants, and anxiolytics. Closely monitor clients
receiving these medications for adverse effects.

● AD medications temporarily slow the course of the
disease and do not work for all clients.

◯ Pharmacotherapeutics is based on the theory that
AD is a result of depleted levels of the enzyme
acetyltransferase, which is necessary to produce the
neurotransmitter acetylcholine.

◯ Benefits for clients who do respond to medication
include improvements in cognition, behavior,
and function.

● If a client fails to improve with one medication, a trial
of one of the other medications is warranted.

◯ Donepezil prevents the breakdown of acetylcholine
(ACh), which increases the amount of ACh available. This
results in increased nerve impulses at the nerve sites.

◯ Memantine is the first of a new classification of
medications with a low-to-moderate affinity. It blocks
nerve cell damage caused by excess glutamate. It has
shown to reduce client deterioration. Memantine may
be given in conjunction with donepezil.

◯ Cholinesterase inhibitors help slow this process.

NURSING ACTIONS
● Observe for frequent stools or upset stomach.
● Monitor for dizziness or headache. The client can feel

lightheaded or have an unsteady gait.
● Use caution when administering this medication to clients

who have asthma or COPD, as lung problems can worsen.

THerAPeUTiC PrOCedUres
ALTERNATIVE THERAPY

● Estrogen therapy for females can prevent Alzheimer’s
disease, but it is not useful in decreasing the effects of
existing dementia.

● Ginkgo biloba, an herbal product taken to increase
memory and blood circulation, can cause a variety of
adverse effects and medication interactions. If a client
is using ginkgo biloba or other nutritional supplements,
that information should be shared with providers.

COMPLEMENTARY MEDICINE
● Massage the client before bedtime to reduce stress and

promote sleep.
● Essential oils (lavender, bergamot) can be used to

promote relaxation and assist with sleeping.

iNTerPrOFessiONAL CAre
● Encourage the client and family to seek legal counsel

regarding advanced directives, guardianship, or durable
medical power of attorney.

● Refer the client and family to social services and
case managers for possible adult day care facilities or
long-term care facilities.

● Refer the client and family to the Alzheimer’s Association
and community outreach programs. This can include
family support groups, in-home care, or respite care.

● Review the resources available to the family as the
client’s health declines. Include long-term care options.
A variety of home care and community resources, such
as respite care, can be available to the family in many
areas of the country. Some respite care allows the client
to remain at home rather than in a facility.

50 CHAPTER 8 ALzHeiMer’s diseAse CONTENT MASTERY SERIES

CLieNT edUCATiON
● Refer to social services and case managers for long-

term/home management, Alzheimer’s Association,
community outreach programs, and support groups.

● Educate family/caregivers about illness, methods of care,
medications, and adaptation of the home environment.

● Provide information about care for seizures that can
happen late in the disease.

● Provide strategies to reduce caregiver stress.

Home safety measures
● Remove scatter rugs.
● Install door locks that cannot be easily opened, and

place alarms on doors.
● Keep a lock on the water heater and thermostat, and

keep the water temperature at a safe level.
● Provide good lighting, especially on stairs.
● Install handrails on stairs and mark step edges with

colored tape.
● Place the mattress on the floor.
● Remove clutter and clear hallways for walking.
● Secure electrical cords to baseboards.
● Keep cleaning supplies in locked cupboards.
● Install handrails in the bathroom, at bedside, and

in the tub.
● Place a shower chair in the tub.
● Wear a medical identification bracelet if living at home

with a caregiver.
● Enroll in Safe Return Home Program (www.alz.org).
● Participate in an exercise program to maintain mobility.

Application Exercises

1. A nurse is providing teaching to the partner of a client
who has Alzheimer’s disease and has a new prescription
for donepezil. Which of the following statements by
the partner indicates the teaching is effective?

A. “This medication should increase
my husband’s appetite.”

B. “This medication should help my
husband sleep better.”

C. “This medication should help my
husband’s daily function.”

d. “This medication should increase
my husband’s energy level.”

2. A nurse working in a long‑term care facility is planning
care for a client who has moderate Alzheimer’s
(mild or moderate stage). Which of the following
interventions should be included in the plan of care?

A. Use a gait belt for ambulation.

B. Thicken all liquids.

C. Provide protective undergarments.

d. reorient the client to self and current events.

3. A nurse is making a home visit to a client who
has Ad. The client’s partner states that the
client is often disoriented to time and place, is
unsteady, and has a history of wandering. Which
of the following safety measures should the nurse
review with the partner? (select all that apply.)

A. remove floor rugs.

B. Have door locks that can be easily opened.

C. Provide increased lighting in stairwells.

d. install handrails in the bathroom.

e. Place the mattress on the floor.

4. A nurse is caring for a client who has Ad and falls
frequently. Which of the following actions should
the nurse take first to keep the client safe?

A. Keep the call light near the client.

B. Place the client in a room close to the nurses’ station.

C. encourage the client to ask for assistance.

d. remind the client to walk with
someone for support.

5. A nurse is caring for a client who has Alzheimer’s disease.
A family member of the client asks the nurse about risk
factors for the disease. Which of the following should be
included in the nurse’s response? (select all that apply.)

A. exposure to metal waste products

B. Long‑term estrogen therapy

C. sustained use of vitamin e

d. Previous head injury

e. History of herpes infection

Active Learning Scenario

A charge nurse in a long‑term care facility is preparing
a program for assistive personnel about caring for a
client who has Alzheimer’s disease. What should be
included in this program? Use the ATi Active Learning
Template: system disorder to complete this item.

NURSING CARE: describe three nursing
interventions for each of the following areas.

● Providing cognitive stimulation
● Providing memory training

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 8 ALzHeiMer’s diseAse 51

Application Exercises Key

1. A. donepezil does not affect appetite.
B. donepezil does not affect sleep or sleep patterns.
C. CORRECT: donepezil helps slow the progression of Ad

and can help improve behavior and daily functions.
d. donepezil does not affect energy levels.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

2. A. Ambulation is affected as the client advances
into severe Alzheimer’s (late stage).

B. impaired swallowing is a finding as the client
advances into severe Alzheimer’s (late stage).

C. The client in severe Alzheimer’s (late stage) experiences
episodes of urinary and fecal incontinence.

d. CORRECT: A client who has moderate Alzheimer’s (middle
or moderate stage) can require reorientation to self
and current events as cognitive function declines.

NCLEX® Connection: Safety and Infection Control, Home Safety

3. A. CORRECT: removing floor rugs can
decrease the risk of falling.

B. easy‑to‑open door locks increase the risk for a client
who wanders to get out of his home and get lost.

C. CORRECT: Good lighting can decrease the risk
for falling in dark areas, such as stairways.

d. CORRECT: installing handrails in the bathroom can be useful
for the client to hold on to when his gait is unsteady.

e. CORRECT: By placing the client’s mattress on the
floor, the risk of falling or tripping is decreased.

NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions

4. A. Keeping the call light within the client’s reach is an
appropriate action, but not the first action because
the client might not remember to use it.

B. CORRECT: Using the safety and risk reduction
priority‑setting framework, placing the client in close
proximity to the nurses’ station for close observation
is the first action the nurse should take.

C. encouraging the client to ask for assistance is an
appropriate action, but not the first action because the
client might not remember to ask for assistance.

d. reminding the client to walk with someone is an
appropriate action, but not the first action because the
client might not remember to call for assistance.

NCLEX® Connection: Safety and Infection Control, Home Safety

5. A. CORRECT: exposure to metal and toxic waste is
a risk factor for Alzheimer’s disease.

B. Long‑term estrogen therapy can
prevent Alzheimer’s disease.

C. Long‑term use of vitamin e is not a risk
factor for Alzheimer’s disease.

d. CORRECT: A previous head injury is a risk
factor for Alzheimer’s disease.

e. CORRECT: A history of herpes infection is a
risk factor for Alzheimer’s disease.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

NURSING CARE
● Providing cognitive stimulation

◯ Offer varied environmental stimulations
(walks, music, craft activities).

◯ Keep a structured environment. introduce change slowly.
◯ Use a calendar to assist with orientation.
◯ Use short directions when explaining care
to be provided, such as a bath.

◯ Be consistent and repetitive.
◯ Use therapeutic touch.

● Providing memory training
◯ reminisce about the past.
◯ Help the client make lists and rehearse.
◯ repeat the client’s last statement to stimulate memory.

NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions

52 CHAPTER 8 ALzHeiMer’s diseAse CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 9 BrAiN TUMOrs 53

UNIT 2 NEUROLOGIC DISORDERS
SECTION: CENTRAL NERVOUS SYSTEM DISORDERS

CHAPTER 9 Brain Tumors
Brain tumors occur in any part of the brain,
occupy space within the skull, and are classified
according to the cell or tissue of origin. Cerebral
tumors are the most common.

Types of brain tumors include benign and
malignant. examples include malignant
gliomas (neuroglial cells), benign meningiomas
(meninges), pituitary adenomas, and acoustic
neuromas (acoustic cranial nerve).

A secondary classification, supratentorial tumors,
occur in the cerebral hemispheres above the
tentorium cerebelli. Those below the tentorium
cerebelli, such as tumors of the brainstem and
cerebellum, are classified as infratentorial tumors.

Brain tumors apply pressure to surrounding
brain tissue, resulting in decreased outflow
of cerebrospinal fluid, increased intracranial
pressure, cerebral edema, and neurologic
deficits. Tumors that involve the pituitary gland
can cause endocrine dysfunction.

Malignant brain tumors are associated with a
high overall mortality rate. Primary malignant
brain tumors originate from neuroglial
tissue and rarely metastasize outside of the
brain. secondary malignant brain tumors are
lesions that are metastases from a primary
cancer located elsewhere in the body. Cranial
metastatic lesions are most common from
breast, kidney, lung, skin (melanomas), and
gastrointestinal tract cancers.

Benign brain tumors develop from the meninges
or cranial nerves and do not metastasize. These
tumors have distinct boundaries and cause
damage either by the pressure they exert
within the cranial cavity and/or by impairing the
function of the cranial nerve.

HEALTH PROMOTION/
DISEASE PREVENTION

There are no routine screening procedures to detect
brain tumors.

ASSESSMENT

risK FACTOrs
The cause is unknown, but several risk factors have
been identified.

● Genetics
● Environmental agents
● Exposure to ionizing radiation
● Exposure to electromagnetic fields
● Previous head injury

eXPeCTed FiNdiNGs
PHYSICAL ASSESSMENT FINDINGS

● Dysarthria
● Dysphagia
● Positive Romberg sign
● Positive Babinski sign
● Vertigo
● Hemiparesis
● Cranial nerve dysfunction (inability to discriminate

sounds, loss of gag reflex, loss of blink response)
● Papilledema

MANIFESTATIONS SPECIFIC TO
SUPRATENTORIAL BRAIN TUMORS

● Severe headache (worse upon awakening but improving
over time; worsened by coughing or straining)

● Visual changes (blurring, visual field deficit)
● Focal or generalized seizures
● Loss of voluntary movement or the inability to

control movement
● Change in cognitive function (memory loss,

language impairment)
● Change in personality, inability to control emotions
● Nausea with or without vomiting
● Paralysis

MANIFESTATIONS SPECIFIC TO
INFRATENTORIAL BRAIN TUMORS

● Hearing loss or ringing in the ear
● Visual changes
● Facial drooping
● Difficulty swallowing
● Nystagmus, crossed eyes, or decreased vision
● Autonomic nervous system (ANS) dysfunction
● Ataxia or clumsy movements
● Hemiparesis
● Cranial nerve dysfunction (inability to discriminate

sounds, loss of gag reflex, loss of blink response)

LABOrATOry TesTs
● CBC and differential to rule out anemia or malnutrition
● Blood alcohol and toxicology screen to rule out these as

possible causes of altered physical assessment findings
● TB and HIV screening if social conditions warrant

CHAPTER 9 Online Media: Nystagmus, Testing for
Romberg Sign, Babinski Reflex

54 CHAPTER 9 BrAiN TUMOrs CONTENT MASTERY SERIES

diAGNOsTiC PrOCedUres
● X-ray, computed tomography (CT) imaging scan,

magnetic resonance imaging (MRI), brain scan,
position emission tomography (PET) scan, and cerebral
angiography are used to determine the size, location,
and extent of the tumor.

● Lumbar puncture (LP) and electroencephalography
(EEG) can provide additional information about
the tumor.

● LP should not be done if the client has or shows
manifestations of increasing intracranial pressure (ICP)
to prevent brain herniation.

● Lab tests can be done to evaluate endocrine function,
renal status, and electrolyte balance.

● Cerebral biopsy identifies cellular pathology.
◯ This procedure can be performed in the surgical suite
or in a radiology specialty suite.

◯ Diagnostic procedure can be used to guide the biopsy,
such as a CT or MRI scan. Image guiding systems,
which use CT or MRI scan information, can be used in
the surgical suite.

◯ A piece of cerebral tissue that appears abnormal on
the CT/MRI scan is obtained. This tissue is then sent
to pathology, where diagnostic tests are performed.

◯ Benefit: Biopsy is minimally disruptive to the rest of
the brain, provides a decreased recovery time, and is
not associated with the risks of an open craniotomy.

◯ Negative: Biopsy does not remove or debulk the tumor,
the diagnostic determination by pathology can be
inconclusive (related to insufficient tissue), and a
misdiagnosis can occur if the tumor contains many
types of tissue or the specimen is taken from one site.

CLIENT EDUCATION: Adhere to the specific instructions
regarding medications.

● If on antiepileptic medications, these must be continued
to prevent seizure activity.

● If on aspirin products, these should be discontinued at
least 72 hr prior to the procedure to minimize the risk
of intracerebral bleeding.

● Other medications can be withheld prior to
the procedure.

● Normally, preprocedure activities can be resumed after
recovering from the general anesthetic. Care of the
incision should include keeping the area clean and dry.
If sutures are in place, they need to be removed 1 to
7 days later. Driving or other dangerous activities should
be avoided until follow-up appointment occurs and
diagnosis is known.

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Maintain airway (monitor oxygen levels, administer

oxygen as needed, monitor lung sounds).
● Monitor neurologic status—in particular, assessing for

changes in level of consciousness, neurologic deficits,
and occurrence of seizures.

● Maintain client safety. (Assist with transfers and
ambulation, provide assistive devices as needed.)

● Implement seizure precautions.
● Administer medications.

MediCATiONs
● Non-opioid analgesics are used to treat headaches.

◯ Opioid medications are avoided because they tend to
decrease level of consciousness.

● Corticosteroids are used to reduce cerebral edema
(relieving headaches, improving altered levels of
consciousness).

◯ Corticosteroid medications quickly reduce cerebral
edema and can be rapidly administered to maximize
their effectiveness.

◯ Chronic administration is used to control cerebral
edema associated with the presence or treatment of
benign or malignant brain tumors.

● Osmotic diuretics decrease fluid content of the brain,
resulting in a decrease in intracranial pressure.

● Anticonvulsant medications are used to control or
prevent seizure activity.

◯ Anticonvulsant medications suppress the
neuronal activity within the brain, which prevents
seizure activity.

◯ There are several classifications of antiepileptic
medications, each specifically designed to treat
specific seizure behavior.

● H2-antagonists are used to decrease the acid content of
the stomach, reducing the risk of stress ulcers.

◯ H2-antagonists are administered during acute
or stressful periods, such as after surgery, at the
initiation of chemotherapy, or during the first several
radiation therapy treatments.

◯ The effect of these treatments, together with
the necessity of corticosteroids, places the
client at risk for stress ulcers. This is primarily
preventative treatment.

● Antiemetics are used if nausea (with or without
vomiting) is present.

◯ Nausea and vomiting can be present as a result
of the increased ICP, the site of the tumor, or the
treatment required.

◯ These medications are administered as prescribed,
and can be provided as a preventative intervention,
especially when the treatment is associated with
nausea and vomiting.

● Chemotherapy can be given in conjunction with
radiation. However, the blood-brain barrier can prevent
adequate doses from reaching the tumor.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 9 BrAiN TUMOrs 55

iNTerPrOFessiONAL CAre
● Initiate appropriate referrals (social services; support

groups; medical equipment; and physical, speech, and
occupational therapy).

● Treatments include steroids, surgery, chemotherapy,
conventional radiation therapy, stereotactic
radiosurgery, and clinical trials. Chemotherapy
and conventional radiation therapy can be administered
prior to surgery to reduce the bulk of the tumor, or after
surgery to prevent tumor recurrence.

● In most cases when the tumor is benign, surgery
is a curative treatment. However, these tumors can
regrow. Radiation and chemotherapy can be provided to
prevent recurrence.

● Some tumors can be malignant by location, meaning
that while the pathology is benign, the location makes
the mortality rate associated with them high.

● In cases where the tumor is a metastatic lesion from a
primary lesion elsewhere in the body, treatments are
palliative. These treatments can consist of surgery,
radiation, and chemotherapy, in any combination, and
are aimed at controlling intracerebral lesions.

THerAPeUTiC PrOCedUres
Craniotomy: complete or partial resection of brain tumor
through surgical opening in the skull

PREOPERATIVE NURSING ACTIONS
● Explain the procedure to the client, answering all

appropriate questions and providing emotional support.
● Questions regarding the surgery and its outcomes

should be written, in an effort to ensure all questions
are answered.

● The client’s partner should be present to hear the
responses and avoid miscommunication.

● If the client takes aspirin, this medication needs to be
stopped at least 72 hr prior to the procedure.

● No alcohol, tobacco, anticoagulants, or NSAIDs for
5 days prior to surgery.

● If the client uses alternative/complementary
medications or treatments, make these known to
the provider.

● A living will and durable power for health care decisions
should be completed.

● Administer medications as prescribed. An anti-anxiety
or muscle relaxant medication can be administered, if
requested, and provided by the provider.

POSTOPERATIVE NURSING ACTIONS
● Closely monitor vital signs and neurologic status,

including using the Glasgow Scale.
● Treat pain adequately.
● Elevate the head of the client 30° for clients who had

supratentorial surgery and in a neutral position to
prevent increased ICP. Turn the client to the side or
supine to decrease risk of pressure injuries and
pneumonia.

● Infratentorial craniotomy clients lie flat and side-lying.
Turn side to side every 2 hr for 24 to 48 hr.

● Straining activities (moving up in bed and attempting
to have a bowel movement) should be avoided to prevent
increased ICP. Postoperative bleeding and seizure
activity are the greatest risks.

● Periorbital edema and ecchymosis is not unusual. Treat
with cold compresses.

● Assess head dressing every 1 to 2 hr for drainage.

COMPLICATIONS

Syndrome of inappropriate antidiuretic hormone

Syndrome of inappropriate antidiuretic hormone (SIADH)
is a condition where fluid is retained as a result of an
overproduction of vasopressin or antidiuretic hormone
(ADH) from the posterior pituitary gland.

● SIADH occurs when the hypothalamus has been
damaged and can no longer regulate the release of ADH.

● Treatment consists of fluid restriction, administration
of oral conivaptan, and treatment of hyponatremia, with
3% hypertonic saline solution for severe cases.

● If SIADH is present, the client can have disorientation,
headache, vomiting, muscle weakness, decreased LOC,
irritability, loss of thirst, and weight gain.

● If severe or untreated, this condition can cause seizures
and a coma.

Diabetes insipidus

Diabetes insipidus (DI) is seen most often after
supratentorial surgery, especially when involving the
pituitary gland or hypothalamus.

● This is a condition where large amounts of urine are
excreted as a result of a deficiency of ADH from the
posterior pituitary gland.

● The condition occurs when the hypothalamus has been
damaged and can no longer regulate the release of ADH.

● Treatment of DI consists of massive fluid replacement,
administration of synthetic vasopressin, careful
attention to laboratory values, and replacement of
essential nutrients as indicated.

56 CHAPTER 9 BrAiN TUMOrs CONTENT MASTERY SERIES

Active Learning Scenario

A nurse is completing preoperative teaching for a client who
has a brain tumor and will undergo a craniotomy. What should
be included in the teaching? Use the ATi Active Learning
Template: Therapeutic Procedure to complete this item.

DESCRIPTION OF PROCEDURE

NURSING INTERVENTIONS: describe three
preoperative and three postoperative interventions.

Application Exercises

1. A nurse is caring for a client who is having
surgery for the removal of an encapsulated
acoustic tumor. Which of the following potential
complications should the nurse monitor for
postoperatively? (select all that apply.)

A. increased intracranial pressure
B. Hemorrhagic shock
C. Hydrocephalus
d. Hypoglycemia
e. seizures

2. A nurse is caring for a client who has just
undergone a craniotomy for a supratentorial
tumor and has a respiratory rate of 12. Which
of the following postoperative prescriptions
should the nurse clarify with the provider?

A. dexamethasone 30 mg iV bolus Bid
B. Morphine sulfate 2 mg iV bolus

PrN every 2 hr for pain
C. Ondansetron 4 mg iV bolus PrN

every 4 to 6 hr for nausea
d. Phenytoin 100 mg iV bolus Tid

3. A nurse is completing an assessment of a client who
has increased intracranial pressure (iCP). Which of the
following are expected findings? (select all that apply.)

A. disoriented to time and place
B. restlessness and irritability
C. Unequal pupils
d. iCP 15 mm Hg
e. Headache

4. A nurse is reviewing a prescription for dexamethasone
with a client who has an expanding brain
tumor. Which of the following are appropriate
statements by the nurse? (select all that apply.)

A. “it is given to reduce swelling of the brain.”
B. “you will need to monitor for low blood sugar.”
C. “you might notice weight gain.”
d. “Tumor growth will be delayed.”
e. “it can cause you to retain fluids.”

5. A nurse is caring for a client who has a benign brain
tumor. The client asks the nurse if this same type of
tumor can occur in other areas of the body. Which
of the following responses should the nurse make?

A. “it can spread to breasts and kidneys.”
B. “it can develop in your gastrointestinal tract.”
C. “it is limited to brain tissue.”
d. “it probably started in another area of

your body and spread to your brain.”

6. A nurse is reviewing the health record of a client who
has a malignant brain tumor and notes the client has a
positive romberg sign. Which of the following actions
should the nurse take to assess for this finding?

A. stroke the lateral aspect of the sole of the foot.
B. Ask the client to blink both eyes.
C. Observe for facial drooping.
d. Have the client stand erect with eyes closed.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 9 BrAiN TUMOrs 57

Application Exercises Key

1. A. CORRECT: A client who has had a craniotomy should be
monitored postoperatively for increased iCP.

B. Although hypovolemic shock can occur secondary
to siAdH, hemorrhagic shock is not a concern.

C. CORRECT: Following a craniotomy, the client should be
monitored for the development of hydrocephalus.

d. An alteration in glucose metabolism is not usually
a postoperative concern after this surgery.

e. CORRECT: seizures are a postoperative complication
that should be monitored following a craniotomy.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

2. A. dexamethasone is given to prevent cerebral edema
and has no CNs depressant effects.

B. CORRECT: identify that if a client following a craniotomy
has a respiratory rate of 12, the provider should be
notified prior to administering morphine. Morphine is
a narcotic analgesic, which can cause CNs depressant
effects such as respiratory depression.

C. Ondansetron is prescribed to manage nausea
and has no CNs depressant effects.

d. Phenytoin is prescribed to prevent seizures
and has no CNs depressant effects.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

3. A. CORRECT: Changes in level of consciousness are
an early indicator of increased iCP.

B. CORRECT: increased iCP can cause behavior
changes, such as restlessness and irritability.

C. CORRECT: Unequal pupils indicates pressure on the
oculomotor nerve secondary to increased iCP.

d. An iCP of 15 mm Hg is within the expected reference range.
e. CORRECT: A headache is a manifestation of increased iCP.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

4. A. CORRECT: dexamethasone is a common steroid
prescribed to reduce cerebral edema.

B. The client can experience hyperglycemia as
an adverse effect of dexamethasone.

C. CORRECT: Weight gain is an adverse
effect of dexamethasone.

d. dexamethasone does not affect tumor growth.
it is given to prevent cerebral edema.

e. CORRECT: Fluid retention is an adverse
effect of dexamethasone.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

5. A. Metastases of a benign brain tumor do not occur.
B. Metastases of a benign brain tumor do not occur.
C. CORRECT: Benign brain tumors develop from the

meninges or cranial nerves and do not metastasize.
d. Benign brain tumors develop from the meninges or cranial

nerves and are not secondary to other types of tumors.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

6. A. A Babinski sign is elicited by stroking the lateral
aspect of the sole of the foot.

B. Asking the client to blink his eyes assesses cranial nerve
function and is not part of the romberg test.

C. Observing for facial drooping assesses cranial nerve
function and is not part of the romberg test.

d. CORRECT: A positive romberg sign is indicated
when a client loses their balance while attempting
to stand erect with their eyes closed.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

DESCRIPTION OF PROCEDURE: A craniotomy is a surgical
opening in the skull to expose brain tissue. it involves a
complete or partial resection of the brain tumor.

NURSING INTERVENTIONS

Preoperative
● explain the procedure, answer appropriate
questions, and provide emotional support.

● Provide written explanations.
● include the client’s partner in teaching.
● remind the client to stop taking aspirin at least 72
hr prior to the procedure, if appropriate.

● review use of alternative/complementary therapies,
and report their use to the provider.

● review the need for a living will and durable
power for health care decisions.

● Administer medications (anxiolytics, muscle relaxants) as prescribed.

Postoperative
● Monitor vital signs and neurologic status
to include use of Glasgow scale.

● Maintain client’s head elevated to 30° and in a
neutral position to prevent increased iCP.

● Monitor for postoperative bleeding and seizures.
● Prevent the client from performing any straining activities
(moving up in bed, attempting to have a bowel movement).

NCLEX® Connection: Reduction of Risk Potential, Therapeutic
Procedures

58 CHAPTER 9 BrAiN TUMOrs CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 10 MULTiPLe sCLerOsis 59

UNIT 2 NEUROLOGIC DISORDERS
SECTION: CENTRAL NERVOUS SYSTEM DISORDERS

CHAPTER 10 Multiple Sclerosis
Multiple sclerosis (Ms) is a neurologic disease
that typically results in impaired and worsening
function of voluntary muscles.

Ms is an autoimmune disorder that affects nerve
cells in the brain and the spinal cord. Ms is a
chronic disease caused by a genetic, immune‑
mediated attack or infection that destroys
myelin (a fatty protein that surrounds nerve
fibers). As a result, demyelination interrupts the
flow of nerve impulses. Plaques can occur on
demyelinated axons, leaving them unable to
regenerate and causing irreversible damage.
The most common areas affected include the
optic nerve, cerebrum, brainstem, cerebellum,
and spinal cord.

Ms follows several possible courses. The most
common is relapsing and remitting. The disease
is marked by relapses and remissions that might
not return the client to their previous baseline
level of function. Over time, the client can
eventually progress to the point of quadriplegia.

Ms is a chronic disease with no known cure that
progresses in severity over time. initial findings
can be so vague that diagnosis is not made for
several years.

some forms of Ms are aggressive and can
shorten the lifespan. in most cases, life
expectancy is not adversely affected by
this disease.

ASSESSMENT

risK FACTOrs
● The onset of MS is typically between 20 and 40 years of

age. MS occurs twice as often in females. The etiology of
MS is unknown. There is a family history (first-degree
relative) of MS in many cases.

● Research shows association with the interleukin (IL)-7
and IL-2 receptor genes.

● Because MS is an autoimmune disease, there are factors
that trigger relapses.

◯ Viruses and infectious agents
◯ Living in a cold climate
◯ Physical injury
◯ Emotional stress
◯ Pregnancy
◯ Fatigue
◯ Overexertion
◯ Temperature extremes
◯ Hot shower/bath

eXPeCTed FiNdiNGs
● Fatigue
● Pain or paresthesia
● Diplopia, changes in peripheral vision, decreased

visual acuity, scotomas (patches of blindness), periods
of total blindness

● Uhthoff’s sign (a temporary worsening of vision and
other neurologic functions commonly seen in clients
who have or are predisposed to MS, just after exertion or
in situations where they are exposed to heat)

● Tinnitus, vertigo, decreased hearing acuity
● Dysphagia
● Dysarthria (slurred and nasal speech)
● Muscle spasticity
● Ataxia or muscle weakness
● Nystagmus
● Bowel dysfunction (constipation, fecal incontinence)
● Bladder dysfunction (areflexia, urgency, nocturia,

incontinence)
● Cognitive changes (memory loss, impaired judgment)
● Sexual dysfunction

LABOrATOry TesTs
Cerebrospinal fluid analysis reveals elevated protein level
and a slight increase in WBCs.

diAGNOsTiC PrOCedUres
Magnetic resonance imaging (MRI) reveals plaques of the
brain and spine, which is most diagnostic.

CHAPTER 10

60 CHAPTER 10 MULTiPLe sCLerOsis CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Monitor the following.

◯ Visual acuity
◯ Speech patterns: fatigue with talking
◯ Swallowing
◯ Activity tolerance
◯ Skin integrity

● Discuss coping mechanisms and sources of support
(family, friends, spiritual figures, support groups).

● Encourage fluid intake and other measures to decrease
the risk of developing a urinary tract infection. Assist
the client with bladder elimination: intermittent
self-catheterization, bladder pacemaker, Credé’s
maneuver (placing manual pressure on abdomen over
the bladder to expel urine). Establish a voiding time
schedule (every 1.5 to 2 hr initially) with gradual
increase of the time interval for those experiencing
incontinence.

● Monitor cognitive changes and plan interventions to
promote cognitive function. (Reorient the client. Place
objects used daily in routine places.)

● Facilitate effective communication for dysarthria using
a communication board.

● Apply eye patches to treat diplopia. Alternate between
eyes every few hours. Teach scanning techniques.
Instruct the client to visually scan their environment by
moving the head from side to side.

● Exercise and stretch involved muscles. (Avoid fatigue
and overheating.)

● Promote energy conservation by grouping care and
planning rest periods.

● Promote and maintain safe home and hospital
environment to reduce the risk of injury (walking with
wide base of support, assistive devices, skin
precautions).

MediCATiONs

Disease‑modifying therapies

Reduce the frequency and duration of relapses

Interferon beta‑1a and beta‑1b

Injectable agents that, if used, should be started early in
the course of the disease

● Flu-like manifestations are an adverse effect.
● Immunomodulators are used to prevent or treat relapses.

Glimmer acetate

Injectable agent

Teriflunomide, fingolimod, dimethyl fumarate

Oral alternatives for those who have experienced
injection reactions

Prednisone, dexamethasone, or methylprednisolone
● Corticosteroids are used to reduce inflammation in

acute exacerbations and are administered in large doses
over a 3- to 5-day period followed by an oral taper
with prednisone.

● NURSING ACTIONS: Monitor for increased risk of
infection, hypervolemia, hypernatremia, hypokalemia,
hyperglycemia, gastrointestinal bleeding, and
personality changes.

Dantrolene, tizanidine, baclofen, and diazepam
● Antispasmodics are used to treat muscle spasticity.
● Intrathecal baclofen can be used for severe cases of MS.

NURSING ACTIONS
● Observe for increased weakness.
● Monitor for liver damage with tizanidine or dantrolene.

CLIENT EDUCATION
● Report increased weakness and jaundice to the provider.
● Avoid stopping baclofen abruptly.

Carbamazepine

Anticonvulsants are used for paresthesia.

Docusate sodium

Stool softeners are used for constipation.

Propantheline

Anticholinergics are used for bladder dysfunction.

Propranolol and clonazepam

A beta blocker and a benzodiazepine used for ataxia

Amantadine, pemoline, dalfampridine,
baclofen, tizanidine

Administered to combat fatigue that can
interfere with ADLs

iNTerPrOFessiONAL CAre
● Plan for disease progression. Provide community

resources and respite services for the client and family.
● Consider referral to occupational and physical therapy

for home environment assessment to determine safety
and ease of mobility. Use adaptive devices to assist with
activities of daily living.

● Refer to speech language therapist for dysarthria
and dysphagia.

● Emphasize need to avoid overexertion, stress, extremes
of temperatures, humidity, and people who have
infections.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 10 MULTiPLe sCLerOsis 61

Active Learning Scenario

A nurse is providing education to family members of a
client who has a new diagnosis of multiple sclerosis. What
should be included in the teaching? Use the ATi Active
Learning Template: system disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)

LABORATORY TESTS

DIAGNOSTIC PROCEDURES

MEDICATIONS: describe four medications
and one teaching point for each.

Application Exercises

1. A nurse is caring for a client who has
multiple sclerosis. Which of the following
findings should the nurse expect?

A. Fluctuations in blood pressure

B. Loss of cognitive function

C. ineffective cough

d. drooping eye lids

2. A nurse is beginning a physical assessment of
a client who has a new diagnosis of multiple
sclerosis. Which of the following findings should
the nurse expect? (select all that apply.)

A. Areas of paresthesia

B. involuntary eye movements

C. Alopecia

d. increased salivation

e. Ataxia

3. A nurse is teaching a client who has multiple
sclerosis and a new prescription for baclofen.
Which of the following statements should
the nurse include in the teaching?

A. “This medication will help you with your tremors.”

B. “This medication will help you with
your bladder function.”

C. “This medication can cause your
skin to bruise easily.”

d. “This medication can cause you
to experience dizziness.”

62 CHAPTER 10 MULTiPLe sCLerOsis CONTENT MASTERY SERIES

Application Exercises Key

1. A. Fluctuations in blood pressure is a manifestation
associated with amyotrophic lateral sclerosis.

B. CORRECT: Loss of cognitive function is a
manifestation associated with Ms.

C. ineffective cough is a manifestation associated
with amyotrophic lateral sclerosis.

d. drooping eyelids is a manifestation
associated with myasthenia gravis.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

2. A. CORRECT: Areas of loss of skin sensation are
a finding in a client who has Ms.

B. CORRECT: Nystagmus is a finding in a client who has Ms.
C. Hair loss is not a finding in a client who has Ms.
d. dysphagia, swallowing difficulty, is a finding in a

client who has amyotrophic lateral sclerosis.
e. CORRECT: Ataxia occurs in the client who has Ms as muscle

weakness develops and there is loss of coordination.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

3. A. Propranolol is a beta blocker and clonazepam
is a benzodiazepine given to clients who
have Ms to treat tremors.

B. Propantheline is an anticholinergic medication that is given
to clients who have Ms to treat bladder dysfunction.

C. Prednisone is a corticosteroid medication that is given to
clients who have Ms to treat inflammation. An adverse
effect of this medication is bruising of the skin.

d. CORRECT: Baclofen is an antispasmodic medication that
is given to clients who have Ms to treat muscle spasms. An
adverse effect of this medication is drowsiness, as well as
dizziness. instruct the client to monitor for these findings,
as they can lead to impaired safety. The client should
be instructed not to discontinue baclofen abruptly.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): Ms is an autoimmune disorder
characterized by the development of plaque in the white matter of
the central nervous system. Plaque damages the myelin sheath and
interferes with impulse transmission between the CNs and the body.

LABORATORY TESTS: Cerebrospinal fluid analysis

DIAGNOSTIC PROCEDURES: Mri of the brain and spine

MEDICATIONS
● Corticosteroids such as prednisone: increased risk for
infection, hypervolemia, hypernatremia, hypokalemia,
Gi bleeding, and personality changes.

● Antispasmodics (dantrolene, tizanidine, baclofen, diazepam)
are used to treat muscle spasticity. report increased weakness
and jaundice to provider. Avoid stopping baclofen abruptly.

● immunomodulators such as interferon beta are
used to prevent and treat relapses.

● Anticonvulsants such as carbamazepine are used for paresthesia.
● stool softeners such as docusate sodium are used for constipation.
● Anticholinergics such as propantheline are
used for bladder dysfunction.

● Propranolol and clonazepam, a beta blocker and
a benzodiazepine, are used for tremors.

NCLEX® Connection: Physiological Adaptation, Alterations in
Body Systems

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 11 HeAdACHes 63

UNIT 2 NEUROLOGICAL DISORDERS
SECTION: CENTRAL NERVOUS SYSTEM DISORDERS

CHAPTER 11 Headaches
Headaches can be acute or chronic, temporary,
or life‑threatening.

Headaches are a common occurrence and affect
individuals of all ages. Headaches are associated
with other conditions such as colds, allergies,
and stress or muscle tension.

Primary headaches have no identifiable organic
cause. They include migraine, tension‑like, and
cluster headaches. They can be managed in the
primary care setting.

secondary headaches are associated with
an organic cause, such as a brain tumor or
aneurysm, and warrant further investigation and
medical management.

This chapter includes migraine headaches and
cluster headaches.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Promote stress management strategies and recognition
of triggers of the onset of a headache.

● Recommend use of a headache diary to help identify
type of headache and response to interventions.

● Promote hand hygiene to prevent the spread of
viruses that produce manifestations similar to the
common cold.

● Review pain management to include over-the-counter
medications and herbal remedies.

● Review risk factors (triggers) for both migraine and
cluster headaches.

◯ Alcohol or environmental allergies
◯ Intense odors, bright lights, overuse of some

medications
◯ Fatigue, sleep deprivation, depression, emotional or

physical stress, anxiety
◯ Hormone fluctuations associated with menstrual

cycles and oral contraceptive use
◯ Foods containing tyramine, monosodium glutamate

(MSG), nitrites, or dairy

Migraine headaches

ASSESSMENT

eXPeCTed FiNdiNGs
● Photophobia and phonophobia (sensitivity to sounds)
● Nausea and vomiting
● Stress and anxiety
● Unilateral pain, often behind one eye or ear
● Health history and family history for headache patterns
● Alterations in ADLs for 4 to 72 hr
● Manifestations that are similar with each headache

Classified by categories and stages

With aura (classic migraine)
● Prodromal stage includes awareness of findings for

hours to days before onset: irritability, depression, food
cravings, diarrhea/constipation, and frequent urination.

● Aura stage develops over minutes to an hour to include
neurologic findings: numbness and tingling of mouth,
lips, face, or hands; acute confusion; visual disturbances
(light flashes, bright spots).

● Second stage: severe, incapacitating, throbbing headache
that intensifies over several hours and is accompanied
by nausea, vomiting, drowsiness, and vertigo.

● Third stage (4 to 72 hr): headache is dull.
● Recovery with pain and aura subsiding. Muscle aches

and contraction of head and neck muscles are common.
Physical activity worsens pain, and client might sleep.

● The older adult client can experience an aura without
pain which is referred to as a visual migraine.

Without aura (common migraine)
● Pain is aggravated by physical activity.
● Unilateral, pulsating pain.
● One or more manifestations present: photophobia,

phonophobia, nausea, and/or vomiting.
● Persists for 4 to 72 hr. Often occurs in early morning,

during periods of stress, or with premenstrual tension
or fluid retention.

Atypical
● Status migrainous: Headache lasts longer than 72 hr.
● Migrainous infarction: Neurologic manifestations

persist for 7 days; neuroimaging can indicate
ischemic infarct.

● Unclassified: Does not fit other criteria.

diAGNOsTiC PrOCedUres
Neuroimaging if neurologic findings present or client is
older than 50 years with a new onset of headaches.

CHAPTER 11

64 CHAPTER 11 HeAdACHes CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE
Nursing care focus during headache is pain management.

● Maintain a cool, dark, quiet environment.
● Elevate the head of the bed to 30°.
● Administer medications as prescribed.

MediCATiONs
● Abortive therapy to alleviate pain during aura or soon

after start of headache
◯ For mild migraines: NSAIDs (ibuprofen,

naproxen), acetaminophen, and over-the-counter
anti-inflammatory medications in formulations
for migraines

◯ Antiemetics (metoclopramide) to relieve nausea
and vomiting.

◯ Severe migraines
■ Triptan preparations (zolmitriptan sumatriptan,

eletriptan) to produce a vasoconstrictive effect
■ Ergotamine preparations with caffeine

(dihydroergotamine) to narrow blood vessels and
reduce inflammation

■ Isometheptene in combination formulations when
other medications do not work

● Preventive therapy for frequent headaches or when
other therapies are ineffective

◯ NSAIDs with beta-blocker (propranolol), calcium
channel blocker, beta-adrenergic blocker or
antiepileptic medications (divalproex, topiramate).

◯ Client is instructed to check pulse when
taking beta-adrenergic blockers and calcium
channel blockers.

◯ OnabotulinumtoxinA is approved for adults for
chronic migraines. Injected into specific areas of the
head and neck up to five treatment cycles.

CLieNT edUCATiON
● Keep a diary to record headache patterns and triggers.
● Report changes in headache intensity, or new visual or

neurologic disturbances.
● Remain in a cool, dark, quiet environment.
● Elevate the head of the bed as desired.
● Females over age 50 are at increased risk for

cardiovascular disease and stroke.

Trigger avoidance and management
● Avoid foods with tyramine (pickles, caffeine, beer, wine,

aged cheese, artificial sweeteners) and foods with MSG
or preservatives.

● Medications known to induce migraines include
ranitidine, estrogen, nitroglycerin, and nifedipine.

● Manage anger issues and handling conflict.
● Get adequate rest and sleep.
● Weather and altitude changes can trigger migraines for

some clients.
● Avoid light glare or flickering lights.
● Monitor menstrual cycle pattern and hormone

fluctuations. Hormone fluctuations during menstruation
and ovulation can trigger migraines.

● Avoid intense environmental odors, perfumes, and
tobacco smoke.

Complementary and alternative therapies
◯ Yoga, meditation, tai chi, exercise, biofeedback,

and massage promote relaxation and alleviate
muscle tension. Some might be offered at local
community centers.

◯ Acupuncture and acupressure therapy can be helpful
for pain management.

◯ Review herbal remedies and nutrition supplements
with the provider because there is insufficient
evidence to support their use in management of
migraines.

◯ An external trigeminal nerve stimulator is a wearable
headband that stimulates branches of the trigeminal
nerve associated with migraine attacks and pain,
to reduce discomfort. Do not use it for more than
20 min/day.

Cluster headaches

ASSESSMENT

risK FACTOrs
● More frequent during spring and fall
● More common in males between 20 to 50 years of age

eXPeCTed FiNdiNGs
● Brief episode of intense, unilateral, nonthrobbing pain

lasting 15 min to 3 hr that can radiate to forehead,
temple, or cheek

◯ Occurring daily 1 to 8 times daily
◯ Followed by period of remission

● No aura or preliminary manifestations
● Less common than migraines
● Tearing of the eye with runny nose and nasal congestion
● Facial sweating
● Drooping eyelid and eyelid edema
● Miosis (pupil constriction)
● Facial pallor or flushing
● Bradycardia
● Nausea and vomiting
● Pacing, walking, or sitting and rocking activities

PATIENT‑CENTERED CARE

MediCATiONs
(See medications for migraine headaches.)

● Triptans
● Ergotamine preparations
● Antiepileptic medications
● Calcium channel blockers
● Corticosteroids
● Over-the-counter capsaicin
● Melatonin
● Glucosamine

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 11 HeAdACHes 65

THerAPeUTiC PrOCedUres
Home oxygen therapy at 12 L/min for 15 to 20 min at onset
of headache can provide relief within 15 min.

CLieNT edUCATiON
● Remain in a cool, dark, quiet environment with

head elevated.
● Remain in sitting position when using oxygen, and

maintain safety precautions when using oxygen in
the home.

● Complementary and alternative therapies can
promote relaxation.

● Avoid foods containing tyramine, MSG, and nitrites
(preservatives).

Prevention strategies
◯ Wear sunglasses to reduce light and glare.
◯ Obtain adequate rest and sleep, exercise,

and relaxation.

Risk factors (triggers) for headaches
◯ Anger outburst
◯ Anxiety and prolonged anticipation, or periods of stress
◯ Excessive physical activity, fatigue
◯ Altered sleep-wake cycles

Active Learning Scenario

A nurse in a clinic is interviewing a client who reports they
think they are having migraine headaches. Using the ATi
Active Learning Template: system disorder and the ATi
Pharmacology review Module to complete this item.

EXPECTED FINDINGS: identify three findings
common to migraine headaches in general.

DIAGNOSTIC PROCEDURES: describe guidelines
for diagnosing migraine headache pain.

NURSING INTERVENTIONS: identify three actions the nurse
can take to assist the client with managing headaches.

Application Exercises

1. A nurse in a clinic is caring for a client who has frequent
migraine headaches. The client asks about foods that
can cause headaches. The nurse should recommend
that the client avoid which of the following foods?

A. Baked salmon

B. salted cashews

C. Frozen strawberries

d. Fresh asparagus

2. A nurse in a clinic is teaching a client who has a history
of migraine headaches about a new prescription for
zolmitriptan. Which of the following statements by
the client indicates understanding of the teaching?

A. “This medication will relieve my symptoms
by causing my blood vessels to dilate.”

B. “i should take this medication daily to
prevent the headache from occurring.”

C. “i should expect facial flushing
when i take this medication.”

d. “This medication will lower my
sensitivity to food triggers.”

3. A nurse in a provider’s office is obtaining a
health history from a client who has cluster
headaches. Which of the following are
expected findings? (select all that apply.)

A. Pain is bilateral across the posterior occipital area.

B. Client experiences altered sleep‑wake cycle.

C. Headache occurs approximately 1 to 8 times daily.

d. Client describes headache pain
as dull and throbbing.

e. Nasal congestion and drainage occur.

4. A nurse is providing discharge instructions to a client
who has a new diagnosis of migraine headaches. Which
of the following instructions should the nurse include?

A. Use music therapy for relaxation with
the onset of the headache.

B. increase physical activity when
a headache is present.

C. drink beverages that contain artificial
sweeteners to prevent headaches.

d. Apply a cool cloth to the face during a headache.

5. A nurse is obtaining a health history from a client who
is being evaluated for the cause of frequent headaches.
Which of the following questions should the nurse
ask to identify the aura type of migraine headaches?

A. “do the headaches occur multiple times each day?”

B. “is your headache accompanied
by profuse facial sweating?”

C. “does your headache occur on
one side of your head?”

d. “do you have the same manifestations
each time the headache occurs?”

66 CHAPTER 11 HeAdACHes CONTENT MASTERY SERIES

Application Exercises Key

1. A. The client should avoid fish that is smoked because it
contains tyramine. Baked salmon does not contain tyramine
and is not a trigger for migraine headaches.

B. CORRECT: Nuts contain tyramine, which
can trigger migraine headaches.

C. Fruits are not a source of tyramine.
d. Vegetables are not a source of tyramine.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

2. A. zolmitriptan causes cranial arteries, the basilar arteries,
and blood vessels in the dura mater to constrict.

B. zolmitriptan is used for abortive therapy in treating migraine
headaches. it is not used for headache prevention.

C. CORRECT: zolmitriptan can cause facial
flushing, tingling, and warmth.

d. zolmitriptan is used as a component of abortive
therapy for treatment of migraine headaches and does
not affect a client’s sensitivity to food triggers.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

3. A. Cluster headaches typically cause pain on one side of the
head and radiate to the forehead, temple, or cheek.

B. CORRECT: Cluster headaches can be due to a
lack of continuity in the sleep‑wake cycle.

C. CORRECT: Cluster headaches occur
approximately 1 to 8 times daily.

d. Cluster headaches are described as unilateral,
intense, and nonthrobbing.

e. CORRECT: A client can have a runny nose and
nasal congestion with a cluster headache.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. A. A quiet, dark environment can provide comfort
during a migraine headache.

B. increasing physical activity during a migraine
headache can worsen the pain.

C. Artificial sweeteners contain tyramine, which
can trigger a migraine headache.

d. CORRECT: A cool cloth placed over the client’s
eyes can provide comfort and relieve pain.

NCLEX® Connection: Basic Care and Comfort,
Non‑Pharmacological Comfort Interventions

5. A. Cluster headaches typically occur 1 to 8 times each day.
B. Profuse facial sweating is typical in the

presence of cluster headaches.
C. Unilateral headaches are associated with cluster

headaches and common migraines.
d. CORRECT: Clients who have aura type

migraines typically have the same manifestations
each time the headache occurs.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

eXPeCTed FiNdiNGs:
● Throbbing, unilateral pain
● Family history of migraine headaches
● Associated manifestations last for 4 to 72 hr

diAGNOsTiC PrOCedUres: Neurologic imaging
is recommended if the client has a new onset of
headaches and is older than 50 years of age.

NUrsiNG iNTerVeNTiONs
● encourage the client to keep a journal to identify triggers
(food, environment, hormone fluctuations).

● Teach the client about medications that
can prevent or stop migraines

● discuss complementary strategies (yoga,
tai chi) to promote relaxation.

● Urge the client to discuss herbal supplements that
claim to provide migraine relief with the provider.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 12 disOrders OF THe eye 67

UNIT 2 NEUROLOGIC DISORDERS
SECTION: SENSORY DISORDERS

CHAPTER 12 Disorders of the Eye
disorders of the eye can be caused by injury,
disease processes, and the aging process.

disorders of the eye that nurses should
be knowledgeable about include macular
degeneration, cataracts, and glaucoma.

Macular degeneration
Macular degeneration, often called age-related macular
degeneration (AMD), is the central loss of vision that
affects the macula of the eye.

● There is no cure for macular degeneration.
● AMD is a common cause of vision loss in older adults.

Two types of macular degeneration

Dry macular degeneration is the most common and is
caused by a gradual blockage in retinal capillary arteries,
which results in the macula becoming ischemic and
necrotic due to the lack of retinal cells.

Wet macular degeneration is a less common form and is
caused by the new growth of blood vessels that have thin
walls that leak blood and fluid.

ASSESSMENT

risK FACTOrs
Dry macular degeneration

● Smoking
● Hypertension
● Female sex
● Short body stature
● Family history
● Diet lacking carotene and vitamin E

Wet macular degeneration can occur at any age

eXPeCTed FiNdiNGs
● Lack of depth perception
● Objects appear distorted
● Blurred vision
● Loss of central vision
● Blindness

diAGNOsTiC PrOCedUres
Ophthalmoscopy: An ophthalmoscope is used to examine
the back part of the eyeball (fundus), including the retina,
optic disc, macula, and blood vessels.

Visual acuity tests: Snellen and Rosenbaum eye charts.

PATIENT‑CENTERED CARE

Wet macular degeneration
● Laser therapy to seal leaking blood vessels
● Ocular injections to inhibit blood vessel growth

◯ Ocular injections include an endothelial growth factor
inhibitor, bevacizumab, or ranibizumab.

CLIENT EDUCATION
● Encourage clients to consume foods high in

antioxidants, carotene, and vitamins E and B12. The
provider may prescribe a daily supplement high in
carotene and vitamin E.

● As loss of vision progresses, clients be challenged with
the inability to eat, drive, write, and read, as well as
other activities of daily living.

● Refer clients to community organizations that can
assist with transportation, reading devices, and
large-print books.

Cataracts
A cataract is an opacity in the lens of an eye that
impairs vision. (12.1)

Common causes of cataracts

Age-related: Drying of lens due to water loss; increase in
lens density due to lens fiber compaction

Traumatic: Blunt or penetrating injury or foreign body in
the eye, exposure to radiation or ultra violet light

Toxic: Long term use of corticosteroids, phenothiazine
derivatives, beta blockers, or miotic medications

Associated: Diabetes mellitus, hypoparathyroidism,
Down syndrome, chronic sunlight exposure

Complicated: Intraocular disease (retinitis pigmentosa,
glaucoma, retinal detachment)

HEALTH PROMOTION AND
DISEASE PREVENTION

● Teach clients to wear sunglasses while outside.
● Educate clients to wear protective eyewear while playing

sports and performing hazardous activities, such as
welding and yard work.

● Encourage annual eye examinations and good eye
health, especially in adults over the age of 40.

CHAPTER 12

Online Image: Cataracts

68 CHAPTER 12 disOrders OF THe eye CONTENT MASTERY SERIES

ASSESSMENT

risK FACTOrs
● Advanced age
● Diabetes
● Heredity
● Smoking
● Eye trauma
● Excessive exposure to the sun
● Chronic use of corticosteroids, phenothiazine

derivatives, beta blockers, or miotic medications

eXPeCTed FiNdiNGs
● Decreased visual acuity (prescription changes, reduced

night vision, decreased color perception)
● Blurred vision
● Diplopia (double vision)

PHYSICAL ASSESSMENT FINDINGS
● Progressive and painless loss of vision
● Visible opacity
● Absent red reflex

diAGNOsTiC PrOCedUres
Cataracts can be determined upon examination of the lens
using an ophthalmoscope.

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Check visual acuity using the Snellen chart.
● Examine external and internal eye structures using

an ophthalmoscope.
● Determine the client’s functional capacity due to

decreased vision.
● Increase the amount of light in a room.
● Provide adaptive devices that accommodate for

reduced vision.
◯ Magnifying lens and large print books/newspapers
◯ Talking devices, such as clocks

MediCATiONs
Anticholinergic agents (atropine 1%
ophthalmic solution): This medication
prevents pupil constriction for
prolonged periods of time (mydriasis)
and relaxes muscles in the eye
(cycloplegia). It is used to dilate the eye
preoperatively and for visualization of
the eye’s internal structures.

NURSING ACTIONS: The medication
has a long duration, but a fast onset.

CLIENT EDUCATION
● Remind the client that the effects of the medication can

last 7 to 12 days.
● The medication can cause photosensitivity, so remind

the client to wear sunglasses to protect the eyes.

iNTerPrOFessiONAL CAre
Consult with an ophthalmologist (eye surgeon) for
cataract surgery.

THerAPeUTiC PrOCedUres

Surgical removal of the lens

A small incision is made, and the lens is either removed in
one piece or in several pieces, after being broken up using
sound waves. The posterior capsule is retained. A replacement
or intraocular lens is inserted. Replacement lenses can
correct refractive errors, resulting in improved vision.

NURSING ACTIONS
Postoperative care should focus on the following.

● Preventing an increase in intraocular pressure.
● Preventing infection.
● Administering ophthalmic medications.
● Providing pain relief.
● Teaching the client about self-care at home and

fall prevention.

CLIENT EDUCATION
● Wear sunglasses while outside or in brightly-lit areas.
● Report manifestations of infection, such as yellow or

green drainage.
● Avoid activities that increase IOP.

◯ Bending over at the waist
◯ Sneezing
◯ Blowing nose
◯ Coughing
◯ Straining
◯ Head hyperflexion
◯ Restrictive clothing, such as tight shirt collars
◯ Sexual intercourse

12.1 Normal and cataract-clouded lenses

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 12 disOrders OF THe eye 69

● Limit activities.
◯ Tilting the head back to wash hair
◯ Cooking and housekeeping
◯ Rapid, jerky movements, such as vacuuming
◯ Driving and operating machinery
◯ Playing sports

● Report pain with nausea/vomiting (indications of
increased IOP or hemorrhage).

● Best vision is not expected until 4 to 6 weeks following
the surgery.

● Report if any changes occur, such as lid swelling,
decreased vision, bleeding or discharge, sharp sudden
eye pain, flashes of light, or floating shapes.

COMPLICATIONS

Infection
● Infection can occur after surgery.

CLIENT EDUCATION: Manifestations of infection that
should be reported include yellow or green drainage,
increased redness or pain, reduction in visual acuity,
increased tear production, and photophobia.

Bleeding

Bleeding is a potential risk several days following surgery.

CLIENT EDUCATION: Immediately report any sudden
change in visual acuity or an increase in pain.

Glaucoma
Glaucoma is a disturbance of the functional or structural
integrity of the optic nerve. Decreased fluid drainage or
increased fluid secretion increases intraocular pressure
(IOP) and can cause atrophic changes of the optic nerve
and visual defects. The expected reference range for IOP is
10 to 21 mm/Hg.

● There are two primary types of glaucoma.
◯ Primary open-angle glaucoma (POAG): This is the
more common form. Open-angle refers to the angle
between the iris and sclera. The aqueous humor
outflow is decreased due to blockages in the eye’s
drainage system (Canal of Schlemm and trabecular
meshwork), causing a gradual rise in IOP.

◯ Primary angle-closure glaucoma: IOP rises suddenly.
The angle between the iris and the sclera suddenly
closes, causing a corresponding increase in IOP. The
onset is sudden and requires immediate treatment.

● Glaucoma is a frequent cause of blindness. Early
diagnosis and treatment is essential in preventing
vision loss from glaucoma.

● Secondary glaucoma can result from trauma, eye
surgery, tumors of the eye, uveitis, iritis, neovascular
disorders, degenerative disease, or central retinal
vein occlusion.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Encourage annual eye examinations and good eye
health, especially adults over the age of 40.

● Educate clients about the disease process and early
indications of glaucoma, such as reduced vision and
mild eye pain.

ASSESSMENT

risK FACTOrs
● Age
● Infection
● Tumors
● Diabetes mellitus
● Genetic predisposition
● Hypertension
● Eye trauma
● Severe myopia
● Retinal detachment

eXPeCTed FiNdiNGs

Primary open‑angle glaucoma
● Headache
● Mild eye pain
● Loss of peripheral vision
● Decreased accommodation
● Halos seen around lights
● Elevated IOP (greater than 21 mm Hg: usually 22 to 32)

Primary angle‑closure glaucoma
● Rapid onset of elevated IOP (30 mm Hg or higher)
● Decreased or blurred vision
● Colored halos seen around lights
● Pupils nonreactive to light
● Severe pain and nausea
● Photophobia

diAGNOsTiC PrOCedUres
Visual assessments: Measures decrease in visual acuity
and peripheral vision

Tonometry: Measures IOP (expected reference range is 10
to 21 mm Hg). IOP is elevated with glaucoma, especially
angle-closure.

Gonioscopy: Used to determine the drainage angle of the
anterior chamber of the eyes

70 CHAPTER 12 disOrders OF THe eye CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Monitor for increased IOP (greater than 21 mm Hg).
● Monitor for decreased vision and light sensitivity.
● Assess for aching or discomfort around the eye.
● Explain the disease process and allow clients to express

their feelings.
● Treat severe pain and nausea that accompanies

angle-closure glaucoma with analgesics and antiemetics.

MediCATiONs
The priority intervention for treating glaucoma is
medication therapy.

CLIENT EDUCATION
● Prescribed eye medication is beneficial if used every 12 hr.
● Instill one drop in each eye twice daily.
● Wait 5 to 10 min between eye drops if more than

one is prescribed to prevent one medication from
diluting another.

● Avoid touching the tip of the application bottle to the eye.
● Always wash hands before and after use.
● Once an eye drop is instilled, apply pressure using the

punctal occlusion technique (placing pressure on the
inner corner of the eye).

Cholinergic agents (carbachol,
echothiophate, pilocarpine)

These are miotic medications, which constrict the pupil
and allows for improved circulation and outflow of
the aqueous humor. Miotics can cause blurred vision.
Pilocarpine is considered a second-line drug for POAG.

CLIENT EDUCATION: Use good lighting to avoid falls.

Adrenergic agonists (apraclonidine, brimonidine
tartrate, dipivefrin hydrochloride)

These medications reduce intraocular pressure by limiting
production of aqueous humor and dilates the pupils to
improve the fluid flow to the site of absorption.

CLIENT EDUCATION: Wear sunglasses in bright light
because of pupil dilation.

Beta blockers (timolol)

Beta blockers are first-line drug therapy for glaucoma, and
decrease IOP by reducing aqueous humor production.

NURSING CONSIDERATIONS: Can be absorbed systemically
and cause bronchoconstriction and hypoglycemia. Use
with caution in clients who have asthma, COPD, and
diabetes mellitus. Can potentiate systemic effects of oral
beta-blockers and cause bradycardia and hypotension.

Carbonic anhydrase inhibitors (acetazolamide,
dorzolamide, and brinzolamide)

Decrease IOP by reducing aqueous humor production.

NURSING ACTIONS: Ask clients whether they are allergic
to sulfa. Carbonic anhydrase inhibitors are sulfa-based.

Prostaglandin analogs

Prostaglandin analogs, such as bimatoprost and
latanoprost, increase outflow of the uveosclera by dilating
blood vessels in the trabecular mesh where aqueous
humor is collected and then drains the humor at a more
rapid rate.

CLIENT EDUCATION
● Check for corneal abrasions and do not instill this

medication if the corneal is not intact.
● Can cause the iris to change color by darkening with

long-term use.

Systemic osmotics (IV mannitol, oral glycerin)

IV mannitol is an osmotic diuretic used in the emergency
treatment for primary angle-closure glaucoma to quickly
decrease IOP.

THerAPeUTiC PrOCedUres

Glaucoma surgery

Laser trabeculectomy, iridotomy, or the placement of a
shunt are procedures used to improve the flow of the
aqueous humor by opening a channel out of the anterior
chamber of the eye.

NURSING ACTIONS: Educate clients about the disease and
importance of adhering to the medication schedule to
treat IOP.

CLIENT EDUCATION
● Wear sunglasses while outside or in brightly-lit areas.
● Report manifestations of infection, such as yellow or

green drainage.
● Avoid activities that increase IOP.

◯ Bending over at the waist
◯ Sneezing
◯ Coughing
◯ Straining
◯ Head hyperflexion
◯ Restrictive clothing, such as tight shirt collars
◯ Sexual intercourse

● Do not lie on the operative side and report severe pain
or nausea (possible hemorrhage).

● Report if any changes occur (lid swelling,
decreased vision, bleeding, discharge, a sharp, sudden
pain in the eye, flashes of light, floating shapes).

● Limit activities.
◯ Tilting head back to wash hair
◯ Cooking and housekeeping
◯ Rapid, jerky movements, such as vacuuming
◯ Driving and operating machinery
◯ Playing sports

● Report pain with nausea/vomiting (indications of
increased IOP or hemorrhage).

● Final best vision is not expected until 4 to 6 weeks
after surgery.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 12 disOrders OF THe eye 71

iNTerPrOFessiONAL CAre
Refer to an ophthalmologist if surgery is necessary.

CLieNT edUCATiON
Set up services such as community outreach programs,
meals on wheels, and services for the blind.

COMPLICATIONS

Blindness

Blindness is a potential consequence of
untreated glaucoma.

CLIENT EDUCATION: Have regular glaucoma checks.
● Before age 40: every 2 to 4 years
● Ages 40 to 54: every 1 to 3 years
● Ages 55 to 64: every 1 to 2 years
● Ages 65 and over: every 6 to 12 months

Active Learning Scenario

A nurse is reviewing discharge instructions for a client who
has a new diagnosis of primary open‑angle glaucoma and
a new prescription for timolol 0.25% eye drops. Use the
ATi Active Learning Template: Medication and the ATi
Pharmacology review Module to complete this item.

COMPLICATIONS: List at least three adverse
effects that should be included in the teaching.

Application Exercises

1. A nurse is caring for a client who has diabetes
mellitus and reports a gradual loss of peripheral
vision. The nurse should recognize this as a
manifestation of which of the following diseases?

A. Cataracts

B. Open‑angle glaucoma

C. Macular degeneration

d. Angle‑closure glaucoma

2. A nurse is providing postoperative teaching to a client
following cataract surgery. Which of the following
statements should the nurse include in the teaching?

A. “you can resume playing golf in 2 days.”

B. “you need to tilt your head back
when washing your hair.”

C. “you can get water in your eyes in 1 day.”

d. “you need to limit your housekeeping activities.”

3. A nurse is caring for a male older adult client who
has a new diagnosis of glaucoma. Which of the
following should the nurse recognize as risk factors
associated with this disease? (select all that apply.)

A. sex

B. Genetic predisposition

C. Hypertension

d. Age

e. diabetes mellitus

4. A nurse is caring for a client who has a new diagnosis
of cataracts. Which of the following manifestations
should the nurse expect? (select all that apply.)

A. eye pain

B. Floating spots

C. Blurred vision

d. White pupils

e. Bilateral red reflexes

5. A nurse is providing teaching for a client who has
a new diagnosis of dry macular degeneration.
Which of the following instructions should
the nurse include in the teaching?

A. increase intake of deep yellow
and orange vegetables.

B. Administer eye drops twice daily.

C. Avoid bending at the waist.

d. Wear an eye patch at night.

72 CHAPTER 12 disOrders OF THe eye CONTENT MASTERY SERIES

Application Exercises Key

1. A. A client who has cataracts experiences a decrease in
peripheral and central vision due to opacity of the lens.

B. CORRECT: This is a manifestation of open‑angle
glaucoma. A gradual loss of peripheral vision is a
manifestation associated with this diagnosis.

C. A client who has macular degeneration
experiences a loss of central vision.

d. A client who has angle‑closure glaucoma experiences
sudden nausea, severe pain, and halos around lights.

NCLEX® Connection: Health Promotion and Maintenance,
Health Screening

2. A. do not instruct the client to resume playing golf for
several weeks. This could cause a rise in intraocular
pressure (iOP) or possible injury to the eye.

B. do not instruct the client to tilt the head back
when washing their hair. This could cause a rise
in iOP or possible injury to the eye.

C. The client should not get water in their eyes for
3 to 7 days following cataract surgery to reduce
the risk for infection and promote healing.

d. CORRECT: instruct the client to limit housekeeping
activities following cataract surgery. This activity
could cause a rise in iOP or injury to the eye.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. A. sex is not a risk factor associated with glaucoma.
B. CORRECT: Genetic predisposition is a risk

factor associated with glaucoma.
C. CORRECT: Hypertension is a risk factor

associated with glaucoma.
d. CORRECT: Age is a risk factor associated with glaucoma.
e. CORRECT: diabetes mellitus is a risk factor

associated with glaucoma.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

4. A. eye pain is a manifestation associated with
primary angle‑closure glaucoma.

B. Floating spots are a manifestation associated
with retinal detachment.

C. CORRECT: Blurred vision is a manifestation
associated with cataracts.

d. CORRECT: White pupils are a manifestation
associated with cataracts.

e. Bilateral red reflexes are absent in a client who has cataracts.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

5. A. CORRECT: instruct the client to increase dietary
intake of carotenoids and antioxidants to slow the
progression of the macular degeneration.

B. A client who has primary open‑angle glaucoma
should administer eye drops twice daily.

C. A client who is at risk for increased intraocular
pressure, such as following cataract surgery,
should avoid bending at the waist.

d. A client who has had eye surgery, such as
cataract surgery, should wear an eye patch at
night to protect the eye from injury.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

COMPLICATIONS
● CNs: Lethargy, fatigue, anxiety, headache, somnolence, depression
● CV: Bradycardia, palpitations, syncope, hypotension,
AV conduction disturbances, CHF

● specific senses: eye stinging, tearing, photophobia, eye irritation
● Gi: Nausea, dry mouth
● respiratory: difficulty breathing, bronchospasm
● Metabolic: Hypoglycemia

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 13 MiddLe ANd iNNer eAr disOrders 73

UNIT 2 NEUROLOGIC DISORDERS
SECTION: SENSORY DISORDERS

CHAPTER 13 Middle and Inner
Ear Disorders

The ear is a sensory organ with two functions:
hearing and balance.

The middle ear consists of the tympanic membrane
(eardrum) and the three smallest bones (ossicles) of
the body (malleus, incus, and stapes), and connects
to the nasopharynx via the eustachian tube.

The inner ear is located deep within the
temporal bone, separated from the middle
ear by the oval window. it consists of the
cochlea (hearing organ) and semicircular canals
(responsible for balance). Cranial nerves Vii
(facial nerve) and Viii (vestibulocochlear nerve)
are part of the inner ear anatomy.

Visual, vestibular, and proprioceptive systems
provide the brain with input regarding balance.
Problems within any of these systems pose a risk
for loss of balance.

Nurses should be knowledgeable about the
types of middle‑ and inner‑ear disorders,
including infection, tumors, and issues with
balance and coordination.

TyPes OF eAr disOrders

Hearing loss
● Environmental or workplace exposure to noise can lead

to hearing loss.
● Conductive hearing loss is caused by factors such as

otitis media, otosclerosis, and presence of a foreign body
(such as impacted cerumen).

● Color of cerumen and external ear canal varies
depending on client’s race and skin tone. Normal
variations should be recognized during assessment.

● Sensorineural hearing loss is caused by damage to
cranial nerve VIII.

● Combined hearing loss is caused by a mixture of
conductive and sensorineural problems.

● Changes in the middle and inner ear related to aging
include thickening of the tympanic membrane (loss of
elasticity), loss of sensory hair cells in the organ of
Corti, and limitations to movement of the ossicles.

Conditions of the middle ear
● Conditions of the middle ear can be caused by injury,

disease, and the aging process.
● Acute otitis media is a viral or bacterial infection of the

middle ear.
● Manifestations include ear pain, pressure, fever,

headache, conductive hearing loss, and purulent or
bloody drainage if perforation of the eardrum occurs.

● An otoscopic exam can show redness, bulging tympanic
membrane, and inability to visualize usual landmarks.

● Medical management includes systemic antibiotic
therapy, analgesics and application of heat for pain,
and decongestants.

● Surgical management includes myringotomy (opening
of the eardrum made surgically) and placement of a
grommet to equalize pressure.

● Refer to RN NURSING CARE OF CHILDREN REVIEW MODULE:

CHAPTER 37: ACUTE OTITIS MEDIA.

Conditions of the inner ear
● Vertigo occurs when the client has the sensation that

they or their surroundings are in motion.
● Benign paroxysmal positional vertigo occurs in response

to a change in position. It is thought to be caused by the
disruption of the debris located within the semicircular
canal (small crystals of calcium carbonate). Onset is
sudden and can last for a few weeks or years. Bed rest is
prescribed along with short course of meclizine.

● Ménière’s disease is characterized by episodic
vertigo, tinnitus (ringing in the ears), and fluctuating
sensorineural hearing loss.

● Labyrinthitis is an inflammation of the labyrinth in
the inner ear, often secondary to otitis media. It is
characterized by the sudden onset of severe vertigo,
nausea, vomiting, and possible hearing loss and tinnitus.
Manifestations are treated with bed rest in a darkened
environment. Meclizine or dimenhydrinate is prescribed
for nausea and vertigo. Systemic antibiotic therapy can
also be prescribed.

CHAPTER 13

74 CHAPTER 13 MiddLe ANd iNNer eAr disOrders CONTENT MASTERY SERIES

ASSESSMENT

risK FACTOrs
Middle ear disorders

● Recurrent colds and otitis media
● Enlarged adenoids
● Trauma
● Changes in air pressure (scuba diving, flying)

Inner ear disorders
● Viral or bacterial infection
● Damage due to ototoxic medications

eXPeCTed FiNdiNGs
Middle ear disorders

● Hearing loss
● Feeling of fullness and/or pain in the ear
● Red, inflamed ear canal and tympanic membrane (TM)
● Bulging TM
● Fluid and/or bubbles behind TM
● Diffuse appearance of or inability to visualize normal

light reflex
● Fever

Inner ear disorders
● Hearing loss
● Tinnitus
● Dizziness or vertigo
● Vomiting
● Nystagmus
● Alterations in balance

diAGNOsTiC PrOCedUres

Audiometry

Audiometry is a noninvasive test of hearing ability,
including frequency, pitch, and intensity. The client
indicates when a tone is heard through earphones. Nurses
might collaborate with an audiologist for this and other
diagnostic procedures.

Tympanogram

Tympanogram measures the mobility of the TM and
middle ear structures relative to sound (effective in
diagnosing middle ear disease).

Weber and Rinne tests

Weber and Rinne tests use tuning forks to determine
whether hearing loss is present.

Otoscopy

An otoscope is used to examine the external auditory
canal, TM, and malleus bone visible through the TM.

NURSING ACTIONS
● Otoscopic examination is done if audiometry results

indicate possible impairment or if a client reports ear pain.
● After selection of a properly-sized speculum, an otoscope

is introduced into the external ear.
● If the ear canal curves, pull up and back on the auricle

of adults, and down and back on the auricle of children,
to straighten out the canal and enhance visualization.

● The TM should be a pearly gray color and intact. It
should provide complete structural separation of the
outer and middle ear structures.

● The light reflex should be visible from the center of the
TM anteriorly (5 o’clock right ear; 7 o’clock left ear). (13.1)

● In the presence of fluid or infection in the middle ear,
the TM becomes inflamed and can bulge from the
pressure of the exudate. This also displaces the light
reflex, causing it to look diffuse or completely obscured,
a significant diagnostic finding.

● Avoid touching the lining of the ear canal, which causes
pain due to sensitivity.

CLIENT EDUCATION: To see the TM clearly, the auricle
might need to be firmly pulled.

Electronystagmography (ENG)

ENG detects involuntary eye movements (nystagmus) in
order to assess for disease of the vestibular system of the
ear. Electrodes are taped near the eyes, and movements
of the eyes are recorded when the ear canal is stimulated
with cold water instillation or injection of air. Recording
of eye movements can be interpreted by a specialist as
either normal or abnormal.

NURSING ACTIONS
● Intraprocedure, the nurse should ask simple questions

(name recall, math problems) to ensure the client
remains alert.

● The client should be maintained on bed rest and NPO
postprocedure until vertigo subsides.

CLIENT EDUCATION
● Fast immediately before the procedure, and restrict

caffeine, alcohol, sedatives, and antihistamines for
several days prior to the test.

● This test is not performed on clients who
have a pacemaker. (Pacemaker signals inhibit
sensitivity of ENG.)

Caloric testing
● Caloric testing can be done concurrently with ENG.
● Water (warmer or cooler than body temperature) is

instilled in the ear in an effort to induce nystagmus.
● The eyes’ response to the instillation of cold and warm

water is diagnostic of vestibular disorders.

NURSING ACTIONS: The client should follow the same
restrictions as those for an ENG.

CLIENT EDUCATION: Be aware of the above restrictions.

Online Image: Light Reflex

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 13 MiddLe ANd iNNer eAr disOrders 75

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Monitor functional ability and balance. Take fall risk

precautions as necessary.
● Evaluate the client’s home situation. Collaborate with

home health to assess home safety and falls risks,
as needed.

● Encourage a client who has balance or functional
limitations to rise slowly and use assistance and
assistive devices as needed.

● Monitor blood levels of ototoxic medication, and teach
clients about adverse effects. Routine audiometry is
indicated with use of ototoxic IV antibiotics. Ototoxic
medications include the following.

◯ Antibiotics: gentamicin, erythromycin
◯ Diuretics: furosemide, ethacrynic acid
◯ NSAIDs: aspirin, ibuprofen
◯ Chemotherapeutic agents: cisplatin

● Assist with ENG and caloric testing as needed.
● Administer antivertigo and antiemetic medications

as needed.

MediCATiONs

Meclizine
● Meclizine has antihistamine and anticholinergic effects

and is used to treat the vertigo that accompanies inner
ear problems.

● NURSING ACTIONS: Observe for sedation, and take
appropriate precautions to ensure safe ambulation.

● CLIENT EDUCATION: Be aware of the sedative
effects of meclizine. (Avoid driving or operating
heavy machinery.)

Antiemetics

Ondansetron is one of several antiemetics used to treat
nausea and vomiting associated with vertigo.

NURSING ACTIONS: Contraindicated for clients who have
certain cardiac rhythm disorders.

CLIENT EDUCATION: Report dizziness or rash.

13.1 Light reflex
Otoscopy

An otoscope is used to examine the external auditory
canal, TM, and malleus bone visible through the TM.

NURSING ACTIONS
● Otoscopic examination is done if audiometry results

indicate possible impairment or if a client reports ear pain.
● After selection of a properly-sized speculum, an otoscope

is introduced into the external ear.
● If the ear canal curves, pull up and back on the auricle

of adults, and down and back on the auricle of children,
to straighten out the canal and enhance visualization.

● The TM should be a pearly gray color and intact. It
should provide complete structural separation of the
outer and middle ear structures.

● The light reflex should be visible from the center of the
TM anteriorly (5 o’clock right ear; 7 o’clock left ear). (13.1)

● In the presence of fluid or infection in the middle ear,
the TM becomes inflamed and can bulge from the
pressure of the exudate. This also displaces the light
reflex, causing it to look diffuse or completely obscured,
a significant diagnostic finding.

● Avoid touching the lining of the ear canal, which causes
pain due to sensitivity.

CLIENT EDUCATION: To see the TM clearly, the auricle
might need to be firmly pulled.

Electronystagmography (ENG)

ENG detects involuntary eye movements (nystagmus) in
order to assess for disease of the vestibular system of the
ear. Electrodes are taped near the eyes, and movements
of the eyes are recorded when the ear canal is stimulated
with cold water instillation or injection of air. Recording
of eye movements can be interpreted by a specialist as
either normal or abnormal.

NURSING ACTIONS
● Intraprocedure, the nurse should ask simple questions

(name recall, math problems) to ensure the client
remains alert.

● The client should be maintained on bed rest and NPO
postprocedure until vertigo subsides.

CLIENT EDUCATION
● Fast immediately before the procedure, and restrict

caffeine, alcohol, sedatives, and antihistamines for
several days prior to the test.

● This test is not performed on clients who
have a pacemaker. (Pacemaker signals inhibit
sensitivity of ENG.)

Caloric testing
● Caloric testing can be done concurrently with ENG.
● Water (warmer or cooler than body temperature) is

instilled in the ear in an effort to induce nystagmus.
● The eyes’ response to the instillation of cold and warm

water is diagnostic of vestibular disorders.

NURSING ACTIONS: The client should follow the same
restrictions as those for an ENG.

CLIENT EDUCATION: Be aware of the above restrictions.

Online Image: Light Reflex

76 CHAPTER 13 MiddLe ANd iNNer eAr disOrders CONTENT MASTERY SERIES

Diphenhydramine and dimenhydrinate

Antihistamines are effective in the treatment of vertigo
and nausea that accompany inner ear problems.

NURSING ACTIONS
● Observe for urinary retention.
● Observe for sedation, and take appropriate precautions

to ensure safe ambulation.

CLIENT EDUCATION
● Be aware of the sedative effects. (Avoid driving or

operating heavy machinery.)
● Dry mouth is expected.

Scopolamine
● Anticholinergics, such as scopolamine, are effective

in the treatment of nausea that accompanies inner
ear problems.

● It is available transdermally and is used for
motion sickness.

NURSING ACTIONS
● Observe for urinary retention.
● Observe for sedation, and take appropriate precautions

to ensure safe ambulation.
● Monitor clients who have open-angle glaucoma for

increasing eye pressure. Contraindicated in clients who
have angle-closure glaucoma.

CLIENT EDUCATION
● Be aware of the sedative effects. (Avoid driving or

operating heavy machinery.)
● Dry mouth is expected.

Diazepam

Diazepam is a benzodiazepine that has a sedative effect
that decreases stimuli to the cerebellum.

NURSING ACTIONS
● Observe for sedation, and take appropriate precautions

to ensure safe ambulation.
● Restrict use in clients who have closed-angle glaucoma.
● For older adult clients, use the smallest effective dose

(prevent oversedation, ataxia).

CLIENT EDUCATION
● Be aware of the sedative effects of diazepam. (Avoid

driving or operating heavy machinery.)
● Be aware of diazepam’s addictive properties and

appropriate use of the medication.

iNTerPrOFessiONAL CAre
Vestibular rehabilitation is an option for clients who
experience frequent episodes of vertigo or are
incapacitated due to vertigo. A team of providers treats the
cause and teaches the client exercises that can help them
adapt to and minimize the effects of vertigo. A
combination of biofeedback, physical therapy, and stress
management can be used. Postural education can teach
the client positions to avoid and positional exercises that
can terminate an attack of vertigo.

13.2 Cochlear implant

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 13 MiddLe ANd iNNer eAr disOrders 77

THerAPeUTiC PrOCedUres

Vertigo‑reducing activities

CLIENT EDUCATION
● Prevent stimulation/exacerbation of vertigo.
● Restrict movement of the head, and change

positions slowly.
● Avoid caffeine and alcohol.
● Rest in a quiet, darkened environment when vertigo

is severe.
● Use assistive devices (cane, walker) as needed for safe

ambulation to assist with balance.
● Maintain a safe environment free of clutter.
● Take a diuretic, if prescribed, to decrease the amount of

fluid in semicircular canals.
● Space intake of fluids evenly throughout the day.
● Decrease intake of salt and sodium-containing foods

(processed meats, MSG).
● Resume these precautions if vertigo returns.

SURGICAL INTERVENTIONS
● Pressure point treatment involves inserting a

tympanostomy tube, which applies micropulses at
intervals to relieve the vertigo of Ménière’s disease by
displacing fluid of the inner ear.

● Myringotomy is an incision to the tympanic membrane
to drain fluid from the middle ear to prevent ear drum
perforation in otitis media. For persistent otitis media,
a pressure-equalizing tube or grommet can be inserted
to temporarily take the place of the Eustachian tube. It
stays in place for 6 to 18 months. Stapedectomy

A stapedectomy is a surgical procedure of the middle
ear in which the stapes is removed and replaced with
a prosthesis.

● The procedure is done through the external ear
canal and TM.

● The TM is repaired, and sterile ear packing is
placed postoperatively.

● The procedure is done when otosclerosis has developed
and the bones of the middle ear fuse together.

● Otosclerosis is one of the causes of conductive hearing
loss in older adults.

NURSING ACTIONS
● Assess for facial nerve damage.
● Intervene for vertigo, nausea, and vomiting (common

findings following the procedure).

Cochlear implant for sensorineural hearing loss
● Cochlear implants consist of a microphone that picks

up sound, a speech processor, a transmitter and
receiver that convert sounds into electric impulses, and
electrodes that are attached to the auditory nerve. (13.2)

● The implant’s transmitter is located outside the head
behind the ear and connects via a magnet to the receiver
located immediately below it, under the skin.

● Young children and adults who lost their hearing after
speech development adapt to cochlear implants more
quickly than those who were born totally deaf.

● Intensive and prolonged language training is necessary
for individuals who did not develop speech.

NURSING ACTIONS: Follow pre-, intra-, and postoperative
outpatient surgery guidelines.

CLIENT EDUCATION
● Immediately after surgery, the unit is not turned on.
● The external unit is applied and the speech processor is

programmed 2 to 6 weeks after surgery.
● Be aware of precautions to prevent infection.
● Avoid MRIs.

Labyrinthectomy

A labyrinthectomy is a surgical treatment for vertigo that
involves removal of the labyrinthine portion of the inner ear.

NURSING ACTIONS: Client will have severe nausea and
vertigo postoperatively. Take appropriate safety
precautions and give antiemetics as needed.

CLIENT EDUCATION: Hearing loss is to be expected in the
affected ear.

CLieNT edUCATiON FOLLOWiNG
MiddLe eAr sUrGery

● Avoid air travel for 2 to 3 weeks.
● Avoid straining or coughing, and blow nose gently with

the mouth open for 2 to 3 weeks following surgery.
● Keep ear canal clean and dry. Avoid washing hair or

showering for several days to 1 week.
● When able to shower, loosely place a cotton ball with

petroleum jelly into the ear canal to prevent water
from entering.

● Expect some temporary hearing loss in the affected ear
due to presence of fluid or packing.

● Drainage from the ear canal should be reported to
the provider.

78 CHAPTER 13 MiddLe ANd iNNer eAr disOrders CONTENT MASTERY SERIES

Application Exercises

1. A nurse is performing an otoscopic examination of a
client. Which of the following is an unexpected finding?

A. Pearly gray tympanic membrane (TM)

B. Malleus visible behind the TM

C. Presence of soft cerumen in the external canal

d. Fluid or bubbles seen behind the TM

2. A nurse is reviewing the health record of a client
who has severe otitis media. Which of the following
are expected findings? (select all that apply.)

A. enlarged adenoids

B. report of recent colds

C. Client prescription for daily furosemide

d. Light reflex visible on otoscopic
exam in the affected ear

e. ear pain relieved by meclizine

3. A nurse in a clinic is caring for a client who has been
experiencing mild to moderate vertigo due to benign
paroxysmal vertigo for several weeks. Which of the
following actions should the nurse recommend to
help control the vertigo? (select all that apply.)

A. reduce exposure to bright lighting.

B. Move head slowly when changing positions.

C. do not eat fruit high in potassium.

d. Plan evenly‑spaced daily fluid intake.

e. Avoid fluids containing caffeine.

4. A nurse is caring for a client who has
suspected Ménière’s disease. Which of the
following is an expected finding?

A. Presence of a purulent lesion in
the external ear canal

B. Feeling of pressure in the ear

C. Bulging, red bilateral tympanic membranes

d. Unilateral hearing loss

5. A nurse is completing discharge teaching to
a client following middle ear surgery. Which
of the following statements by the client
indicates understanding of the teaching?

A. “i should restrict rapid movements and avoid
bending from the waist for several weeks.”

B. “i should wait until the day after
surgery to wash my hair.”

C. “i will remove the dressing
behind my ear in 7 days.”

d. “My hearing should be back to
normal right after my surgery.”

Active Learning Scenario

A nurse in a clinic is completing preoperative teaching for an
adult client who will receive a cochlear implant. What should
the nurse include in the teaching? Use the ATi Active Learning
Template: Therapeutic Procedure to complete this item.

DESCRIPTION OF PROCEDURE: describe a cochlear implant.

INDICATIONS: describe the indication for a cochlear implant.

NURSING INTERVENTIONS: List at least four.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 13 MiddLe ANd iNNer eAr disOrders 79

Application Exercises Key

1. A. A pearly gray TM is an expected finding
during an otoscopic examination.

B. Visualization of the malleus behind the TM is an
expected finding during an otoscopic examination.

C. Cerumen of various colors, depending on the
client’s skin color or ethnic background, is an
expected finding in the external ear canal.

d. CORRECT: Fluid behind the TM indicates the possibility
of otitis media and is not an expected finding.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

2. A. CORRECT: enlarged tonsils and adenoids are a finding
associated with a middle ear infection.

B. CORRECT: Frequent colds are findings
associated with a middle ear infection.

C. Furosemide is an ototoxic medication and can cause
sensorineural hearing loss, but taking furosemide
does not cause a middle ear disorder.

d. Light reflexes are absent or in altered positions
in a client who has a middle ear disorder.

e. Meclizine is prescribed to relieve vertigo
for inner ear disorders, but does not relieve
the pain of a middle ear infection.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. A. CORRECT: remaining in a darkened, quiet environment
can reduce vertigo, particularly when it is severe.

B. CORRECT: Moving slowly when standing or
changing positions can reduce vertigo.

C. The client who has vertigo should be instructed
to avoid foods containing high levels of sodium to
reduce fluid retention, which can cause vertigo.

d. CORRECT: Fluid intake should be planned so that it is
evenly spaced throughout the day to prevent excess
fluid accumulation in the semicircular canals.

e. The client should avoid fluids containing
caffeine or alcohol to minimize vertigo.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. A. Ménière’s disease is an inner ear disorder. A purulent lesion
in the external ear canal is not an expected finding.

B. A feeling of pressure in the ear can occur with otitis
media, but is not an expected finding in Ménière’s.

C. Ménière’s disease is an inner ear disorder. Bulging,
red bilateral tympanic membranes is a finding
associated with a middle ear infection.

d. CORRECT: Unilateral sensorineural hearing loss is
an expected finding in Ménière’s disease.

NCLEX® Connection: Physiological Adaptation,
Illness Management

5. A. CORRECT: rapid movements and bending from the waist
should be avoided for 3 weeks following ear surgery.

B. Avoid showering and washing hair for at least
several days up to 1 week following ear surgery.
The ear must remain dry during this time.

C. Middle ear surgery is performed through the tympanic
membrane, and the client will have a dry dressing
within the ear canal. There is no external excision.

d. decreased hearing is expected following middle
ear surgery due to presence of a dressing within
the ear canal and possible drainage.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

DESCRIPTION OF PROCEDURE: A cochlear implant consists of a
microphone to pick up sound, a speech processor, a transmitter
and receiver to convert sounds into electrical impulses, and
electrodes that are attached to the auditory nerve. The implant’s
transmitter is placed outside the head, behind the ear, via a magnet
that attaches to the receiver located under the skin below it.

INDICATIONS: A cochlear implant is performed
for sensorineural hearing loss.

NURSING INTERVENTIONS
● Pre‑ and postoperative teaching is completed.
● intraoperative care is provided in an outpatient setting.
● Client education includes:

◯ The unit is not turned on immediately after surgery.
◯ The external unit is applied and the speech processor
is programmed 2 to 6 weeks after surgery.

◯ Prevent infection.
◯ Mris should be avoided.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

80 CHAPTER 13 MiddLe ANd iNNer eAr disOrders CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 14 HeAd iNJUry 81

UNIT 2 NEUROLOGIC DISORDERS
SECTION: NEUROLOGIC EMERGENCIES

CHAPTER 14 Head Injury
Head injuries are classified as open or closed.
in an open head injury, the integrity of the
skull is compromised by either a penetrating
object or blunt force trauma. A closed
head injury occurs from blunt trauma that
causes acceleration of the head and then
deceleration or hits a stationary object. Head
injuries are also classified as mild, moderate,
or severe, depending upon Glasgow Coma
scale ratings and the length of time the client
was unconscious.

TyPes OF BrAiN iNJUry
● Types of brain injury include concussion, contusion,

diffuse axonal injury, and intracranial hemorrhage.
◯ A concussion, or mild traumatic brain injury ,
occurs after head trauma that results in a change
in the client’s neurologic function but no identified
brain damage and usually resolves within 72 hr.
Post-concussion syndrome includes persistence
of cognitive and physical manifestations for an
unknown period of time.

◯ A contusion occurs when the brain is bruised and the
client has a period of unconsciousness associated with
stupor and or confusion.

◯ Diffuse axonal injury is a widespread injury to the
brain that results in coma and is seen in severe
head trauma.

◯ Intracranial hemorrhage can occur in the epidural,
subdural, or intracerebral space. It is a collection of
blood following head trauma. There can be a delay of
weeks to months in presenting manifestations for a
subacute or chronic subdural hematoma.

● Open-head injuries pose a high risk for infection. Scalp
injuries often result in profuse bleeding due to the poor
vasoconstriction of the blood vessels of the scalp.

● Skull fractures can occur following forceful head
injury. The brain might be damaged as a result. The
client can have localized pain at the site of the fracture,
and swelling can occur. The nurse should be alert
for drainage from the ears or eyes (cerebral spinal
fluid [CSF]).

● A cervical spine injury should always be suspected when
a head injury occurs. A cervical spine injury must be
ruled out prior to removing any devices used to stabilize
the cervical spine.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Wear helmets when skateboarding, riding a bike or
motorcycle, skiing, and playing football or any other
sport that could cause a head injury.

● Wear seat belts when driving or riding in a car.
● Avoid dangerous activities (speeding, driving under the

influence of alcohol or drugs).
● Owners of firearms should lock all firearms.
● Avoid riding in the back of a pick-up truck.
● Promote programs directed at older adults to prevent

falls, which are a major cause of neurologic injury in
adults ages 65 to 75. Older adults who sustain head
injuries are at greater risk for complications
(hematomas) due to increased adherence of dura mater
to skull and because of higher rates of anticoagulants
prescribed to the older population.

ASSESSMENT

risK FACTOrs
● Motor vehicle or motorcycle crashes
● Illicit drug and alcohol use
● Sports injuries
● Assault
● Gunshot wounds
● Falls

eXPeCTed FiNdiNGs
● Amnesia (loss of memory) before or after the injury.
● Loss of consciousness: Length of time the client is

unconscious is significant.
● CSF leakage from the nose and ears can indicate a

basilar skull fracture. Test for the “halo sign,” clear or
yellow-tinted ring surrounding a drop of blood when
bloody drainage is placed on a piece of gauze.

● Manifestations of increased intracranial pressure
◯ Severe headache, nausea, vomiting
◯ Deteriorating level of consciousness, restlessness,
irritability

◯ Dilated or pinpoint nonreactive pupils
◯ Cranial nerve dysfunction
◯ Alteration in breathing pattern (Cheyne-Stokes
respirations, central neurogenic hyperventilation, apnea)

◯ Deterioration in motor function, abnormal posturing
(decerebrate, decorticate, flaccidity)

◯ Cushing’s triad: a late finding characterized by severe
hypertension with a widening pulse pressure (systolic

– diastolic) and bradycardia
◯ Seizures

CHAPTER 14

82 CHAPTER 14 HeAd iNJUry CONTENT MASTERY SERIES

LABOrATOry TesTs
● ABGs
● CBC with differential
● Blood glucose level
● Electrolyte levels
● Blood and urine osmolarity
● Toxicology screen
● Monitor anti-seizure medication blood levels

diAGNOsTiC PrOCedUres
● Cervical spine films to diagnose a cervical spine injury
● Computerized tomography (CT) and/or a magnetic

resonance imaging (MRI) of the head and/or neck (with
and without contrast if indicated)

● Calculation of cerebral perfusion using the ICP monitor,
if it is in place

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Support of the family following head injury is of great

importance. Effective coping can be very difficult to
achieve without support from providers and community
members. The Brain Injury Association of America
provides families and clients with information needed
to cope with this potentially devastating injury.

● The family can face difficult decisions following head
injury. If brain death has occurred, the family needs
support when deciding whether to donate organs.

● Maintain cervical spine stability until cleared by
an x-ray.

● Report presence of CSF from nose or ears to the provider.
● Determine whether the client could possibly be under

the influence of alcohol, illicit drugs, or medications
which could impair neurologic responsiveness and
affect monitoring.

● Implement measures to prevent complications of
immobility (turn every 2 hr, footboard, and splints).
Specialty beds can be used.

● Monitor fluid and electrolyte values and osmolality to
detect changes in sodium regulation, onset of diabetes
insipidus, or severe hypovolemia.

● Provide adequate fluids to maintain cerebral perfusion
and to minimize cerebral edema. When a large amount
of IV fluids are prescribed, monitor for excess fluid
volume which could increase ICP.

● Maintain safety and seizure precautions (side rails up,
padded side rails, call light within the client’s reach).

● Even if the level of consciousness is decreased, explain
to the client the actions being taken and why. (Hearing
is the last sense affected by a head injury.)

Assess/monitor the client at
regularly scheduled intervals

Respiratory status (the priority assessment): The brain
is dependent upon oxygen to maintain function and has
little reserve available if oxygen is deprived. Untreated
hypoxia leads to brain injury or death if the brain has
been denied adequate oxygenation for 3 to 5 min. Changes
in level of consciousness, using the Glasgow Coma
Scale (GCS), provide the earliest indication of neurologic
deterioration.

Cranial nerve function: Eye blink response, gag reflex,
tongue and shoulder movement

Assess pupils for size, equality, and reaction to light:
Pupils that are equal, round, and react to light and
accommodation (PERRLA) are a normal finding.

Bilateral sensory and motor responses

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 14 HeAd iNJUry 83

Increased intracranial pressure (ICP)
Monitored by placing a screw, catheter, or sensor through
a burr hole into the ventricle, or the subarachnoid,
epidural, or subdural space. Expected reference range is
10 to 15 mm Hg.

● ICP can be increased by
◯ Hypercarbia, which leads to cerebral vasodilation
◯ Endotracheal or oral tracheal suctioning
◯ Coughing
◯ Extreme neck or hip flexion/extension
◯ Maintaining the head of the bed at an angle
less than 30°

◯ Increasing intra-abdominal pressure (restrictive
clothing, Valsalva maneuver)

● Implement actions that decrease ICP.
◯ Elevate head at least 30° to reduce ICP and to promote
venous drainage.

◯ Avoid extreme flexion, extension, or rotation of the
head, and maintain the body in a midline neutral
position.

◯ Maintain a patent airway. Provide mechanical
ventilation as indicated.

◯ Administer oxygen as indicated to maintain PaO2
greater than 60 mm Hg.

◯ The client should receive stool softeners and avoid the
Valsalva maneuver with increased ICP.

◯ Provide a calm, restful environment. (Limit visitors.
Minimize noise.)

◯ Brief periods of hyperventilation for the intubated
client can be used after the first 24 hr following
injury to help lower ICP. During the first 24 hr,
hyperventilation can cause cerebral vasoconstriction,
which can cause ischemia.

MediCATiONs

Mannitol

Mannitol is an osmotic diuretic used to treat cerebral
edema. When used for increased ICP, the medication draws
fluid from the brain into the blood.

NURSING ACTIONS
● Administer IV to treat acute cerebral edema.
● Insert indwelling urinary catheter to monitor fluid and

renal status.
● Monitor electrolytes and osmolality closely.

Barbiturates

Client can be placed in a coma (barbiturate coma)
to decrease cellular metabolic demand until ICP can
be decreased.

● Commonly used medications include pentobarbital
and thiopental.

● When barbiturate coma is used, the ability to assess
neurologic function is made more difficult.

● Medication dosage is adjusted to keep the client
completely unresponsive.

● Mechanical ventilation, cardiac and hemodynamic
monitoring, and ICP monitoring are required.

Phenytoin
● Phenytoin is used prophylactically to prevent or treat

seizures. It was the first medication used to suppress
seizure that did not depress the entire CNS.

● Dosing for this medication is client-specific and based
on therapeutic blood levels.

NURSING ACTIONS: Check for medication interactions.

Opioids

Morphine sulfate or fentanyl are analgesics used to control
pain and restlessness.

NURSING ACTIONS
● Avoid opioid use with clients who are not mechanically

ventilated due to CNS depressant effects.
◯ Prevents accurate assessment of neurologic system
◯ Can cause respiratory depression

● Administer naloxone, the reversal agent, if client
becomes overmedicated or does not tolerate the opioids.

84 CHAPTER 14 HeAd iNJUry CONTENT MASTERY SERIES

THerAPeUTiC PrOCedUres

Craniotomy

A craniotomy is the removal of nonviable brain tissue
that allows for expansion and/or removal of epidural or
subdural hematomas. It is also used to decrease ICP and
remove brain tumors. It involves drilling a burr hole or
creating a bone flap to permit access to the affected area.

● Treatment of intracranial hemorrhages requires surgical
evacuation. There are three surgical approaches:
supratentorial (above the tentorial), infratentorial
(below the tentorial, brain stem), and transsphenoidal
(through the mouth and nasal sinuses).

● Burr holes are circular openings through the skull. The
burr hole is used to assess cerebral swelling, injury, size,
and position of the ventricles.

● This is a life-saving procedure, and is associated
with many potential complications (severe neurologic
impairment, infection, persistent seizures, neurologic
deficiencies, and death).

NURSING ACTIONS
● Medications (mannitol and dexamethasone) can be

administered every 6 hr for 24 to 72 hr postoperatively.
● Phenytoin or diazepam can be used to prevent

seizure activity.
● Monitor ICP. Follow written protocols to assess for

changes in ICP.
● For supratentorial surgery, maintain HOB at least 30°

with body positioning to prevent increased ICP.
● For infratentorial craniotomy, keep client flat and on

either side for 24 to 48 hr to prevent pressure on neck
incision site.

● Calm and reassure clients, clarifying misconceptions
(brain surgery can be an extremely fearful procedure).

iNTerPrOFessiONAL CAre
● Care should include professionals from other disciplines

as indicated. This can include physical, occupational,
recreational, and/or speech therapists due to neurologic
deficits that can occur secondary to the area of the
brain damaged.

● Contact social services or case manager to provide links
to social service agencies and schools.

● Rehabilitation facilities are frequently used to compress
the time required to recover from a head injury and
support re-emergence into society.

COMPLICATIONS

Brain herniation
● A brain herniation is the downward shift of brain tissue

due to cerebral edema.
● The brain consists of brain tissue, cerebrospinal fluid,

and blood. Due to the limited space within the skull, an
alteration of any one of the components of the brain
results in a compromise in the other components. When
trauma creates a shift in these components, and the
other components are unable to accommodate, the brain
shifts from the cranial vault, or herniates. This can
result in brain tissue moving downward, through the
foramen magnum.

● Findings include fixed dilated pupils, deteriorating
level of consciousness, Cheyne-Stokes respirations,
hemodynamic instability, and abnormal posturing.

● Recovery after this occurrence is rare, and urgent
medical treatment (mannitol) and/or surgical
(debulking) treatment is indicated.

● With treatment, severe neurologic impairment
usually persists.

NURSING ACTIONS
● This situation should be prevented before treatment

is needed.
● Close monitoring of vital signs and neurologic status

allows early reporting of changes in the GCS score, an
increase in the blood pressure, and an alteration in
respiratory pattern and effort.

● Frequently update family members on the health status
of the client. Frequent updates and repeating medical
information is often necessary to ensure comprehension
among family members.

CLIENT EDUCATION
● The decision to surgically treat brain herniation is made

in the presence of a critical situation.
● Social service workers and/or pastoral personnel can be

helpful to support the family, while reinforcing the
medical situation.

Hematoma and intracranial hemorrhage
● Monitor for severe headache, rapid decline in level

of consciousness, worsening neurologic function and
herniation, and changes in ICP.

● Surgery is required to remove subdural and
epidural hematoma.

● Intracranial hemorrhage is treated with
osmotic diuretics.

Online Image: Brain Herniation

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 14 HeAd iNJUry 85

Pulmonary edema
● Findings mimic acute pulmonary edema without

cardiac involvement.
● This is a life-threatening emergency. Immediate,

aggressive treatment is used. Survival is rare.

Diabetes insipidus or syndrome of
inappropriate antidiuretic hormone

Diabetes insipidus or syndrome of inappropriate
antidiuretic hormone (SIADH) is a possible complication.

NURSING ACTIONS
● Monitor blood electrolytes and osmolality daily.
● Document strict intake and output.
● Weigh client daily.
● Treat electrolyte and fluid imbalance, as prescribed.
● Monitor for dehydration or fluid overload

during treatment.

Active Learning Scenario

A nurse is reviewing the plan of care for a client
who has a head injury. What should be included
in the plan of care? Use the ATi Active Learning
Template: system disorder to complete this item.

DIAGNOSTIC PROCEDURES
● identify the priority nursing assessment
and describe why this is important.

● identify the nursing assessment that will provide the
earliest indication of neurologic deterioration.

NURSING CARE: describe three additional nursing actions.

CLIENT EDUCATION: describe two activities the nurse
should instruct the client to avoid that will increase iCP.

Application Exercises

1. A nurse is caring for a client who was recently admitted
to the emergency department following a head‑on
motor vehicle crash. The client is unresponsive,
has spontaneous respirations of 22/min, and has a
laceration on the forehead that is bleeding. Which of
the following is the priority nursing action at this time?

A. Keep neck stabilized.

B. insert nasogastric tube.

C. Monitor pulse and blood pressure frequently.

d. establish iV access and start fluid replacement.

2. A nurse is caring for a client who has just been admitted
following surgical evacuation of a subdural hematoma.
Which of the following is the priority assessment?

A. Glasgow Coma scale

B. Cranial nerve function

C. Oxygen saturation

d. Pupillary response

3. A nursing is caring for a client who has a
closed‑head injury with iCP readings ranging from
16 to 22 mm Hg. Which of the following actions
should the nurse take to decrease the potential for
raising the client’s iCP? (select all that apply.)

A. suction the endotracheal tube frequently.

B. decrease the noise level in the client’s room.

C. elevate the client’s head on two pillows.

d. Administer a stool softener.

e. Keep the client well hydrated.

4. A nurse in the critical care unit is completing
an admission assessment of a client who has
a gunshot wound to the head. Which of the
following assessment findings are indicative
of increased iCP? (select all that apply.)

A. Headache

B. dilated pupils

C. Tachycardia

d. decorticate posturing

e. Hypotension

5. A nurse is caring for a client who has increased iCP
and a new prescription for mannitol. For which of the
following adverse effects should the nurse monitor?

A. Hyperglycemia

B. Hyponatremia

C. Hypervolemia

d. Oliguria

86 CHAPTER 14 HeAd iNJUry CONTENT MASTERY SERIES

Application Exercises Key

1. A. CORRECT: The greatest risk to the client is permanent
damage to the spinal cord if a cervical injury does exist. The
priority nursing intervention is to keep the neck immobile
until damage to the cervical spine can be ruled out.

B. insertion of a nasogastric tube is not the
priority nursing action at this time.

C. Frequent monitoring of pulse and blood pressure is
important but not the priority nursing action at this time.

d. establishing iV access for fluid replacement is important
but not the priority nursing action at this time.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

2. A. The Glasgow Coma scale is important. However,
another assessment is the priority.

B. Assessment of cranial nerve function is important.
However, another assessment is the priority.

C. CORRECT: Using the airway, breathing, and circulation
(ABC) priority‑setting framework, assessment of oxygen
saturation is the priority action. Brain tissue can only
survive for 3 min before permanent damage occurs.

d. Assessment of pupillary response is important.
However, another assessment is the priority.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

3. A. suctioning increases iCP and should be
performed only when indicated.

B. CORRECT: decreasing the noise level and
restricting the number of people in the client’s
room can help prevent increases in iCP.

C. Hyperflexion of the client’s neck with pillows carries the
risk of increasing iCP and should be avoided. The head
of the bed should be raised to at least 30°, but the head
should be maintained in an upright, neutral position.

d. CORRECT: Administration of a stool softener will
decrease the need to bear down (Valsalva maneuver)
during bowel movements, which can increase iCP.

e. Overhydration carries the risk of increasing iCP and
should be avoided. Monitor fluid and electrolyte levels
closely for the client who has increased iCP.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

4. A. CORRECT: Headache is a finding associated
with increased iCP.

B. CORRECT: dilated pupils is a finding
associated with increased iCP.

C. Bradycardia, not tachycardia, is a finding
associated with increased iCP.

d. CORRECT: decorticate or decerebrate posturing
is a finding associated with increased iCP.

e. Hypertension, not hypotension, is a finding
associated with increased iCP.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

5. A. Hyperglycemia is not an adverse effect of mannitol.
B. CORRECT: Mannitol is a powerful osmotic

diuretic. Adverse effects include electrolyte
imbalances, such as hyponatremia.

C. Hypovolemia is an adverse effect of mannitol
and should be monitored.

d. Polyuria is an adverse of mannitol and should be monitored.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

DIAGNOSTIC PROCEDURES
● The priority nursing assessment is respiratory status. The
brain is dependent on oxygen to maintain function and has
minimal reserve if oxygen is not available. Brain function
begins to diminish after 3 min of oxygen deprivation.

● The assessment indication of early neurologic
deterioration is changes in level of consciousness.

NURSING CARE
● elevate the head to at least 30°.
● Maintain patent airway.
● Administer oxygen to keep oxygen saturation greater than 92%.
● Maintain cervical spine stability until cleared by x‑ray.
● report presence of cerebrospinal fluid from
nose or ears to the provider.

● Provide a calm, restful environment. (Limit visitors. Minimize noise.)
● implement measures to prevent complications of immobility. (Turn
every 2 hr. Use footboard and splints.) Provide a specialty bed.

● Monitor fluid and electrolyte values and osmolarity.
● Provide adequate fluids but do not overhydrate. Monitor iV fluids.
● Maintain safety and seizure precautions (side rails up,
padded side rails, call light within client’s reach).

● explain all nursing actions to the client and family.

CLIENT EDUCATION: Coughing and blowing the nose forcefully.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 15 sTrOKe 87

UNIT 2 NEUROLOGIC DISORDERS
SECTION: NEUROLOGIC EMERGENCIES

CHAPTER 15 Stroke
strokes, also known as cerebrovascular
accidents or brain attacks, involve a disruption
in the cerebral blood flow secondary
to ischemia, hemorrhage, brain attack,
or embolism.

Classifications of strokes are hemorrhagic and
ischemic. (ischemic strokes are thrombotic
or embolic.)

Hemorrhagic occur secondary to a ruptured
artery or aneurysm. The prognosis for a
client who has experienced a hemorrhagic
stroke is poor due to the amount of ischemia
and increased iCP caused by the expanding
collection of blood. if it is caught early and
evacuation of the clot can be done with
cessation of the active bleed, the prognosis of a
hemorrhagic stroke improves significantly. (15.1)

Thrombotic strokes occur secondary to
the development of a blood clot on an
atherosclerotic plaque in a cerebral artery
that gradually shuts off the artery and causes
ischemia distal to the occlusion. Manifestations
of a thrombotic stroke evolve over a period of
several hours to days. (15.2)

Embolic strokes are caused by an embolus
traveling from another part of the body to a
cerebral artery. Blood to the brain distal to
the occlusion is immediately shut off causing
neurologic deficits or a loss of consciousness to
instantly occur. (15.3)

Ischemic strokes (thrombotic or embolic) can be
reversed with fibrinolytic therapy using
alteplase, also known as tissue plasminogen
activator (tPA), if given within 3 to 4.5 hr of the
initial manifestations (unless contraindicated by
factors [presence of active bleeding]).

CHAPTER 15

Online Images: Hemorrhagic Stroke, Thrombotic
Stroke, Embolic Stroke

15.1 Hemorrhagic stroke

15.2 Thrombotic stroke

88 CHAPTER 15 sTrOKe CONTENT MASTERY SERIES

HEALTH PROMOTION AND
DISEASE PREVENTION

● Hypertension, diabetes mellitus, smoking, and other
related disorders can increase a client’s risk for
a stroke.

● Early treatment of hypertension, maintenance of blood
glucose within expected range, and refraining from
smoking will decrease these risk factors.

● Maintaining a healthy weight and getting regular
exercise can also decrease the risk of a stroke.

ASSESSMENT

risK FACTOrs
● Cerebral aneurysm
● Arteriovenous (AV) malformation
● Diabetes mellitus
● Obesity
● Hypertension
● Atherosclerosis
● Hyperlipidemia
● Hypercoagulability
● Atrial fibrillation
● Use of oral contraceptives
● Smoking
● Cocaine use

eXPeCTed FiNdiNGs
Some clients report transient manifestations (visual
disturbances, dizziness, slurred speech, a weak extremity).

● These manifestations can indicate a transient
ischemic attack (TIA), which can be a warning of an
impending stroke.

● Antithrombotic medication and/or surgical removal of
atherosclerotic plaques in the carotid artery can prevent
the subsequent occurrence of a stroke.

PHYSICAL ASSESSMENT FINDINGS
Manifestations vary based on the area of the brain that is
deprived of oxygenated blood.

● The left cerebral hemisphere is responsible for
language, mathematics skills, and analytic thinking.

◯ Expressive and receptive aphasia (inability to speak
and understand language)

◯ Agnosia (unable to recognize familiar objects)
◯ Alexia (reading difficulty)
◯ Agraphia (writing difficulty)
◯ Right extremity hemiplegia (paralysis) or

hemiparesis (weakness)
◯ Slow, cautious behavior
◯ Depression, anger, and quick to become frustrated
◯ Visual changes (hemianopsia [loss of visual field in
one or both eyes]).

Online Image: Hemianopsia

15.3 Embolic stroke

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 15 sTrOKe 89

● The right cerebral hemisphere is responsible for visual
and spatial awareness and proprioception.

◯ Altered perception of deficits (overestimation
of abilities)

◯ Unilateral neglect syndrome (ignore left side of the
body: cannot see, feel, or move affected side, so
client unaware of its existence). Can occur with
left-hemispheric strokes, but is more common with
right-hemispheric strokes.

◯ Loss of depth perception
◯ Poor impulse control and judgment
◯ Left hemiplegia or hemiparesis
◯ Visual changes (hemianopsia)

diAGNOsTiC PrOCedUres
A non-contrast computed tomography (CT) scan is the
initial diagnostic test and should be performed within
25 min from the time of client arrival to the emergency
department. This will assist with the determination of
type of stroke (ischemic versus hemorrhagic) and whether
the client is a candidate for thrombolytic therapy.

A magnetic resonance imaging (MRI) can be used to
identify edema, ischemia, and necrosis.

A magnetic resonance angiography or a cerebral
angiography are used to identify the presence of a cerebral
hemorrhage, abnormal vessel structures (AV malformation,
aneurysms), vessel ruptures, and regional perfusion of
blood flow in the carotid arteries and brain.

A lumbar puncture is used to assess for the presence
of blood in the cerebrospinal fluid. A positive finding is
consistent with a cerebral hemorrhage or ruptured aneurysm.

The Glasgow Coma Scale is used when the client has a
decreased level of consciousness or orientation. The risk
for increased intracranial pressure (ICP) exists related
to the swelling of the brain that can occur secondary to
ischemic insult.

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Monitor vital signs every l to 2 hr. Notify the provider

immediately if blood pressure exceeds a systolic greater
than 180 mm Hg or a diastolic greater than 110 mm Hg.
This can indicate the client is experiencing an
ischemic stroke.

● Monitor the client’s temperature. A fever can cause an
increase in intracranial pressure.

● Provide oxygen therapy to maintain oxygen saturation
level greater than 92%, or if the client’s level of
consciousness is decreased.

● Place the client on a cardiac monitor to detect arrhythmias.
● Conduct a cardiac assessment, and auscultate apical

heart rate to detect murmurs or irregularity.
● Monitor for changes in level of consciousness (indicates

increased ICP).
● Monitor vital signs, electrocardiogram.

● Monitor for hyperglycemia, which is associated with
poor neurologic outcome.

● Elevate the head of the bed approximately 30° to reduce
ICP and to promote venous drainage. Avoid extreme
flexion or extension of the neck, and maintain the
client’s head in the midline neutral position.

● Institute seizure precautions.
● Assist with the client’s communication skills if speech

is impaired. (15.4)
◯ Assess the ability to understand speech by asking the
client to follow simple commands.

◯ Observe for consistently affirmative answers when the
client actually does not comprehend what is being said.

◯ Assess accuracy of yes/no responses in relation to
closed-ended questions.

◯ Supply the client with a picture board of commonly
requested items/needs.

◯ For expressive and receptive aphasia, speak slowly
and clearly, use one-step commands.

● Assist with safe feeding.
◯ Assess swallowing and gag reflexes before feeding.
The speech-language pathologist (SLP) may request
a swallowing study that can involve swallowing a
barium substrate and radiography of the peristaltic
activity of the esophagus.

◯ Four liquid consistencies have been identified by a
collaborative group of specialists for clients who
have dysphagia: thin (water, juice), nectar-like
(cream soups, nectars), honey-like (honey, yogurt),
and spoon-thick (pudding, cooked cereals). Food
levels for dysphagia include pureed, mechanically
altered, advanced/mechanically soft, and regular.
Use the appropriate consistency and food type as
recommended by the SLP to minimize choking.

◯ Have the client eat in an upright position and swallow
with the head and neck flexed slightly forward.

◯ Place food in the back of the mouth on the
unaffected side.

◯ Have suction on standby.
◯ Maintain a distraction-free environment during meals.
◯ Collaborate with dietitian to ensure appropriate
caloric intake, because weight loss is common
following stroke.

● Prevent complications of immobility (atelectasis,
pneumonia, pressure injury, and deep-vein thrombosis
[DVT]). Clients who have experienced strokes are
ambulated as soon as possible to prevent complications.
However, during periods of inactivity, preventive
measures related to complications of immobility should
be implemented.

● If the client has one-sided neglect, teach them to
protect and care for the affected extremity to avoid
injuring it in the wheel of the wheelchair or hitting/
smashing it against a doorway.

● Encourage range of motion exercises every 2 hr (active
for unaffected extremities, passive for affected).

● Elevate affected extremities to promote venous return
and reduce swelling. An elastic glove can be placed on
the affected hand if swelling is severe.

90 CHAPTER 15 sTrOKe CONTENT MASTERY SERIES

● Maintain a safe environment to reduce the risk of falls.
Assistive devices (transfer belts and sliding boards)
should be used during transfers. Sit-to-stand lifts can
also facilitate transfers and reduce strain on the care
provider’s body.

● If the client has homonymous hemianopsia (loss of the
same visual field in both eyes), instruct them to use a
scanning technique (turning head from the direction
of the unaffected side to the affected side) when eating
and ambulating.

● Provide assistance with ADLs as needed. Instruct
the client to dress the affected side first and sit in a
supportive chair that aids in balance. Have occupational
therapy assess the client for adaptive aids (a plate guard,
utensils with built-up handles, a reaching tool to pick
things up, and shirts and shoes that have hook and loop
fasteners or tape instead of buttons and ties).

● Clients who have experienced strokes have decreased
endurance and impaired balance due to paralysis on one
side of the body. Provide frequent rest periods from sitting
in the wheelchair by returning the client to bed after
therapies and meals. When sitting the client up in bed or in
the wheelchair, leaning to the affected side typically occurs
and should be countered with some manner of support.

● Shoulder subluxation can occur if the affected arm is not
supported. The weight of the arm is such that it can cause
a painful dislocation of the shoulder from its socket.

● Support the client during periods of emotional lability
and depression.

CLIENT EDUCATION
● Use the unaffected side to exercise the affected side

of the body.
● For edema of the extremities, massage by stroking from

the fingertips or toes back toward the body to encourage
fluid movement.

● Support the arm while in bed, the wheelchair, or
during ambulation with an arm sling or strategically
placed pillows.

MediCATiONs
Thrombolytic medications reteplase recombinant:
Give within 4.5 hr of initial manifestations for clients
experiencing ischemic stroke due to embolic event as
evidenced by CT scan results.

Anticoagulants (warfarin): Warfarin is indicated for
clients who have atrial fibrillation (or cardioembolic
stroke) with a target international normalized ratio (INR)
or 2 to 3 (secondary prevention). Anticoagulants should
not be used in hemorrhagic stroke.

Novel oral anticoagulants (NOACs) (dabigatran, apixaban,
rivaroxaban): Alternative medications to warfarin
therapy for clients experiencing atrial fibrillation
(cardioembolic stroke)

Antiplatelets (aspirin, dipyridamole, clopidogrel)
● Low-dose aspirin is given within 24 to 48 hr following

an ischemic stroke to prevent further clot formation.
● Platelet inhibitors (dipyridamole, clopidogrel) can be

given to clients who have experienced thrombotic or
embolic stroke.

Antiepileptic medications (phenytoin, gabapentin)
● These medications are not commonly given following a

stroke unless the client develops seizures.
● Gabapentin can be given for paresthetic pain in an

affected extremity.

THerAPeUTiC PrOCedUres
Systemic or catheter-directed thrombolytic therapy
restores cerebral blood flow. It must be administered
within 6 hr of the onset of manifestations. It is
contraindicated for treatment of a hemorrhagic stroke
and for clients who have an increased risk of bleeding
due to anticoagulant therapy or other bleeding anomalies.
Possibility of hemorrhagic stroke is ruled out with an MRI
prior to the initiation of thrombolytic therapy.

● Carotid artery angioplasty with stenting (CAS) involves
inserting a catheter in the femoral artery and placing a
distal/embolic protection device to catch clot debris during
the procedure while a stent is being placed in the carotid
artery to open a blockage. CAS is less invasive, blood
loss is decreased, and length of hospitalization is shorter.
Postoperative care is the same as carotid endarterectomy.

● Carotid endarterectomy is performed to open the artery
by removing atherosclerotic plaque. This procedure is
performed when the carotid artery is blocked or when
the client is experiencing TIAs.

◯ Assess for increased headache, neck swelling, and
hoarseness of the throat.

● Extracranial-intracranial bypass is a craniotomy
performed to improve cerebral perfusion following a
stroke or for clients who have had a TIA that is likely
to progress to a stroke. It increases blood flow around
a blocked artery and can help restore blood flow to
affected areas of the brain.

iNTerPrOFessiONAL CAre
● Speech and language therapists can be consulted for

language therapy and swallowing exercises.
● Physical therapy can be consulted for assistance with

reestablishment of ambulation with or without assistive
devices (single or quad cane, walker) or wheelchair support.
Wheelchair adaptations (an extended brake handle on the
client’s affected side of the wheelchair) can be necessary.

● Occupational therapy can be consulted for assistance
with reestablishment of partial or full function of the
affected hand and arm. If function does not return to
the extremity, measures (massage and elastic gloves)
will be prescribed by occupational therapy to prevent
swelling of the extremity.

● Social services can be consulted to make arrangements
for rehabilitation services and temporary placement on a
skilled rehabilitation unit or extended-care facility during
provision of these services. Prior to discharge, the social
worker can make a home visit with selected therapists and
nurses to evaluate the need for environmental alterations
in the home and adaptive equipment needed for ADLs.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 15 sTrOKe 91

COMPLICATIONS

Dysphagia and aspiration
● Dysphagia can result from neurologic involvement of

the cranial nerves that innervate the face, tongue, soft
palate, and throat. As a result, the client’s risk of
aspiration is great.

● Not all clients who have experienced a stroke have
dysphagia, but all should be evaluated prior to
reestablishing oral nutrition and hydration.

NURSING ACTIONS
● Assess gag reflex. If the gag reflex is present, give

the client a small sip of water to determine if
choking occurs.

● If the client exhibits difficulty managing food or fluids,
a swallowing evaluation should be done by an SLP.

● Keep the client completely NPO until evaluated
by the SLP.

● When resuming intake, provide the client with the
prescribed liquid-consistency regimen from the
National Dysphagia Diet and observe closely for choking.
Have suction equipment available, but feed with care
because nasotracheal suctioning increases ICP.

● An RN should provide the initial feeding and intervene
if choking occurs. Some clients require an eating
environment without distractions to prevent choking.

CLIENT EDUCATION
● Use recommended techniques for eating and adhere to

instructions regarding prescribed consistency of liquids
and solid foods.

● Sit upright and flex the head forward when swallowing
to decrease the risk of choking.

Unilateral neglect

Unilateral neglect is the loss of awareness of the side
affected by the stroke. The client cannot see, feel, or move
the affected side of the body; therefore, they forget that it
exists. This lack of awareness poses a great risk for injury
to the neglected extremities and creates a self-care deficit.

NURSING ACTIONS
● Observe affected extremities for injury (bruises and

abrasions of the affected hand and arm, hyperflexion
of the foot from it falling off of the wheelchair
during transport).

● Apply an arm sling if the client is unable to remember
to care for the affected extremity.

● Ensure that the foot rest is on the wheelchair and that
an ankle brace is on the affected foot.

CLIENT EDUCATION
● Dress the affected side first.
● Care for the affected side.
● Use the unaffected hand to pull the affected extremity

to midline and out of danger from the wheel of the
wheelchair or from hitting or smashing it against
a doorway.

● Look over the affected side periodically.

15.4 Communication board

92 CHAPTER 15 sTrOKe CONTENT MASTERY SERIES

Active Learning Scenario

A nurse is caring for a client who has dysphagia. Use the ATi
Active Learning Template: Nursing skill to complete this item.

NURSING INTERVENTIONS: List three nursing actions
the nurse should include while caring for this client.

Application Exercises

1. A nurse is caring for a client who has experienced
a right‑hemispheric stroke. The nurse should
expect the client to have difficulty with which
of the following? (select all that apply.)

A. impulse control

B. Moving the left side

C. depth perception

d. speaking

e. situational awareness

2. A nurse is caring for a client who has left
homonymous hemianopsia. Which of the following
is an appropriate nursing intervention?

A. Teach the client to scan to the right to see
objects on the right side of the body.

B. Place the bedside table on the
right side of the bed.

C. Orient the client to the food on the
plate using the clock method.

d. Place the wheelchair on the client’s left side.

3. A nurse is planning care for a client who has
dysphagia and a new dietary prescription.
Which of the following should the nurse include
in the plan of care? (select all that apply.)

A. Have suction equipment available for use.

B. Feed the client thickened liquids.

C. Place food on the unaffected
side of the client’s mouth.

d. Assign an assistive personnel to
feed the client slowly.

e. Teach the client to swallow with the neck flexed.

4. A nurse is caring for a client who has global
aphasia (both receptive and expressive). Which
of the following should the nurse include in the
client’s plan of care? (select all that apply.)

A. speak to the client at a slower rate.

B. Assist the client to use cards with pictures.

C. speak to the client in a loud voice.

d. Complete sentences that the client cannot finish.

e. Give instructions one step at a time.

5. A nurse is assessing a client. Which of the
following findings indicates that the client has
experienced a left‑hemispheric stroke?

A. impulse control difficulty

B. Poor judgment

C. inability to recognize familiar objects

d. Loss of depth perception

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 15 sTrOKe 93

Application Exercises Key

1. A. CORRECT: A client who has experienced a right‑hemispheric
stroke can exhibit impulse control difficulty, such
as the urgency to use the restroom.

B. CORRECT: A client who has experienced a right‑hemispheric
stroke can exhibit left‑sided hemiplegia.

C. CORRECT: A client who has experienced a right‑hemispheric
stroke can experience a loss in depth perception.

d. A client who has experienced a left‑hemispheric
stroke can experience aphasia.

e. CORRECT: A client who has experienced a right‑hemispheric
stroke can demonstrate a lack of awareness of surroundings.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. A. A client who has left homonymous hemianopsia
has lost the left visual field of both eyes. The client
should be taught to turn the head to the left to
visualize the entire field of vision.

B. CORRECT: The client is unable to visualize to the
left midline of their body. Placing the bedside
table on the right side of the client’s bed will
permit visualization of items on the table.

C. Using the clock method of food placement will be
ineffective because only half of the plate can be seen.

d. The wheelchair should be placed to the
client’s right or unaffected side.

NCLEX® Connection: Physiological Adaptation,
Illness Management

3. A. CORRECT: suction equipment should be available
in case of choking and aspiration.

B. CORRECT: The client should be given liquids that
are thicker than water to prevent aspiration.

C. CORRECT: Placing food on the unaffected side of the
client’s mouth will allow them to have better control
of the food and reduce the risk of aspiration.

d. due to the risk of aspiration, assistive personnel
should not be assigned to feed the client because the
client’s swallowing ability should be assessed, and
suctioning can be needed if choking occurs.

e. CORRECT: The client should be taught to flex
the neck, tucking the chin down and under to
close the epiglottis during swallowing.

NCLEX® Connection: Reduction of Risk Potential,
Potential for Alterations in Body Systems

4. A. CORRECT: Clients who have global aphasia have
difficulty with speaking and understanding speech.
One strategy that can enhance client understanding
is speaking to the client at a slower rate.

B. CORRECT: One strategy that can enhance understanding
is the use of alternative forms of communication,
such as cards with pictures or a computer.

C. For the client who has aphasia, speaking in a loud voice is
unnecessary and can be interpreted as patronizing.

d. Allow the client adequate time to finish sentences
and not complete the sentences for them.

e. CORRECT: One strategy that can enhance understanding
is giving instructions one step at a time.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

5. A. A client who has experienced a right‑hemispheric stroke
will experience difficulty with impulse control.

B. A client who has experienced a right‑hemispheric
stroke will experience poor judgment.

C. CORRECT: A client who experienced a left‑hemispheric
stroke will demonstrate the inability to recognize
familiar objects, known as agnosia.

d. A client who experienced a right‑hemispheric stroke
will experience a loss of depth perception.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

Active Learning Scenario Key

Using the ATI Active Learning Template: Nursing Skill

NURSING INTERVENTIONS
● Assess gag reflex. if the gag reflex is present, give the client
a small sip of water to determine if choking occurs.

● if the client exhibits difficulty managing food or fluids, a
speech therapist should do a swallowing evaluation.

● Provide the client with the prescribed diet and observe closely
for choking. Have suction equipment available. An rN should
provide the initial feeding and intervene if choking occurs.

● Thicker liquids are usually tolerated better than thin liquids.
Collaborate with the speech‑language pathologist and
dietitian to find the proper consistency and type of diet.

NCLEX® Connection: Physiological Adaptation, Illness
Management

94 CHAPTER 15 sTrOKe CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 16 sPiNAL COrd iNJUry 95

UNIT 2 NEUROLOGIC DISORDERS
SECTION: NEUROLOGIC EMERGENCIES

CHAPTER 16 Spinal Cord Injury
spinal cord injuries (sCis) involve the loss of
motor function, sensory function, reflexes, and
control of elimination. injuries in the cervical
region result in quadriplegia: paralysis/paresis
of all four extremities and trunk. injuries below
T1 result in paraplegia: paralysis/paresis of the
lower extremities. Truncal instability also results
if the lesion is in the upper thoracic region.

The level of cord involved dictates the
consequences of spinal cord injury. For example,
an injury at C4 or above poses a great risk for
impaired spontaneous ventilation due to the
involvement of the phrenic nerve. (16.1)

Not all fractures of the vertebrae cause sCis.
direct injury to the spinal cord secondary to
the trauma or bone fragments in the spinal
canal must occur for the spinal cord itself to
become damaged.

sCis range from contusions or incomplete
lesions of the spinal cord to complete lesions
that extend across the entire diameter of the
cord, or an actual transection of the spinal
cord. Complete lesions result in the loss of all
voluntary movement and sensation below the
level of the injury. incomplete lesions result
in varying losses of voluntary movement and
sensation below the level of the injury.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Causes of most SCIs are trauma (such as motor vehicle
accidents), diving accidents, and gunshot wounds.

● Hyperflexion injuries are caused by acceleration injuries
that cause sharp forward flexion of the spine (head-on
collision, fall, or diving). Hyperextension injuries are
caused by a backward snap of the spine (rear-end
collision or a downward fall onto the chin).

ASSESSMENT

risK FACTOrs
● High-risk activities (extreme sports or high-

speed driving)
● Participation in impact sports (football or diving)
● Acts of violence (gunshot and knife wounds)
● Substance use
● Disease (metastatic cancer or arthritis of the spine)
● Falls, especially in older adults

eXPeCTed FiNdiNGs
● Report of lack of sensation of dermatomes below the

level of the lesion
● Report of neck or back pain

PHYSICAL ASSESSMENT FINDINGS
● Inability to feel light touch when touched by a cotton

ball, inability to discriminate between sharp and dull
when touched with a safety pin or other sharp objects,
and inability to discriminate between hot and cold when
touched with containers of hot and cold water

● Absent deep tendon reflexes
● Flaccidity of muscles
● Hypotension that is more severe when the client is

sitting in an upright position
● Shallow respirations
● Spinal shock, a complication of spinal cord injury,

causes a total but temporary loss of all reflexive and
autonomic function below the level of injury, lasting for
a period of days to weeks.

CHAPTER 16

Online Image: Spinal Cord and Cauda Equina

16.1 Spinal cord and cauda equina

96 CHAPTER 16 sPiNAL COrd iNJUry CONTENT MASTERY SERIES

LABOrATOry TesTs
Urinalysis, hemoglobin, ABGs, CBCs (for evaluation of
platelets and WBCs): Used to monitor for undiagnosed
internal bleeding (the client might not feel pain from
internal injuries) and impaired respiratory exchange (due
to phrenic nerve involvement and/or inability to
voluntarily increase depth and rate of respirations)

diAGNOsTiC PrOCedUres
X-rays, magnetic resonance imaging (MRI), and computed
tomography (CT) imaging/computed axial tomography
(CAT) scan can be used to assess the extent of the damage
and the location of blood and bone fragments.

PATIENT‑CENTERED CARE

NUrsiNG CAre

Respiratory status
● Monitoring respiratory status is the first priority.

Involuntary respirations can be affected due to a lesion
at or above the phrenic nerve or swelling from a lesion
immediately below C4. Lesions in the cervical or upper
thoracic area will also impair voluntary movement of
muscles used in respiration (increase in depth or rate).

● Provide oxygen and suction as needed.
● Assist with intubation and mechanical ventilation

if necessary.
● Assist the client to cough by applying abdominal

pressure when attempting to cough.
● Teach the client about incentive spirometer use, and

encourage the client to perform coughing and deep
breathing regularly.

Tissue perfusion

Neurogenic shock , which is a complication of spinal
trauma, causes a sudden loss of communication within
the sympathetic nervous system that maintains the
normal muscle tone in blood vessel walls. Neurogenic
shock can occur within 24 hr of a SCI, resulting in
peripheral vasodilation that leads to venous pooling in
the extremities, a drop in cardiac output and heart rate,
and a life-threatening decrease in blood pressure. This
complication can last for several days to weeks.

● Ensure proper positioning of the client by stabilizing
the spinal cord following an injury.

● Monitor for hypotension, bradycardia, dependent edema,
and loss of temperature regulation (abrupt onset of
fever), which are common manifestations.

● Clients who experience neurogenic shock are at greater
risk for development of venous thromboembolism (VTE).

◯ Monitor for manifestations of VTE (swelling of
extremity, absent/decreased pulses, and areas of
warmth and/or tenderness). The client might be
on anticoagulants to prevent development of lower
extremity thrombi.

Intake and output

The client might be NPO for several days. Regulation of
fluid balance and nutritional support is necessary. Provide
adequate fluid intake for the client to prevent urinary
calculi and bladder infections, and maintain soft stools.

Neurologic status

After determining the baseline, monitor for an increasing
loss of neurologic function.

Muscle strength and tone

After determining the baseline, monitor for an increasing
loss of muscle strength in the affected extremities.

● Clients who have upper motor neuron injuries (above
L1 and L2) will convert to a spastic muscle tone after
neurogenic shock.

● Clients who have lower motor neuron injuries (below L1
and L2) will convert to a flaccid type of paralysis.

● Because most lower motor neuron lesions involve
the cauda equina, the motor and sensory deficits
can be patchy, with some areas of innervation and
others without.

● Encourage active range-of-motion (ROM) exercises
when possible, and assist with passive ROM if the client
lacks all motor function.

● Muscle spasticity can be so severe that clients
develop pressure injuries, which can make sitting in a
wheelchair very difficult.

● Muscle spasms can be painful for some clients while
others do not feel pain.

Mobility

Clients who have complete injuries will not regain
mobility. Clients who have incomplete injuries can regain
some function that will allow mobility with various types
of braces. However, functional mobility can still be best
attained through the use of a wheelchair.

● When in an upright position, clients with high levels of
spinal cord injury may experience postural hypotension.
Transferring the client to a wheelchair should occur
in stages.

◯ Raise the head of the bed and be ready to lower the
angle if the client reports dizziness.

◯ Transfer the client into a reclining wheelchair with
the back of the wheelchair reclined.

◯ Be ready to lock and lean the wheelchair back onto
the knee to a fully-reclined position if the client
reports dizziness after the transfer.

◯ Do not attempt to return the client to the bed.

Sensation

The amount of sensation lost depends on whether the
lesion is complete or incomplete. Take care to prevent skin
breakdown in both the bed and wheelchair. Various types
of foam and air mattresses are available for beds and
wheelchairs.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 16 sPiNAL COrd iNJUry 97

Bowel and bladder function
● Spastic neurogenic bladder: Clients who have upper

motor neuron injuries develop spastic bladder after
the neurogenic shock resolves. Bladder management
options for male clients include condom catheters and
stimulation of the micturition reflex by tugging on the
pubic hair. Female clients need to use an indwelling
urinary catheter due to the unpredictably of the
release of urine.

● Flaccid neurogenic bladder: Clients who have lower
motor neuron injuries develop a flaccid bladder. Bladder
management options for males and females include
intermittent catheterization and Credé’s method
(downward pressure placed on the bladder to manually
express the urine).

● Neurogenic bowel functioning does not differ much
between upper and lower motor neuron injuries. Daily
use of stool softeners or bulk-forming laxatives
is recommended to keep the stool soft. A bowel
movement can be stimulated daily or every other day
by administration of a bisacodyl suppository or digital
stimulation (stimulation of the rectal sphincter with a
gloved and lubricated finger) only if requested by the
provider. Digital stimulation should be used cautiously
to avoid provoking a vagal response, which can result in
bradycardia and syncope.

● Development of a schedule as part of bladder and bowel
training is critical in preventing complications related
to immobility and promoting adequate nutrition and
fluid balance.

Gastrointestinal function

An ileus can develop immediately after injury. Monitor
bowel sounds.

Skin integrity

Changing the client’s position every 2 hr (every 1 hr
when in a wheelchair) is critical. Clients who have a SCI
can neither move nor feel pain from prolonged pressure.
Pressure-relief devices in both the bed and the wheelchair
must be consistently used.

Sexual function

Teach the client about alterations in sexual function and
possible adaptive strategies. Clients who have quadriplegia
and other clients who have upper motor neuron lesions are
usually capable of reflexogenic erections (erections
secondary to manual manipulation). Ejaculation
coordinated with emission might not occur. Clients who
have lower motor neuron injuries are less able to have
reflexogenic erections, but clients who have incomplete
injuries might be able to have a combination of
reflexogenic and psychogenic erections (erections
stimulated by sexual thoughts and images). Medications
can help, in some instances.

MediCATiONs

Vasopressors

Norepinephrine and dopamine are administered to treat
hypotension, particularly during neurogenic shock.

Antimuscarinic

Atropine may be used to treat bradycardia.

Plasma expanders

Dextran, a volume expander, is used to treat hypotension
secondary to spinal shock.

NURSING ACTIONS: Observe for manifestations of
fluid overload.

Muscle relaxants

Baclofen and dantrolene: Administered to clients who
have severe muscle spasticity.

● Monitor for drowsiness and muscle weakness.
● Baclofen may be administered intrathecally to reduce

the sedative effects.

Cholinergics

Bethanechol: Decreases spasticity of the bladder, allowing
for easier bladder training and fewer accidents.

NURSING ACTIONS: Observe for urinary retention.
Measure residual periodically.

Analgesics

Opioids, non-opioids, and NSAIDs are
administered for pain.

Anticoagulants

Heparin or low-molecular-weight heparins are used for
DVT prophylaxis.

NURSING ACTIONS
● Monitor INR, PT, and aPTT for therapeutic levels

of anticoagulation.
● Observe for manifestations of gastrointestinal bleeding

or bleeding secondary to unrecognized injury.

Stool softeners and bulk‑forming laxatives

Docusate sodium or polycarbophil prevent constipation
and keep the stool soft.

Vasodilators
● Hydralazine and nitroglycerin: Use PRN to treat

episodes of hypertension during automatic dysreflexia.
● NURSING ACTIONS: Monitor blood pressure frequently.

98 CHAPTER 16 sPiNAL COrd iNJUry CONTENT MASTERY SERIES

THerAPeUTiC PrOCedUres

Application of immobilization devices and traction

Clients who have cervical fractures may be placed in a
halo fixation (16.2) device or cervical tongs. The purpose is
to provide traction and/or immobilize the spinal column.

NURSING ACTIONS
● Maintain body alignment and ensure cervical tong

weights hang freely.
● Monitor skin integrity by providing pin care and assessing

the skin under the halo fixation vest as appropriate.
● Do not use the halo device to turn or move a client.

CLIENT EDUCATION
● If going home with a halo fixation device on, follow

instructions for pin and vest care.
● Report indications of infection and skin breakdown.

Spinal surgery
● Spinal fusion is commonly performed when a spinal

fracture creates an area of instability of the spine.
● Spinal fusions in the cervical area usually are performed

through the front of the neck.
● Spinal fusions in the thoracic or lumbar areas are

performed using a posterior approach and can be
combined with a decompressive laminectomy.

● A decompressive laminectomy is performed by removing
a section of lamina; accessing the spinal canal; and
removing bone fragments, foreign bodies, or
hematomas that can place pressure on the spinal cord.

● Donor bone often is obtained from the iliac crest and
used to fuse together the vertebrae that are unstable.

● Application of paravertebral rods can be used to
mechanically immobilize several vertebral levels.

NURSING ACTIONS
● In clients who have undergone an anterior cervical fusion,

monitor for possible airway compromise from swelling or
hemorrhage. Observe for deviation of the trachea.

● Assess neurologic status and vital signs every hour for
the first 4 hr following spinal fusion.

CLIENT EDUCATION
● An area of decreased range of motion will always exist

in the area of fusion or paravertebral rods.
● Rods are usually not removed unless they cause pain.

Removal can be done after the spine has restabilized.

iNTerPrOFessiONAL CAre
● Occupational and physical therapy teach the client

how to perform ADLs and reestablish mobility using a
wheelchair, braces, or crutches. The client also will be
fitted for splints to prevent contractures and provided
wrist support for eating and manipulating the joystick
on an electric wheelchair.

● Social services needs to determine the client’s financial
resources, home care needs, and home modifications.

● Referral of the client to a SCI support group can aid in
emotionally adapting to changes in body image and role.

CLieNT edUCATiON
● Clients who have experienced SCI with subsequent loss

of function will need varying levels of support upon
discharge, and multiple referrals can be required.

● Clients who have quadriplegia require a lengthy and
extensive rehabilitative experience, which can occur on
an outpatient or in-home basis. Less extensive therapy
is required for paraplegia, but many accommodations
need to be made.

● A family member or support person should understand
how to assist with care (ADLs, transfers, medications).

● Many adaptations might also need to be made to the
home to make it wheelchair accessible.

COMPLICATIONS

Orthostatic hypotension

Occurs when clients change position due to the
interruption in functioning of the automatic nervous
system and pooling of blood in lower extremities when in
an upright position.

NURSING ACTIONS
● Change the client’s positioning slowly and place the

client in a wheelchair that reclines.
● Use thigh-high elastic hose or elastic wraps to

increase venous return. Elastic wraps might need to
extend all the way up the client’s legs and include the
client’s abdomen.

Spinal shock
● Spinal shock is the spinal cord’s response to the

inflammation caused by the injury.
● Manifestations include flaccid paralysis, loss of reflex

activity below the level of injury, and paralytic ileus due
to the loss of autonomic function. The client can have
hypotension and bradycardia.

● Keeping mean arterial pressure at least 85 mm Hg can
prevent further damage to the spinal cord.

Neurogenic shock
● Neurogenic shock is a common response of the spinal

cord following an injury.
● Manifestations of bradycardia, hypotension, dependent

edema, and loss of temperature regulation are caused by
a sudden loss of communication within the sympathetic
nervous system that maintains the normal muscle tone
in blood vessel walls.

NURSING ACTIONS: Treat adverse findings with
appropriate medications (vasopressors or atropine) and
IV fluids.

Online Image: Halo Traction

Online Image: Laminectomy

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 16 sPiNAL COrd iNJUry 99

Autonomic dysreflexia
● Occurs secondary to the stimulation of the sympathetic
nervous system and inadequate compensatory response
by the parasympathetic nervous system. Clients who
have lesions below T6 do not experience dysreflexia
because the parasympathetic nervous system is able to
neutralize the sympathetic response.

● Sympathetic stimulation is usually caused by a
triggering stimulus in the lower part of the body. (See
Nursing Actions).

● Stimulation of the sympathetic nervous system causes
extreme hypertension, sudden severe headache, pallor
below the level of the spinal cord’s lesion dermatome,
blurred vision, diaphoresis, restlessness, nausea, and
piloerection (goose bumps).

● Stimulation of the parasympathetic nervous system
causes bradycardia, flushing above the corresponding
dermatome to the spinal cord lesion (flushed face and
neck), and nasal stuffiness.

NURSING ACTIONS
● Sit the client up to decrease blood pressure secondary
to postural hypotension.

● Notify the provider.
● Determine and treat the cause.

◯ Distended bladder is the most common cause (kinked
or blocked indwelling urinary catheter, urinary
retention, urinary calculi). Insert a catheter for
distended bladder using anesthetic ointment on the
catheter tip, or check existing catheter for kinks, and
irrigate if needed.

◯ Remove fecal impaction (use anesthetic ointment
prior to removal).

◯ Adjust the room temperature and block drafts.
◯ Remove tight clothing.
◯ Assess for injury (lower extremity fracture, kidney/
bladder infection).

● Monitor vital signs for severe hypertension
and bradycardia.

● Administer antihypertensives (nitrates or hydralazine).

CLIENT EDUCATION
● Understand and prevent potential causes of dysreflexia.
● If fluid intake is temporarily increased, drink a little
more at various times throughout the day rather than
all at once.

● Keep a list of actions to take if an episode of
dysreflexia occurs.

16.2 Halo traction

16.3 Laminectomy

100 CHAPTER 16 sPiNAL COrd iNJUry CONTENT MASTERY SERIES

Application Exercises

1. A nurse is planning care for a client who has a
spinal cord injury (sCi) involving a T12 fracture
1 week ago. The client has no muscle control of
the lower limbs, bowel, or bladder. Which of the
following should be the nurse’s highest priority?

A. Prevention of further damage to the spinal cord

B. Prevention of contractures of the lower extremities

C. Prevention of skin breakdown of
areas that lack sensation

d. Prevention of postural hypotension when
placing the client in a wheelchair

2. A nurse is caring for a client who has a spinal
cord injury who reports a severe headache and is
sweating profusely. Vital signs include blood pressure
220/110 mm Hg and apical heart rate 54/min. Which
of the following actions should the nurse take first?

A. examine skin for irritation or pressure.

B. sit the client upright in bed.

C. Check the urinary catheter for blockage.

d. Administer antihypertensive medication.

3. A nurse is caring for a client who has a C4 spinal cord
injury. The nurse should recognize the client is at
greatest risk for which of the following complications?

A. Neurogenic shock

B. Paralytic ileus

C. stress ulcer

d. respiratory compromise

4. A nurse is caring for a client who experienced a
cervical spine injury 24 hr ago. Which of the following
prescriptions should the nurse clarify with the provider?

A. Anticoagulant

B. Plasma expanders

C. H2 antagonists

d. Muscle relaxants

5. A nurse is caring for a client who experienced
a cervical spine injury 3 months ago. The nurse
should plan to implement which of the following
types of bladder management methods?

A. Condom catheter

B. intermittent urinary catheterization

C. Credé’s method

d. indwelling urinary catheter

Active Learning Scenario

A nurse is assessing a client who has a spinal cord
injury. Use the ATi Active Learning Template:
system disorder to complete this item.

EXPECTED FINDINGS: List three physical
assessment findings the nurse should look for.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 16 sPiNAL COrd iNJUry 101

Application Exercises Key

1. A. CORRECT: The greatest risk to the client during the acute
phase of an sCi is further damage to the spinal cord. When
planning care, the priority intervention to take is to prevent
further damage to the spinal cord by minimizing movement
of the client until spinal stabilization is accomplished through
either traction or surgery, and adequate oxygenation of
the client to decrease ischemia of the spinal cord.

B. implement rOM exercise to prevent contractures.
However, another action is the priority.

C. implement a turning schedule to prevent skin
breakdown. However, another action is the priority.

d. slowly move the client to an upright position
to prevent postural hypotension. However,
another action is the priority.

NCLEX® Connection: Physiological Adaptation,
Illness Management

2. A. examine the client’s skin for areas of irritation, pressure,
or broken skin to alleviate a triggering stimulus.
However, another action is the priority.

B. CORRECT: The greatest risk to the client is experiencing
a cerebrovascular accident (stroke) secondary to elevated
blood pressure caused by autonomic dysreflexia. The first
action to take is to elevate the head of the bed until the
client is in an upright position, which should lower the
blood pressure secondary to postural hypotension.

C. Check the client’s catheter for blockage.
However, another action is the priority.

d. Administer an antihypertensive medication if indicated.
However, another action is the priority.

NCLEX® Connection: Reduction of Risk Potential,
Changes/Abnormalities in Vital Signs

3. A. Monitor for neurogenic shock, which is a response of the
sympathetic nervous system of a client who has a sCi.
However, another complication is the priority.

B. Monitor for a paralytic ileus, which is a complication
immediately following a sCi. However,
another complication is the priority.

C. Monitor for a stress ulcer, which is a response
to changes caused from the sCi. However,
another complication is the priority.

d. CORRECT: When using the airway, breathing, and circulation
(ABC) approach to client care, the priority complication is
respiratory compromise secondary to involvement of the
phrenic nerve. Maintenance of an airway and provision of
ventilatory support as needed is the priority intervention.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. A. Administer an anticoagulant to decrease
the risk of developing a VTe.

B. Administer plasma expanders to treat
hypotension caused by the sCi.

C. Administer H2 antagonists to decrease the complication
of developing a gastric ulcer from stress.

d. CORRECT: Clarify with the provider the need for the client
to receive muscle relaxants. The client will not experience
muscle spasms until after the spinal shock has resolved,
making muscle relaxants unnecessary at this time.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

5. A. CORRECT: implement the noninvasive use of a condom
catheter, because the bladder will empty on its own
due to the client having an upper motor neuron injury,
which is manifested by a spastic bladder.

B. implement the intermittent urinary catheterization
method for a client who has a flaccid bladder.

C. implement the Credé’s method for a client
who has a flaccid bladder.

d. An indwelling urinary catheter is an invasive procedure. do not
implement this bladder management method for the client.

NCLEX® Connection: Basic Care and Comfort, Elimination

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

EXPECTED FINDINGS
● inability to feel light touch when touched by a cotton ball, inability
to discriminate between sharp and dull when touched with a safety
pin or other sharp objects, and an inability to discriminate between
hot and cold when touched with containers of hot and cold water

● Absent deep tendon reflexes
● Flaccidity of muscles
● Hypotension that is more severe when the
client is sitting in an upright position

● shallow respirations
● dependent edema
● Neurogenic shock, which accompanies spinal trauma and
causes a total loss of all reflexive and autonomic function below
the level of the injury for a period of several days to weeks

● Loss of temperature regulation: hyperthermia or hypothermia

NCLEX® Connection: Reduction of Risk Potential, System Specific
Assessments

102 CHAPTER 16 sPiNAL COrd iNJUry CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING NCLeX® CONNeCTiONs 103

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Pharmacological and Parenteral Therapies
ADVERSE EFFECTS/CONTRAINDICATIONS/SIDE EFFECTS/
INTERACTIONS: Assess the client for actual or potential
side effects and adverse effects of medications.

EXPECTED ACTIONS/OUTCOMES: Evaluate
client response to medication.

MEDICATION ADMINISTRATION: Educate the client
on medication self-administration procedures.

Reduction of Risk Potential
LABORATORY VALUES: Identify laboratory values for ABGs, BUN,
cholesterol, glucose, hematocrit, hemoglobin, glycosylated hemoglobin,
platelets, potassium, sodium, WBC, creatinine, PT, PTT & APTT, INR.

POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC TESTS/
TREATMENTS/PROCEDURES: Maintain tube patency.

SYSTEM SPECIFIC ASSESSMENTS: Perform focused assessments.

THERAPEUTIC PROCEDURES
Educate client about home management of care.

Monitor effective functioning of therapeutic devices.

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104 NCLeX® CONNeCTiONs CONTENT MASTERY SERIES

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS
Monitor and care for clients on a ventilator.

Identify signs, symptoms and incubation periods of infectious diseases.

ILLNESS MANAGEMENT: Manage the care of a
client with impaired ventilation/oxygenation.

MEDICAL EMERGENCIES: Apply knowledge of nursing
procedures and psychomotor skills when caring for a
client experiencing a medical emergency.

PATHOPHYSIOLOGY
Identify pathophysiology related to an acute or chronic condition.

Understand general principles of pathophysiology.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 17 resPirATOry diAGNOsTiC PrOCedUres 105

UNIT 3 RESPIRATORY DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 17 Respiratory
Diagnostic
Procedures

respiratory diagnostic procedures are used to
evaluate a client’s respiratory status by checking
indicators such as the oxygenation of the blood,
lung functioning, and the integrity of the airway.

respiratory diagnostic procedures nurses
should be knowledgeable about include
pulmonary function tests, arterial blood gases,
bronchoscopy, and thoracentesis.

Pulmonary function tests
Pulmonary function tests (PFTs) determine lung function
and breathing difficulties.

● PFTs measure lung volumes and capacities, diffusion
capacity, gas exchange, flow rates, and airway
resistance, along with distribution of ventilation.

● Helpful in identifying clients who have lung disease.
● Commonly performed for clients who have dyspnea.
● Can be performed before surgical procedures to identify

clients who have respiratory risks.
● If client is a smoker, instruct client not to smoke 6 to

8 hr prior to testing.
● If a client uses inhalers, withhold 4 to 6 hr prior to

testing. (This can vary according to facility policy.)

Arterial blood gases
An arterial blood gas (ABG) sample reports the status of
oxygenation and acid-base balance of the blood.

● An ABG measures the following.
◯ pH: amount of free hydrogen ions in the arterial

blood (H+)
◯ PaO2: partial pressure of oxygen
◯ PaCO2: partial pressure of carbon dioxide
◯ HCO3¯: concentration of bicarbonate in arterial blood
◯ SaO2: percentage of oxygen bound to Hgb as compared
with the total amount that can be possibly carried

● ABGs can be obtained by an arterial puncture or
through an arterial line.

INDICATIONS
POTENTIAL DIAGNOSES

● Blood pH levels can be affected by a number of
conditions (respiratory, renal, malnutrition, electrolyte
imbalance, endocrine, or neurologic).

● These assessments are helpful in monitoring the
effectiveness of various treatments (such as acidosis
interventions), in guiding oxygen therapy, and
in evaluating client responses to weaning from
mechanical ventilation.

CONSIDERATIONS

Arterial puncture

PrePrOCedUre
NURSING ACTIONS

● Obtain a heparinized syringe for the sample collection.
● Perform an Allen’s test prior to arterial puncture to

verify patent radial and ulnar circulation. Compress
the ulnar and radial arteries simultaneously while
instructing the client to form a fist. Then instruct the
client to relax his hand while assessing the palm and
fingers for blanching. Next, release pressure on the
ulnar artery while observing the hand for flushing
caused by capillary refilling. The client’s hand should
turn pink within 15 seconds, indicating patency of the
ulnar artery and an ability to use the radial artery to
obtain arterial blood gases. (17.1)

● Explain and reinforce the procedure with the client.
Clients often experience pain with repeated ABG level
checks and are often unaware of the purpose of the
puncture.

CHAPTER 17

17.1 Allen’s test

106 CHAPTER 17 resPirATOry diAGNOsTiC PrOCedUres CONTENT MASTERY SERIES

iNTrAPrOCedUre
NURSING ACTIONS

● Perform an arterial puncture using surgical
aseptic technique, and collect a specimen into a
heparinized syringe.

● Place the collected and capped specimen into a basin
of ice and water to preserve pH levels and oxygen
pressure. The specimen should be transported to the
laboratory immediately.

● Accessing the radial artery for sampling can be more
difficult with older adult clients due to impaired
peripheral vasculature.

! Note: Arterial puncture is frequently done by
a respiratory therapist in hospital settings.

POsTPrOCedUre
NURSING ACTIONS

● Immediately after an arterial puncture, hold direct
pressure over the site for at least 5 min. Pressure must
be maintained for at least 20 min if the client is
receiving anticoagulant therapy. Ensure that bleeding
has stopped prior to removing direct pressure.

● Monitor the ABG sampling site for bleeding, loss of
pulse, swelling, and changes in temperature and color.

● Document all interventions and client response.
● Report results to the provider as soon as they

are available.
● Implement respiratory interventions as indicated or

prescribed, based on results (adjusting oxygen delivery
or ventilator settings).

INTERPRETATION OF FINDINGS
Blood pH levels less than 7.35 reflect acidosis, and levels
greater than 7.45 reflect alkalosis. (17.2)

COMPLICATIONS
Hematoma, arterial occlusion

A hematoma occurs when blood accumulates under the
skin at the IV site.

NURSING ACTIONS
● Observe for changes in temperature, swelling, color, loss

of pulse, or pain.
● Notify the provider immediately if

manifestations persist.
● Apply pressure to the hematoma site.

Air embolism

Air enters the arterial system during catheter insertion.

NURSING ACTIONS
● Place the client in the flat or Trendelenburg position.
● Ask the client to bear down while holding their breath

(Valsalva maneuver).
● Monitor for sudden onset of shortness of breath,

decrease in SaO2 levels, chest pain, anxiety, and
air hunger.

● Notify the provider immediately if manifestations
occur, administer oxygen therapy, and obtain ABGs.
Continue to assess the client’s respiratory status for
any deterioration.

Bronchoscopy
Bronchoscopy permits visualization of the larynx, trachea,
and bronchi through either a flexible fiber-optic or
rigid bronchoscope.

● Bronchoscopy can be performed as an outpatient
procedure, in a surgical suite under general anesthesia,
or at the bedside under local anesthesia and moderate
(conscious) sedation.

● Bronchoscopy can also be performed on clients who are
receiving mechanical ventilation by inserting the scope
through the client’s endotracheal tube.

INDICATIONS
POTENTIAL DIAGNOSES

● Visualization of abnormalities (tumors, inflammation,
strictures)

● Biopsy of suspicious tissue (lung cancer)
◯ Clients undergoing a bronchoscopy with biopsy have
additional risks for bleeding and/or perforation.

● Aspiration of deep sputum or lung abscesses for culture
and sensitivity or cytology (pneumonia)

! Bronchoscopy is also performed for
therapeutic reasons, such as removal of
foreign bodies and secretions from the
tracheobronchial tree, treating postoperative
atelectasis, and to destroy and excise lesions.

CONSIDERATIONS

PrePrOCedUre
NURSING ACTIONS

● Assess for allergies to anesthetic agents or routine use
of anticoagulants.

● Ensure that a consent form is signed by the client prior
to the procedure.

● Remove the client’s dentures, if applicable, prior to
the procedure.

● Maintain the client on NPO status prior to the procedure,
usually 4 to 8 hr, to reduce the risk of aspiration when
the cough reflex is blocked by anesthesia.

● Administer preprocedure medications (anxiolytic,
atropine, viscous lidocaine, local anesthetic
throat spray).

17.2 ABG measures and expected
reference ranges

ABG MEASURE EXPECTED REFERENCE RANGE
pH 7.35 to 7.45
PAO2 80 to 100 mm Hg
PACO2 35 to 45 mm Hg
HCO3¯ 21 to 28 meq/L
sAO2 95% to 100%

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 17 resPirATOry diAGNOsTiC PrOCedUres 107

iNTrAPrOCedUre
NURSING ACTIONS

● Position the client in a sitting or supine position.
● Assist in collecting and labeling specimens. Ensure

prompt delivery to the laboratory.
● Monitor vital signs, respiratory pattern, and

oxygenation status throughout the procedure.
● Sedation given to older adult clients who have

respiratory insufficiency can precipitate
respiratory arrest.

POsTPrOCedUre
NURSING ACTIONS

● Continuously monitor respirations, blood pressure,
pulse oximetry, heart rate, and level of consciousness
during the recovery period.

◯ Assess level of consciousness while recognizing that
older adult clients can develop confusion or lethargy
due to the effects of medications given during
the bronchoscopy.

● Assess level of consciousness, presence of gag reflex,
and ability to swallow prior to resuming oral intake.

◯ Allow adequate time for the cough and gag reflex to
return prior to resuming oral intake. The gag reflex
can be slower to return in older adult clients receiving
local anesthesia due to impaired laryngeal reflex.

◯ Once the gag reflex returns, the nurse can offer ice
chips to the client and eventually fluids.

● Monitor for development of significant fever (mild
fever for less than 24 hr is expected), productive cough,
significant hemoptysis indicative of hemorrhage (a
small amount of blood-tinged sputum is expected),
and hypoxemia.

● Be prepared to intervene for unexpected responses,
aspiration, and laryngospasm.

● Provide oral hygiene.
● For older adult clients, encourage coughing and deep

breathing every 2 hr. There is an increased risk of
respiratory infection and pneumonia in older adult
clients due to decreased cough effectiveness and
decreased secretion clearance. Respiratory infections can
be more severe and last longer in older adult clients.

● The client is not discharged from the recovery room
until adequate cough reflex and respiratory effort
are present.

CLIENT EDUCATION: Gargling with salt water or using
throat lozenges can provide comfort for throat soreness.

COMPLICATIONS

Laryngospasm

Laryngospasm is uncontrolled muscle contractions of
the laryngeal cords (vocal cords) that impede the ability
to inhale.

NURSING ACTIONS : Continuously monitor for
manifestations of respiratory distress.

Pneumothorax

Pneumothorax can occur following a rigid bronchoscopy.

NURSING ACTIONS : Assess breath sounds and oxygen
saturation, and obtain a follow-up chest x-ray.

Aspiration

Aspiration can occur if the client chokes on oral or
gastric secretions.

NURSING ACTIONS
● Prevent aspiration by withholding oral fluids or food

until the gag reflex returns (usually 2 hr).
● Perform suctioning as needed.

Thoracentesis
Thoracentesis is the surgical perforation of the chest
wall and pleural space with a large-bore needle. It is
performed to obtain specimens for diagnostic evaluation,
instill medication into the pleural space, and remove fluid
(effusion) or air from the pleural space for therapeutic
relief of pleural pressure.

● Thoracentesis is performed under local anesthesia by a
provider at the client’s bedside, in a procedure room, or
in a provider’s office.

● Use of an ultrasound for guidance decreases the risk
of complications.

INDICATIONS

POTeNTiAL diAGNOses
● Transudates (heart failure, cirrhosis, nephritic

syndrome, hypoproteinemia)
● Exudates (inflammatory, infectious,

neoplastic conditions)
● Empyema
● Pneumonia
● Blunt, crushing, or penetrating chest injuries/trauma,

or invasive thoracic procedures, such as lung or
cardiac surgery

CLieNT PreseNTATiON
● Large amounts of fluid in the pleural space compress

lung tissue and can cause pain, shortness of breath,
cough, and other manifestations of pleural pressure.

● Assessment of the effusion area can reveal abnormal
breath sounds, dull percussion sounds, and decreased
chest wall expansion. Pain can occur due to
inflammatory process.

INTERPRETATION OF FINDINGS
Aspirated fluid is analyzed for general appearance, cell
counts, protein and glucose content, the presence of
enzymes such as lactate dehydrogenase (LDH) and
amylase, abnormal cells, and culture.

108 CHAPTER 17 resPirATOry diAGNOsTiC PrOCedUres CONTENT MASTERY SERIES

CONSIDERATIONS

PrePrOCedUre
Percussion, auscultation, radiography, or sonography is
used to locate the effusion and needle insertion site.
It can be necessary for the nurse to assist the older adult
client to maintain an appropriate position for the
thoracentesis. Arthritis, tremors, or weakness can make it
difficult for the client to remain still in the required
position for the procedure.

NURSING ACTIONS
● Ensure that the client has signed the informed

consent form.
● Gather all needed supplies.
● Obtain preprocedure x-ray to locate pleural effusion and

to determine needle insertion site.
● Position the client sitting upright with arms and

shoulders raised and supported on pillows and/or on an
overbed table and with feet and legs well-supported.

CLIENT EDUCATION: Remain absolutely still (risk of
accidental needle damage) during the procedure and do
not cough or talk unless instructed by the provider.

iNTrAPrOCedUre
NURSING ACTIONS

● Assist the provider with the procedure (strict surgical
aseptic technique).

● Prepare the client for a feeling of pressure with needle
insertion and fluid removal.

● Monitor vital signs, skin color, and oxygen saturation
throughout the procedure.

● Measure and record the amount of fluid removed from
the chest.

● Label specimens at the bedside, and promptly send
them to the laboratory.

! The amount of fluid removed is limited to 1 L at
a time to prevent re‑expansion pulmonary edema.

POsTPrOCedUre
NURSING ACTIONS

● Apply a dressing over the puncture site, and assess the
dressing for bleeding or drainage.

● Monitor vital signs and respiratory status (respiratory
rate and rhythm, breath sounds, oxygenation status)
hourly for the first several hours after the thoracentesis.

● Auscultate lungs for reduced breath sounds on side
of thoracentesis.

● Encourage the client to deep breathe to assist with
lung expansion.

● Obtain a postprocedure chest x-ray (check resolution of
effusions, rule out pneumothorax).

COMPLICATIONS

Mediastinal shift

Shift of thoracic structures to one side of the body.

NURSING ACTIONS
● Monitor vital signs.
● Auscultate lungs for a decrease in or absence of

breath sounds.

Pneumothorax

Pneumothorax is a collapsed lung. It can occur due to
injury to the lung during the procedure.

NURSING ACTIONS
● Monitor for manifestations of pneumothorax

(diminished breath sounds, distended neck veins,
asymmetry of the chest wall, respiratory distress,
cyanosis).

● Monitor postprocedure chest x-ray results.

CLIENT EDUCATION: A pneumothorax can develop during
the first 24 hr following a thoracentesis. Indications
include deviated trachea, pain on the affected side
that worsens at the end of inhalation and exhalation,
affected side not moving in and out upon inhalation
and exhalation, increased heart rate, rapid shallow
respirations, nagging cough, or feeling of air hunger.

Bleeding

Bleeding can occur if the client is moved during the
procedure or is at an increased risk for bleeding.

NURSING ACTIONS
● Monitor for coughing and hemoptysis.
● Monitor vital signs and laboratory results for evidence

of bleeding (hypotension, reduced Hgb level).
● Assess thoracentesis site for bleeding.

Infection

Infection can occur due to the introduction of bacteria
with the needle puncture.

NURSING ACTIONS
● Ensure that sterile technique is maintained.
● Monitor the client’s temperature following

the procedure

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 17 resPirATOry diAGNOsTiC PrOCedUres 109

Application Exercises

1. A nurse is caring for a client who is scheduled for
a thoracentesis. Prior to the procedure, which of
the following actions should the nurse take?

A. Position the client in an upright position,
leaning over the bedside table.

B. explain the procedure.

C. Obtain ABGs.

d. Administer benzocaine spray.

2. A nurse at a provider’s office is reviewing
information with a client scheduled for pulmonary
function tests (PFTs). Which of the following
information should the nurse include?

A. “do not use inhaler medications
for 6 hr following the test.”

B. “do not smoke tobacco for 6 to
8 hr prior to the test.”

C. “you will be asked to bear down and
hold your breath during the test.”

d. “The arterial blood flow to your hand will
be evaluated as part of the test.”

3. A nurse is assessing a client following a
bronchoscopy. Which of the following findings
should the nurse report to the provider?

A. Blood‑tinged sputum

B. dry, nonproductive cough

C. sore throat

d. Bronchospasms

4. A nurse is caring for a client who is scheduled
for a thoracentesis. Which of the following
supplies should the nurse ensure are in the
client’s room? (select all that apply.)

A. Oxygen equipment

B. incentive spirometer

C. Pulse oximeter

d. sterile dressing

e. suture removal kit

5. A nurse is caring for a client following
a thoracentesis. Which of the following
manifestations should the nurse recognize as
risks for complications? (select all that apply.)

A. dyspnea

B. Localized bloody drainage on the dressing

C. Fever

d. Hypotension

e. report of pain at the puncture site

Active Learning Scenario

A nurse is assessing a client following a thoracentesis.
Use the ATi Active Learning Template: Therapeutic
Procedure to complete this item.

NURSING INTERVENTIONS (PRE, INTRA, POST):
List three postprocedure nursing actions the
nurse should take while caring for this client.

110 CHAPTER 17 resPirATOry diAGNOsTiC PrOCedUres CONTENT MASTERY SERIES

Application Exercises Key

1. A. CORRECT: Positioning the client in an upright position
and bent over the bedside table widens the intercostal
space for the provider to access the pleural fluid.

B. it is the responsibility of the provider, not the nurse,
to explain the procedure to the client.

C. it is not indicated that the client needs ABGs drawn.
d. Benzocaine spray is administered for a

bronchoscopy, not a thoracentesis.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

2. A. depending on the reason for the test, the client
might be asked to not use inhaler medications
for 4 to 6 hr before testing.

B. CORRECT: To ensure accurate results, the client should
not smoke tobacco for 6 to 8 hr prior to the test.

C. The Valsalva maneuver is not required for PFT
testing, but can be used during arterial blood
gas sampling to prevent an air embolus.

d. Allen’s test to evaluate arterial perfusion of the hand is
performed prior to arterial blood gas sampling.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

3. A. Blood‑tinged sputum is an expected finding
following a bronchoscopy.

B. A dry, nonproductive cough is an expected
finding following a bronchoscopy.

C. A sore throat is an expected finding
following a bronchoscopy.

d. CORRECT: Bronchospasms can indicate the client
is having difficulty maintaining a patent airway. The
nurse should notify the provider immediately.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

4. A. CORRECT: Oxygen equipment is necessary to
have in the client’s room if the client becomes
short of breath following the procedure.

B. An incentive spirometer is indicated for a client
following thoracic surgery to promote improved
oxygenation and pulmonary function.

C. CORRECT: Pulse oximetry is necessary to monitor
oxygen saturation level during the procedure.

d. CORRECT: A sterile dressing is necessary to apply
to the puncture site following the procedure.

e. A suture removal kit is needed to remove
sutures following surgery.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

5. A. CORRECT: dyspnea can indicate a pneumothorax
or a reaccumulation of fluid. The nurse should
notify the provider immediately.

B. Localized bloody drainage contained on a dressing is
an expected finding following a thoracentesis.

C. CORRECT: Fever can indicate an infection. The
nurse should notify the provider immediately.

d. CORRECT: Hypotension can indicate intrathoracic bleeding.
The nurse should notify the provider immediately.

e. The client’s report of pain at the puncture site is an
expected finding following a thoracentesis.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

NURSING INTERVENTIONS (PRE, INTRA, POST)
● Apply a dressing over the puncture site, and
assess dressing for bleeding or drainage.

● Monitor vital signs and respiratory status (respiratory rate
and rhythm, breath sounds, oxygenation status) hourly
for the first several hours after the thoracentesis.

● Auscultate lungs for reduced breath sounds on side of thoracentesis.
● encourage the client to deep breathe to assist with lung expansion.

NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 18 CHesT TUBe iNserTiON ANd MONiTOriNG 111

UNIT 3 RESPIRATORY DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 18 Chest Tube Insertion
and Monitoring

Chest tubes are inserted into the pleural
space to drain fluid, blood, or air; reestablish a
negative pressure; facilitate lung expansion; and
restore normal intrapleural pressure.

Chest tubes can be inserted in the emergency
department, at the bedside, or in the operating
room through a thoracotomy incision.

Chest tubes are removed when the lungs have
re‑expanded or there is no more fluid drainage
into the pleural space.

Chest tube systems
A disposable three-chamber drainage system is most
often used.

● First chamber: drainage collection
● Second chamber: water seal
● Third chamber: suction control (can be wet or dry)

Water seals are created by adding sterile fluid to a
chamber up to the 2 cm line. While this is the minimum
amount required for functioning, recommended amounts
can vary by manufacturer. The water seal allows air to exit
from the pleural space on exhalation and stops air from
entering the lungs with inhalation.

● To maintain the water seal, keep the chamber upright
and below the chest tube insertion site at all times.
Routinely monitor the water level due to the possibility
of evaporation. Add fluid as needed to maintain the
manufacturer’s recommended water seal level.

● Wet suction: The height of the sterile fluid in the
suction control chamber determines the amount of
suction transmitted to the pleural space. A suction
pressure of -20 cm H2O is commonly prescribed.
The level of water in the suction control chamber
determines the suction pressure. The system is
attached a suction source, and suction initiated until
gentle bubbling begins in the suction chamber.

● Dry suction: When a dry suction control device is used,
the provider prescribes a level of suction for the device,
typically -20 cm H2O. When connected to wall suction,
the regulator on the chest tube drainage system is set
to the manufacturer’s recommendation.

● Tidaling (movement of the fluid level with respiration)
is expected in the water seal chamber. With
spontaneous respirations, the fluid level will rise with
inspiration (increase in negative pressure in lung)
and will fall with expiration. With positive-pressure
mechanical ventilation, the fluid level will rise with
expiration and fall with inspiration.

● Cessation of tidaling in the water seal chamber signals
lung re-expansion or an obstruction within the system.

● Continuous bubbling in the water seal chamber
indicates an air leak in the system. When the tubes
are inserted to remove air from the pleural space,
intermittent bubbling is expected; it is common to see
bubbling during exhalation, sneezing, or coughing. In
this case, when bubbling is no longer seen, it indicates
that all of the air has been removed.

● When tubes are in the mediastinal space (such as
following open heart surgery), bubbling and tidaling are
not expected; pulsations in the fluid level might be seen.

Chest tube insertion

INDICATIONS

POTeNTiAL diAGNOses
Pneumothorax: partial to complete collapse of the lung
due to accumulation of air in the pleural space

Hemothorax: partial to complete collapse of the lung due
to accumulation of blood in the pleural space

Postoperative chest drainage: thoracotomy or open-heart
surgery

Pleural effusion: abnormal accumulation of fluid in the
pleural space

Pulmonary empyema: accumulation of pus in the pleural
space due to pulmonary infection, lung abscess, or
infected pleural effusion

CHAPTER 18

18.1 Chest tube drainage system

112 CHAPTER 18 CHesT TUBe iNserTiON ANd MONiTOriNG CONTENT MASTERY SERIES

CLieNT PreseNTATiON
● Dyspnea
● Distended neck veins
● Hemodynamic instability
● Pleuritic chest pain
● Cough
● Absent or reduced breath sounds on the affected side
● Hyperresonance on percussion of affected side

(pneumothorax)
● Dullness or flatness on percussion of the affected side

(hemothorax, pleural effusion)
● Asymmetrical chest wall motion

CONSIDERATIONS

PrePrOCedUre
● Verify that the consent form is signed.
● Inform the client that breathing will improve when the

chest tube is in place.
● Assess for allergies to local anesthetics.
● Assist the client into the desired position (supine or

semi-Fowler’s).
● Prepare the chest drainage system per the facility’s

protocol. (Fill the water seal chamber.)
● Administer pain and sedation medications as prescribed.
● Prep the insertion site with povidone-iodine or other

facility-approved agent.

iNTrAPrOCedUre
● When the chest tube is inserted to drain fluid from the

lung, the tip of the tube is inserted near the base of the
lung on the side. When the chest tube is inserted to
remove air from the pleural space, the tip of the tube
will be near the apex of the lung.

● Assist the provider with insertion of the chest tube,
application of a dressing to the insertion site, and
set-up of the drainage system.

◯ Place the chest tube drainage system below the
client’s chest level with the tubing coiled on the bed.
Ensure that the tubing from the bed to the drainage
system is straight to promote drainage via gravity.

● Continually monitor vital signs and response to
the procedure.

POsTPrOCedUre
● Assess vital signs, breath sounds, SaO2, color, and

respiratory effort as indicated by the status of the client
and at least every 4 hr.

● Encourage coughing and deep breathing every 2 hr.
● Keep the drainage system below the client’s chest level,

including during ambulation.
● Monitor chest tube placement and function.

◯ Check the water seal level every 2 hr, and add fluid
as needed. The fluid level should fluctuate with
respiratory effort.

◯ Document the amount and color of drainage hourly
for the first 24 hr and then at least every 8 hr. Mark
the date, hour, and drainage level on the container
at the end of each shift. Report excessive drainage
(greater than 70 mL/hr) or drainage that is cloudy
or red to the provider. Drainage often increases with
position changes or coughing.

◯ Monitor the fluid in the suction control chamber, and
maintain the prescribed fluid level.

◯ Ensure the regulator dial on the dry suction device is
at the prescribed level.

◯ Check for expected findings of tidaling in the water
seal chamber and continuous bubbling only in the
suction chamber.

● Routinely monitor tubing for kinks, occlusions, or
loose connections.

● Monitor the chest tube insertion site for redness, pain,
infection, and crepitus (air leakage in subcutaneous tissue).

● Tape all connections between the chest tube and chest
tube drainage system.

● Position the client in the semi-to high-Fowler’s position
to promote optimal lung expansion and drainage of
fluid from the lungs.

● Administer pain medications as prescribed.
● Obtain a chest x-ray to verify the chest tube’s placement.
● Keep two enclosed hemostats, sterile water, and an

occlusive dressing located at the bedside at all times.
● Due to the risk of causing a tension pneumothorax, chest

tubes are clamped only when prescribed in specific
circumstances, such as in the case of an air leak, during
drainage system change, accidental disconnection of
tubing, or damage to the drainage system.

● Do not clamp, strip, or milk tubing; only perform
this action when prescribed. Stripping creates a high
negative pressure and can damage lung tissue.

● Notify the provider immediately if the client’s SaO2 is
less than 90%, if the eyelets of the chest tube become
visible, if drainage is above the prescribed amount or
stops in the first 24 hr, or complications occur.

18.2 Chest tube

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 18 CHesT TUBe iNserTiON ANd MONiTOriNG 113

COMPLICATIONS

Air leaks

Air leaks can result if a connection is not taped securely.

NURSING ACTIONS
● Monitor the water seal chamber for continuous bubbling

(air leak finding). If observed, locate the source of
the air leak, and intervene accordingly (tighten the
connection, replace drainage system).

● Check all connections.
● Notify the provider if an air leak is noted. If prescribed,

gently apply a padded clamp to determine the location
of the air leak. Remove the clamp immediately following
assessment.

Accidental disconnection,
system breakage, or removal

These complications can occur at any time and
require immediate notification of the provider or rapid
response team.

NURSING ACTIONS
● If the tubing separates, instruct the client to exhale as

much as possible and to cough to remove as much air as
possible from the pleural space.

● If the chest tube drainage system is compromised,
immerse the end of the chest tube in sterile water to
provide a temporary water seal.

● If a chest tube is accidentally removed, dress the area
with dry, sterile gauze.

Tension pneumothorax
● Sucking chest wounds, prolonged clamping of the

tubing, kinks or obstruction in the tubing, or mechanical
ventilation with high levels of positive end expiratory
pressure (PEEP) can cause a tension pneumothorax.

● Assessment findings include tracheal deviation, absent
breath sounds on one side, distended neck veins,
respiratory distress, asymmetry of the chest, and cyanosis.

● Notify the provider or rapid response team immediately.

Chest tube removal
● Provide pain medication 30 min before removing

chest tubes.
● Assist the provider with sutures and chest tube removal.
● Instruct the client to take a deep breath, exhale, and

bear down (Valsalva maneuver) or to take a deep breath
and hold it (increases intrathoracic pressure and reduces
risk of air emboli) during chest tube removal.

● Apply airtight sterile petroleum jelly gauze dressing.
Secure in place with a heavyweight stretch tape.

● Obtain chest x-rays as prescribed. This is performed
to verify continued resolution of the pneumothorax,
hemothorax, or pleural effusion.

● Monitor for excessive wound drainage, findings of
infection, or recurrent pneumothorax

Active Learning Scenario

A nurse is caring for a client who is scheduled for a chest
tube placement. Use the ATi Active Learning Template:
Therapeutic Procedure to complete this item.

NURSING INTERVENTIONS (PRE, INTRA, POST):
include three preprocedure nursing actions.

Application Exercises

1. A nurse is preparing to care for a client following chest
tube placement. Which of the following items should
be available in the client’s room? (select all that apply.)

A. Oxygen
B. sterile water
C. enclosed hemostat clamps
d. indwelling urinary catheter
e. Occlusive dressing

2. A nurse is caring for a client who has a chest tube and
drainage system in place. The nurse observes that
the chest tube was accidentally removed. Which of
the following actions should the nurse take first?

A. Obtain a chest x‑ray.
B. Apply sterile gauze to the insertion site.
C. Place tape around the insertion site.
d. Assess respiratory status.

3. A nurse is assessing a client who has a chest tube
and drainage system in place. Which of the following
are expected findings? (select all that apply.)

A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the

suction control chamber
C. rise and fall in the level of water in the water

seal chamber with inspiration and expiration
d. exposed sutures without dressing
e. drainage system upright at chest level

4. A nurse is assisting a provider with the
removal of a chest tube. Which of the
following actions should the nurse take?

A. instruct the client to lie prone
with arms by the sides.

B. Complete a surgical checklist on the client.
C. remind the client that there is minimal

discomfort during the removal process.
d. Place an occlusive dressing over the

site once the tube is removed.

5. A nurse is planning care for a client following the
insertion of a chest tube and drainage system.
Which of the following should be included in
the plan of care? (select all that apply.)

A. encourage the client to cough and deep breathe.
B. Check for continuous bubbling

in the suction chamber.
C. strip the drainage tubing every 4 hr.
d. Clamp the tube once a day.
e. Obtain a chest x‑ray.

114 CHAPTER 18 CHesT TUBe iNserTiON ANd MONiTOriNG CONTENT MASTERY SERIES

Application Exercises Key

1. A. CORRECT: Oxygen should be readily available in case
the client develops respiratory distress following chest
tube placement. The nurse should monitor respiration,
oxygen saturation, and lung sounds.

B. CORRECT: if the chest tubing becomes disconnected,
the end of the tubing should be placed in
sterile water to restore the water seal.

C. CORRECT: Hemostat clamps should be available
for the nurse to use to check for air leaks.

d. An indwelling urinary catheter is not indicated
for a client who has a chest tube.

e. CORRECT: if the chest tubing becomes disconnected,
the nurse should immediately place a gauze dressing
over the site. An occlusive dressing can also be necessary
to prevent the redevelopment of a pneumothorax.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

2. A. Obtaining a chest x‑ray determines if the lung is inflated
or if the client has a pneumothorax after the chest tube
was accidentally pulled out is an appropriate action, but
it is not the first action the nurse should take.

B. CORRECT: Using the airway, breathing, and circulation
(ABC) priority‑setting framework, application of a sterile
gauze to the site should be the first action for the nurse
to take. This allows air to escape and reduces the risk
for development of a tension pneumothorax.

C. Placing tape around the insertion site ensures
that the sterile gauze remains intact and is an
appropriate action, but it is not the first action.

d. Assessing respiratory status is an appropriate
action, but it is not the first action.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

3. A. Continuous bubbling in the water seal
chamber indicates an air leak.

B. CORRECT: Gentle bubbling in the suction control chamber
is an expected finding as air is being removed.

C. CORRECT: A rise and fall of the fluid level in the water
seal chamber upon inspiration and expiration indicates
that the drainage system is functioning properly.

d. The nurse should cover the sutures at the
insertion site with an airtight dressing.

e. The drainage system should be maintained in an upright
position below the level of the client’s chest.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. A. The position the client should assume during removal
of a chest tube depends upon the location of the
insertion site. The client would need to ensure the arm
is not covering the ribs on the side of insertion.

B. Chest tubes are removed by the provider
at the client’s bedside.

C. removal of a chest tube can be painful.
d. CORRECT: The nurse should place an occlusive

dressing over the site once the tube is removed
and observe the site for drainage.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. A. CORRECT: The nurse should instruct the client
to cough and deep breathe. This promotes
oxygenation and lung re‑expansion.

B. CORRECT: The nurse should check for continuous
bubbling in the suction chamber to verify that suction
is being maintained at an appropriate level.

C. The nurse should not milk or strip the drainage
tubing to check for kinks. This action is only to be
done when prescribed. stripping creates negative
high pressure and can damage lung tissue.

d. The nurse should not clamp the tubing unless indicated by
the provider. This is done to verify for the presence of an
air leak or if the tubing accidentally has been disconnected.
Clamping can cause a tension pneumothorax.

e. CORRECT: A chest x‑ray is obtained following the
procedure to verify chest tube placement.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

NURSING INTERVENTIONS (PRE, INTRA, POST)
● Verify that the consent form is signed.
● reinforce client teaching. Breathing will improve
when the chest tube is in place.

● Assess for allergies to local anesthetics.
● Assist the client into the desired position (supine or semi‑Fowler’s).
● Prepare the chest drainage system per the facility’s
protocol. (Fill the water seal chamber.)

● Administer pain and sedation medications as prescribed.
● Prep the insertion site with povidone‑iodine
or other facility‑approved agent.

NCLEX® Connection: Reduction of Risk Potential, Therapeutic
Procedures

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 19 resPirATOry MANAGeMeNT ANd MeCHANiCAL VeNTiLATiON 115

UNIT 3 RESPIRATORY DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 19 Respiratory
Management
and Mechanical
Ventilation

Oxygen is a tasteless and colorless gas that
accounts for 21% of atmospheric air.

Oxygen is used to maintain adequate cellular
oxygenation. it is used in the treatment of many
acute and chronic respiratory problems.

Oxygen is administered in an attempt to
maintain an saO2 of 95% to 100% by using the
lowest amount of oxygen without putting the
client at risk for complications.

Clients who cannot spontaneously breathe
on their own require mechanical ventilation.
This can include clients who need respiratory
assistance due to severe respiratory disease,
general anesthesia, trauma, or other illnesses.

Oxygen delivery devices
Supplemental oxygen can be delivered by a variety of
methods based on the client’s particular circumstances.
The percentage of oxygen delivered is expressed as the
fraction of inspired oxygen (FiO2). While the client is
receiving oxygen, the nurse should continue to monitor
vital signs, including SaO2 for changes, and intervene
as needed.

LOW‑FLOW OXyGeN deLiVery sysTeMs
These deliver varying amounts of oxygen based on the
method and the client’s breathing pattern.

Nasal cannula
● A length of tubing with two small prongs for insertion

into the nares (19.1)
● FiO2 24% to 44% at flow rates of 1 to 6 L/min

ADVANTAGES
● Safe, easy to apply, comfortable, and well tolerated.
● The client is able to eat, talk, and ambulate.

DISADVANTAGES
● FiO2 varies with the flow rate, and the client’s rate and

depth of breathing.
● Extended use can lead to skin breakdown and drying of

the mucous membranes.
● Tubing is easily dislodged.

NURSING ACTIONS
● Assess patency of the nares.
● Ensure that the prongs fit in the nares properly.
● Use water-soluble gel to prevent dry nares.
● Provide humidification for flow rates of 4 L/min

and greater.

CHAPTER 19

Online Image: Nasal Cannula

19.2 Simple face mask19.1 Nasal cannula

116 CHAPTER 19 resPirATOry MANAGeMeNT ANd MeCHANiCAL VeNTiLATiON CONTENT MASTERY SERIES

Simple face mask
● Covers the client’s nose and mouth. (19.2)
● FiO2 40% to 60% at flow rates of 5 to 8 L/min. (The

minimum flow rate is 5 L/min to ensure flushing of CO2
from the mask.)

ADVANTAGES: A face mask is easy to apply and can be
more comfortable than a nasal cannula.

DISADVANTAGES
● Flow rates of less than 5 L/min can result in

rebreathing of CO2.
● Device is poorly tolerated by clients who have anxiety

or claustrophobia.
● Eating, drinking, and talking are impaired.
● Use caution with clients who have a high risk of

aspiration or airway obstruction.
● Moisture and pressure can collect under the mask and

cause skin breakdown.

NURSING ACTIONS
● Assess proper fit to ensure a secure seal over the nose

and mouth.
● Ensure that the client wears a nasal cannula

during meals.

Partial rebreather mask
● Covers the client’s nose and mouth
● FiO2 40% to 75% at flow rates of 6 to 11 L/min

ADVANTAGES: The mask has a reservoir bag attached with
no valve, which allows the client to rebreathe up to one
third of exhaled air together with room air.

DISADVANTAGES
● Complete deflation of the reservoir bag during

inspiration causes CO2 buildup.
● FiO2 varies with the client’s breathing pattern.
● Mask is poorly tolerated by clients who have anxiety

or claustrophobia.
● Eating, drinking, and talking are impaired.
● Use with caution for clients who have a high risk of

aspiration or airway obstruction.

NURSING ACTIONS
● Keep the reservoir bag from deflating by adjusting the

oxygen flow rate to keep it inflated.
● Assess proper fit to ensure a secure seal over the nose

and mouth.
● Assess for skin breakdown beneath the edges of the

mask and bridge of nose.
● Ensure that the client uses a nasal cannula

during meals.

Nonrebreather mask
● Covers the client’s nose and mouth (19.3)
● FiO2 80% to 95% at flow rates of 10 to 15 L/min to keep

the reservoir bag two-thirds full during inspiration
and expiration

ADVANTAGES
● Delivers the highest O2 concentration possible (except

for intubation).
● A one-way valve situated between the mask and

reservoir allows the client to inhale maximum O2
from the reservoir bag. The two exhalation ports
have flaps covering them that prevent room air from
entering the mask.

DISADVANTAGES
● The valve and flap on the mask must be intact and

functional during each breath.
● Poorly tolerated by clients who have anxiety

or claustrophobia.
● Eating, drinking, and talking are impaired.
● Use with caution for clients who have a high risk of

aspiration or airway obstruction.

NURSING ACTIONS
● Perform an hourly assessment of the valve and flap.
● Assess proper fit to ensure a secure seal over the nose

and mouth.
● Assess for skin breakdown beneath the edges of the

mask and bridge of nose.
● Ensure that the client uses a nasal cannula

during meals.

HiGH‑FLOW OXyGeN deLiVery sysTeMs
These deliver precise amounts of oxygen when
properly fitted.

Venturi mask
● Covers the client’s nose and mouth (19.4)
● FiO2 24% to 60% at flow rates of 4 to 12 L/min via

different sizes of adapters, which allow specific amounts
of air to mix with oxygen

ADVANTAGES
● Delivers the most precise oxygen concentration.
● Humidification is not required.
● Best suited for clients who have chronic lung disease.

DISADVANTAGES: Use of a Venturi mask is expensive.

NURSING ACTIONS
● Assess frequently to ensure an accurate flow rate.
● Make sure the tubing is free of kinks.
● Assess for skin breakdown beneath the edges of the

mask, particularly on the nares.
● Ensure that the client wears a nasal cannula

during meals.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 19 resPirATOry MANAGeMeNT ANd MeCHANiCAL VeNTiLATiON 117

Aerosol mask, face tent, and tracheostomy collar
● Face tent fits loosely around the face and neck. (19.5)
● Tracheostomy collar is a small mask that covers a

surgically created opening in the trachea.
● FiO2 24% to 100% at flow rates of at least 10 L/min.

(Provide high humidification with oxygen delivery.)

ADVANTAGES
● Good for clients who do not tolerate masks well.
● Useful for clients who have facial trauma, burns, or

thick secretions.

DISADVANTAGES: High humidification requires frequent
monitoring.

NURSING ACTIONS
● Empty condensation from the tubing often.
● Ensure that there is adequate water in the

humidification canister.
● Ensure that the aerosol mist leaves from the vents

during inspiration and expiration.
● Make sure the tubing does not pull on the tracheostomy.

T‑piece

FiO2 24% to 100% at flow rates of at least 10 L/min

ADVANTAGES: Can be used for clients who have
tracheostomies, laryngectomies, or endotracheal tubes (ET).

DISADVANTAGES: High humidification requires frequent
monitoring.

NURSING ACTIONS
● Ensure that the exhalation port is open and uncovered.
● Ensure that the T-piece does not pull on the

tracheostomy or ET tube.
● Ensure that the mist is evident during inspiration

and expiration.

Oxygen therapy

INDICATIONS

POTeNTiAL diAGNOses
Hypoxemia and hypoxia:

● Hypoxemia is an inadequate level of oxygen in the
blood. Hypovolemia, hypoventilation, and interruption
of arterial flow can lead to hypoxemia.

● Hypoxia is a decrease in tissue oxygenation.

CLieNT PreseNTATiON

Early findings
● Tachypnea
● Tachycardia
● Restlessness
● Pale skin and mucous membranes
● Elevated blood pressure
● Findings of respiratory distress (use of accessory

muscles, nasal flaring, tracheal tugging, and
adventitious lung sounds)

Late findings
● Confusion and stupor
● Cyanotic skin and mucous membranes
● Bradypnea
● Bradycardia
● Hypotension
● Cardiac dysrhythmias

19.4 Venturi mask19.3 Nonrebreather mask 19.5 Face tent

118 CHAPTER 19 resPirATOry MANAGeMeNT ANd MeCHANiCAL VeNTiLATiON CONTENT MASTERY SERIES

CONSIDERATIONS

PrePArATiON OF THe CLieNT
● Explain all procedures to the client.
● Place the client in semi-Fowler’s or Fowler’s position to

facilitate breathing and promote chest expansion.
● Ensure that all equipment is working properly.

ONGOiNG CAre
● Provide oxygen therapy at the lowest flow that will

correct hypoxemia.
● Assess/monitor respiratory rate, rhythm and effort, lung

sounds, and SaO2 to determine the client’s need for
supplemental oxygen.

◯ Manifestations of hypoxemia are shortness of breath,
anxiety, tachypnea, tachycardia, restlessness, pallor
or cyanosis of the skin or mucous membranes,
adventitious breath sounds, and confusion.

◯ Manifestations of hypercarbia (elevated levels of CO2)
are restlessness, hypertension, and headache.

● Monitor diagnostic reports that show information
related to oxygenation, including ABGs.

● Promote good oral hygiene, and provide as needed.
● Promote turning, coughing, deep breathing, use of

incentive spirometer, and suctioning.
● Promote rest, and decrease environmental stimuli.
● Provide emotional support for clients who

appear anxious.
● Assess nutritional status. Provide supplements

as prescribed.
● Assess/monitor skin integrity. Provide moisture and

pressure-relief devices as indicated.
● Assess/monitor and document the client’s response to

oxygen therapy.
● Titrate oxygen to maintain prescribed oxygen saturation.
● Discontinue supplemental oxygen gradually.

iNTerVeNTiONs
Monitor for manifestations of respiratory depression,
such as decreased respiratory rate and decreased level of
consciousness. Notify the provider if findings are present.

Respiratory distress
● Position the client for maximum ventilation (Fowler’s or

semi-Fowler’s position).
● Complete a focused respiratory assessment.
● Promote deep breathing, and use supplemental oxygen

as prescribed.
● Stay with the client, and provide emotional support to

decrease anxiety.
● Promote airway clearance by encouraging coughing and

oral/oropharyngeal suctioning if necessary.

COMPLICATIONS

Oxygen toxicity
● Oxygen toxicity can result from high concentrations of

oxygen (typically above 50%), long durations of oxygen
therapy (typically more than 24 to 48 hr), and the
client’s degree of lung disease.

● Manifestations include a nonproductive cough,
substernal pain, nasal stuffiness, nausea, vomiting,
fatigue, headache, sore throat, and hypoventilation.

NURSING ACTIONS
● Use the lowest level of oxygen necessary to maintain

the prescribed SaO2.
● Monitor ABGs. Notify the provider if results are outside

the expected or prescribed ranges.
● Use an oxygen mask with continuous positive airway

pressure (CPAP) or bi-level positive airway pressure
(BiPAP) if prescribed to help decrease the amount of
oxygen needed.

● Use positive end expiratory pressure (PEEP) as
prescribed while the client is receiving mechanical
ventilation to help decrease the amount of
needed oxygen.

Oxygen‑induced hypoventilation

Oxygen-induced hypoventilation can develop in clients
who have COPD and chronic hypoxemia with hypercarbia.

NURSING ACTIONS
● Monitor respiratory rate and pattern, level of

consciousness, and SaO2.
● Provide oxygen therapy at the lowest flow rate that

manages hypoxemia.
● If the client tolerates it, use a Venturi mask to deliver

precise oxygen levels.
● Notify the provider of findings of respiratory depression,

such as a decreased respiratory rate or a decreased level
of consciousness.

Combustion

Oxygen is combustible.

NURSING ACTIONS
● Post “No Smoking” or “Oxygen in Use” signs to alert

others of a fire hazard.
● Know where the closest fire extinguisher is located.
● Educate the client and others about the fire hazard of

smoking during oxygen use.
● Have the client wear a cotton gown because synthetic or

wool fabrics can generate static electricity.
● Ensure that all electric devices (razors, hearing aids,

radios) are working well.
● Ensure electric machinery (monitors, suction machines)

are well-grounded.
● Do not use volatile, flammable materials (alcohol or

acetone) near clients who are receiving oxygen.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 19 resPirATOry MANAGeMeNT ANd MeCHANiCAL VeNTiLATiON 119

Noninvasive positive
pressure ventilation

Continuous positive airway pressure

Provides positive pressure using a leak-proof mask via
noninvasive positive-pressure ventilation device.

● The device is to keep the airways throughout the
respiratory cycle open and improve gas exchange in
the alveoli.

● Most effective treatment for sleep apnea because the
positive pressure acts as a splint to keep the upper
airway and trachea open during sleep

Bi‑level positive airway pressure

Machine cycles to provide a set positive inspiratory
pressure when inspiration takes place and then during
expiration to deliver a lower set end expiratory pressure.

● Requires wearing a leak-proof mask.
● Most often used for clients who have COPD and who

require ventilatory assistance.

NURSING ACTIONS
● Assess skin around the masks for breakdown as a tight

seal is required.
● Check the percentage of oxygen on the machine

(both) for both the inspiratory pressure and expiratory
pressure when the client is receiving BiPAP.

Transtracheal oxygen therapy

Delivers oxygen directly in to the lungs per a small,
flexible catheter that is passed through the trachea via a
small incision.

● The oxygen delivery is reduced by 55% for a client at
rest and 30% for a client who is active.

● The catheter is less visible and avoids irritation that
occurs from the use of nasal prongs.

Endotracheal tube and
endotracheal intubation

INDICATIONS
● A tube is inserted through the client’s nose or mouth

into the trachea. This allows for emergency airway
management of the client.

● Oral intubation is the easiest and quickest form
of intubation and is often performed in the
emergency department.

● Nasal intubation is performed when the client has facial
or oral trauma. This route is not used if the client has a
clotting problem.

PLACeMeNT
● Intubation is typically performed by a nurse anesthetist,

anesthesiologist, critical care or emergency physician,
or pulmonologist.

● A chest x-ray verifies correct placement of the
endotracheal (ET) tube.

● ET tubes can be cuffed or uncuffed. The cuff on the
tracheal end of an ET tube is inflated to ensure proper
placement and the formation of a seal between the cuff
and the tracheal wall. This prevents air from leaking
around the ET tube.

● The seal ensures that an adequate amount of tidal
volume is delivered by the mechanical ventilator when
attached to the external end of the ET tube.

● The client is unable to talk when the cuff is inflated.

NURSING ACTIONS
● Have resuscitation equipment to include a manual

resuscitation bag with a face mask at the bedside at
all times.

● Ensure the intubation attempts last no longer than
30 seconds and then reoxygenate before another attempt
to intubate.

● Monitor vital signs and verify ET tube placement
by checking end-tidal carbon dioxide levels and
chest x-ray.

● Auscultate for breath sounds bilaterally after intubation.
● Observe for symmetric chest movement.
● Stabilize the endotracheal tube with a tube-holding

device or secure with tape.
● Monitor for hypoxemia, dysrhythmias, and aspiration.

Mechanical ventilation
Mechanical ventilation provides breathing support until
lung function is restored, delivering 100% oxygen that
is warmed (body temperature 37° C [98.6° F]) and%
humidified at FiO2 levels between 21% to 100%.

● Positive-pressure ventilators deliver air to the lungs
under pressure throughout inspiration to keep the
alveoli open and to prevent alveolar collapse during
expiration. Benefits include the following.

◯ Forced/enhanced lung expansion
◯ Improved gas exchange (oxygenation)
◯ Decreased work of breathing

● Mechanical ventilation can be delivered via:
◯ ET tube.
◯ Tracheostomy tube.

● Mechanical ventilators can be cycled based on pressure,
volume, time, and/or flow. (19.6)

Online Videos: Noninvasive Positive Pressure Ventilation, Transtracheal Oxygen Therapy

120 CHAPTER 19 resPirATOry MANAGeMeNT ANd MeCHANiCAL VeNTiLATiON CONTENT MASTERY SERIES

INDICATIONS
To maintain a patent airway and adequate oxygen
saturation of 95% or greater.

POTeNTiAL diAGNOses
● Hypoxemia, hypoventilation with respiratory acidosis

◯ Airway trauma
◯ Exacerbation of COPD
◯ Acute pulmonary edema due to myocardial infarction
or heart failure

◯ Asthma attack
◯ Head injuries, cerebrovascular accident, or coma
◯ Neurological disorders (multiple sclerosis, myasthenia
gravis, Guillain-Barré)

◯ Obstructive sleep apnea
● Respiratory support following surgery

(decrease workload)
● Respiratory support while under general anesthesia or

heavy sedation

CONSIDERATIONS

PrePArATiON OF THe CLieNT
● Explain the procedure to the client.
● Establish a method for the client to communicate, such

as asking yes/no questions, providing writing materials,
using a dry-erase and/or picture communication board,
or lip reading.

ONGOiNG CAre
● Maintain a patent airway.

◯ Assess the position and placement of tube.
◯ Document tube placement in centimeters at the
client’s teeth or lips.

◯ Use two staff members for repositioning and
resecuring the tube.

◯ Apply protective barriers (soft wrist restraints) according
to hospital protocol to prevent self-extubation.

◯ Use caution when moving the client.

19.6 Common modes of ventilation, adjunctive therapy, and weaning modalities

Mode of ventilation
ASSIST‑CONTROL (AC)

● Preset rate and tidal volume. Client initiates breath and
ventilator takes over for the intubated client.

● Hyperventilation can result in respiratory alkalosis.
● Client can require sedation to decrease respiratory rate.

SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV)
● Preset rate and tidal volume for machine breaths.
● Client initiates breath and tidal volume will depend upon client’s effort.
● Ventilator initiated breaths are synchronized to reduce
competition between ventilator and client.

● Used as a regular mode of ventilation or a weaning mode (rate decreased
to allow more spontaneous ventilation) for the intubated client.

● Can increase work of breathing, causing respiratory muscle fatigue.

INVERSE RATIO VENTILATION (IRV)
● Lengthens inspiratory phase to maximize oxygenation in the intubated client.
● Used for hypoxemia refractory to PeeP.
● Uncomfortable for clients and requires sedation
and/or neuromuscular blocking agents.

● High risk of volutrauma and decreased cardiac output due to air trapping.

AIRWAY PRESSURE RELEASE VENTILATION (APRV)
● Allows alveolar gas to be expelled by the lungs own natural recoil
● Time‑triggered and pressure‑limited
● Breaths can be initiated spontaneously or by the ventilator
● Causes less ventilator‑induced lung injury and fewer
adverse effects on the cardiovascular system

INDEPENDENT LUNG VENTILATION (ILV)
● double‑lumen eT tube allows ventilation of each lung separately.
● Used for clients who have unilateral lung disease.
● requires two ventilators, sedation and/or use of neuromuscular blocking agents.

HIGH‑FREQUENCY VENTILATION
● delivers small amount of gas at rates of 60 to 3,000 cycles/min.
● High frequency ventilation often used in children.
● Client must be sedated and/or receiving neuromuscular blocking agents.
● Breath sounds difficult to assess.

Adjunctive therapy
POSITIVE END EXPIRATORY
PRESSURE (PEEP)

● Preset pressure delivered
during expiration.

● Added to prescribed ventilator
settings to treat persistent hypoxemia.

● improves oxygenation by
enhancing gas exchange and
preventing atelectasis.

● Amount of PeeP added is
typically 5 to 15 cm H2O.

Weaning modality
PRESSURE SUPPORT
VENTILATION (PSV)

● Works to keep the alveoli from
collapsing during expiration.

● Allows for greater oxygenation and
makes the work of breathing easier.

● Allows for lower levels of
FiO2 to be used.

● Can be used with iMV or AC modes
to treat or prevent atelectasis.

● settings 5 to 20 cm H2O (greater than
20 cm H2O can cause lung damage).

CONTINUOUS POSITIVE
AIRWAY PRESSURE (CPAP)

● Positive pressure supplied during
spontaneous breathing. No
ventilator breaths delivered unless
in conjunction with siMV.

● risks include volutrauma, decreased
cardiac output and iCP.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 19 resPirATOry MANAGeMeNT ANd MeCHANiCAL VeNTiLATiON 121

◯ Suction oral and tracheal secretions to maintain
tube patency.

◯ Support ventilator tubing to prevent mucosal erosion
and displacement.

◯ Have a resuscitation bag with a face mask available
at the bedside at all times in case of ventilator
malfunction or accidental extubation.

● Assess respiratory status every 1 to 2 hr: breath sounds
equal bilaterally, presence of reduced or absent breath
sounds, respiratory effort, or spontaneous breaths.

● Suction the tracheal tube to clear secretions from
the airway.

● Monitor and document ventilator settings hourly.
◯ Rate, FiO2, and tidal volume
◯ Mode of ventilation
◯ Use of adjuncts (PEEP, CPAP)
◯ Plateau or peak inspiratory pressure (PIP)
◯ Alarm settings

● Monitor ventilator alarms, which signal if the client is
not receiving the correct ventilation.

◯ Never turn off ventilator alarms.
◯ There are three types of ventilator alarms.

■ Volume (low pressure) alarms indicate a low
exhaled volume due to a disconnection, cuff leak,
and/or tube displacement.

■ Pressure (high pressure) alarms indicate excess
secretions, client biting the tubing, kinks in
the tubing, client coughing, pulmonary edema,
bronchospasm, or pneumothorax.

■ Apnea alarms indicate that the ventilator does
not detect spontaneous respiration in a preset
time period.

● Maintain adequate (but not excessive) volume in the cuff
of the endotracheal tube.

◯ Assess the cuff pressure at least every 8 hr. Maintain
the cuff pressure below 20 mm Hg (or 20 to
30 cm H2O) to reduce the risk of tracheal necrosis.

◯ Assess for an air leak around the cuff (client speaking,
air hissing, or decreasing SaO2). Inadequate cuff
pressure can result in inadequate oxygenation and/or
accidental extubation.

● Administer medications as prescribed.
◯ Analgesics: morphine and fentanyl
◯ Sedatives: propofol, diazepam, lorazepam, midazolam,
and haloperidol

■ Clients receiving mechanical ventilation can require
sedation or paralytic agents to prevent competition
between extrinsic and intrinsic breathing and the
resulting effects of hyperventilation.

◯ Neuromuscular blocking agents: pancuronium,
atracurium, and vecuronium are infrequently used in
the clinical setting due to the their long half-life.

■ Neuromuscular-blocking agents paralyze
muscles, but do not sedate or relieve pain. The
use of a sedative or analgesic agent in conjunction
with a neuromuscular blocking agent is
typically prescribed.

◯ Ulcer-preventing agents: famotidine or lansoprazole
◯ Antibiotics for established infections

● Reposition the oral endotracheal tube every 24 hr or
according to protocol. Assess for skin breakdown.

◯ Older adult clients have fragile skin and are more
prone to skin and mucous membrane breakdown.
Older adult clients have decreased oral secretions.
They require frequent, gentle skin and oral care.

● Provide adequate nutrition.
◯ Assess gastrointestinal functioning every 8 hr.
◯ Monitor bowel habits.
◯ Administer enteral or parenteral feedings
as prescribed.

● Continually monitor the client during the weaning
process and watch for signs of weaning intolerance.

◯ Respirations greater than 30/min or less than 8/min
◯ Blood pressure or heart rate changes more than 20%
of baseline

◯ SaO2 less than 90%
◯ Dysrhythmias, elevated ST segment
◯ Significant decrease in tidal volume
◯ Labored respirations, increased use of accessory
muscles, and diaphoresis

◯ Restlessness, anxiety, and decreased level of
consciousness

● Have a manual resuscitation bag with a face mask and
oxygen readily available at the client’s bedside.

● Have reintubation equipment at bedside.
● Suction the oropharynx and trachea.
● Deflate the cuff on the endotracheal tube, and remove

the tube during peak inspiration.
● Following extubation, monitor for signs of respiratory

distress or airway obstruction (ineffective cough,
dyspnea, stridor).

● Assess SpO2 and vital signs every 5 min.
● Encourage coughing, deep breathing, and use of the

incentive spirometer.
● Reposition the client to promote mobility of secretions.
● Older adult clients have decreased respiratory muscle

strength and chest wall compliance, which makes them
more susceptible to aspiration, atelectasis, and
pulmonary infections. Older adult clients require more
frequent position changes to promote mobility of
secretions.

COMPLICATIONS

Trauma

Barotrauma (damage to the lungs by positive pressure)
can occur due to a pneumothorax, subcutaneous
emphysema or pneumomediastinum.
Volutrauma (damage to the lungs by volume delivered
from one lung to the other).

Fluid retention

Fluid retention in clients who are receiving mechanical
ventilation is due to decreased cardiac output, activation
of renin-angiotensin-aldosterone system, and/or
ventilator humidification.

NURSING ACTIONS: Monitor intake and output, weight,
breath sounds, and endotracheal secretions.

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Oxygen toxicity

Oxygen toxicity can result from high concentrations of
oxygen (typically greater than 50%), long durations of
oxygen therapy (typically more than 24 to 48 hr), and/or
the client’s degree of lung disease.

NURSING ACTIONS: Monitor for fatigue, restlessness, severe
dyspnea, tachycardia, tachypnea, crackles, and cyanosis.

Hemodynamic compromise

Mechanical ventilation has a risk of increased thoracic
pressure (positive pressure), which can result in decreased
venous return.

NURSING ACTIONS: Monitor for tachycardia, hypotension,
urine output less than or equal to 30 mL/hr, cool, clammy
extremities, decreased peripheral pulses, and a decreased
level of consciousness.

Aspiration

Keep the head of the bed elevated 30° at all times to
decrease the risk of aspiration.

NURSING ACTIONS: Check residuals every 4 hr if the
client is receiving enteral feedings to decrease the risk
of aspiration.

Gastrointestinal ulceration (stress ulcer)

Gastric ulcers can be evident in clients receiving
mechanical ventilation.

NURSING ACTIONS
● Monitor gastrointestinal drainage and stools for

occult blood.
● Administer ulcer prevention medications (sucralfate and

histamine2 blockers).

Application Exercises

1. A nurse is caring for a client who is receiving mechanical
ventilation and is on pressure support ventilation
(PsV) mode. Which of the following statements by
the nurse indicates an understanding of PsV?

A. “it keeps the alveoli open and prevents atelectasis.”
B. “it allows preset pressure delivered

during spontaneous ventilation.”
C. “it guarantees minimal minute ventilator.”
d. “it delivers a preset ventilatory rate

and tidal volume to the client.”

2. A nurse is caring for a client who is experiencing
respiratory distress. Which of the following
early manifestations of hypoxemia should the
nurse recognize? (select all that apply.)

A. Confusion
B. Pale skin
C. Bradycardia
d. Hypotension
e. elevated blood pressure

3. A nurse is caring for a client who is receiving
mechanical ventilation via an endotracheal tube.
Which of the following actions should the nurse take?

A. Apply a vest restraint if
self‑extubation is attempted.

B. Monitor ventilator settings every 8 hr.
C. document tube placement in

centimeters at the angle of jaw.
d. Assess breath sounds every 4 hr.

4. A nurse is caring for a client who has dyspnea and
will receive oxygen continuously. Which of the
following oxygen devices should the nurse use to
deliver a precise amount of oxygen to the client?

A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
d. simple face mask

5. A nurse is reviewing the plan of care for a client
who is receiving mechanical ventilation. Which of
the following ventilator modes will increase the
client’s work of breathing? (select all that apply.)

A. Assist‑control
B. synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
d. Pressure support ventilation
e. independent lung ventilation

Active Learning Scenario

A nurse is planning care for a client who is receiving
mechanical ventilation. Use the ATi Active Learning
Template: Therapeutic Procedure to complete this item.

NURSING INTERVENTIONS: describe three
nursing actions to maintain the client’s airway.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 19 resPirATOry MANAGeMeNT ANd MeCHANiCAL VeNTiLATiON 123

Application Exercises Key

1. A. PeeP maintains pressure in the lungs to keep
alveoli open or prevent atelectasis.

B. CORRECT: PsV allows preset pressure delivered during
spontaneous ventilation to decrease the work of breathing.

C. PsV does not guarantee minimal minute ventilation
because no ventilator breaths are delivered.

d. Assist‑control (AC) mode delivers a preset
ventilatory rate and tidal volume to the client.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

2. A. Confusion is a late manifestation of hypoxemia.
B. CORRECT: Pale skin is an early manifestation of hypoxemia.
C. Bradycardia is a late manifestation of hypoxemia.
d. Hypotension is a late manifestation of hypoxemia.
e. CORRECT: elevated blood pressure is an

early manifestation of hypoxemia.

NCLEX® Connection: Physiological Adaptation,
Illness Management

3. A. The nurse should apply soft wrist restraints to prevent
self‑extubation or according to facility policy.

B. The nurse should monitor ventilator settings hourly.
C. The nurse should document tube placement in

centimeters at the client’s teeth or lips.
d. CORRECT: The nurse should assess the breath sounds of

a client receiving mechanical ventilation every 4 hr.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. A. A nonrebreather mask delivers an
approximated amount of oxygen.

B. CORRECT: A venturi mask incorporates an adapter that
allows a precise amount of oxygen to be delivered.

C. A nasal cannula delivers an approximated amount of oxygen.
d. A simple face mask delivers an

approximated amount of oxygen.

NCLEX® Connection: Physiological Adaptation,
Illness Management

5. A. Assist‑control mode takes over the work of breathing.
B. CORRECT: synchronized intermittent mandatory

ventilation requires that the client generate
force to take spontaneous breaths.

C. CORRECT: Continuous positive airway pressure requires that
the client generate force to take spontaneous breaths.

d. CORRECT: Pressure support ventilation requires that the
client generate force to take spontaneous breaths.

e. independent lung ventilation mode is used for unilateral
lung disease to ventilate the lung individually.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

Active Learning Scenario Key

Using ATI Active Learning Template: Therapeutic Procedure

NURSING INTERVENTIONS
● Assess the position and placement of the tube.
● document tube placement in centimeters at the client’s teeth or lips.
● Use two staff members for repositioning and resecuring the tube.
● Apply protective barriers (soft wrist restraints) according
to hospital protocol to prevent self‑extubation.

● Use caution when moving the client.
● suction oral and tracheal secretions to maintain tube patency.
● support ventilator tubing to prevent mucosal
erosion and displacement.

● Have a resuscitation bag with a face mask available at the bedside at
all times in case of ventilator malfunction or accidental extubation.

NCLEX® Connection: Physiological Adaptation, Alterations in
Body Systems

124 CHAPTER 19 resPirATOry MANAGeMeNT ANd MeCHANiCAL VeNTiLATiON CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 20 ACUTe resPirATOry disOrders 125

UNIT 3 RESPIRATORY DISORDERS
SECTION: RESPIRATORY SYSTEM DISORDERS

CHAPTER 20 Acute Respiratory
Disorders

The airway structures permit air to enter and
provide for adequate oxygenation and tissue
perfusion. Common acute and chronic disorders
affect these airway structures.

A nursing priority for clients who have acute
respiratory disorders is to maintain a patent
airway to promote oxygenation.

Acute respiratory disorders include rhinitis,
sinusitis, influenza, and pneumonia.

Pneumonia is an inflammatory process in the
lungs that produces excess fluid. Pneumonia is
triggered by infectious organisms or by the
aspiration of an irritant, such as fluid or a foreign
object. The inflammatory process in the lung
parenchyma results in edema and exudate that
fills the alveoli. Pneumonia can be a primary
disease or a complication of another disease or
condition. it affects people of all ages, but
young clients, older adult clients, and clients
who are immunocompromised are more
susceptible. immobility is a contributing factor in
the development of pneumonia.

There are two types of pneumonia.
Community‑acquired pneumonia (CAP) is
the most common type and often occurs
as a complication of influenza. Health
care‑associated pneumonia (HAP) has a higher
mortality rate and is more likely to be resistant
to antibiotics. it usually takes 24 to 48 hr from
the time the client is exposed to acquire HAP.

Older adult clients are more susceptible to
infections and have decreased pulmonary reserves
due to age‑related lung changes, including
decreased lung elasticity and thickening alveoli.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Perform hand hygiene to prevent the spread of infection
by bacteria and viruses.

● Encourage immunizations that prevent respiratory
disorders, especially immunizations for influenza and
pneumonia to younger children and older adults, and
people who have chronic illnesses or who are
immunocompromised.

● Limit exposure to airborne allergens, which trigger a
hypersensitivity reaction.

● Promote smoking cessation.

risK FACTOrs
● Extremely young or advanced age
● Recent exposure to viral, bacterial, or influenza infections
● Lack of current immunization status (pneumonia,

influenza)
● Exposure to plant pollen, molds, animal dander, foods,

medications, and environmental contaminants
● Tobacco smoke
● Substance use (alcohol, cocaine)
● Chronic lung disease (asthma, emphysema)
● Immunocompromised status
● Presence of a foreign body
● Conditions that increase the risk of aspiration (dysphagia)
● Impaired ability to mobilize secretions (decreased level

of consciousness, immobility, recent abdominal or
thoracic surgery)

● Inactivity and immobility
● Mechanical ventilation (ventilator-acquired pneumonia)

Rhinitis
Rhinitis is an inflammation of the nasal mucosa and often
the mucosa in the sinuses that can be caused by infection
(viral or bacterial) or allergens.

● The common cold (coryza) is caused by viruses spread
from person to person in droplets from sneezing and
coughing, or by direct contact.

● This disorder often coexists with other disorders, such
as asthma and allergies, and can be acute or chronic,
nonallergic or allergic (seasonal or perennial).

● The presence of an allergen causes histamine release and
other mediators from WBCs in the nasal mucosa. The
mediators bind to blood vessel receptors causing capillary
leakage, which leads to local edema and swelling.

CHAPTER 20

126 CHAPTER 20 ACUTe resPirATOry disOrders CONTENT MASTERY SERIES

ASSESSMENT

eXPeCTed FiNdiNGs
● Excessive nasal drainage, runny nose (rhinorrhea), and

nasal congestion
● Purulent nasal discharge
● Sneezing and pruritus of the nose, throat, and ears
● Itchy, watery eyes
● Sore, dry throat
● Red, inflamed, swollen nasal mucosa
● Low-grade fever
● Diagnostic testing can include allergy tests to identify

possible allergens.

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Encourage rest (8 to 10 hr/day) and increased fluid

intake (at least 2,000 mL/day).
● Encourage the use of a home humidifier or breathing

steamy air after running hot shower water.
● Promote proper disposal of tissues and use of cough

etiquette (sneeze or cough into tissue, elbow or shoulder
and not the hands).

MediCATiONs
Antihistamines , such as brompheniramine/
pseudoephedrine; leukotriene inhibitors, such as
montelukast; and mast cell stabilizers, such as cromolyn,
are used to block the release of chemicals from WBCs that
bind with receptors in nasal tissues, which prevent edema
and itching.

● Older adults should be aware of adverse effects (vertigo,
hypertension, urinary retention).

Decongestants , such as phenylephrine, constrict blood
vessels and decrease edema.

● CLIENT EDUCATION: Use as prescribed for 3 to 4 days to
avoid rebound nasal congestion.

Intranasal glucocorticoid sprays are the most effective for
prevention and treatment of seasonal and perennial rhinitis.

Antipyretics are used if fever is present.

Antibiotics are given if a bacterial infection can be identified.

CLieNT edUCATiON
● Hand hygiene is a measure to prevent transmission.
● Complementary therapies such as echinacea, large doses

of vitamin C, and zinc preparations (lozenges and nasal
sprays) can be useful in promoting improved immune
response.

● Limiting exposure to others will prevent and reduce
transmission. This is especially important for
vulnerable populations such as the very young, older
adults, and people who are immunosuppressed.

Sinusitis
Sinusitis, often called rhinosinusitis, is an inflammation
of the mucous membranes of one or more of the sinuses,
usually the maxillary or frontal sinus. Swelling of the
mucosa can block the drainage of secretions, which can
cause a sinus infection.

● Sinusitis often occurs after rhinitis and can be
associated with a deviated nasal septum, nasal polyps,
inhaled air pollutants or cocaine, facial trauma, dental
infections, or loss of immune function.

● The infection is often caused by a virus, Streptococcus
pneumoniae, Haemophilus influenzae, diplococcus,
and bacteroides.

ASSESSMENT

eXPeCTed FiNdiNGs
● Nasal congestion
● Headache
● Facial pressure or pain (worse when head is

tilted forward)
● Cough
● Bloody or purulent nasal drainage
● Tenderness to palpation of forehead, orbital, and

facial areas
● Low-grade fever

diAGNOsTiC PrOCedUres
● CT scan or sinus x-rays confirm the diagnosis, which is

typically based upon findings and physical assessment.
● Endoscopic sinus cavity lavage or surgery to relieve

the obstruction and promote drainage of secretions
may be done.

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Encourage the use of steam humidification, sinus

irrigation, saline nasal sprays, and hot and wet packs to
relieve sinus congestion and pain.

● Teach the client to increase fluid intake and rest.
● Discourage air travel, swimming, and diving.
● Encourage cessation of tobacco use in any form.
● Instruct the client on correct technique for sinus

irrigation and self-administration of nasal sprays.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 20 ACUTe resPirATOry disOrders 127

MediCATiONs
Nasal decongestants , such as phenylephrine, are used to
reduce swelling of the mucosa.

CLIENT EDUCATION
● Begin over-the-counter decongestant use at the first

manifestation of sinusitis.
● Manifestations of rebound nasal congestion can occur if

decongestants are used for more than 3 to 4 days.

Broad-spectrum antibiotics , such as amoxicillin, are
used on a limited basis for a confirmed causative bacterial
pathogen.

Pain relief medications include NSAIDs, acetaminophen,
and aspirin.

CLieNT edUCATiON
● Sinus irrigation and saline nasal sprays are an effective

alternative to antibiotics for relieving nasal congestion.
● Contact the provider for manifestations of a severe

headache, neck stiffness (nuchal rigidity), and high
fever, which can indicate possible complications.

COMPLICATIONS
Meningitis and encephalitis can occur if pathogens enter
the bloodstream from the sinus cavity.

Influenza
Seasonal influenza , or “flu,” occurs as an epidemic,
usually in the fall and winter months.

● It is a highly contagious acute viral infection that occurs
in children and adults of all ages.

● Influenza can be caused by one of several virus families,
and this can vary yearly. Adults are contagious from
24 hr before manifestations develop and up to 5 days
after they begin.

Pandemic influenza refers to a viral infection among
animals or birds that has mutated and is becoming highly
infectious to humans. The resulting viral infection has the
potential to spread globally, such as H1N1 (“swine flu”)
and H5N1 (“avian flu”).

ASSESSMENT

eXPeCTed FiNdiNGs
● Severe headache and muscle aches
● Chills
● Fatigue, weakness
● Severe diarrhea and cough (avian flu)
● Fever
● Hypoxia (avian flu)

diAGNOsTiC PrOCedUres
AV Avantage A/H5N1 Flu Test

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Maintain droplet and contact precautions for

hospitalized clients who have pandemic influenza.
● Provide saline gargles.
● Monitor hydration status, intake, and output.
● Administer fluid therapy as prescribed.
● Monitor respiratory status.

MediCATiONs

Antivirals
● Amantadine, rimantadine, and ribavirin may be

prescribed for treatment and prevention of influenza.
● Duration of the influenza infection can be shortened by

antivirals such as the oral inhalant zanamivir and the
oral tablet oseltamivir. In cases of pandemic influenza,
these medications may be distributed widely among
the population.

CLIENT EDUCATION: Begin antiviral medications within
24 to 48 hr after the onset of manifestations.

Influenza vaccines
● Quadrivalent and trivalent vaccines are prepared yearly

depending upon the suspected strain of influenza
expected to appear. They include an IM injection of
Fluvirin or Fluzone.

◯ Vaccination is encouraged for everyone older than
6 months of age.

◯ Clients who have a history of pneumonia, chronic
medical conditions, and those over age 65, pregnant
women, and health care providers are at higher risk
and require vaccination.

● H1N1 vaccine is available for the general population.
● H5N1 vaccine is stockpiled for distribution if a

pandemic occurs.

iNTerPrOFessiONAL CAre
● Respiratory services should be consulted for

respiratory support.
● Community health officials are notified of

influenza outbreaks.
● State and federal public health officials are consulted

for containment and prevention directives during
pandemic influenza.

128 CHAPTER 20 ACUTe resPirATOry disOrders CONTENT MASTERY SERIES

CLieNT edUCATiON
● Obtain an annual influenza immunization when

vaccines become available.
● Reduce the risk for spreading viruses by thoroughly

washing hands and following cough etiquette.
● Avoid places where people gather. Avoid close personal

contact (handshaking, kissing, and hugging).
● If flu manifestations develop, increase fluid intake, rest

and stay home from work or school.
● Avoid travel to areas where pandemic influenza

is identified.
● Be aware of public health announcements and activation

of the early warning system by public health officials in
case of pandemic influenza.

COMPLICATIONS
Pneumonia is a complication of influenza and affects older
adults and clients who are debilitated or
immunocompromised.

Pneumonia

ASSESSMENT

eXPeCTed FiNdiNGs
● Anxiety
● Fatigue
● Weakness
● Chest discomfort due to coughing
● Confusion from hypoxia is the most
common manifestation of pneumonia
in older adult clients.

PHYSICAL ASSESSMENT FINDINGS
● Fever
● Chills
● Flushed face
● Diaphoresis
● Shortness of breath or
difficulty breathing

● Tachypnea
● Pleuritic chest pain (sharp)
● Sputum production (yellow-tinged)
● Crackles and wheezes
● Coughing
● Dull chest percussion over areas of
consolidation

● Decreased oxygen saturation
levels (expected reference range is
95% to 100%)

● Purulent, blood-tinged or rust-colored
sputum, which may not always
be present

LABOrATOry TesTs
Sputum culture and sensitivity

● Obtain specimen before starting antibiotic therapy.
● Obtain specimen by suctioning if the client is

unable to cough.
● Older adult clients might have a weak cough reflex and

decreased muscle strength. Therefore, older adult clients
can have trouble expectorating, which can lead to difficulty
in breathing and make specimen retrieval more difficult.

CBC: Elevated WBC count (might not be present in older
adult clients)

ABGs: Hypoxemia (decreased PaO2 less than 80 mm Hg)

Blood culture: To rule out organisms in the blood

Electrolytes: To identify manifestations of dehydration
(elevated BUN, hypernatremia)

diAGNOsTiC PrOCedUres

Chest x‑ray
● A chest x-ray will show consolidation (solidification,

density) of lung tissue. (20.1)
● Chest x-ray might not indicate pneumonia for a few

days after manifestations.
● A chest x-ray is an important diagnostic tool because

the early manifestations of pneumonia are often vague
in older adult clients.

Pulse oximetry

Clients who have pneumonia usually have oximetry levels
less than the expected reference range of 95% to 100%.

Online Video: Metered Dose Inhaler

20.1 Pneumonia

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 20 ACUTe resPirATOry disOrders 129

PATIENT‑CENTERED CARE

NUrsiNG CAre
● Position the client to maximize ventilation

(high-Fowler’s = 90%) unless contraindicated.
● Encourage coughing or suction to remove secretions.
● Administer breathing treatments and medications.
● Administer oxygen therapy.
● Monitor for skin breakdown around the nose and mouth

from the oxygen device.
● Encourage deep breathing with an incentive spirometer

to prevent alveolar collapse.
● Determine the client’s physical limitations and

structure activity to include periods of rest.
● Promote adequate nutrition and fluid intake.

◯ The increased work of breathing requires
additional calories.

◯ Proper nutrition aids in the prevention of secondary
respiratory infections.

◯ Encourage fluid intake of 2 to 3 L/day to promote
hydration and thinning of secretions, unless
contraindicated due to another condition.

● Provide rest periods for clients who have dyspnea.
● Reassure the client who is experiencing

respiratory distress.

MediCATiONs

Antibiotics
● Antibiotics are given to destroy infectious pathogens.

Commonly used antibiotics include penicillins
and cephalosporins.

● Antibiotics are often initially given via IV and then
switched to an oral form as the condition improves.

● It is important to obtain any culture specimens prior to
giving the first dose of an antibiotic. Once the specimen
has been obtained, the antibiotics can be given while
waiting for the results of the prescribed culture.

NURSING ACTIONS
● Observe clients for frequent stools.
● Monitor kidney function, especially for older adults who

are taking penicillins and cephalosporins.

CLIENT EDUCATION: Take penicillins and cephalosporins
with food. Some penicillins should be taken 1 hr before
meals or 2 hr after.

Bronchodilators
● Bronchodilators are given to reduce bronchospasms and

reduce irritation.
● Short-acting beta2 agonists, such as albuterol, provide

rapid relief.
● Cholinergic antagonists (anticholinergic medications),

such as ipratropium, block the parasympathetic nervous
system, allowing for increased bronchodilation and
decreased pulmonary secretions.

● Methylxanthines, such as theophylline, require close
monitoring of blood medication levels due to the narrow
therapeutic range.

NURSING ACTIONS
● Monitor blood medication levels for toxicity for clients

taking theophylline. Adverse effects will include
tachycardia, nausea, and diarrhea.

● Watch for tremors and tachycardia for clients
taking albuterol.

● Observe for dry mouth in clients taking ipratropium, and
monitor heart rate. Adverse effects can include headache,
blurred vision, and palpitations, which can indicate toxicity.

CLIENT EDUCATION
● Suck on hard candies to moisten dry mouth while

taking ipratropium.
● Increase fluid intake unless contraindicated.

Anti‑inflammatories
● Anti-inflammatories decrease airway inflammation.
● Glucocorticosteroids, such as fluticasone and prednisone,

are prescribed to reduce inflammation. Monitor for
immunosuppression, fluid retention, hyperglycemia,
hypokalemia, and poor wound healing.

NURSING ACTIONS
● Monitor for decreased immunity function.
● Monitor for hyperglycemia.
● Observe for fluid retention and weight gain. This can

be common.
● Monitor the throat and mouth for aphthous lesions

(canker sores).

CLIENT EDUCATION
● Report black, tarry stools.
● Drink plenty of fluids to promote hydration.
● Take glucocorticosteroids with food.
● Avoid discontinuing glucocorticosteroids without

consulting the provider.

iNTerPrOFessiONAL CAre
● Respiratory services should be consulted for

inhalers, breathing treatments, and suctioning for
airway management.

● Nutritional services can be contacted for weight loss or
gain related to medications or diagnosis.

● Rehabilitation care can be consulted if the client
has prolonged weakness and needs assistance with
increasing level of activity.

CLieNT edUCATiON
● It is important to continue medications for treatment of

pneumonia.
● Rest as needed.
● Maintain hand hygiene to prevent infection.
● Avoid crowded areas to reduce the risk of infection.
● Treatment and recovery from pneumonia can take time.
● Obtain immunizations for influenza and pneumonia.
● Discontinue tobacco use if needed.

130 CHAPTER 20 ACUTe resPirATOry disOrders CONTENT MASTERY SERIES

COMPLICATIONS
Atelectasis

● Airway inflammation and edema lead to alveolar
collapse and increase the risk of hypoxemia.

● The client reports shortness of breath and exhibits
findings of hypoxemia.

● The client has diminished or absent breath sounds over
the affected area.

● A chest x-ray shows an area of density.

Bacteremia (sepsis): This occurs if pathogens enter the
bloodstream from the infection in the lungs.

Acute respiratory distress syndrome
● Hypoxemia persists despite oxygen therapy.
● Lung volume capacity and elasticity is reduced.
● Dyspnea worsens as bilateral pulmonary edema

develops that is noncardiac related.
● A chest x-ray shows an area of density with a

ground-glass appearance.
● Blood gas findings demonstrate high arterial blood

levels of carbon dioxide (hypercarbia) even though pulse
oximetry shows decreased saturation.

Application Exercises

1. A nurse is monitoring a group of clients for
increased risk for developing pneumonia.
Which of the following clients should the nurse
expect to be at risk? (select all that apply.)

A. Client who has dysphagia

B. Client who has Aids

C. Client who was vaccinated for pneumococcus
and influenza 6 months ago

d. Client who is postoperative and has
received local anesthesia

e. Client who has a closed head injury and
is receiving mechanical ventilation

F. Client who has myasthenia gravis

2. A nurse is caring for a client who, upon
awakening, was disoriented to person, place,
and time. The client reports chills and chest
pain that is worse upon inspiration. Which of
the following actions is the nursing priority?

A. Obtain baseline vital signs and oxygen saturation.

B. Obtain a sputum culture.

C. Obtain a complete history from the client.

d. Provide a pneumococcal vaccine.

3. A nurse is caring for a client who has pneumonia.
Assessment findings include temperature
37.8° C (100° F), respirations 30/min, blood pressure
130/76, heart rate 100/min, and saO2 91% on room
air. Prioritize the following nursing interventions.

A. Administer antibiotics.

B. Administer oxygen therapy.

C. Perform a sputum culture.

d. instruct the client to obtain a yearly
influenza vaccination.

4. A nurse in a clinic is assessing a client who has sinusitis.
Which of the following techniques should the nurse
use to identify manifestations of this disorder?

A. Percussion of posterior lobes of lungs

B. Auscultation of the trachea

C. inspection of the conjunctiva

d. Palpation of the orbital areas

5. A nurse is teaching a group of clients about
influenza. Which of the following client statements
indicates an understanding of the teaching?

A. “i should wash my hands after blowing my
nose to prevent spreading the virus.”

B. “i need to avoid drinking fluids
if i develop symptoms.”

C. “i need a flu shot every 2 years because
of the different flu strains.”

d. “i should cover my mouth with
my hand when i sneeze.”

Active Learning Scenario

A nurse in a clinic is discussing health promotion and disease
management with a client who has rhinitis. What should
the nurse include in this discussion? Use the ATi Active
Learning Template: system disorder to complete this item.

RISK FACTORS: identify three risk factors for rhinitis.

EXPECTED FINDINGS: describe at least four.

CLIENT EDUCATION: describe two client self‑care activities.

MEDICATIONS: identify two over‑the‑counter
medications the client can use.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 20 ACUTe resPirATOry disOrders 131

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS
● recent exposure to viral, bacterial or influenza infections
● Lack of current immunization status (pneumonia, influenza)
● exposure to plant pollen, molds, animal dander, foods,
medications, and environmental contaminants

● Tobacco smoke
● substance use (alcohol, cocaine)
● Presence of a foreign body
● inactivity and immobility

EXPECTED FINDINGS
● excessive nasal drainage, runny nose (rhinorrhea), nasal congestion
● Purulent nasal drainage
● sneezing and pruritus of the nose, throat, and ears
● itchy, watery eyes
● sore, dry throat
● red, inflamed, swollen nasal mucosa
● Low‑grade fever

CLIENT EDUCATION
● rest (8 to 10 hr/day), increased fluid intake (at least 2,000 mL/day)
● Use of a home humidifier or breathing steamy
air after running hot shower water

● Proper disposal of tissues and use of cough etiquette

MEDICATIONS: Brompheniramine/pseudoephedrine,
cromolyn sodium, phenylephrine, antipyretics

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

Application Exercises Key

1. A. CORRECT: The client who has difficulty swallowing is at
increased risk for pneumonia due to aspiration.

B. CORRECT: The client who has Aids is
immunocompromised, which increases the risk of
opportunistic infections, such as pneumonia.

C. The client who has recently been vaccinated in the past
few months has a decreased risk to acquire pneumonia.

d. A client who is postoperative and has received local
anesthesia has a decreased risk to acquire pneumonia.

e. CORRECT: Mechanical ventilation is invasive and places
the client at risk for ventilator‑associated pneumonia.

F. CORRECT: A client who has myasthenia gravis has
generalized weakness and can have difficulty clearing airway
secretions, which increases the risk of pneumonia.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

2. A. CORRECT: The first action the nurse should take
using the nursing process is to assess the client in
order to determine the next nursing intervention
and provide safe and effective client care.

B. The nurse should obtain a sputum culture to determine
sensitivity for antibiotic therapy. However, there is
another action the nurse should take first.

C. The nurse should obtain a complete history from the
client to determine the plan of care. However, there
is another action the nurse should take first.

d. The nurse should provide for a pneumococcal vaccination
to decrease the risk of pneumonia in the future. However,
there is another action the nurse should take first.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

3. Correct order
B. The client’s respiratory and heart rates are elevated, and her

oxygen saturation is 91% on room air. Using the ABC priority
framework, providing oxygen is the first intervention.

C. Obtaining a sputum culture is the second nursing
intervention. it should be done prior to administering
oral medications to obtain an accurate specimen.

A. Administration of antibiotics is the third action the
nurse should take. The sputum culture should be
obtained prior to antibiotic administration.

d. The last action the nurse should take is to instruct the client
to receive yearly influenza vaccinations, to reduce the risk
of acquiring influenza that can lead to pneumonia.

NCLEX® Connection: Physiological Adaptation,
Illness Management

4. A. Lung percussion is used to assess a client
who has pneumonia.

B. Auscultation of the trachea is used to assess
a client who has bronchitis.

C. inspection of the conjunctiva is used to
assess a client who has anemia.

d. CORRECT: A client who has sinusitis will report tenderness
when the orbital, frontal, and facial areas are palpated.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. A. CORRECT: Hand hygiene decreases the risk of
the client spreading influenza viruses.

B. The client should increase fluid intake to loosen mucous,
promote expectoration, and maintain hydration.

C. The client should receive an influenza vaccination
yearly to reduce the risk for acquiring influenza.

d. The client should sneeze into the shoulder or
elbow, rather than the hands, to reduce the
risk of spreading the influenza virus..

NCLEX® Connection: Physiological Adaptation,
Illness Management

132 CHAPTER 20 ACUTe resPirATOry disOrders CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 21 AsthmA 133

UNIT 3 RESPIRATORY DISORDERS
SECTION: RESPIRATORY SYSTEM DISORDERS

CHAPTER 21 Asthma
Asthma is a chronic disorder of the airways
that results in intermittent and reversible
airflow obstruction of the bronchioles. the
obstruction occurs either by inflammation
or airway hyperresponsiveness. Asthma can
occur at any age. the cause is unknown.
manifestations of asthma include mucosal
edema, bronchoconstriction, and excessive
mucus production.

HEALTH PROMOTION AND
DISEASE PREVENTION

● If the client smokes, promote smoking cessation.
● Advise the client to use protective equipment (mask)

and ensure proper ventilation while working in
environments that contain carcinogens or particles
in the air.

● Encourage influenza and pneumonia vaccinations for
older adults and all clients who have asthma.

● Instruct the client how to recognize and avoid
triggering agents.

◯ Environmental factors, such as changes in
temperature (especially warm to cold) and humidity

◯ Air pollutants
◯ Strong odors (perfume)
◯ Seasonal allergens (grass, tree, and weed pollens) and

perennial allergens (mold, feathers, dust, roaches,
animal dander, foods treated with sulfites)

◯ Stress and emotional distress
◯ Medications (aspirin, NSAIDs, beta‑blockers,
cholinergics)

◯ Enzymes, including those in laundry detergents
◯ Chemicals (household cleaners)
◯ Sinusitis with postnasal drip
◯ Viral respiratory tract infection

● Teach the client how to self‑administer medications
(nebulizers and inhalers).

● Educate the client regarding infection
prevention techniques.

● Encourage regular exercise as part of asthma therapy.
◯ Promotes ventilation and perfusion.
◯ Maintains cardiac health.
◯ Enhances skeletal muscle strength.
◯ Clients can require premedication.

● Instruct the client to use hot water to eliminate dust
mites in bed linens.

ASSESSMENT
Diagnosis is based on findings and classified into one of
the following four categories.

● Mild intermittent: Symptoms occur less than
twice a week.

● Mild persistent: Symptoms arise more than twice a
week but not daily.

● Moderate persistent: Daily symptoms occur in
conjunction with exacerbations twice a week.

● Severe persistent: Symptoms occur continually, along
with frequent exacerbations that limit physical activity
and quality of life.

RIsK FACtORs
● Older adult clients have decreased pulmonary reserves

due to physiologic lung changes that occur with the
aging process.

◯ Older adult clients are more susceptible to infections.
◯ The sensitivity of beta‑adrenergic receptors
decreases with age. As the beta receptors age and
lose sensitivity, they are less able to respond to
agonists, which relax smooth muscle and can result
in bronchospasms.

● Family history of asthma
● Smoking
● Secondhand smoke exposure
● Environmental allergies
● Exposure to chemical irritants or dust
● Gastroesophageal reflux disease (GERD)

EXPECtED FINDINGs
● Dyspnea
● Chest tightness
● Anxiety or stress

CHAPTER 21

Online Image: Normal and Asthmatic Lung Changes

21.1 Normal and asthmatic bronchioles

134 CHAPTER 21 AsthmA CONTENT MASTERY SERIES

PHYSICAL ASSESSMENT FINDINGS
● Coughing
● Wheezing
● Mucus production
● Use of accessory muscles
● Prolonged exhalation
● Poor oxygen saturation (low SaO2)
● Barrel chest or increased chest diameter

Obtain history regarding current and previous asthma
exacerbations.

● Onset and duration
● Precipitating factors (stress, exercise, exposure

to irritant)
● Changes in medication regimen
● Medications that provide relief
● Other medications taken
● Self‑care methods used to promote relief

LABORAtORY tEsts

Arterial blood gases

Hypoxemia (decreased PaO2 less than 80 mm Hg)

Hypocarbia (decreased PaCO2 less than 35 mm Hg: early
in attack)

Hypercarbia (increased PaCO2 greater than 45 mm Hg:
later in attack)

Sputum cultures

Bacteria can indicate infection.

DIAGNOstIC PROCEDUREs
● Pulmonary function tests (PFTs) are the most accurate

tests for diagnosing asthma and its severity.
◯ Forced vital capacity (FVC) is the volume of air
exhaled from full inhalation to full exhalation.

◯ Forced expiratory volume in the first second (FEV1)
is the volume of air blown out as hard and fast as
possible during the first second of the most forceful
exhalation after the greatest full inhalation.

◯ Peak expiratory flow is the fastest airflow rate
reached during exhalation.

◯ A decrease in FEV1 by 15% to 20% below the expected
value is common in clients who have asthma. An
increase in these values by 12% following the
administration of bronchodilators is diagnostic
for asthma.

● A chest x‑ray is used to diagnose changes in chest
structure over time.

PATIENT‑CENTERED CARE

NURsING CARE
● Position the client to maximize ventilation

(high‑Fowler’s).
● Administer oxygen therapy as prescribed.
● Monitor cardiac rate and rhythm for changes during an

acute attack (can be irregular, tachycardic, or with PVCs).
● Monitor respiratory rate and rhythm for changes in

effort, symmetry, SaO2; auscultate lung sounds.
● Initiate and maintain IV access.
● Remain calm and reassuring.
● Provide rest periods for older adult clients who have

dyspnea. Design room and walkways with opportunities
for rest. Incorporate rest into ADLs.

● Encourage prompt medical attention for infections and
appropriate immunizations.

● Administer medications as prescribed.

mEDICAtIONs

Bronchodilators (inhalers)
● Short‑acting beta2 agonists, such as albuterol, provide

rapid relief of acute manifestations and prevent
exercise‑induced asthma.

● Anticholinergic medications, such as ipratropium, block
the parasympathetic nervous system. This allows for
the sympathetic nervous system effects of increased
bronchodilation and decreased pulmonary secretions.
These medications are long‑acting and used to
prevent bronchospasms.

● Methylxanthines, such as theophylline, require close
monitoring of blood medication levels due to a narrow
therapeutic range. Use only when other treatments
are ineffective.

● Long‑acting beta2 agonists, such as salmeterol,
primarily are used for asthma attack prevention.

NURSING ACTIONS
● Albuterol: Watch for tremors and tachycardia.
● Ipratropium: Observe for dry mouth.
● Theophylline: Monitor blood levels for toxicity. Adverse

effects include tachycardia, nausea, and diarrhea.

CLIENT EDUCATION
● Ipratropium: Suck on hard candies to help relieve dry

mouth; increase fluid intake; and report headache,
blurred vision, or palpitations, which can indicate
toxicity of ipratropium. Monitor heart rate.

● Salmeterol: Use to prevent an asthma attack and not at
the onset of an attack.

Anti‑inflammatory agents

These medications are for prophylaxis and are used to
decrease airway inflammation.

● Corticosteroids, such as fluticasone and prednisone
● Leukotriene antagonists, such as montelukast
● Mast cell stabilizers, such as cromolyn
● Monoclonal antibodies, such as omalizumab

Online Animation: Metered‑Dose Inhaler

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 21 AsthmA 135

NURSING ACTIONS
● Watch for decreased immunity function and

wound healing.
● Monitor for hyperglycemia.
● Observe for fluid retention and weight gain. This can

be common.
● Monitor the throat and mouth for aphthous lesions

(canker sores).
● Omalizumab can cause anaphylaxis.

CLIENT EDUCATION
● Report black, tarry stools.
● Drink plenty of fluids to promote hydration.
● Take prednisone with food.
● Use these medications to prevent asthma, not for the

onset of an attack.
● Avoid people who have respiratory infections.
● Use good mouth care and hand washing regimen.
● Do not discontinue medication suddenly.
● Perform daily peak flow meter assessments. If only able

to achieve a reading in the red zone, immediately use
the reliever medications and seek emergency care.

Combination agents (bronchodilator
and anti‑inflammatory)

If prescribed separately for inhalation administration at
the same time, administer the bronchodilator first in order
to increase the absorption of the anti‑inflammatory agent.

● Ipratropium and albuterol
● Fluticasone and salmeterol

INtERPROFEssIONAL CARE
● Respiratory services should be consulted for inhalers

and breathing treatments for airway management.
● Nutritional services can be contacted for weight loss or

gain related to medications or diagnosis.
● Rehabilitation care can be consulted if the client

has prolonged weakness and needs assistance with
increasing level of activity.

COMPLICATIONS

Respiratory failure

Persistent hypoxemia related to asthma can lead to
respiratory failure.

NURSING ACTIONS
● Monitor oxygenation levels and acid‑base balance.
● Prepare for intubation and mechanical ventilation.

Status asthmaticus

This is a life‑threatening episode of airway obstruction
that is often unresponsive to common treatment. It
involves extreme wheezing, labored breathing, use of
accessory muscles, distended neck veins, and creates a
risk for cardiac and/or respiratory arrest.

NURSING ACTIONS
● Prepare for emergency intubation.
● Administer IV fluids, oxygen, bronchodilators, and

epinephrine. Initiate systemic steroid therapy.

Active Learning Scenario

A nurse is caring for a client who has asthma and a
prescription for prednisone. Use the AtI Active Learning
template: medication to complete this item.

NURSING INTERVENTIONS: Include at least three.

Application Exercises

1. A nurse in the emergency department is caring for
a client who is experiencing an acute asthma attack.
Which of the following assessments indicates that the
respiratory status is declining? (select all that apply.)

A. saO2 95%
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. tachycardia

2. A nurse is caring for a client 2 hr after admission.
the client has an saO2 of 91%, exhibits audible
wheezes, and is using accessory muscles when
breathing. Which of the following classes of
medications should the nurse expect to administer?

A. Antibiotic
B. Beta‑blocker
C. Antiviral
D. Beta2 agonist

3. A nurse is providing discharge teaching to a
client who has a new prescription for prednisone
for asthma. Which of the following client
statements indicates understanding?

A. “I will decrease my fluid intake while
taking this medication.”

B. “I will expect to have black, tarry stools.”

C. “I will take my medication with meals.”

D. “I will monitor for weight loss
while on this medication.”

4. A nurse is assessing a client who has a history of
asthma. Which of the following factors should
the nurse identify as a risk for asthma?

A. sex
B. Environmental allergies
C. Alcohol use
D. history of diabetes

5. A nurse is reinforcing teaching with a client on the
purpose of taking a bronchodilator. Which of the
following client statements indicates understanding?

A. “this medication can decrease
my immune response.”

B. “I take this medication to prevent asthma attacks.”

C. “I need to take this medication with food.”

D. “this medication has a slow onset
to treat my symptoms.”

136 CHAPTER 21 AsthmA CONTENT MASTERY SERIES

Application Exercises Key

1. A. Oxygen saturation 95% is an expected finding and does
not indicate the client’s condition is declining.

B. CORRECT: Wheezing indicates airway narrowing
and is a manifestation indicating the client’s
respiratory status is declining.

C. CORRECT: Retraction of sternal muscles is associated
with increased work of breathing and is a manifestation
that the client’s respiratory status is declining.

D. Pink mucous membranes is an expected finding and
does not indicate the client’s condition is declining.

E. CORRECT: tachycardia can be a manifestation
of decreased oxygenation and an indicator that
the client’s respiratory status is declining.

NCLEX® Connection: Physiological Adaptation,
Illness Management

2. A. An antibiotic typically is given for a bacterial infection.
B. A beta‑blocker typically is given for dysrhythmias,

heart disease, or hypertension.
C. An antiviral typically is given for a virus.
D. CORRECT: Administer a beta2 agonist, which causes dilation

of the bronchioles to relieve wheezing and open the airways.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

3. A. the client should drink plenty of fluids while taking
prednisone. this medication can cause the client to
have a dry mouth or to become thirsty.

B. the client should inform the provider of any black, tarry
stools. this medication can increase bleeding tendency.
Black stools can be an indication of blood in the stool.

C. CORRECT: the client should take this medication
with food. taking prednisone on an empty stomach
can cause gastrointestinal distress.

D. the client should monitor the mouth for canker sores. this
medication can cause bleeding of the gums and soreness
in the mouth. It also decreases immune function.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

4. A. sex is not a risk factor associated with asthma.
B. CORRECT: Environmental allergies are a risk factor associated

with asthma. A client who has environmental allergies typically
has other allergic problems, such as rhinitis or a skin rash.

C. Alcohol use is not a risk factor associated with asthma.
D. A history of diabetes is not a risk factor

associate with asthma.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

5. A. A bronchodilator does not decrease the body’s
immune response. however, an anti‑inflammatory
medication can cause this effect.

B. CORRECT: A bronchodilator can prevent
asthma attacks from occurring.

C. An oral bronchodilator does not need to be
taken with food. however, an anti‑inflammatory
medication can cause gastrointestinal distress
and needs to be to be given with food.

D. A bronchodilator has a fast onset to relieve the
manifestations associated with an asthma attack.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

NURSING INTERVENTIONS
● Watch for decreased immune function.
● monitor for hyperglycemia.
● Advise the client to report black, tarry stools.
● Observe for fluid retention and weight gain.
● monitor the throat and mouth for aphthous lesions (canker sores).

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 22 ChRONIC OBstRUCtIvE PULmONARY DIsEAsE 137

UNIT 3 RESPIRATORY DISORDERS
SECTION: RESPIRATORY SYSTEM DISORDERS

CHAPTER 22 Chronic Obstructive
Pulmonary Disease

Chronic obstructive pulmonary disease (COPD)
encompasses two diseases: emphysema and
chronic bronchitis. most clients who have
emphysema also have chronic bronchitis. COPD
is irreversible.

Emphysema is characterized by the loss of
lung elasticity and hyperinflation of lung
tissue. Emphysema causes destruction of the
alveoli, leading to a decreased surface area for
gas exchange, carbon dioxide retention, and
respiratory acidosis.

Chronic bronchitis is an inflammation of
the bronchi and bronchioles due to chronic
exposure to irritants.

COPD typically affects middle‑age to
older adults.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Promote smoking cessation.
● Avoid exposure to secondhand smoke.
● Use protective equipment, such as a mask, and ensure
proper ventilation while working in environments that
contain carcinogens or particles in the air.

● Influenza and pneumonia immunizations are
important for all clients who have COPD, but especially
for older adults.

ASSESSMENT

RIsK FACtORs
● Advanced age: Older adult clients have a decreased
pulmonary reserve due to age‑related lung changes.

● Cigarette smoking is the primary risk factor for the
development of COPD.

● Alpha1‑antitrypsin (AAT) deficiency
● Exposure to environmental factors (air pollution)

EXPECtED FINDINGs
Chronic dyspnea. The respiratory rate can reach
40 to 50/min during acute exacerbations.

PHYSICAL ASSESSMENT FINDINGS
● Dyspnea upon exertion
● Productive cough that is most severe upon rising in

the morning
● Hypoxemia
● Crackles and wheezes
● Rapid and shallow respirations
● Use of accessory muscles
● Barrel chest or increased chest diameter

(with emphysema) (22.1)
● Hyperresonance on percussion due to “trapped air”

(with emphysema)
● Irregular breathing pattern
● Thin extremities and enlarged neck muscles
● Dependent edema secondary to right‑sided heart failure
● Clubbing of fingers and toes (late stages of the disease)
● Pallor and cyanosis of nail beds and mucous membranes

(late stages of the disease)
● Decreased oxygen saturation levels (expected reference

range is 95% to 100%)
● In older adults or clients who have dark‑colored skin,

oxygen saturation levels can be slightly lower.

CHAPTER 22

Online Image: COPD

22.1 Chronic obstructive pulmonary disease

138 CHAPTER 22 ChRONIC OBstRUCtIvE PULmONARY DIsEAsE CONTENT MASTERY SERIES

LABORAtORY tEsts
● Increased hematocrit level is due to low oxygenation levels.
● Use sputum cultures and WBC counts to diagnose acute

respiratory infections.
● Arterial blood gases (ABGs)

◯ Hypoxemia (decreased PaO2 less than 80 mm Hg)
◯ Hypercarbia (increased PaCO2 greater than 45 mm Hg)

● Blood electrolytes

DIAGNOstIC PROCEDUREs

Pulmonary function tests

These tests are used for diagnosis, as well as determining
the effectiveness of therapy.

● Comparisons of forced expiratory volume (FEV) to
forced vital capacity (FVC) are used to classify COPD as
mild to very severe.

● As COPD advances, the FEV‑to‑FVC ratio decreases. The
expected reference range is 100%. For mild COPD, the
FEV/FVC ratio is decreased to less than 70%. As the
disease progresses to moderate and severe, the ratio
decreases to less than 50%.

Chest x‑ray
● Reveals hyperinflation of alveoli and flattened

diaphragm in the late stages of emphysema. (22.2)
● It is often not useful for the diagnosis of early or

moderate disease.

Alpha1 antitrypsin levels

Used to assess for deficiency in AAT, an enzyme produced
by the liver that helps regulate other enzymes (which help
break down pollutants) from attacking lung tissue.

PATIENT‑CENTERED CARE

NURsING CARE
● Position the client to maximize ventilation

(high‑Fowler’s).
● Encourage effective coughing, or suction to

remove secretions.
● Encourage deep breathing and use of an

incentive spirometer.
● Administer breathing treatments and medications.
● Administer oxygen as prescribed. In COPD, low

arterial levels of oxygen serve as the primary drive for
breathing. However, in most cases, oxygen levels should
be maintained between 88% and 92%.

● Clients who have COPD can need 2 to 4 L/min of oxygen
via nasal cannula or up to 40% via Venturi mask. Clients
who have chronically increased PaCO2 levels usually
require 1 to 2 L/min of oxygen via nasal cannula.

● Monitor for skin breakdown around the nose and mouth
from the oxygen device.

● Promote adequate nutrition.
◯ Increased work of breathing increases caloric demands.
◯ Proper nutrition aids in the prevention of infection.
◯ Encourage fluids to promote adequate hydration.
◯ Dyspnea decreases energy available for eating, so soft,

high‑calorie foods should be encouraged.
● Monitor weight and note any changes.
● Instruct the client to practice breathing techniques to

control dyspneic episodes.
◯ For diaphragmatic (abdominal) breathing, instruct the
client to:

■ Take breaths deep from the diaphragm.
■ Lie on back with knees bent.
■ Rest a hand over the abdomen to create resistance.
■ If the client’s hand rises and lowers upon
inhalation and exhalation, the breathing is being
performed correctly.

◯ For pursed‑lip breathing, instruct the client to:
■ Form the mouth as if preparing to whistle.
■ Take a breath in through the nose and out through

the lips/mouth.
■ Not puff the cheeks.
■ Take breaths deep and slow.

● Positive expiratory pressure device
◯ Assists client to remove airway secretions.
◯ Client inhales deeply and exhales through device.
◯ While exhaling, a ball inside the device moves, causing
a vibration that results in loosening secretions.

● Exercise conditioning
◯ Includes improving pulmonary status by
strengthening the condition of the lungs by exercise.

◯ The client walks daily at a self‑paced rate until
dyspnea occurs, then stops to rest. Once dyspnea
resolves, the client resumes.

◯ The client walks 20 min daily 2 to 3 times weekly.
◯ Determine the client’s physical limitations, and
structure activity to include periods of rest.

◯ Provide rest periods for older adult clients who have
dyspnea. Design the room and walkways with
opportunities for relaxation.

● Provide support to the client and family. Talk about
disease and lifestyle changes, including home care
services such as portable oxygen.

● Increase fluid intake. Encourage the client to drink 2 to
3 L/day to liquefy mucus.

Incentive spirometry

Incentive spirometry is used to monitor optimal
lung expansion.

NURSING ACTIONS: Show the client how to use the
incentive spirometry machine.

CLIENT EDUCATION: Keep a tight mouth seal around the
mouthpiece and inhale and hold breath for 3 to 5 seconds.
During inhalation, the needle of the spirometry machine
will rise. This promotes lung expansion.

Online Image: X‑ray of Lungs with Emphysema

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 22 ChRONIC OBstRUCtIvE PULmONARY DIsEAsE 139

mEDICAtIONs

Bronchodilators (inhalers)

Short‑acting beta2 agonists , such as albuterol, provide
rapid relief.

Cholinergic antagonists (anticholinergic medications) ,
such as ipratropium, block the parasympathetic nervous
system. This allows for the sympathetic nervous system
effects of increased bronchodilation and decreased
pulmonary secretions. These medications are long‑acting
and are used to prevent bronchospasms.

Methylxanthines , such as theophylline, relax smooth
muscles of the bronchi. These medications require close
monitoring of blood medication levels due to narrow
therapeutic ranges. Use only when other treatments are
ineffective.

NURSING ACTIONS
● Monitor for toxicity when taking theophylline. Adverse

effects include tachycardia, nausea, and diarrhea.
● Watch for tremors and tachycardia when taking albuterol.
● Observe for dry mouth when taking ipratropium.

CLIENT EDUCATION
● Suck on hard candies to help moisten dry mouth while

taking ipratropium.
● Increase fluid intake, report headaches, or blurred vision.
● Monitor heart rate. Palpitations can occur, which can

indicate toxicity of ipratropium.

Anti‑inflammatory agents

These medications decrease airway inflammation.
● If corticosteroids, such as fluticasone and prednisone,

are given systemically, monitor for serious adverse
effects (immunosuppression, fluid retention,
hyperglycemia, hypokalemia, poor wound healing).

● Leukotriene antagonists, such as montelukast; mast
cell stabilizers, such as cromolyn; and monoclonal
antibodies, such as omalizumab, can be used.

NURSING ACTIONS
● Watch for a decrease in immunity function.
● Monitor for delayed wound healing.
● Monitor for hyperglycemia.
● Observe for fluid retention and weight gain. This

is common.
● Check the throat and mouth for aphthous lesions

(canker sores).
● Omalizumab can cause anaphylaxis.

CLIENT EDUCATION
● Drink plenty of fluids to promote hydration.
● Report black, tarry stools.
● Take glucocorticoids with food.
● Use medication to prevent and control bronchospasms.
● Avoid people who have respiratory infections.
● Use good mouth care.
● Use medication as a prophylactic prevention of

COPD manifestations.
● Do not discontinue medication suddenly.

Mucolytic agents

These agents help thin secretions, making them easier for
the client to expel.

● Nebulizer treatments include acetylcysteine and
dornase alfa.

● Guaifenesin is an oral agent that can be taken.
● A combination of guaifenesin and dextromethorphan

also can be taken orally to loosen secretions.

thERAPEUtIC PROCEDUREs
● Chest physiotherapy uses percussion and vibration to

mobilize secretions.
● Raising the foot of the bed slightly higher than the

head can facilitate optimal drainage and removal of
secretions by gravity.

● Humidifiers can be useful for who live in a dry climate
or who use dry heat during the winter.

INtERPROFEssIONAL CARE
● Consult respiratory services for inhalers, breathing

treatments, and suctioning for airway management.
● Contact nutritional services for weight loss or gain

related to medications or diagnosis.
● Consult rehabilitative care if the client has prolonged

weakness and needs assistance with increasing
activity level.

● COPD is debilitating for older adult clients. Management of
the disease is continuous. Referrals to assistance programs,
such as food delivery services, can be indicated.

● Set up referral services, including home care services
such as portable oxygen.

● Provide support to the client and family.

22.2 X‑ray of lungs with emphysema
LABORAtORY tEsts

● Increased hematocrit level is due to low oxygenation levels.
● Use sputum cultures and WBC counts to diagnose acute

respiratory infections.
● Arterial blood gases (ABGs)

◯ Hypoxemia (decreased PaO2 less than 80 mm Hg)
◯ Hypercarbia (increased PaCO2 greater than 45 mm Hg)

● Blood electrolytes

DIAGNOstIC PROCEDUREs

Pulmonary function tests

These tests are used for diagnosis, as well as determining
the effectiveness of therapy.

● Comparisons of forced expiratory volume (FEV) to
forced vital capacity (FVC) are used to classify COPD as
mild to very severe.

● As COPD advances, the FEV‑to‑FVC ratio decreases. The
expected reference range is 100%. For mild COPD, the
FEV/FVC ratio is decreased to less than 70%. As the
disease progresses to moderate and severe, the ratio
decreases to less than 50%.

Chest x‑ray
● Reveals hyperinflation of alveoli and flattened

diaphragm in the late stages of emphysema. (22.2)
● It is often not useful for the diagnosis of early or

moderate disease.

Alpha1 antitrypsin levels

Used to assess for deficiency in AAT, an enzyme produced
by the liver that helps regulate other enzymes (which help
break down pollutants) from attacking lung tissue.

PATIENT‑CENTERED CARE

NURsING CARE
● Position the client to maximize ventilation

(high‑Fowler’s).
● Encourage effective coughing, or suction to

remove secretions.
● Encourage deep breathing and use of an

incentive spirometer.
● Administer breathing treatments and medications.
● Administer oxygen as prescribed. In COPD, low

arterial levels of oxygen serve as the primary drive for
breathing. However, in most cases, oxygen levels should
be maintained between 88% and 92%.

● Clients who have COPD can need 2 to 4 L/min of oxygen
via nasal cannula or up to 40% via Venturi mask. Clients
who have chronically increased PaCO2 levels usually
require 1 to 2 L/min of oxygen via nasal cannula.

● Monitor for skin breakdown around the nose and mouth
from the oxygen device.

Online Image: X‑ray of Lungs with Emphysema

140 CHAPTER 22 ChRONIC OBstRUCtIvE PULmONARY DIsEAsE CONTENT MASTERY SERIES

CLIENt EDUCAtION
● Eat high‑calorie foods to promote energy.
● Rest as needed.
● Practice hand hygiene to prevent infection.
● Take medications (inhalers, oral medications) as prescribed.
● Stop smoking if needed.
● Obtain immunizations, such as influenza and

pneumonia, to decrease the risk of infection.
● Use oxygen as prescribed. Inform other caregivers not to

smoke around the oxygen due to flammability.
● Acute infections and other complications often require

hospital stays. Report unusual findings or concerns to
the provider.

● Ensure fluid intake of at least 2 L (68 oz) daily to thin
secretions, unless the provider recommends otherwise.

COMPLICATIONS

Respiratory infection

Respiratory infections result from increased mucus
production and poor oxygenation levels.

NURSING ACTIONS
● Administer oxygen therapy.
● Monitor oxygenation levels.
● Monitor for indications of infection (increased WBC, CRP,

decreased SaO2, change in temperature).
● Administer antibiotics and other medications.

CLIENT EDUCATION
● Avoid crowds and people who have respiratory infections.
● Obtain pneumonia and influenza immunizations.

Right‑sided heart failure (cor pulmonale)
● Air trapping, airway collapse, and stiff alveoli lead to

increased pulmonary pressures.
● Blood flow through the lung tissue is difficult. This

increased workload leads to enlargement and thickening
of the right atrium and ventricle.

MANIFESTATIONS
● Low oxygenation levels
● Cyanosis
● Enlarged and tender liver
● Distended neck veins
● Dependent edema

NURSING ACTIONS
● Monitor respiratory status and administer oxygen therapy.
● Monitor for GI disturbances (nausea, anorexia).
● Monitor heart rate and rhythm.
● Administer medications as prescribed.
● Administer IV fluids and diuretics to maintain fluid balance.

Active Learning Scenario

A nurse is reviewing discharge instructions for a client who
has a new prescription for ipratropium. Use the AtI Active
Learning template: medication to complete this item.

NURSING INTERVENTIONS: List at least three.

Application Exercises

1. A nurse is providing discharge teaching to a client
who has COPD and a new prescription for albuterol.
Which of the following statements by the client
indicates an understanding of the teaching?

A. “this medication can increase
my blood sugar levels.”

B. “this medication can decrease
my immune response.”

C. “I can have an increase in my heart rate
while taking this medication.”

D. “I can have mouth sores while
taking this medication.”

2. A nurse is preparing to administer an initial dose of
prednisone to a client who has COPD. the nurse
should monitor for which of the following adverse
effects of this medication? (select all that apply.)

A. hypokalemia

B. tachycardia

C. Fluid retention

D. Nausea

E. Black, tarry stools

3. A nurse is discharging a client who has COPD.
the client is concerned about not being able
to leave the house due to the need for staying
on continuous oxygen. Which of the following
responses should the nurse make?

A. “there are portable oxygen delivery
systems that you can take with you.”

B. “When you go out, you can remove the oxygen
and then reapply it when you get home.”

C. “You probably will not be able to go
out as much as you used to.”

D. “home health services will come to you
so you will not need to get out.”

4. A nurse is instructing a client on the use of an incentive
spirometer. Which of the following statements by the
client indicates an understanding of the teaching?

A. “I will place the adapter on my finger to
read my blood oxygen saturation level.”

B. “I will lie on my back with my knees bent.”

C. “I will rest my hand over my abdomen
to create resistance.”

D. “I will take in a deep breath and
hold it before exhaling.”

5. A nurse is planning to instruct a client on how
to perform pursed‑lip breathing. Which of the
following statements should the nurse include?

A. “take quick breaths upon inhalation.”

B. “Place your hand over your stomach.”

C. “take a deep breath in through your nose.”

D. “Puff your cheeks upon exhalation.”

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 22 ChRONIC OBstRUCtIvE PULmONARY DIsEAsE 141

Application Exercises Key

1. A. Anti‑inflammatory agents, such as corticosteroids,
can cause hyperglycemia.

B. Anti‑inflammatory agents can decrease
the immune response.

C. CORRECT: Bronchodilators, such as
albuterol, can cause tachycardia.

D. Anti‑inflammatory agents can cause mouth sores.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

2. A. CORRECT: Observe for hypokalemia. this is
an adverse effect of prednisone.

B. tachycardia is an adverse effect of a bronchodilator.
C. CORRECT: Observe for fluid retention. this

is an adverse effect of prednisone.
D. Nausea is an adverse effect of a bronchodilator.
E. CORRECT: monitor for black, tarry stools. this

is an adverse effect of prednisone.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Expected Actions/Outcomes

3. A. CORRECT: Inform the client that there are portable
oxygen systems that can be used to leave the house.
this should alleviate the client’s anxiety.

B. tell the client to use oxygen at all times
to prevent becoming hypoxic.

C. Encourage the client to return to a daily
routine, but include periods of rest.

D. Encourage the client to return to a daily routine. home
health services promote a client’s independence.

NCLEX® Connection: Physiological Adaptation,
Illness Management

4. A. the client should place an adapter on a finger
to read the blood oxygen saturation level while
performing a pulse oximetry reading.

B. the client who practices diaphragmatic or abdominal
breathing should lie supine with knees bent.

C. the client who practices diaphragmatic or abdominal
breathing should rest a hand over the abdomen to
determine if the breathing is done correctly.

D. CORRECT: the client who is using the spirometer
should take in as deep a breath as possible before
exhaling. As the client exhales, the needle of the
spirometer rises. this promotes lung expansion.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

5. A. the client should take a slow deep breath upon inhalation.
this improves breathing and allows oxygen into lungs.

B. the client should place a hand on the stomach while
performing diaphragmatic or abdominal breathing.
this allows resistance to be met and serves as a guide
that the client is inhaling and exhaling correctly.

C. CORRECT: the client should take a deep breath
in through the nose while performing pursed‑lip
breathing. this controls the client’s breathing.

D. the client should not puff their cheeks upon
exhalation. this does not allow the client to optimally
exhale the carbon dioxide from the lungs.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

Active Learning Scenario Key

Using ATI Active Learning Template: Medication

NURSING INTERVENTIONS
● Observe the client for dry mouth when taking this medication.
● Encourage the client to suck on hard candies to help
moisten dry mouth while taking ipratropium.

● Encourage the client to increase fluid intake, and
to report headaches or blurred vision.

● monitor heart rate. Palpitations can occur, which
can indicate toxicity of ipratropium.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

142 CHAPTER 22 ChRONIC OBstRUCtIvE PULmONARY DIsEAsE CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 23 tUBERCULOsIs 143

UNIT 3 RESPIRATORY DISORDERS
SECTION: RESPIRATORY SYSTEM DISORDERS

CHAPTER 23 Tuberculosis
tuberculosis (tB) is an infectious disease
caused by Mycobacterium tuberculosis.
tB is transmitted through aerosolization
(airborne route).

Once inside the lung, the body encases the
tB bacillus with collagen and other cells. this
can appear as a round nodule or tubercle on a
chest x‑ray.

Only a small percentage of people infected
with tB actually develop an active form of the
infection. the tB bacillus can lie dormant for
many years before producing the disease.

tB primarily affects the lungs but can
spread to any organ in the blood. the risk of
transmission decreases after 2 to 3 weeks of
antituberculin therapy.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Clients who live in high‑risk areas for tuberculosis
should be screened on a yearly basis.

● Family members of clients who have tuberculosis should
be screened.

● Screening is particularly important for people born
outside the U.S. and migrant workers.

● Early detection and treatment are vital. TB has a slow
onset, and the client might not be aware until the
disease is advanced. TB diagnosis should be considered
for any client who has a persistent cough, chest pain,
weakness, weight loss, anorexia, hemoptysis, dyspnea,
fever, night sweats, or chills.

● National and global health goals for tuberculosis include
increasing the percentage of clients who complete
treatment for TB.

● Individuals who have been exposed to TB but have not
developed the disease can have latent TB. This means
that Mycobacterium tuberculosis is in the body, but the
body has been able to fight off the infection. If not
treated, it can lie dormant for several years and then
become active as the individual becomes older or
immunocompromised.

ASSESSMENT

RIsK FACtORs
● Frequent and close contact with an untreated individual
● Lower socioeconomic status and homelessness
● Immunocompromised status (HIV, chemotherapy,

kidney disease, diabetes mellitus, Crohn’s disease)
● Poorly ventilated, crowded environments (correctional

or long‑term care facilities)
● Advanced age
● Recent travel outside of the United States to areas where

TB is endemic
● Immigration (especially from Mexico,

Philippines, Vietnam, China, Japan, and Eastern
Mediterranean countries)

● Substance use
● Health care occupation that involves performance of

high‑risk activities (respiratory treatments, suctioning,
coughing procedures)

EXPECtED FINDINGs
● Persistent cough lasting longer than 3 weeks
● Purulent sputum, possibly blood‑streaked
● Fatigue and lethargy
● Weight loss and anorexia
● Night sweats and low‑grade fever in the afternoon

PHYSICAL ASSESSMENT FINDINGS: Older adult clients
often present with atypical findings of the disease (altered
mentation or unusual behavior, fever, anorexia,
weight loss).

LABORAtORY tEsts

Nucleic acid amplification testing
● Detects the presence of M. tuberculosis in respiratory

secretions and can check for rifampin resistance.
Results are available in less than 2 hr.

● The most rapid and accurate screening test for TB.

QuantiFERON‑TB Gold

Blood test that detects release of
interferon‑gamma (IFN‑g) in fresh heparinized whole
blood from sensitized people.

● Diagnostic for infection, whether active or latent.
● Results are available within 24 hr.

Acid‑fast bacilli smear and culture
● A positive acid‑fast test suggests an active infection.
● The diagnosis is confirmed by a positive culture for

Mycobacterium tuberculosis.

NURSING ACTIONS
● Obtain three early‑morning sputum samples.
● Wear personal protective equipment when

obtaining specimens.
● Samples should also be obtained in a negative

airflow room.

CHAPTER 23

144 CHAPTER 23 tUBERCULOsIs CONTENT MASTERY SERIES

DIAGNOstIC PROCEDUREs

Mantoux test (23.1)

● A client will have a positive intradermal TB test within
2 to 10 weeks of exposure to the infection.

● An intradermal injection of an extract of the tubercle
bacillus is made. It should be read in 48 to 72 hr.

● An induration (palpable, raised, hardened area) of
10 mm or greater in diameter indicates a positive
skin test.

● An induration of 5 mm is considered a positive test for
immunocompromised clients.

● A positive Mantoux test can indicate that the client
has developed an immune response to TB. It does not
confirm that active disease is present.

● Clients who have had a positive Mantoux test or have
received a Bacillus Calmette‑Guerin vaccine within the
past 10 years can have a false‑positive Mantoux test.
These clients need a chest x‑ray or QuantiFERON‑TB
Gold test to evaluate the presence of active TB
infection.

● Clients experiencing immunocompromise can
demonstrate anergy, or lack of response to Mantoux
testing, even if M. tuberculosis is present in the body. In
this case, other diagnostic testing is indicated to rule
out infection.

● Individuals who have latent TB can have a positive
Mantoux test and can receive treatment to prevent
development of an active form of the disease.

● Clients who are immunocompromised (such as those
who have HIV) and older adult clients should be tested
for TB. Clients starting immunosuppressive therapy
(such as tumor necrosis factor antagonists) should be
tested for TB prior to starting treatment.

CLIENT EDUCATION: Return for a reading of the injection
site by a health care personnel between 48 and 72 hr.

Chest x‑ray

Can be prescribed to detect active lesions in the lungs.

PATIENT‑CENTERED CARE

NURsING CARE
● Administer heated and humidified oxygen therapy

as prescribed.
● Prevent infection transmission.

◯ Wear a N95 HEPA filter or powered air purifying
respirator when caring for clients who are
hospitalized with TB. (23.2)

◯ Place the client in a negative‑airflow room, and
implement airborne precautions.

◯ Use barrier protection when the risk of hand or
clothing contamination exists.

◯ Have the client wear a surgical mask if transportation
to another department is necessary. The client should
be transported using the shortest and least busy route.

◯ Teach the client to cough and expectorate sputum
into tissues that are disposed of by the client into
provided plastic bags or no‑touch receptacles.

● Administer prescribed medications.
● Promote adequate nutrition.

◯ Encourage fluid intake and a well‑balanced diet for
adequate caloric intake.

◯ Encourage foods that are rich in protein, iron, and
vitamins C and B.

● Provide emotional support.

Online Image: Positive Mantoux Test

23.2 N95 mask23.1 Mantoux test

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 23 tUBERCULOsIs 145

mEDICAtIONs
Due to the resistance that is developing against the
antituberculin medications, combination therapy of two or
more medications at a time is recommended.

● Because these medications must be taken for 6 to
12 months, medication noncompliance is a significant
contributing factor in the development of resistant
strains of TB.

● The typical four‑medication regimen includes isoniazid,
rifampin, pyrazinamide, and ethambutol.

CLIENT EDUCATION: Complete the series of prescribed
medication to ensure all bacteria are eliminated and to
decrease the chance of resistance.

Isoniazid

Isoniazid, commonly referred to as INH, is bactericidal and
inhibits growth of mycobacteria by preventing synthesis
of mycolic acid in the cell wall.

NURSING ACTIONS
● This medication should be taken on an empty stomach.
● Monitor for hepatotoxicity (jaundice, anorexia, malaise,

fatigue, and nausea) and neurotoxicity (such as tingling
of the hands and feet).

● Vitamin B6 (pyridoxine) is often prescribed concurrently
to prevent neurotoxicity from isoniazid.

● Liver function testing should be completed prior to and
monthly after starting INH.

CLIENT EDUCATION
● Do not drink alcohol while taking isoniazid, because it

can increase the risk for hepatotoxicity.
● Report any manifestations of hepatotoxicity.

Rifampin

Rifampin, commonly referred to as RIF, is a bacteriostatic
and bactericidal antibiotic that inhibits DNA‑dependent
RNA polymerase activity in susceptible cells.

NURSING ACTIONS
● Observe for hepatotoxicity.
● Liver function testing should be completed prior to and

at least monthly after starting RIF.

CLIENT EDUCATION
● Urine and other secretions will be orange.
● Immediately report pain or swelling of joints, loss of

appetite, jaundice, or malaise.
● This medication can interfere with the efficacy of

oral contraceptives.

Pyrazinamide

Pyrazinamide, commonly referred to as PZA, is a
bacteriostatic and bactericidal. Its exact mechanism of
action is unknown.

NURSING ACTIONS
● Observe for hepatotoxicity.
● Assess for history of gout, as the medication will cause

an adverse effect of nongouty polyarthralgias.
● Liver enzymes should be completed baseline and every
2 weeks after starting PZA.

CLIENT EDUCATION
● Drink a glass of water with each dose and increase

fluids during the day to help prevent gout and
kidney problems.

● Immediately report yellowing of the skin or eyes, pain
or swelling of joints, loss of appetite, or malaise.

● Avoid using alcohol while taking pyrazinamide.

Ethambutol
● Ethambutol, commonly referred to as EMB, is a

bacteriostatic and works by suppressing RNA synthesis,
subsequently inhibiting protein synthesis.

● This medication should not be given to children younger
than 8 years of age.

NURSING ACTIONS
● Obtain baseline visual acuity tests, and complete

monthly after starting treatment.
● Determine color discrimination ability before starting

treatment, and periodically.
● Stop medication immediately if ocular toxicity occurs.

CLIENT EDUCATION: Report changes in vision
immediately.

Streptomycin sulfate

Streptomycin sulfate is an aminoglycoside
antibiotic. It potentiates the efficacy of macrophages
during phagocytosis.

NURSING ACTIONS
● Due to its high level of toxicity, this medication should

be used only in clients who have multidrug‑resistant
TB (MDR‑TB).

● Streptomycin can cause ototoxicity, so monitor hearing
function and tolerance often.

● Report significant changes in urine output and renal
function studies.

CLIENT EDUCATION
● Drink at least 2 L of fluid daily.
● Notify the provider if hearing declines.

DIAGNOstIC PROCEDUREs

Mantoux test (23.1)

● A client will have a positive intradermal TB test within
2 to 10 weeks of exposure to the infection.

● An intradermal injection of an extract of the tubercle
bacillus is made. It should be read in 48 to 72 hr.

● An induration (palpable, raised, hardened area) of
10 mm or greater in diameter indicates a positive
skin test.

● An induration of 5 mm is considered a positive test for
immunocompromised clients.

● A positive Mantoux test can indicate that the client
has developed an immune response to TB. It does not
confirm that active disease is present.

● Clients who have had a positive Mantoux test or have
received a Bacillus Calmette‑Guerin vaccine within the
past 10 years can have a false‑positive Mantoux test.
These clients need a chest x‑ray or QuantiFERON‑TB
Gold test to evaluate the presence of active TB
infection.

● Clients experiencing immunocompromise can
demonstrate anergy, or lack of response to Mantoux
testing, even if M. tuberculosis is present in the body. In
this case, other diagnostic testing is indicated to rule
out infection.

● Individuals who have latent TB can have a positive
Mantoux test and can receive treatment to prevent
development of an active form of the disease.

● Clients who are immunocompromised (such as those
who have HIV) and older adult clients should be tested
for TB. Clients starting immunosuppressive therapy
(such as tumor necrosis factor antagonists) should be
tested for TB prior to starting treatment.

CLIENT EDUCATION: Return for a reading of the injection
site by a health care personnel between 48 and 72 hr.

Online Image: Positive Mantoux Test

146 CHAPTER 23 tUBERCULOsIs CONTENT MASTERY SERIES

INtERPROFEssIONAL CARE
● Contact social services if the client will need assistance

in obtaining prescribed medications.
● Refer the client to a community clinic as needed for

follow‑up appointments to monitor medication regimen
and status of disease.

CLIENt EDUCAtION
● TB is often treated in the home setting.
● Airborne precautions are not needed in the home setting

because family members have already been exposed.
● Exposed family members should be tested for TB.
● Continue medication therapy for its full duration of 6 to
12 months, even up to 2 years for multidrug‑resistant
TB. Failure to take the medications can lead to a
resistant strain of TB.

● Continue with follow‑up care for 1 full year.
● Sputum samples are needed every 2 to 4 weeks

to monitor therapy effectiveness. Clients are no
longer considered infectious after three consecutive
negative sputum cultures, and can resume work and
social interactions.

● Practice proper hand hygiene.
● Cover mouth and nose when coughing or sneezing.
● Contaminated tissues should be disposed of in

plastic bags.
● While TB is active, wear a mask when in public places or

in contact with crowds.

COMPLICATIONS

Miliary TB

The organism invades the bloodstream and can spread
to multiple body organs with complications including
the following.

● Headaches, neck stiffness, and drowsiness (can be
life‑threatening)

● Pericarditis: Dyspnea, swollen neck veins, pleuritic
pain, and hypotension due to an accumulation of fluid
in pericardial sac that inhibits the heart’s ability to
pump effectively

NURSING ACTIONS: Treatment is the same as for
pulmonary TB.

Active Learning Scenario

A nurse is caring for a client who has tuberculosis.
Use the AtI Active Learning template: system
Disorder to complete this item.

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM

NURSING CARE: Include three nursing interventions.

COMPLICATIONS: Identify one potential complication.

Application Exercises

1. A home health nurse is teaching a client who has
active tuberculosis and is following a medication
regimen that includes a combination of isoniazid,
rifampin, pyrazinamide, and ethambutol. Which
of the following client statements indicate
understanding? (select all that apply.)

A. “I can substitute one medication for another
if I run out because they all fight infection.”

B. “I will wash my hands each time I cough.”

C. “I will wear a mask when I am in a public area.”

D. “I am glad I don’t have to have any
more sputum specimens.”

E. “I don’t need to worry where I go once
I start taking my medications.”

2. A nurse is teaching a client who has tuberculosis. Which
of the following statements should the nurse include?

A. “You will need to continue to take the
multimedication regimen for 4 months.”

B. “You will need to provide sputum
samples every 4 weeks to monitor the
effectiveness of the medication.”

C. “You will need to remain
hospitalized for treatment.”

D. “You will need to wear a mask at all times.”

3. A nurse is caring for a client who has a new diagnosis of
tuberculosis and has been placed on a multimedication
regimen. Which of the following instructions should
the nurse give the client related to ethambutol?

A. “Your urine can turn a dark orange.”

B. “Watch for a change in the sclera of your eyes.”

C. “Watch for any changes in vision.”

D. “take vitamin B6 daily.”

4. A nurse is preparing to administer a new prescription
for isoniazid (INh) to a light‑skinned client who
has tuberculosis. the nurse should instruct the
client to report which of the following findings
as an adverse effect of the medication?

A. “You might notice yellowing of your skin.”

B. “You might experience pain in your joints.”

C. “You might notice tingling of your hands.”

D. “You might experience a loss of appetite.”

5. A nurse is providing information about tuberculosis
to a group of clients at a local community center.
Which of the following manifestations should
the nurse include? (select all that apply.)

A. Persistent cough

B. Weight gain

C. Fatigue

D. Night sweats

E. Purulent sputum

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 23 tUBERCULOsIs 147

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM: tuberculosis
(tB) is an infectious disease caused by Mycobacterium tuberculosis.
tB is transmitted through aerosolization (airborne route). Once
inside the lung, the body encases the tB bacillus with collagen
and other cells. this can appear as a Ghon tubercle on a chest
x‑ray. Only a small percentage of people infected with tB actually
develop an active form of the infection. the tB bacillus can lie
dormant for many years before producing the disease. tB primarily
affects the lungs but can spread to any organ in the blood.

NURSING CARE

Nursing Interventions
● Administer heated and humidified oxygen therapy as prescribed.
● Prevent infection transmission.
● Wear an N95 or hEPA respirator when caring for
clients who are hospitalized with tB.

● Place the client in a negative airflow room, and
implement airborne precautions.

● Use barrier protection when the risk of hand
or clothing contamination exists.

● have the client wear a surgical mask if transportation
to another department is necessary.

● transport the client using the shortest and least busy route.
● teach the client to cough and expectorate sputum into tissues
that are disposed of by the client into provided sacks.

● Administer medications as prescribed.
● Promote adequate nutrition.
● Encourage fluid intake and a well‑balanced
diet for adequate caloric intake.

COMPLICATIONS

miliary tB: the organism invades the bloodstream and can spread
to multiple body organs with complications including the following:

● headaches, neck stiffness, and drowsiness (can be life‑threatening)
● Pericarditis: dyspnea, swollen neck veins, pleuritic pain, and
hypotension due to an accumulation of fluid in the pericardial
sac that inhibits the heart’s ability to pump effectively

● Nursing Actions: treatment is the same as for pulmonary tB.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

Application Exercises Key

1. A. medications should not be replaced for one another. It is
important that the client adhere to the multimedication
regimen prescribed to treat tuberculosis.

B. CORRECT: the client should wash their hands each time
they cough to prevent spreading the infection.

C. CORRECT: the client should wear a mask while in public
areas to prevent spreading the infection. the client has active
tB, which is transmitted through the airborne route.

D. the client will need to collect sputum cultures
every 2 to 4 weeks until three consecutive sputum
cultures have come back negative.

E. the client should continue to avoid crowded
areas if possible and take preventative measures,
such as wearing a mask when going out.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

2. A. the client who has tuberculosis needs to continue taking
the multimedication regimen for 6 to 12 months.

B. CORRECT: the client who has tuberculosis needs
to provide sputum samples every 2 to 4 weeks to
monitor the effectiveness of the medication.

C. the client who has tuberculosis is often
treated in the home setting.

D. the client who has tuberculosis needs to
wear a mask when in public areas.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

3. A. the client who is receiving rifampin should expect
to see his urine turn a dark orange.

B. the client who is taking ethambutol does not have an adverse
effect resulting in changes to the sclera of the eyes.

C. CORRECT: the client who is receiving ethambutol will
need to watch for visual changes due to optic neuritis,
which can result from taking this medication.

D. the client who is taking isoniazid should take vitamin B6
daily and observe for signs of hepatotoxicity.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. A. Yellowing of the skin can be an adverse effect of rifampin
or pyrazinamide in a client who has light skin.

B. Experiencing pain in the joints can be
an adverse effect of rifampin.

C. CORRECT: tingling of the hands can be
an adverse effect of isoniazid.

D. Loss of appetite can be an adverse effect of rifampin.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

5. A. CORRECT: A persistent cough is a
manifestation of tuberculosis.

B. Weight loss is a manifestation of tuberculosis.
C. CORRECT: Fatigue is a manifestation of tuberculosis.
D. CORRECT: Night sweats is a manifestation of tuberculosis.
E. CORRECT: Purulent sputum is a

manifestation of tuberculosis.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

148 CHAPTER 23 tUBERCULOsIs CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 24 PULmONARY EmBOLIsm 149

UNIT 3 RESPIRATORY DISORDERS
SECTION: RESPIRATORY EMERGENCIES

CHAPTER 24 Pulmonary
Embolism

A pulmonary embolism (PE) occurs when a
substance (solid, gaseous, or liquid) enters
venous circulation and forms a blockage in the
pulmonary vasculature.

Emboli originating from venous thromboembolism,
also known as deep‑vein thrombosis (Dvt), are the
most common cause. Other types of emboli
include fat, air, septic (due to bacterial invasion of a
thrombus), and amniotic fluid.

Increased hypoxia to pulmonary tissue and
impaired blood flow can result from a large
embolus. A PE is a medical emergency.

Prevention, rapid recognition, and treatment of
a PE are essential for a positive outcome.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Promote smoking cessation.
● Encourage maintenance of appropriate weight for height

and body frame.
● Encourage a healthy diet and physical activity.
● Prevent DVT by encouraging clients to do leg exercises,

wear compression stockings, and avoid sitting for long
periods of time.

ASSESSMENT

RIsK FACtORs
● Long‑term immobility
● Oral contraceptive use and estrogen therapy
● Pregnancy
● Tobacco use
● Hypercoagulability (elevated platelet count)
● Obesity
● Surgery (especially orthopedic surgery of the lower

extremities or pelvis)
● Central venous catheters
● Heart failure or chronic atrial fibrillation
● Autoimmune hemolytic anemia (sickle cell)
● Long bone fractures
● Cancer
● Trauma
● Septicemia
● Advanced age

◯ Older adult clients have decreased pulmonary reserves
due to normal lung changes, including decreased lung
elasticity and thickening alveoli. Older adult clients
can decompensate more quickly.

◯ Certain pathological conditions and procedures that
predispose clients to DVT formation (peripheral
vascular disease, hypertension, hip and knee
arthroplasty) are more prevalent in older adults.

◯ Many older adult clients experience decreased
physical activity levels, thus predisposing them to
DVT formation and pulmonary emboli.

CHAPTER 24

Online Image: Pulmonary Embolism

24.1 Pulmonary embolism

150 CHAPTER 24 PULmONARY EmBOLIsm CONTENT MASTERY SERIES

EXPECtED FINDINGs
● Anxiety
● Feelings of impending doom
● Sudden onset of chest pressure
● Pain upon inspiration and chest wall tenderness
● Dyspnea and air hunger
● Cough
● Hemoptysis

PHYSICAL ASSESSMENT FINDINGS
● Pleurisy
● Pleural friction rub
● Tachycardia
● Hypotension
● Tachypnea
● Adventitious breath sounds (crackles) and cough
● Heart murmur in S3 and S4

● Diaphoresis
● Low‑grade fever
● Decreased oxygen saturation levels (expected reference

range is 95% to 100%), low SaO2, cyanosis
● Petechiae (red dots under the skin) over chest

and axillae
● Distended neck veins
● Syncope
● Cyanosis

LABORAtORY tEsts

ABG analysis
● PaCO2 levels are low (expected reference range is
35 to 45 mm Hg) due to initial hyperventilation
(respiratory alkalosis).

● As hypoxemia progresses, respiratory acidosis occurs.
● Further progression leads to metabolic acidosis due to

buildup of lactic acid from tissue hypoxia.

D‑dimer

Elevated above expected reference range in response to
clot formation and release of fibrin degradation products
(expected reference range is less than 0.4 mcg/mL).

DIAGNOstIC PROCEDUREs

Computed tomography scan

The multidetector‑row computed tomography angiography
(MDCTA) is the criterion standard for detecting PE when
available, as it provides high‑quality visualization of the
lung parenchyma.

Ventilation‑perfusion scan

Ventilation‑perfusion (V/Q) scan images show circulation
of air and blood in the lungs and can detect a PE. Useful
when client allergy to contrast media is a contraindication
to other types of imaging.

Pulmonary angiography
● This is the gold standard test when MDCTA is

unavailable to detect a PE, but it is invasive and costly.
A catheter is inserted into the vena cava to visualize
the embolus.

● Pulmonary angiography is a higher risk procedure than
a V/Q scan.

NURSING ACTIONS
● Verify that informed consent has been obtained.
● Monitor status (vital signs, SaO2, anxiety, bleeding with

angiography) during and after the procedure.

Chest x‑ray

The chest x‑ray can provide data to support the
occurrence of pulmonary embolism, such as elevation of
the diaphragm on the affected side or pleural effusion.

PATIENT‑CENTERED CARE

NURsING CARE
● Administer oxygen therapy to relieve hypoxemia and

dyspnea. Position the client to maximize ventilation
(high‑Fowler’s = 90°).

● Initiate and maintain IV access.
● Administer medications as prescribed.
● Assess respiratory status at least every 30 min.

◯ Auscultate lung sounds.
◯ Measure rate, rhythm, and ease of respirations.
◯ Inspect skin color and capillary refill.
◯ Examine for position of trachea.

● Assess cardiac status.
◯ Compare blood pressure in both arms.
◯ Palpate pulse quality.
◯ Check for dysrhythmias on cardiac monitor.
◯ Examine the neck for distended neck veins.
◯ Inspect the thorax for petechiae.

● Provide emotional support and comfort to control
client anxiety.

● Monitor changes in level of consciousness and
mental status.

mEDICAtIONs

Anticoagulants

Unfractionated and low molecular weight heparin,
enoxaparin, and warfarin are used to prevent clots from
getting larger or additional clots from forming.

NURSING ACTIONS
● Assess for contraindications (active bleeding, peptic

ulcer disease, history of stroke, recent trauma).
● Monitor bleeding times: Prothrombin time (PT) and

international normalized ratio (INR) for warfarin,
partial thromboplastin time (aPTT) for heparin, and
complete blood count (CBC).

● Monitor for adverse effects of anticoagulants
(thrombocytopenia, anemia, hemorrhage).

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 24 PULmONARY EmBOLIsm 151

Direct factor Xa inhibitor

Rivaroxaban, apixaban, and fondaparinux bind directly
with the active center of factor Xa, which inhibits the
production of thrombin.

NURSING ACTIONS
● Assess for bleeding from any site. (Clients have

experienced epidural hematomas, as well as intracranial,
retinal, adrenal, and GI bleeds.)

● Hold medication for 18 hr prior to and 6 hr after removal
of an epidural catheter.

Direct thrombin inhibitor

Dabigatran acts as a direct inhibitor of thrombin.

NURSING ACTIONS: Assess for bleeding and
manifestations of blood loss.

Thrombolytic therapy
● Alteplase, reteplase, and tenecteplase are used to

dissolve blood clots and restore pulmonary blood flow.
● Similar adverse effects and contraindications

as anticoagulants.

NURSING ACTIONS
● Assess for contraindications (known bleeding disorders,

uncontrolled hypertension, active bleeding, peptic
ulcer disease, history of stroke, recent trauma or
surgery, pregnancy).

● Monitor for evidence of bleeding, thrombocytopenia,
and anemia.

● Monitor blood pressure, heart rate, respirations, and
oxygen saturation per facility protocol before, during,
and after administration of medication.

INtERPROFEssIONAL CARE
● Cardiology and pulmonary services should be consulted

to manage a PE and treatment.
● Respiratory services should be consulted for oxygen

therapy, breathing treatments, and ABGs.
● Radiology should be consulted for diagnostic studies to

determine PE.

thERAPEUtIC PROCEDUREs

Embolectomy

Surgical removal of embolus

NURSING ACTIONS
● Prepare the client for the procedure (NPO status,

informed consent).
● Monitor postoperatively (vital signs, SaO2, incision

drainage, pain management).

Vena cava filter

Insertion of a filter in the vena cava to prevent further
emboli from reaching the pulmonary vasculature

NURSING ACTIONS
● Prepare the client for the procedure (NPO status,

informed consent).
● Monitor postoperatively (vital signs, SaO2, incision

drainage, pain management).

CLIENt EDUCAtION
● If homebound, set up home care services to perform

weekly blood draws.
● For severe dyspnea, set up referral services to supply

portable oxygen.
● Follow recommendations for prevention of a PE.

◯ If smoking, consider smoking cessation.
◯ Avoid long periods of immobility.
◯ Perform physical activity, such as walking.
◯ Wear compression stockings to promote circulation.
◯ Avoid crossing the legs.

● If taking warfarin, do not increase or decrease the amount
of vitamin K foods consumed (green, leafy vegetables).
Vitamin K can reduce the anticoagulant effects of warfarin.

● Adhere to a schedule for monitoring PT and INR, and
follow instructions regarding medication dosage
adjustments (if on warfarin) and regular blood draws.

● There is an increased risk for bruising and bleeding.
◯ Avoid taking aspirin products, unless specified by the

provider.
◯ Check the mouth and skin daily for bleeding
and bruising.

◯ Use electric shavers and soft‑bristled toothbrushes.
◯ Avoid blowing the nose hard, and gently apply

pressure if nose bleeds occur.
● If traveling, takes measures to prevent PE.

◯ Arise from a sitting position for 5 min out of every hour.
◯ Wear support stockings.
◯ Remain hydrated by drinking plenty of water.
◯ Perform active ROM exercises when sitting (ankle

pump exercises).

152 CHAPTER 24 PULmONARY EmBOLIsm CONTENT MASTERY SERIES

COMPLICATIONS

Decreased cardiac output

Blood volume is decreased.

NURSING ACTIONS
● Monitor for hypotension, tachycardia, cyanosis, jugular

venous distention, and syncope.
● Assess for the presence of S3 or S4 heart sounds.
● Initiate and maintain IV access.
● Monitor urinary output (should be 30 mL/hr or more).
● Administer IV fluids (crystalloids) to replace

vascular volume.
● Continuously monitor the ECG.
● Monitor pulmonary pressures. IV fluids can contribute

to pulmonary hypertension for clients who have
right‑sided heart failure (cor pulmonale).

● Administer inotropic agents (milrinone, dobutamine) to
increase myocardial contractility.

● Vasodilators can be needed if pulmonary artery pressure
is high enough to interfere with cardiac contractility.

Hemorrhage

Risk for bleeding increases due to anticoagulant therapy.

NURSING ACTIONS
● Assess for bleeding from or bruising around injection

and surgical sites at least every 2 hr.
● Monitor cardiovascular status (blood pressure, heart

rate and rhythm).
● Monitor CBC (hemoglobin, hematocrit, platelets) and

bleeding times (PT, aPTT, INR).
● Administer IV fluids and blood products as required.
● Test stool, urine, and emesis for occult blood.
● Monitor for internal bleeding (measure abdominal girth

and check for abdominal or flank pain) at least every 8 hr.
● Have antidote available for use if necessary.

Active Learning Scenario

A nurse is caring for a client who has a pulmonary
embolism. Use the AtI Active Learning template:
system Disorder to complete this item.

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM

NURSING CARE: Describe three nursing interventions.

MEDICATIONS: Identify two.

Application Exercises

1. A nurse is caring for a group of clients.
Which of the following clients are at risk for a
pulmonary embolism? (select all that apply.)

A. A client who has a BmI of 30

B. A female client who is postmenopausal

C. A client who has a fractured femur

D. A client who is a marathon runner

E. A client who has chronic atrial fibrillation

2. A nurse is assessing a client who has a pulmonary
embolism. Which of the following manifestations
should the nurse expect? (select all that apply.)

A. Bradypnea

B. Pleural friction rub

C. hypertension

D. Petechiae

E. tachycardia

3. A nurse is reviewing prescriptions for a client who has
acute dyspnea and diaphoresis. the client states, “I am
anxious and unable to get enough air.” vital signs are
heart rate 117/min, respirations 38/min, temperature
38.4° C (101.2° F), and blood pressure 100/54 mm hg.
Which of the following nursing actions is the priority?

A. Notify the provider.

B. Administer heparin via Iv infusion.

C. Administer oxygen therapy.

D. Obtain a Ct scan.

4. A nurse is caring for a client who has a new
prescription for heparin therapy. Which of
the following statements by the client should
indicate an immediate concern for the nurse?

A. “I am allergic to morphine.”

B. “I take antacids several times a day for my ulcer.”

C. “I had a blood clot in my leg several years ago.”

D. “It hurts to take a deep breath.”

5. A nurse is caring for a client who is to
receive thrombolytic therapy. Which of the
following factors should the nurse recognize
as a contraindication to the therapy?

A. hip arthroplasty 2 weeks ago

B. Elevated sedimentation rate

C. Incident of exercise‑induced asthma 1 week ago

D. Elevated platelet count

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 24 PULmONARY EmBOLIsm 153

Application Exercises Key

1. A. CORRECT: the client who has a BmI of 30 is considered
obese and is at increased risk for a blood clot.

B. A female who is postmenopausal has decreased
estrogen levels. Increased estrogen levels are a risk
factor for developing a pulmonary embolism.

C. CORRECT: the client who has a fractured
bone, particularly in a long bone such as the
femur, increases the risk of fat emboli.

D. the client who is a marathon runner has increased
blood flow and circulation of his body, which decreases
the risk for developing a pulmonary embolism.

E. CORRECT: the client who has turbulent blood
flow in the heart, such as with atrial defibrillation,
is also at increased risk of a blood clot.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

2. A. Expect the client to have tachypnea.
B. CORRECT: Expect the client to have a pleural friction rub.
C. Expect the client to have hypotension.
D. CORRECT: Expect the client to have petechiae.
E. CORRECT: Expect the client to have tachycardia.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

3. A. Notify the provider about the condition to obtain guidance
on treatment. however, another action is the priority.

B. Administer Iv heparin as a treatment to prevent growth
of the existing clot and to prevent additional clots from
forming. however, another action is the priority.

C. CORRECT: When using the airway, breathing,
circulation (ABC) priority approach to care, determine
that the priority finding is related to the respiratory
status. meeting oxygenation needs by administering
oxygen therapy is the priority action.

D. Obtain a Ct scan to detect the presence and location of
the blood clot. however, another action is the priority.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

4. A. Document the client’s allergy to morphine to
manage the client’s discomfort due to a blood clot.
however, another action is the priority.

B. CORRECT: the greatest risk to the client is the
possibility of bleeding from a peptic ulcer. the priority
intervention is to notify the provider of the finding.

C. Document the client’s history of a blood clot
to provide preventative measures. however,
another action is the priority.

D. Expect the client to report pain with breathing.
however, another action is the priority.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Expected Actions/Outcomes

5. A. CORRECT: the client who has undergone a major
surgical procedure within the last 3 weeks should
not receive thrombolytic therapy because of the
risk of hemorrhage from the surgical site.

B. An elevated sedimentation rate is not a
contraindication to receiving heparin.

C. An incident of exercise‑induced asthma is not
a contraindication to receiving heparin.

D. An elevated platelet count is not a
contraindication to receiving heparin.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM: A pulmonary
embolism (PE) occurs when a substance (solid, gaseous, or liquid)
enters venous circulation and forms a blockage in the pulmonary
vasculature. Emboli originating from deep‑vein thrombosis
(Dvt) are the most common cause. tumors, bone marrow,
amniotic fluid, and foreign matter can also become emboli.

NURSING CARE
● Administer oxygen therapy as prescribed to
relieve hypoxemia and dyspnea.

● Position the client to maximize ventilation (high‑Fowler’s = 90%).
● Initiate and maintain Iv access.
● Administer medications as prescribed.
● Provide emotional support and comfort to control client anxiety.
● monitor changes in level of consciousness and mental status.

MEDICATIONS
● Anticoagulants: enoxaparin, heparin, and warfarin
● thrombolytic therapy: alteplase, reteplase, and tenecteplase

NCLEX® Connection: Physiological Adaptation, Unexpected
Response to Therapies

154 CHAPTER 24 PULmONARY EmBOLIsm CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 25 PNEUmOthORAX, hEmOthORAX, AND FLAIL ChEst 155

UNIT 3 RESPIRATORY DISORDERS
SECTION: RESPIRATORY EMERGENCIES

CHAPTER 25 Pneumothorax,
Hemothorax, and
Flail Chest

A pneumothorax is the presence of air or gas in
the pleural space that causes lung collapse.

A tension pneumothorax occurs when air enters
the pleural space during inspiration through
a one‑way valve and is not able to exit upon
expiration. the trapped air causes pressure
on the heart and the lung. As a result, the
increase in pressure compresses blood vessels
and limits venous return, leading to a decrease
in cardiac output. Death can result if not
treated immediately. As a result of a tension
pneumothorax, air and pressure continue
to rise in the pleural cavity, which causes a
mediastinal shift.

A hemothorax is an accumulation of blood in
the pleural space.

A spontaneous pneumothorax can occur when
there has been no trauma. A small bleb on the
lung ruptures and air enters the pleural space.

A flail chest occurs when at least two
neighboring ribs, usually on one side of the
chest, sustain multiple fractures, causing
instability of the chest wall and paradoxical
chest wall movement. this results in significant
limitation in chest wall expansion.

Pneumothorax and
hemothorax

ASSESSMENT

RIsK FACtORs
● Blunt chest trauma
● Penetrating chest wounds
● Closed/occluded chest tube
● Older adult clients have decreased pulmonary reserves

due to normal lung changes, including decreased lung
elasticity and thickening alveoli.

● Chronic obstructive pulmonary disease (COPD)

EXPECtED FINDINGs
● Anxiety
● Pleuritic pain

PHYSICAL ASSESSMENT FINDINGS
● Manifestations of respiratory distress (tachypnea,

tachycardia, hypoxia, cyanosis, dyspnea, and use of
accessory muscles)

● Tracheal deviation to the unaffected side
(tension pneumothorax)

● Reduced or absent breath sounds on the affected side
● Asymmetrical chest wall movement
● Hyperresonance on percussion due to trapped air

(pneumothorax)
● Dull percussion (hemothorax)
● Subcutaneous emphysema (air accumulating in

subcutaneous tissue)

LABORAtORY tEsts
ABGs: Hypoxemia (PaO2 less than 80 mm Hg)

CHAPTER 25

25.1 Pneumothorax

156 CHAPTER 25 PNEUmOthORAX, hEmOthORAX, AND FLAIL ChEst CONTENT MASTERY SERIES

DIAGNOstIC PROCEDUREs

Chest x‑ray

Used to confirm pneumothorax or hemothorax

Thoracentesis

Thoracentesis can be used to confirm hemothorax.
Thoracentesis is the surgical perforation of the chest wall
and pleural space with a large‑bore needle.

NURSING ACTIONS
● Ensure that informed consent has been obtained.
● Assist with client positioning and specimen transport.
● Monitor status (vital signs, SaO2, injection site).
● Assist the client to the edge of the bed and to lean over

a bedside table.

CLIENT EDUCATION
● Remain still during the procedure (no moving, coughing,

or deep breathing).
● Discomfort will be felt when the local anesthetic

solution is injected. When the needle is inserted into the
pleural space, some pressure can be felt, but no pain.

PATIENT‑CENTERED CARE

NURsING CARE
● Administer oxygen therapy.
● Auscultate heart and lung sounds and monitor vital

signs every 4 hr.
● Document ventilator settings hourly if the client is

receiving mechanical ventilation.
● Check ABGs, SaO2, CBC, and chest x‑ray results.
● Position the client to maximize ventilation

(high‑Fowler’s = 90°).
● Provide emotional support to the client and family.
● Monitor chest tube drainage.

● Administer medications as prescribed.
● Encourage prompt medical attention when evidence of

infection occurs.
● Set up referral services (home health, respiratory

services) to provide portable oxygen if needed.

mEDICAtIONs

Benzodiazepines (sedatives)

Lorazepam or midazolam can be used to decrease anxiety.

NURSING ACTIONS
● Monitor vital signs. (Benzodiazepines can cause

hypotension and respiratory distress.)
● Remember that the medications have amnesiac effects.
● Monitor for paradoxical effects (euphoria, rage).

CLIENT EDUCATION: Medications have amnesic effects
and cause drowsiness.

Opioid agonists (pain medications)
● Morphine sulfate and fentanyl are opioid agents used to

treat moderate to severe pain. These medications act on
the mu and kappa receptors that help alleviate pain.

● Activation of these receptors produces analgesia (pain
relief), respiratory depression, euphoria, sedation, and
decrease in gastrointestinal motility.

● If the client is receiving mechanical ventilation, the
nursing actions and client education can vary.

NURSING ACTIONS
● Use cautiously for clients who have asthma or

emphysema, due to the risk of respiratory depression.
● Assess pain every 4 hr.
● Monitor clients, especially older adults, for

manifestations of respiratory depression. If respirations
are 12/min or less, stop the medication and notify
provider immediately.

● Monitor vital signs for hypotension and bradypnea.
● Assess for nausea and vomiting.
● Assess level of sedation (drowsiness, level of

consciousness).
● Monitor for constipation.
● Encourage fluid intake and activity related to a decrease

in gastric motility.
● Monitor intake and output. Report fluid retention as an

adverse effect of opioid medications.

CLIENT EDUCATION
● If receiving a fentanyl patch, the initial patch takes

several hours to take effect. A short‑acting pain
medication is administered for breakthrough pain.

● If there are no fluid restrictions due to other conditions,
drink plenty of fluids to prevent constipation.

● Follow instructions on how to use a patient‑controlled
analgesia (PCA) pump if applicable. The client is the only
person who should push the medication administration
button. The safety lockout mechanism on the PCA
prevents the client from using too much medication.

25.2 Hemothorax

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 25 PNEUmOthORAX, hEmOthORAX, AND FLAIL ChEst 157

INtERPROFEssIONAL CARE
Respiratory services should be consulted for ABGs,
breathing treatments, and suctioning for airway
management.

Pulmonary services can be consulted for chest tube
management and pulmonary care.

Pain management services can be consulted if pain
persists or is uncontrolled.

Rehabilitation care can be consulted if the client has
prolonged weakness and needs assistance with an
increasing level of activity.

thERAPEUtIC PROCEDUREs

Chest tube insertion

Chest tubes are inserted in the pleural space to drain fluid,
blood, or air; re‑establish a negative pressure; facilitate
lung expansion; and restore normal intrapleural pressure.

NURSING ACTIONS
● Obtain informed consent, gather supplies, monitor the

client’s status (vital signs, SaO2, chest tube drainage),
report abnormalities to the provider, and administer
pain medications.

● Continually monitor vital signs and the client’s
response to the procedure.

● Monitor chest tube placement, function of chest
drainage system, and dressing.

CLIENt EDUCAtION
● Deep breathe to promote lung expansion.
● Take rest periods as needed.
● Use proper hand hygiene to prevent infection.
● Participate in coughing, deep breathing, and use of

incentive spirometry.
● Obtain immunizations for influenza and pneumonia.
● Recovery from a pneumothorax/hemothorax can

be lengthy.
● Talk with family or other support people to express

feelings about the condition and recovery.
● If applicable, consider smoking cessation.
● Follow up with the provider as instructed, and report

the following to the provider.
◯ Upper respiratory infection
◯ Fever
◯ Cough
◯ Difficulty breathing
◯ Sharp chest pain

COMPLICATIONS

Decreased cardiac output
● The amount of blood pumped by the heart decreases as

intrathoracic pressure rises.
● Hypotension develops.

NURSING ACTIONS
● Administer IV fluids and blood products as prescribed.
● Monitor heart rate and rhythm.
● Monitor intake and output (chest tube drainage).

Respiratory failure

Inadequate gas exchange due to lung collapse

NURSING ACTIONS
● Prepare for mechanical ventilation.
● Continue respiratory assessment.

Flail chest
As a result of the free‑floating rib segments, the lung
below the flail segment caves in on inhalation and
balloons out on exhalation. The portion of the lung below
the flail segment cannot participate in gas exchange, so
oxygenation is compromised.

ASSESSMENT

RIsK FACtORs
Multiple rib fractures from blunt chest trauma
(often caused by motor‑vehicle crash or as a result of
cardiopulmonary resuscitation on older adults)

EXPECtED FINDINGs
● Unequal chest expansion (the unaffected side of the

chest will expand, while the affected side can appear to
diminish in size or remain stationary)

● Paradoxical chest wall movement (inward movement
of segment during inspiration, outward movement of
segment during expiration)

● Tachycardia
● Hypotension
● Dyspnea
● Cyanosis
● Anxiety
● Chest pain

158 CHAPTER 25 PNEUmOthORAX, hEmOthORAX, AND FLAIL ChEst CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

NURsING CARE
● Administer humidified oxygen.
● Monitor vital signs and SaO2.
● Review findings of pulmonary function tests, periodic

chest x‑rays, and ABGs.
● Assess lung sounds, color, and capillary refill.
● Promote lung expansion by encouraging deep breathing

and proper positioning.
● Maintain mechanical ventilation in the event of

severe injury to establish adequate gas exchange and
stabilize the injury. (Flail chest is usually stabilized by
positive‑pressure ventilation.)

● Suction trachea and endotracheal tube as needed.
● Administer pain medication. Patient‑controlled

analgesia or an epidural block commonly is used.
● Administer IV fluids as prescribed.
● Monitor intake and output.
● Offer support and reassurance by explaining

all procedures.

Active Learning Scenario

A nurse is teaching a newly licensed nurse regarding
care for a client who has a hemothorax. What should
be included in this review? Use the AtI Active Learning
template: system Disorder to complete this item.

DESCRIPTION OF DISORDER/DISEASE PROCESS

NURSING CARE: Describe three nursing interventions.

MEDICATIONS: Describe two medications
used for hemothorax.

Application Exercises

1. A nurse is assessing a client following a gunshot
wound to the chest. For which of the following
findings should the nurse monitor to detect
a pneumothorax? (select all that apply.)

A. tachypnea

B. Deviation of the trachea

C. Bradycardia

D. Decreased use of accessory muscles

E. Pleuritic pain

2. A nurse is assisting the provider to care for a client who
has developed a spontaneous pneumothorax. Which
of the following actions should the nurse perform first?

A. Assess the client’s pain.

B. Obtain a large‑bore Iv needle for decompression.

C. Administer lorazepam.

D. Prepare for chest tube insertion.

3. A nurse is reviewing discharge instructions
for a client who has COPD and experienced
a pneumothorax. Which of the following
statements should the nurse include?

A. “Notify your provider if you experience weakness.”

B. “You should be able to return to work in 1 week.”

C. “You need to wear a mask when in crowded areas.”

D. “Notify your provider if you experience
a productive cough.”

4. A nurse in the emergency department is assessing
a client who has sustained multiple rib fractures
and has a flail chest. Which of the following findings
should the nurse expect? (select all that apply.)

A. Bradycardia

B. Cyanosis

C. hypotension

D. Dyspnea

E. Paradoxical chest movement

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 25 PNEUmOthORAX, hEmOthORAX, AND FLAIL ChEst 159

Application Exercises Key

1. A. CORRECT: the client who has a pneumothorax
can experience tachypnea related to respiratory
distress caused by the injury.

B. CORRECT: the client who has a pneumothorax
can experience deviation of the trachea as
tension increases within the chest.

C. the client who has a pneumothorax can experience
tachycardia related to respiratory distress and pain.

D. the client who has a pneumothorax can
experience an increase in the use of accessory
muscles as respiratory distress occurs.

E. CORRECT: the client who has a pneumothorax can
experience pleuritic pain related to the inflammation
of the pleura of the lung caused by the injury.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

2. A. Assessing the client’s pain and administer pain medication
is important. however, another action is the priority.

B. CORRECT: the priority action when using the airway,
breathing, circulation (ABC) approach to client care
is to establish and maintain the client’s respiratory
function. Obtaining a large‑bore Iv needle for
decompression is the priority action by the nurse.

C. Administering a benzodiazepine will treat the client’s
anxiety. however, another action is the priority.

D. Gathering supplies to prepare for chest tube insertion is
important. however, another action is the priority.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. A. Weakness is an expected finding following
recovery from a pneumothorax.

B. the client should expect a lengthy recovery
following a pneumothorax.

C. It is not necessary to wear a mask following a
pneumothorax, unless the client has another
condition, such as immunosuppression.

D. CORRECT: the client should notify the provider of a
productive or persistent cough. this can indicate that the
client might need treatment of a respiratory infection.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. A. the client can have tachycardia as a
manifestation when experiencing a flail chest
due to inadequate oxygenation.

B. CORRECT: the client can have cyanosis as a
manifestation when experiencing a flail chest
due to inadequate oxygenation.

C. CORRECT: the client can have hypotension as a
manifestation when experiencing a flail chest.

D. CORRECT: the client can have dyspnea as a manifestation
when experiencing a flail chest due to injury and the
client’s inability to effectively inhale and exhale.

E. CORRECT: the client can have paradoxical chest movement
as a manifestation when experiencing a flail chest due to
injury to the chest and the inability to inhale and exhale.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): hemothorax
is an accumulation of blood in the pleural space.

NURSING CARE
● Administer oxygen therapy.
● Document ventilator settings hourly if the
client is receiving ventilation.

● monitor ABGs, saO2, CBC, and chest x‑ray findings.
● Position the client to maximize ventilation (high‑Fowler’s = 90°).
● Provide emotional support to the client and family.
● monitor chest tube drainage.
● Administer medications as prescribed.
● Encourage prompt medical attention when
manifestations of infection occur.

● Auscultate heart and lung sounds and monitor vital signs every 4 hr.

MEDICATIONS
● Benzodiazepines (sedatives): Lorazepam or
midazolam can be used to decrease anxiety.

● Opioid agonists (pain medications): morphine sulfate
and fentanyl are opioid agents used to treat moderate
to severe pain. these medications act on the mu
and kappa receptors that help alleviate pain.

NCLEX® Connection: Physiological Adaptation, Medical
Emergencies

160 CHAPTER 25 PNEUmOthORAX, hEmOthORAX, AND FLAIL ChEst CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 26 REsPIRAtORY FAILURE 161

UNIT 3 RESPIRATORY DISORDERS
SECTION: RESPIRATORY EMERGENCIES

CHAPTER 26 Respiratory Failure
Respiratory failure includes acute respiratory failure
(ARF), acute respiratory distress syndrome (ARDs),
and severe acute respiratory syndrome (sARs).
Because older adult clients have decreased
pulmonary reserves due to normal lung changes,
including decreased lung elasticity and thickening
alveoli, they can decompensate more quickly.

Acute respiratory failure

ARF is caused by failure to adequately ventilate
and/or oxygenate.

● Ventilatory failure is due to a mechanical abnormality
of the lungs or chest wall, impaired muscle function
(especially the diaphragm), or a malfunction in the
respiratory control center of the brain.

● Oxygenation failure can result from a lack of perfusion
to the pulmonary capillary bed (pulmonary embolism)
or a condition that alters the gas exchange medium
(pulmonary edema, pneumonia).

● Both inadequate ventilation and oxygenation can occur
in clients who have diseased lungs (asthma, emphysema,
or cystic fibrosis). Diseased lung tissue can cause
oxygenation failure and increased work of breathing,
eventually resulting in respiratory muscle fatigue and
ventilatory failure. Combined failure leads to more
profound hypoxemia than either ventilatory failure or
oxygenation failure alone.

● Criteria for acute respiratory failure are based on
ABG values.

Acute respiratory distress syndrome

ARDS is a state of acute respiratory failure with a
mortality rate as high as 58%.

● A systemic inflammatory response injures the
alveolar‑capillary membrane. It becomes permeable to
large molecules, and the lung space is filled with fluid.

● A reduction in surfactant weakens the alveoli, which causes
collapse or filling of fluid, leading to worsening edema.

Severe acute respiratory syndrome

SARS is the result of a viral infection from a mutated
strain of the coronaviruses, a group of viruses that also
cause the common cold.

● The virus invades the pulmonary tissue, which leads to
an inflammatory response.

● The virus is spread easily through airborne droplets
from sneezing, coughing, or talking.

● The virus does not spread to the bloodstream because it
flourishes at temperatures slightly below normal core
body temperature.

ASSESSMENT

RIsK FACtORs

Acute respiratory failure

Ventilatory failure
● COPD
● Pulmonary embolism
● Pneumothorax
● Flail chest
● ARDS
● Asthma
● Pulmonary edema
● Fibrosis of lung tissue
● Neuromuscular disorders (multiple sclerosis,

Guillain‑Barré syndrome), spinal cord injuries, and
cerebrovascular accidents that impair the client’s rate
and depth of respiration

● Elevated intracranial pressure (closed‑head injuries,
cerebral edema, hemorrhagic stroke)

Oxygenation failure
● Pneumonia
● Hypoventilation
● Hypovolemic shock
● Pulmonary edema
● Pulmonary embolism
● ARDS
● Low hemoglobin
● Low concentrations of oxygen in the blood

(carbon monoxide poisoning, high altitude,
smoke inhalation)

Combined ventilatory and oxygenation failure
Decreased gas exchange results in poor diffusion of
oxygen into arterial blood with carbon dioxide retention

● Hypoventilation (poor respiratory movement)
● Chronic bronchitis
● Asthma attack
● Emphysema
● Cardiac failure

Acute respiratory distress syndrome
● Can result from localized lung damage or from the

effects of other systemic problems
● Shock
● Disseminated intravascular coagulopathy (DIC)
● Aspiration
● Pulmonary emboli (fat, amniotic fluid)
● Pneumonia and other pulmonary infections
● Sepsis
● Near‑drowning
● Trauma
● Multiple blood transfusions
● Damage to the central nervous system
● Smoke or toxic gas inhalation
● Drug ingestion/toxicity (heroin, opioids, salicylates)

Severe acute respiratory syndrome
● Exposure to an infected individual
● Immunocompromised individuals (chemotherapy, AIDS)

CHAPTER 26

162 CHAPTER 26 REsPIRAtORY FAILURE CONTENT MASTERY SERIES

EXPECtED FINDINGs
● Shortness of breath
● Dyspnea with or without exertion
● Orthopnea (difficulty breathing lying flat)
● Rapid, shallow breathing
● Cyanotic, mottled, dusky skin or mucous

membranes
● Tachycardia
● Hypotension
● Substernal or suprasternal retractions
● Decreased SaO2 (less than 90%)
● Adventitious breath sounds (wheezing, rales)
● Cardiac arrhythmias
● Confusion
● Lethargy

Acute respiratory failure
● Dyspnea
● Orthopnea
● Cyanosis
● Pallor
● Hypoxemia
● Tachycardia
● Confusion
● Irritability or agitation
● Restlessness
● Hypercarbia (high levels of carbon dioxide in the blood)

Acute respiratory distress syndrome
● Dyspnea
● Bilateral noncardiogenic pulmonary edema (crackles

upon auscultation)
● Reduced lung compliance
● Dense patchy bilateral pulmonary infiltrates
● Severe hypoxemia despite administration of
100% oxygen

LABORAtORY tEsts
ABGs to confirm and monitor ARF, ARDS, and SARS

● PaO2 less 60 mm Hg and oxygen saturation less than
90% on room air (hypoxemia)

● PaCO2 greater than 45 mm Hg and pH less than 7.35
(hypoxemia, hypercarbia)

Acute respiratory failure

ABGs to confirm and monitor combined ventilatory and
oxygenation failure

● Room air, PaO2 less than 60 mm Hg (hypoxemic/
oxygenation failure), OR PaCO2 greater than 45 mm Hg
in conjunction with a pH less than 7.35 (hypercapnic/
ventilatory failure)

● AND SaO2 less than 90% in both cases

DIAGNOstIC PROCEDUREs

Chest x‑ray

Results can include
● Pulmonary edema (ARF, ARDS)
● Cardiomegaly (ARF)
● Diffuse infiltrates and white‑out or ground‑glass

appearance (ARDS)
● Infiltrates (SARS)

NURSING ACTIONS
● Assist with client positioning before and after the x‑ray.
● Communicate the results to the appropriate personnel in

a timely manner.

Electrocardiogram (ECG)

To rule out cardiac involvement.

Hemodynamic monitoring

Pulmonary capillary wedge pressure with ARDS is
usually low or within the expected reference range (4 to
12 mm Hg). Continuous hemodynamic monitoring is
important for fluid management.

NURSING ACTIONS
● Monitor the ECG during placement of central venous

pressure catheter and hemodynamic monitor.
● Have resuscitation medications and

equipment available.
● Monitor hemodynamic waveforms and readings.
● Confirm catheter placement using a chest x‑ray.

PATIENT‑CENTERED CARE

NURsING CARE
● Maintain a patent airway and monitor respiratory status

every hour and more often as needed.
● Mechanical ventilation is often required with

positive‑end expiratory pressure (PEEP) or continuous
positive airway pressure (CPAP) to prevent alveolar
collapse during expiration. Follow facility protocol for
monitoring and documenting ventilator settings.

● Oxygenate before suctioning secretions to prevent
further hypoxemia.

● Suction the client as needed.
● Assess and document sputum color, amount,

and consistency.
● Assess lung sounds per facility protocol.
● Monitor for pneumothorax (a high PEEP can cause the

lungs to collapse).
● Obtain ABGs as prescribed and following each ventilator

setting adjustment.
● Maintain continuous ECG monitoring for changes that

can indicate increased hypoxemia, especially when
repositioning and applying suction.

● Continually monitor vital signs, including SaO2. Assess
pain level.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 26 REsPIRAtORY FAILURE 163

● Position the client to facilitate ventilation and perfusion.
● Prevent infection.

◯ Perform frequent hand hygiene.
◯ Use appropriate suctioning technique.
◯ Provide oral care every 2 hr and as needed.
◯ Wear protective clothing (gown, gloves, mask)
when appropriate.

● Promote nutrition.
◯ Assess bowel sounds.
◯ Monitor elimination patterns.
◯ Obtain daily weights.
◯ Monitor intake and output.
◯ Administer enteral and/or parenteral feedings
as prescribed.

◯ Prevent aspiration with enteral feedings (elevate the
head of the bed 30° to 45°).

◯ Confirm nasogastric (NG) tube placement prior
to feeding.

● Provide emotional support to the client and family.
◯ Encourage verbalization of feelings.
◯ Provide alternative communication means (dry erase

board, pen and paper).

mEDICAtIONs

Benzodiazepines

EXAMPLES
● Lorazepam
● Midazolam

ACTIONS: Reduces anxiety and resistance to ventilation
and decreases oxygen consumption

NURSING ACTIONS
● Monitor respirations on clients who are not receiving

mechanical ventilation.
● Monitor blood pressure and SaO2.
● Use cautiously in conjunction with opioid narcotics.

General anesthesia

EXAMPLES: Propofol

ACTIONS
● Induces and maintains anesthesia
● Sedates clients for mechanical ventilation

NURSING ACTIONS
● Contraindicated for clients who have hyperlipidemia and

egg allergies.
● Administer only to clients who are intubated

and ventilated.
● Monitor ECG, blood pressure, and sedation levels.
● IV rate must be slowed to assess neurologic status.

(Follow facility protocol.)
● Monitor for hypotension.
● Titrate to desired sedation.
● No analgesic actions. Monitor pain, and administer

analgesics as prescribed

Corticosteroids

EXAMPLES
● Cortisone acetate
● Methylprednisolone sodium succinate
● Dexamethasone sodium phosphate

ACTIONS: Reduces WBC migration and decreases
inflammation

NURSING ACTIONS
● Discontinue medication gradually.
● Administer with an antiulcer medication to prevent

peptic ulcer formation.
● Monitor weight and blood pressure.
● Monitor glucose and electrolytes.

CLIENT EDUCATION: Take oral doses with food and avoid
stopping the medication suddenly.

Opioid analgesics

EXAMPLES
● Morphine sulfate
● Fentanyl

ACTIONS: Provides pain management

NURSING ACTIONS
● Monitor respirations for clients who are not receiving

mechanical ventilation.
● Monitor blood pressure, heart rate, and SaO2.
● Monitor ABGs. (Hypercapnia can result from

depressed respirations.)
● Use cautiously in conjunction with hypnotic sedatives.
● Assess pain level and response to medication.
● Have naloxone and resuscitation equipment available

for severe respiratory depression in clients who are not
receiving mechanical ventilation.

Neuromuscular blocking agents

EXAMPLES: Vecuronium, atracurium, rocuronium

ACTIONS
● Facilitates ventilation and decreases oxygen consumption
● Often used with painful ventilatory modes (inverse ratio

ventilation and PEEP)

NURSING ACTIONS
● Administer only to clients who are intubated

and ventilated.
● Monitor ECG, blood pressure, and muscle strength.
● Give pain medication and sedatives with neuromuscular

blocking agents.
● Neuromuscular blocking agents do not sedate or relieve

pain. (Clients can be awake and frightened.)
● Have neostigmine and atropine available to reverse the

effects of the neuromuscular blocking agent.
● Have resuscitation equipment available.
● Explain all procedures.

CLIENT EDUCATION: Paralysis is medication‑induced.

164 CHAPTER 26 REsPIRAtORY FAILURE CONTENT MASTERY SERIES

Antibiotics sensitive to cultured organism(s)

EXAMPLES: Vancomycin

ACTIONS: Treats identified organisms

NURSING ACTIONS
● Culture sputum prior to administration of first dose.
● Monitor for a hypersensitivity reaction.
● Give IV doses slowly (over at least 60 min) to avoid red

man syndrome.
● Monitor the IV site for infiltration.
● Do not give with other medications.
● Monitor coagulopathy and renal function.

CLIENT EDUCATION: Take oral doses with food and finish
the prescribed dose.

INtERPROFEssIONAL CARE
Respiratory therapy

● The respiratory therapist typically manages the
ventilator, adjusts the settings, and provides
chest physiotherapy to improve ventilation and
chest expansion.

● The respiratory therapist also can suction the
endotracheal tube and administer inhalation
medications, such as bronchodilators.

Physical therapy for extended ventilatory support and
rehabilitation

Nutritional therapy
● Enteral or parenteral feeding
● Nutritional support following extubation

thERAPEUtIC PROCEDUREs

Intubation and mechanical ventilation

Artificial airway insertion with mechanical ventilation

NURSING ACTIONS
● Monitor ECG, SaO2, lung sounds, and color.
● Sedate as needed.
● Provide reassurance to calm the client.
● Have suction equipment, manual resuscitation bag, and

face mask available at all times.
● Suction secretions as needed.
● PREINTUBATION

◯ Oxygenate with 100% oxygen.
◯ Assist ventilation with manual resuscitation bag and
face mask.

◯ Have emergency resuscitation equipment
readily available.

● POSTINTUBATION
◯ Assess end‑tidal carbon dioxide levels, bilateral lung
sounds, symmetrical chest movement, and chest
x‑ray findings to confirm placement of the
endotracheal tube.

◯ Secure the endotracheal tube per facility guidelines.
◯ Assess the balloon cuff for air leaks periodically.

● PEEP
◯ Positive pressure is applied at the end of expiration to

keep the alveoli expanded.
◯ PEEP is added to the ventilator setting to increase
oxygenation and improve lung expansion.

CLIENT EDUCATION: Alternate methods of communication
will be provided because speaking is not possible while
the endotracheal tube is in place.

Kinetic therapy

A kinetic bed that rotates laterally alters client positioning
to reduce atelectasis and improve ventilation.

NURSING ACTIONS
● Begin slowly and gradually to increase the degree of

rotation as tolerated.
● Monitor ECG, SaO2, breath sounds, and blood pressure.
● Stop rotation if the client becomes distressed.
● Provide routine skin care to prevent breakdown.
● Sedate as needed.

COMPLICATIONS

ENDOtRAChEAL tUBE

Trauma
● Trauma during intubation or long‑term intubation can

cause damage to trachea and vocal cords.
● A tracheostomy might be required for

long‑term ventilation.

Altered position of endotracheal tube

NURSING ACTIONS
● Check tube positioning every 1 to 2 hr and as needed.
● Assess lung sounds, SaO2, and chest movement each

time the client is moved, transferred, or turned.
● Secure endotracheal tube per facility guidelines to

maintain tube placement.

Aspiration pneumonia

NURSING ACTIONS
● Check the cuff on the endotracheal tube for leaks.
● Assess suction contents for gastric secretions.
● Verify NG tube placement.

Infection

NURSING ACTIONS
● Prevent infection by using proper hand hygiene and

suctioning technique.
● Assess color, amount, and consistency of secretions.

Blocked endotracheal tube

Indicated by high‑pressure alarm on ventilator

NURSING ACTIONS: Suction secretions to relieve a mucous
plug or insert an oral airway to prevent biting on the tube.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 26 REsPIRAtORY FAILURE 165

mEChANICAL vENtILAtION

Increased intrathoracic pressure
● PEEP increases intrathoracic pressure, which can cause

a decreased blood return to the heart, decreased cardiac
output, and/or hypotension.

● Decreased cardiac output can activate the
renin‑angiotensin‑aldosterone system, leading to fluid
retention and/or decreased urine output.

NURSING ACTIONS: Monitor input and output, weight,
and hydration status.

CLIENT EDUCATION: Avoid using the Valsalva maneuver
(straining with bowel movement), because it can further
increase intrathoracic pressure.

Barotrauma

Ventilation with positive pressure causes damage to the
lungs (pneumothorax, subcutaneous emphysema).

NURSING ACTIONS
● Monitor oxygenation status and chest x‑ray.
● Assess for subcutaneous emphysema (crackles and/or air

movement felt under skin).
● Monitor for a high‑pressure ventilator alarm, which can

indicate pneumothorax.

Immobilization

Can result in muscle atrophy, pneumonia, and
pressure injury

NURSING ACTIONS
● Reposition and suction every 2 hr and as needed.
● Provide routine skin care.
● Implement range‑of‑motion exercises to prevent

muscle atrophy.

Active Learning Scenario

A nurse is reviewing the plan of care for a client who has
acute respiratory distress syndrome (ARDs). What should
be included in the plan of care? Use the AtI Active Learning
template: system Disorder to complete this item.

RISK FACTORS: Describe three conditions related to ARDs.

NURSING CARE: Describe three nursing
actions to maintain oxygenation.

COMPLICATIONS: Identify two complications of ARDs.

Application Exercises

1. A nurse in the emergency department is assessing
a client who was in a motor vehicle crash. Findings
include absent breath sounds in the left lower lobe
with dyspnea, blood pressure 118/68 mm hg, heart
rate 124/min, respirations 38/min, temperature
38.6° C (101.4° F), and saO2 92% on room air. Which
of the following actions should the nurse take first?

A. Obtain a chest x‑ray.

B. Prepare for chest tube insertion.

C. Administer oxygen via a high‑flow mask.

D. Initiate Iv access.

2. A nurse is orienting a newly licensed nurse on the
purpose of administering vecuronium to a client who
has acute respiratory distress syndrome (ARDs). Which
of the following statements by the newly licensed
nurse indicates understanding of the teaching?

A. “this medication is given to treat infection.”

B. “this medication is given to facilitate ventilation.”

C. “this medication is given to
decrease inflammation.”

D. “this medication is given to reduce anxiety.”

3. A nurse is reviewing the health records of
five clients. Which of the following clients
are at risk for developing acute respiratory
distress syndrome? (select all that apply.)

A. A client who experienced a near‑drowning incident

B. A client following coronary artery
bypass graft surgery

C. A client who has a hemoglobin of 15.1 mg/dL

D. A client who has dysphagia

E. A client who experienced acute drug toxicity

4. A nurse is planning care for a client who has
severe acute respiratory distress system
(sARs). Which of the following actions should
the nurse include? (select all that apply.)

A. Administer antibiotics.

B. Provide supplemental oxygen.

C. Administer antiviral medications.

D. Administer of bronchodilators.

E. maintain ventilatory support.

5. A nurse is caring for a client who is receiving
vecuronium during mechanical ventilation.
Which of the following medications should
the nurse anticipate administering with this
medication? (select all that apply.)

A. Fentanyl

B. Furosemide

C. midazolam

D. Famotidine

E. Dexamethasone

166 CHAPTER 26 REsPIRAtORY FAILURE CONTENT MASTERY SERIES

Application Exercises Key

1. A. Obtaining a chest x‑ray to determine the level
of injury to the lungs is important, but is not
the priority action at this time.

B. Preparing the client for chest tube insertion is important
to facilitate lung expansion and restore normal intrapleural
pressure, but is not the priority action at this time.

C. CORRECT: According to the airway, breathing, and
circulation to client care, the nurse should place the
priority on administering oxygen via high‑flow mask
to restore optimal breathing because the client is
experiencing dyspnea and has decreased lung sounds.

D. Initiating Iv access to administer medications is
important, but is not the priority action at this time.

NCLEX® Connection: Physiological Adaptation,
Illness Management

2. A. Antibiotics are given to treat infection.
B. CORRECT: vecuronium is a neuromuscular

blocking agent given to facilitate ventilation
and decrease oxygen consumption.

C. Corticosteroids are given to treat inflammation.
D. Benzodiazepines are given to treat anxiety.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Expected Actions/Outcomes

3. A. CORRECT: A client who experienced a near‑drowning
incident is at risk for developing ARDs due to
trauma to the lungs and cerebral edema.

B. CORRECT: A client following coronary artery
bypass graft surgery is at risk for developing
ARDs due to trauma to the chest.

C. hemoglobin of 15.1 mg/dL is within the
expected reference range. A client who has a low
hemoglobin is at risk for developing ARDs.

D. CORRECT: A client who has dysphagia is at risk for developing
ARDs due to difficulty swallowing and risk for aspiration.

E. CORRECT: A client who experienced acute drug
toxicity is at risk for developing ARDs due to
damage to the central nervous system.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. A. Antibiotics are given to treat bacterial infections.
this would not be indicated for sARs.

B. CORRECT: Providing supplemental oxygen should
be included in the plan of care for sARs. Oxygen
is administered to treat severe hypoxemia.

C. sARs is caused by the coronavirus. there are no
effective antiviral medications to treat this virus.

D. CORRECT: Administration of bronchodilators should be
included in the plan of care for sARs. Bronchodilators
are used to vasodilate the client’s airway.

E. CORRECT: maintaining ventilatory support should
be included in the plan of care for sARs. Intubation
can be required to maintain a patent airway.

NCLEX® Connection: Physiological Adaptation,
Illness Management

5. A. CORRECT: Fentanyl is a pain medication administered
to clients when a neuromuscular blocking agent,
such as vecuronium, is administered.

B. Furosemide is a diuretic used to release fluid from the body.
C. CORRECT: midazolam is a sedative medication

administered to clients when a neuromuscular blocking
agent, such as vecuronium, is administered.

D. Famotidine is an h2 receptor antagonist given
to treat upset stomach and heartburn.

E. Dexamethasone is a corticosteroid used to treat
inflammation, such as arthritis or an immune disorder.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS
● Can result from localized lung
damage or from the effects
of other systemic problems

● Aspiration
● Pulmonary emboli
(fat, amniotic fluid)

● Pneumonia and other
pulmonary infections

● sepsis
● Near‑drowning accident
● trauma
● Damage to the central
nervous system

● smoke or toxic gas inhalation
● Drug ingestion/toxicity
(heroin, opioids, salicylates)

NURSING CARE
● maintain a patent airway and monitor respiratory
status every hour as needed.

● suction the client as needed.
● Assess lung sounds.
● Assess and document sputum color, amount, and consistency.
● Oxygenate before suctioning secretions
to prevent further hypoxemia.

● mechanical ventilation often is required. PEEP often is
used to prevent alveolar collapse during expiration.

● monitor for pneumothorax. (A high PEEP
can cause the lungs to collapse.)

● Obtain ABGs as prescribed and following
each ventilator setting adjustment.

● maintain continuous ECG monitoring for changes
that can indicate increased hypoxemia, especially
when repositioning and applying suction.

● Continually monitor vital signs, including saO2.
● Position the client to facilitate ventilation and perfusion.

COMPLICATIONS
● Endotracheal tube

◯ trauma during intubation or long‑term intubation
◯ Can cause damage to trachea and vocal cords
◯ Nursing Actions: Consider a tracheostomy
for long‑term ventilation.

● Aspiration pneumonia nursing actions
◯ Check the cuff on the endotracheal tube for leaks.
◯ Assess suction contents for gastric secretions.
◯ verify NG tube placement.

● Infection nursing actions
◯ Prevent infection by using proper hand
hygiene and suctioning technique.

◯ Assess color, amount, and consistency of secretions.
● Blocked endotracheal tube

◯ the high‑pressure alarm on the ventilator can
indicate a blocked endotracheal tube.

◯ Nursing Actions: suction secretions to relieve a mucous plug
or insert an oral airway to prevent biting on the tube.

● Altered position of endotracheal tube nursing actions
◯ Check tube positioning every 1 to 2 hr and as needed.
◯ Assess breath sounds, saO2, and chest movement.
◯ secure endotracheal tube per institution’s
guidelines to maintain tube placement.

● mechanical ventilation
◯ Increased intrathoracic pressure
◯ PEEP increases intrathoracic pressure, which can
cause a decreased blood return to the heart,
decreased cardiac output and/or hypotension.

◯ Decreased cardiac output can activate the
renin‑angiotensin‑aldosterone system, leading to
fluid retention and/or decreased urine output.

◯ Nursing Actions: monitor input and output,
weight, and hydration status.

◯ Client Education: Avoid using the valsalva maneuver
(straining with bowel movement), because it can
further increase intrathoracic pressure.

● Barotrauma: ventilation with positive pressure causes damage
to the lungs (pneumothorax, subcutaneous emphysema).

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

07/24/15 April 9, 2019 11:28 AM rm_rn_2019_ams_unit4

RN ADULT MEDICAL SURGICAL NURSING NCLEX® CONNECtIONs 167

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Pharmacological and Parenteral Therapies
ADVERSE EFFECTS/CONTRAINDICATIONS/SIDE EFFECTS/
INTERACTIONS: Identify a contraindication to the
administration of a medication to the client.

CENTRAL VENOUS ACCESS DEVICES: Provide care
for client with a central venous access device.

PHARMACOLOGICAL PAIN MANAGEMENT: Assess client
need for administration of a PRN pain medication.

Reduction of Risk Potential
CHANGES/ABNORMALITIES IN VITAL SIGNS:
Evaluate invasive monitoring data.

DIAGNOSTIC TESTS
Apply knowledge of related nursing procedures and psychomotor
skills when caring for clients undergoing diagnostic testing.

Perform diagnostic testing.

POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC
TESTS/TREATMENTS/PROCEDURES: Apply and/
or maintain devices used to promote venous return.

SYSTEM SPECIFIC ASSESSMENTS: Assess the client for
abnormal peripheral pulses after a procedure or treatment.

07/24/15 April 9, 2019 11:28 AM rm_rn_2019_ams_unit4

168 NCLEX® CONNECtIONs CONTENT MASTERY SERIES

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS: Assist with invasive procedures.

HEMODYNAMICS
Identify cardiac rhythm strip abnormalities.

Apply knowledge of pathophysiology to interventions
in response to client abnormal hemodynamics.

Manage the are of a client with a pacing device.

ILLNESS MANAGEMENT: Educate client
regarding an acute or chronic condition.

UNEXPECTED RESPONSES TO THERAPIES: Assess the
client for unexpected adverse response to therapy.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs 169

UNIT 4 NURSING CARE OF CLIENTS WHO HAVE
CARDIOVASCULAR DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 27 Cardiovascular
Diagnostic and
Therapeutic
Procedures

Cardiovascular diagnostic procedures evaluate
the functioning of the heart by monitoring
for enzymes in the blood; using ultrasound
to visualize the heart; determining the heart’s
response to exercise; and using catheters
to determine blood volume, perfusion, fluid
status, how the heart is pumping, and degree of
artery blockage.

Cardiovascular diagnostic procedures that nurses
should be familiar with include cardiac enzymes
and lipid profile, echocardiogram, stress testing,
hemodynamic monitoring, and angiography.
Cardiovascular therapeutic procedures include
central vascular Iv access placement and
percutaneous coronary interventions.

Cardiac enzymes
and lipid profile

Cardiac enzymes are released into the bloodstream when
the heart muscle suffers ischemia.

A lipid profile provides information regarding cholesterol
levels and is used for early detection of heart disease.
Cardiac enzymes are specific markers in diagnosing a
myocardial infarction (MI).

INDICATIONS
● Angina
● MI
● Heart disease
● Hyperlipidemia

CONSIDERATIONS
PREPROCEDURE: Fasting for 12 to 14 hr is recommended
prior to lipid profile sampling.

INTERPRETATION OF FINDINGS

27.1 Cardiac enzymes

EXPECTED
REFERENCE
RANGE

ELEVATED LEVELS
FIRST DETECTABLE
FOLLOWING
MYOCARDIAL INJURY

EXPECTED
DURATION
OF ELEVATED
LEVELS

Creatine kinase MB isoenzyme
more sensitive to myocardium

0% of total CK
(30 to 170 units/L) 3 to 6 hr 2 to 3 days

Troponin T
Less than 0.1 ng/mL 2 to 3 hr 10 to 14 days

Troponin I
Less than
0.03 ng/mL 2 to 3 hr 7 to 10 days

Myoglobin
Less than 90 mcg/L 2 to 3 hr 24 hr

27.2 Cardiac tests
EXPECTED
REFERENCE RANGE PURPOSE

Cholesterol (total)
Less than 200 mg/dL screening for heart disease

LDL

Less than 130 mg/dL
“Bad” cholesterol
transports cholesterol to the
body’s cells from the liver

Triglycerides
MALES: 40 to 160 mg/dL
FEMALES: 35 to 135 mg/dL

Evaluates the client’s risk
for heart disease

HDL
FEMALES: greater
than 55 mg/dL
MALES: greater
than 45 mg/dL

“Good” cholesterol
Protects coronary arteries from heart
disease by transporting cholesterol
from the body’s cells to the liver

Transthoracic
echocardiography

A transthoracic echocardiogram is used to diagnose valve
disorders and cardiomyopathy; evaluate the size, shape,
and motion of the structure of the heart; and measure the
ejection fraction.

INDICATIONS
● Cardiomyopathy
● Heart failure
● Angina
● MI

CONSIDERATIONS
PREPROCEDURE: Explain that this is a noninvasive test
and takes up to 1 hr.
INTRAPROCEDURE: Instruct the client to lie on the left
side and remain still.
POSTPROCEDURE: Provider reviews test results and a plan
for follow‑up care with the client.

CHAPTER 27

170 CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs CONTENT MASTERY SERIES

Transesophageal
Echocardiography

Transesophageal echocardiography provides clearer
ultrasonic images, because the waves pass through less
tissue. A small transducer is passed through the mouth
and into the esophagus to provide images of the heart.

INDICATIONS
● Heart failure
● Valvular heart disease
● Atrial or ventricular thrombi
● Monitoring during valve replacement and coronary

artery bypass surgeries

CONSIDERATIONS
PREPROCEDURE: Ensure that informed consent has been
signed. Instruct the client to be NPO for 6 hr prior to the
procedure. Insert an IV access.

INTRAPROCEDURE: Monitor the client’s level of
consciousness, ECG, blood pressure, heart rate, respiratory
rate, and oxygenation status, as moderate sedation is
needed for the procedure.

POSTPROCEDURE: Monitor the client’s vital signs,
oxygenation status, level of consciousness, and return
of gag reflex (topical anesthetics are used in the throat).
Maintain the head of the bed at 45º.

Stress testing
The client exercises the cardiac muscle by walking on a
treadmill, which is called exercise stress testing. This
provides information regarding the workload of the heart.
The test is discontinued once the heart rate reaches a
certain rate.

Fatigue or disability can prevent traditional exercise
testing or test completion. The provider can prescribe the
test to be done as a pharmacological (chemical) stress test.

INDICATIONS
● Angina
● Heart failure
● MI
● Dysrhythmia

CONSIDERATIONS

PREPROCEDURE
● Assist the provider in obtaining a signed informed

consent form.
● Explain to the client that they will be walking on a

treadmill, and comfortable athletic shoes and clothing
are recommended.

◯ If pharmacological stress testing is prescribed, a
medication (dipyridamole, adenosine, regadenoson,
dobutamine) is given to stress the heart instead of
walking on the treadmill.

● Instruct the client to fast 2 to 4 hr before the procedure
according to facility policy and to avoid tobacco, alcohol,
and caffeine before the test.

● Instruct the client to get adequate rest the night before
the procedure.

INtRAPROCEDURE
● Apply a 12‑lead ECG to monitor heart rate during

the test. Monitor for dysrhythmias throughout
the procedure.

● Instruct the client to report any chest pain, shortness of
breath, or dizziness during the procedure.

POstPROCEDURE
● Monitor the client by 12‑lead ECG.
● Check blood pressure frequently until the client is stable.
● The provider reviews findings with the client.

Hemodynamic monitoring
Hemodynamic monitoring involves special indwelling
catheters, which provide information about blood volume and
perfusion, fluid status, and how well the heart is pumping.

● Hemodynamic status is assessed with several parameters.
◯ Central venous pressure (CVP)
◯ Pulmonary artery pressure (PAP)
◯ Pulmonary artery wedge pressure (PAWP)
◯ Cardiac output (CO)
◯ Intra‑arterial blood pressure

● Mixed venous oxygen saturation (SvO2) indicates
the balance between oxygen supply and demand. It
is measured by a pulmonary artery catheter with
fiber optics.

● A hemodynamic monitoring system is used to display a
client’s hemodynamic data.

◯ Pressure transducer
◯ Pressure tubing
◯ Monitor
◯ Pressure bag and flush device

Online Image: Hemodynamic Monitoring

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs 171

● Arterial lines are placed in the radial (most common),
brachial, or femoral artery.

◯ Arterial lines provide continuous information about
changes in blood pressure and permit the withdrawal
of samples of arterial blood. Intra‑arterial pressures
can differ from cuff pressures.

◯ The integrity of the arterial waveform should
be assessed to verify the accuracy of blood
pressure readings.

◯ Monitor circulation in the limb with the arterial line
(capillary refill, temperature, color).

◯ Arterial lines are not used for IV fluid administration.

Pulmonary artery (PA) catheters

The PA catheter is inserted into a large vein (internal
jugular, femoral, subclavian, brachial) and threaded
through the right atria and ventricle into a branch of the PA.

● PA catheters have multiple lumens, ports, and
components that allow for various hemodynamic
measurements, blood sampling, and infusion of IV fluids.

◯ The proximal lumen can be used to measure right
atrial pressure (CVP), infuse IV fluids, and obtain
venous blood samples.

◯ The distal lumen can be used to measure PAPs
(PA systolic, PA diastolic, mean PA pressure, and
PA wedge pressure). This lumen is not used for IV
fluid administration.

◯ The balloon inflation port is intermittently used for
PAWP measurements. When not in use, it should be
left deflated and in the locked position.

◯ The thermistor measures the temperature differences
between the right atrium and the PA in order to
determine CO.

◯ Additional infusion ports can be available, depending
on the brand.

INDICATIONS
● Serious or critical illness
● Heart failure
● Post coronary artery bypass graft (CABG) clients
● ARDS
● Acute kidney injury
● Burn injury
● Trauma injury

CONSIDERATIONS

PREPROCEDURE

Line insertion

NURSING ACTIONS
● Ensure the client’s understanding of the procedure prior

to obtaining signed informed consent form.
● Assemble the pressure monitoring system. Purge air

from the system and maintain sterility of connections.
● Place the client in supine or Trendelenburg position.
● Administer sedation and pain medications as prescribed.
● Level transducer with phlebostatic axis (4th intercostal

space, midaxillary line), which corresponds with the
right atrium.

● Zero system with atmospheric pressure, because the
hemodynamic pressure lines must be calibrated to read
zero atmospheric pressure.

● Obtain initial readings as prescribed. Compare arterial
blood pressure to noninvasive blood pressure (NIBP).

● Document the client’s response.

INtRAPROCEDURE
Monitor for manifestations of altered hemodynamics.

27.3 Manifestations of
altered hemodynamics

Preload Afterload
RIGHT HEART: CvP
LEFT HEART: PAWP

RIGHT HEART: pulmonary
vascular resistance
LEFT HEART: systemic
vascular resistance

ELEVATED DECREASED ELEVATED DECREASED
Crackles in lungs
Jugular vein
distention
hepatomegaly
Peripheral edema
taut skin turgor

Poor skin
turgor
Dry mucous
membranes

Cool
extremities
Weak
peripheral
pulses

Warm
extremities
Bounding
peripheral
pulses

POstPROCEDURE
NURSING ACTIONS

● Obtain chest x‑ray to confirm catheter placement.
● Continually monitor respiratory and cardiac status (vital

signs, heart rhythm, SaO2).
◯ Observe respiratory pattern and effort.
◯ Compare noninvasive blood pressure (NIBP) to arterial

blood pressure.
● Maintain line placement and integrity.

◯ Observe and document waveforms. Report changes
in waveforms to the provider, as this can indicate
catheter migration or displacement.

◯ Document catheter placement each shift and as
needed (after movement for transport).

◯ Monitor and secure connections between pressure
tubing, transducers, and catheter ports.

172 CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs CONTENT MASTERY SERIES

● Obtain readings from hemodynamic catheter.
◯ Place the client in supine position prior to recording

hemodynamic values. Head of bed can be elevated
15° to 30°.

◯ Level the transducer at the phlebostatic axis before
readings and with all position changes.

◯ Zero system to atmospheric pressure.
◯ Compare hemodynamic findings to physical assessment.
◯ Monitor trends in values obtained over time.

INTERPRETATION OF FINDINGS

27.4 Hemodynamic
monitoring

EXPECTED
REFERENCE
RANGES

CVP 2 to 6 mm hg
PULMONARY ARTERY SYSTOLIC 15 to 28 mm hg

PULMONARY ARTERY DIASTOLIC 5 to 16 mm hg
PAWP 6 to 15 mm hg

CO 3 to 6 L/min
SVO2 60% to 80%

The intravascular volume in older adult clients is often
reduced. The nurse should anticipate lower hemodynamic
values, particularly if dehydration is a complication.

COMPLICATIONS

Infection/Sepsis

Infection at insertion site can occur if aseptic technique
is not used.

NURSING ACTIONS
● Change dressings per facility protocol and as needed.
● Use surgical aseptic technique with dressing changes

(mask, sterile gloves, maintain sterile field).
● Monitor for evidence of infection (elevated WBC count

or temperature).
● Perform thorough hand hygiene.
● Collect specimens (blood cultures, catheter tip cultures)

and deliver to the laboratory.
● Administer antibiotic therapy as prescribed.
● Administer IV fluids for intravascular support.
● Administer vasopressors for vasodilation secondary

to sepsis.

Embolism

Plaque or a clot can become dislodged during the procedure.

NURSING ACTIONS
● Use 0.9% sodium chloride for flushing system. Flush can

include heparin and is based on facility protocol.
● Avoid introduction of air into flushing

system to prevent air embolism.
● Recognize the risk of pneumothorax

with insertion of the line.
● Recognize the risk of dysrhythmias with

insertion/movement of the line.

Angiography
Coronary angiography, also called a cardiac catheterization,
is an invasive diagnostic procedure used to evaluate the
presence and degree of coronary artery blockage.

● A renal or liver angiogram, cerebral angiogram, or
upper and lower extremity angiogram can be done to
determine blood flow and areas of possible blockage
of a vessel. Procedural care is the same for any type of
angiography or according to facility protocol.

● Coronary angiography involves the insertion of a catheter
into a femoral, brachial, or radial vessel and threading it
into the right or left side of the heart. Coronary artery
narrowings and/or occlusions are identified by the
injection of contrast media under fluoroscopy.

INDICATIONS
● Unstable angina and ECG changes (T wave inversion,

ST segment elevation, depression).
● Confirm and determine location and extent of

heart disease.

CONSIDERATIONS

PREPROCEDURE
NURSING ACTIONS

● Maintain NPO status for at least 8 hr due to the risk for
aspiration when lying flat for the procedure.

● Obtain vital signs, auscultate heart and lung sounds,
and assess peripheral pulses.

● Ensure that the consent form is signed.
● Ensure that the client and family understand the procedure.
● Assess for iodine/shellfish allergy (contrast media).
● Assess renal function prior to introduction of

contrast media.
● Administer premedications as prescribed

(methylprednisolone, diphenhydramine).
● If the client takes metformin, ask the provider about

withholding prior to and following the procedure (up to
48 hr). Metformin can cause hypoglycemia or acidosis
when receiving iodine media.

CLIENT EDUCATION:
● A mild sedative will be given to promote relaxation, and

local anesthetic.
● The groin is the most common site used for the

procedure; sensations of warmth or flushing might be
felt when the dye is injected.

● After the procedure, pressure will be held on the access
site. If a vascular closure device is not used, the
extremity must be kept straight for a prescribed amount
of time to prevent bleeding.

Online Image: Cardiac Catheter

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs 173

INtRAPROCEDURE
NURSING ACTIONS

● Administer sedatives and analgesia as prescribed.
● Continually monitor vital signs, heart rhythm, and

chest pain.
● Be prepared to intervene for dysrhythmias.
● Have resuscitation equipment and emergency

medications readily available.

POstPROCEDURE
NURSING ACTIONS

● Assess vital signs every 15 min × 4, every 30 min × 2,
every hour × 4, and then every 4 hr. (Follow
facility protocol.)

● Assess the affected extremity at the same intervals for:
◯ Bleeding and hematoma formation at the
insertion site.

◯ Thrombosis. (Document pedal pulse, extremity color,
and temperature.)

● Maintain bed rest in supine position with extremity
straight for prescribed time.

◯ A vascular closure device can be used to hasten
hemostasis following catheter removal.

◯ Older adult clients can have arthritis, which can make
lying in bed for 4 to 6 hr after the procedure painful.
The provider can prescribe medication.

● Conduct continuous cardiac monitoring for
dysrhythmias. (Reperfusion following angioplasty can
cause dysrhythmias.)

● Administer antiplatelet or thrombolytic agents as
prescribed to prevent clot formation and restenosis.

◯ Aspirin
◯ Clopidogrel (if having percutaneous coronary
intervention [PCI], other antiplatelet medication—
such as ticagrelor, prasugrel, or cangrelor—can be
administered)

◯ Heparin
◯ Low molecular weight heparin (enoxaparin)
◯ GP IIb/IIIa inhibitors, such as eptifibatide

● Administer anxiolytics and analgesics as needed.
● Monitor urine output and administer IV fluids
for hydration.

◯ Contrast media acts as an osmotic diuretic.
● Perform/assist with sheath removal from vessel.

◯ The catheter sheath is a short, hollow tube placed
inside the artery or vein at the insertion site. If
a percutaneous coronary angioplasty (PTCA) is
performed, the sheath is used as a guide for the
balloon catheter. After the PTCA, the catheter sheath
can be left in for access, if the PTCA would need to
be repeated.

◯ Apply pressure to arterial/venous sites for the
prescribed period of time (varies depending
upon the method used for vessel closure).

◯ Observe for vagal response (hypotension,
bradycardia) from compression of nerves.

◯ Apply pressure dressing.
◯ Withhold administration of metformin for 48 hr after
angiography to prevent lactic acidosis and possible
acute kidney injury.

CLIENT EDUCATION
● Leave the dressing in place for the first 24 hr following

discharge.
● Avoid strenuous exercise for the prescribed period of time.
● Immediately report bleeding from the insertion site,

chest pain, shortness of breath, and changes in the color
or temperature of the extremity.

● Restrict lifting to less than 10 lb (4.5 kg), bending at the
waist, or straining for at least 24 hr or for the prescribed
period of time if the groin was used for access. Restrict
lifting to 5 lb or less if a vessel in the arm or wrist was
used for at least 48 hr or for the prescribed period of time.

● Resume metformin as prescribed.

If a having a stent placement
● Take antiplatelet therapy as prescribed, which can be for

up to 12 months.
◯ Take the medication at the same time each day.
◯ Have regular laboratory tests to determine
therapeutic levels.

◯ Avoid activities that could cause bleeding. (Use soft
toothbrush. Wear shoes when out of bed.)

● Follow lifestyle guidelines. (Manage weight. Consume
a low‑fat/low‑sodium diet. Exercise regularly. Stop
smoking. Decrease alcohol intake.)

COMPLICATIONS

Artery dissection
● Perforation of an artery by the catheter can cause

cardiac tamponade or require emergency coronary
artery bypass surgery.

● Findings include severe hypotension and tachycardia,
and might require extended occlusion or perforation
with a balloon catheter and reversal of anticoagulants.

27.5 Cardiac catheters

174 CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs CONTENT MASTERY SERIES

Cardiac tamponade

Cardiac tamponade can result from fluid accumulation in
the pericardial sac.

● Manifestations include hypotension, jugular venous
distention, muffled heart sounds, and paradoxical
pulse (variance of 10 mm Hg or more in systolic blood
pressure between expiration and inspiration).

● Hemodynamic monitoring reveals intracardiac and PAPs
are similar and elevated (plateau pressures).

NURSING ACTIONS
● Notify the provider immediately.
● Administer IV fluids to combat hypotension.
● Obtain a chest x‑ray or echocardiogram

to confirm diagnosis.
● Prepare the client for pericardiocentesis.

(Verify informed consent. Gather materials.
Administer medications as appropriate.)

● Monitor hemodynamic pressures.
● Monitor heart rhythm. Changes indicate

improper positioning of the needle.
● Monitor for reoccurrence of manifestations

after the procedure.
● Monitor for dyspnea, and provide oxygen as indicated.

Hematoma formation

Blood clots can form near the insertion site.

NURSING ACTIONS
● Monitor for sensation, color, capillary refill, and peripheral

pulses in the extremity distal to the insertion site.
● Assess the groin at prescribed intervals and as needed.
● Hold pressure for uncontrolled oozing/bleeding.
● Monitor peripheral circulation.
● Notify the provider.

Allergic reaction related to the contrast media

Manifestations can include chills, fever, rash, wheezing,
tachycardia, and bradycardia.

NURSING ACTIONS
● Monitor for an allergic reaction.
● Have resuscitation equipment readily available.
● Administer diphenhydramine or epinephrine if prescribed.

External bleeding at the insertion site

NURSING ACTIONS
● Monitor insertion site for bleeding or swelling.
● Apply pressure to site.
● Keep client’s leg or arm straight.

Embolism

Plaque or a clot can become dislodged.

NURSING ACTIONS
● Monitor for chest pain during and after the procedure.
● Monitor vital signs and SaO2.

Restenosis of treated vessel

Clot reformation in the coronary artery can occur
immediately or several weeks after procedure.

NURSING ACTIONS
● Assess ECG patterns and for occurrence of chest pain.
● Notify the provider immediately.
● Prepare the client for return to the cardiac

catheterization laboratory.

CLIENT EDUCATION: Notify the provider of cardiac
manifestations, and take medications as prescribed.

Retroperitoneal bleeding

Bleeding into retroperitoneal space (abdominal cavity
behind the peritoneum) can occur due to femoral
artery puncture.

NURSING ACTIONS
● Assess for flank pain and hypotension.
● Notify the provider immediately and hold firm pressure

at the puncture site.
● Administer IV fluids and blood products as prescribed.

CLIENT EDUCATION
● Keep the leg straight.
● Report chest pain, shortness of breath, and

cardiac manifestations.

Acute kidney injury

Damage to the kidney can result from use of contrast
agent, which is nephrotoxic.

NURSING ACTIONS
● Monitor urine output, BUN, and blood creatinine and

electrolyte levels.
● Promote adequate hydration (oral, IV).

Vascular access
The site and type of vascular access device (VAD) is
determined by the characteristics of the prescribed
therapy (medication type, pH and osmolality, length of
time for therapy). The goal is to minimize the number of
catheter insertions and the risk for adverse reactions.

Central intravenous therapy
● Central IV catheters are appropriate for any fluids due to

rapid hemodilution in the superior vena cava (SVC).
● Ensure x‑ray verification of tip placement prior to use.
● Central IV catheters are inserted using sterile technique

by a provider, physician assistant, or specifically trained
nurses. Insertion occurs in the OR, the client’s room, or
in an outpatient facility.

● Tunneled and implanted catheters require
surgical removal.

● Central IV catheter types include nontunneled
percutaneous central venous catheters, peripherally
inserted central catheters, tunneled central venous
catheters (Hickman, Groshong), and implanted ports.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs 175

Nontunneled percutaneous central venous catheter (CVC)
● Description: 18 to 25 cm (7 to 10 in) in length with one

to five lumens
● Length of use: short‑term use only
● Insertion location: subclavian vein, jugular vein; tip in

the distal third of the superior vena cava
● Indications: administration of blood, long‑term

administration of chemotherapeutic agents, antibiotics,
and total parenteral nutrition

Tunneled percutaneous central venous catheter
● For long‑term use.
● Insertion location: A portion of the catheter lies in a

subcutaneous tunnel separating the point where the
catheter enters the vein from where it enters the skin
with a cuff. Tissue granulates into the cuff to provide a
mechanical barrier to organisms and an anchoring for
the catheter.

● Indications: Frequent and long‑term need for
vascular access.

● No dressing is needed because entrance into skin and
vein are separate and tissue granulates into catheter
cuff, providing a barrier. Groshong catheters have
pressure‑sensitive valves to prevent blood reflux and do
not require a clamp.

Peripherally inserted central catheter (PICC)
● Description: 45 to 74 cm (18 to 29 in) with single or

multiple lumens
● Length of use: up to 12 months
● Insertion location: basilic or cephalic vein at least one

fingerbreadth below or above the antecubital fossa. The
catheter should be advanced until the tip is positioned
in the lower one‑third of the SVC.

● Indications: administration of blood, long‑term
administration of chemotherapeutic agents, antibiotics,
and total parenteral nutrition

● When possible, insert a PICC early in the
course of therapy before veins are exposed to
repeated venipunctures.

CONSIDERATIONS

PREPROCEDURE
● Ensure informed consent has been signed.
● Cleanse the site with chlorhexidine.
● Ensure sterility of equipment.
● Place a STOP sign on the door to the room to restrict

entry during the procedure.

POstPROCEDURE
● Confirm placement of the PICC with an x‑ray.
● Assess the site for redness, swelling, drainage,

tenderness, and condition of the dressing.
● Clean the insertion port with alcohol for 15 seconds and

allow it to dry completely prior to accessing it. Valve
disinfection caps which contain alcohol are available for
single use.

● Use transparent dressing to allow for visualization.
Follow facility protocol for dressing changes, usually
every 7 days and when indicated (wet, loose, soiled).

● Advise the client not to immerse the arm in water. To
shower, cover dressing site to avoid water exposure.

● Educate the client not to have venipuncture or blood
pressure taken in arm with PICC line.

● Follow the Infusion Nurses Society (INS) practice
recommendations for flushing.

◯ Use a 10 mL syringe for flushing the PICC line. Do not
apply force if resistance is met.

◯ Flush with 10 mL 0.9% sodium chloride before,
between, and after medications.

◯ Flush with 20 mL 0.9% sodium chloride after
drawing blood.

◯ Flush with 5 mL heparin (10 units/mL) when the
PICC is not actively in use. The frequency of the flush
depends on the type of PICC.

Implanted port
● Description: Port is comprised of a small reservoir

covered by a thick septum.
● Insertion location: Port is surgically implanted into

chest wall pocket. The catheter is inserted into the
subclavian vein with the tip in the SVC.

● Indications: Long‑term (1 year or more) need for
vascular access; commonly used for chemotherapy.

● Only specifically trained personnel wearing a mask and
aseptic technique should access implanted ports.

◯ Apply topical anesthetic cream to skin if indicated.
Palpate skin to locate the port body septum to ensure
proper insertion of the needle.

◯ Access with a noncoring (Huber) needle.
◯ Check for blood return prior to medication
administration to confirm patency and placement.

◯ Flush with 5 mL heparin 100 units/mL after every use
and at least once per month (INS recommendation).

COMPLICATIONS

Phlebitis

Phlebitis is a common complication of PICCs and can be
chemical (osmolarity or pH is different, veins too small
for substance), bacterial, or mechanical irritation (excess
IV manipulation).

NURSING ACTIONS
● Monitor for findings.

◯ Erythema at the site (usual initial indication)
◯ Pain or burning at the site and the length of the vein
◯ Discomfort when the skin over the tip is palpated
◯ Warmth over the site
◯ Edema at the site
◯ Vein indurated (hard), red streak, and/or cordlike
◯ Slowing infusion rate
◯ Temperature elevation of 1° F or more
◯ Infection appearing 7 to 10 days after insertion

176 CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs CONTENT MASTERY SERIES

● Take preventive measures.
◯ Practice hand hygiene before working with a CVC.
◯ Observe the site every 2 hr for infection or infiltration.
◯ Nontunneled catheters require an intact sterile
dressing (tunneled catheters do not).

◯ Clean the site with chlorhexidine for 30 seconds and
allow to air dry prior to insertion.

Occlusion

Occlusion is a blockage in the central IV catheter that
impedes flow. Thrombosis/emboli can coagulate and cause
an occlusion.

NURSING ACTIONS
● Flush the line according to INS recommendations or

facility policy.
● Do not force fluid if resistance is encountered (can

dislodge thrombosis).
● Use a 10 mL to avoid excess pressure per square inch

that could cause catheter fracture/rupture.

Mechanical complications

Implanted ports can have the catheter tip and port
become dislodged.

NURSING ACTIONS
● Use only a noncoring (Huber) needle to avoid damaging

the mesh on implanted ports.

CLIENT EDUCATION
● Manifestations of a dislodged port include swelling at

the port site, unrestricted movement of the port, and
inability to access the port. Report findings to the
provider immediately.

● Manifestations of a dislodged catheter tip include
gurgling or swishing sounds, and pain on the affected
side in the neck or ear. Report findings to the provider
immediately.

Application Exercises

1. A nurse is orienting a newly licensed nurse on the care
of a client who is to have a line placed for hemodynamic
monitoring. Which of the following statements by
the newly licensed nurse indicates understanding?

A. “Air should be instilled into the monitoring
system prior to the procedure.”

B. “the client should be positioned on the
left side during the procedure.”

C. “the transducer should be level with the second
intercostal space after the line is placed.”

D. “A chest x‑ray is needed to verify
placement after the procedure.”

2. A nurse is assessing a client who is undergoing
hemodynamic monitoring. the client has a CvP of 7 mm
hg and a PAWP of 17 mm hg. Which of the following
findings should the nurse expect? (select all that apply.)

A. Poor skin turgor
B. Bilateral crackles in the lungs
C. Jugular vein distension
D. Dry mucous membranes
E. hepatomegaly

3. A nurse is teaching a client who is scheduled for
coronary angiography. Which of the following
statements should the nurse include?

A. “You should have nothing to eat or drink
for 4 hours prior to the procedure.”

B. “You will be given general anesthesia
during the procedure.”

C. “You should not have this procedure
done if you are allergic to eggs.”

D. “You will need to keep your affected leg
straight following the procedure.”

4. A nurse at a provider’s office is reviewing the laboratory
test results for a group of clients. the nurse should
identify that which of the following results indicates the
client is at risk for heart disease? (select all that apply.)

A. Cholesterol (total) 245 mg/dL
B. hDL 90 mg/dL
C. LDL 140 mg/dL
D. triglycerides 125 mg/dL
E. troponin I 0.02 ng/mL

5. A nurse is planning care for a client who has a PICC line
in the right arm. Which of the following interventions
should the nurse include? (select all that apply.)

A. Use a 10 mL syringe to flush the PICC line.
B. Apply gentle force if resistance

is met during injection.
C. Cleanse ports with alcohol for

15 seconds prior to use.
D. maintain a transparent dressing

over the insertion site.
E. Flush with 10 mL heparin before and

after medication administration.

Active Learning Scenario

A nurse is reviewing the plan of care for a client
who is scheduled for a cardiac exercise stress test.
What information should the nurse include in the
review? Use the AtI Active Learning template:
Diagnostic Procedure to complete this item.

DESCRIPTION OF THE PROCEDURE

INDICATIONS: List at least two.

NURSING INTERVENTIONS (PRE, INTRA, POST)
● Describe at least four preprocedure actions.
● Describe at least two intraprocedure actions.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs 177

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

DESCRIPTION OF THE PROCEDURE: During a cardiac exercise
stress test, the cardiac muscle is exercised by walking on a treadmill.
this provides information regarding the workload of the heart.

INDICATIONS
● Angina
● heart failure
● myocardial infarction
● Dysrhythmia

NURSING ACTIONS (PRE, INTRA, POST)

Preprocedure
● Ensure that a signed informed consent form is obtained.
● Explain to the client that they will walk on a treadmill.
Comfortable athletic shoes and clothing are recommended.

● Explain that a pharmacological stress test can be prescribed if
the client cannot walk on the treadmill and complete the test. A
medication (dipyridamole, adenosine, dobutamine) is administered
to stress the heart instead of walking on the treadmill.

● Instruct the client to fast 2 to 4 hr before the
procedure or according to facility policy and to avoid
tobacco, alcohol, and caffeine before the test.

● Instruct the client to get adequate rest the night before the test.

Intraprocedure
● monitor heart rate and rhythm with a 12‑lead ECG during the test.
● Instruct the client to report any chest pain, shortness
of breath, or dizziness during the test.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Application Exercises Key

1. A. Purge air from, rather than instill air into,
the monitoring system.

B. Place the client in the supine or trendelenburg position.
C. For hemodynamic monitoring, place the

transducer level with the 4th intercostal space,
which is at the base of the right atrium.

D. CORRECT: Ensure that a chest x‑ray is obtained to confirm
proper placement of the lines following placement.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

2. A. the client’s CvP and PAWP are above the expected
reference range. Expect the client to have poor skin
turgor for a decreased CvP and PAWP.

B. CORRECT: Expect the client to have bilateral crackles
in the lungs for an increased CvP and PAWP.

C. CORRECT: Expect the client to have jugular vein
distension for an increased CvP and PAWP.

D. Expect the client to have dry mucous membranes
for a decreased CvP and PAWP.

E. CORRECT: Expect the client to have hepatomegaly
for an increased CvP and PAWP.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

3. A. Instruct the client to remain NPO for at least 8 hr prior
to the procedure to decrease the risk for aspiration
while lying flat during the angiography.

B. Instruct the client that they are awake and sedated
during the procedure and that a local anesthetic
is used at the catheter insertion site.

C. Assess the client for an allergy to iodine/shellfish
due to the use of contrast dye. An allergy to eggs
is not a contraindication to angiography.

D. CORRECT: Instruct the client of the need to remain
on bed rest in the supine position with the affected
leg straight for a prescribed amount of time. this
positioning decreases the client’s risk for bleeding and
hematoma formation at the catheter insertion site.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. A. CORRECT: A client who has a total cholesterol level greater
than 200 mg/dL is at increased risk for heart disease.

B. An hDL level greater than 55 mg/dL for a female
client or greater than 45 mg/dL for a male client
decreases the client’s risk for heart disease.

C. CORRECT: A client who has an LDL level greater than
130 mg/dL is at increased risk for heart disease.

D. A triglyceride level between 35 and 135 mg/dL for a
female client or 40 and 160 mg/dL for a male client
is within the expected reference range and does not
indicate an increased risk for heart disease.

E. troponin I level is monitored to detect cardiac injury
due to an mI rather than to identify a client’s risk for
heart disease. A troponin I level less than 0.03 ng/
mL is within the expected reference range.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

5. A. CORRECT: Use a 10 mL syringe to flush the
PICC line to avoid excess pressure that could
cause catheter fracture/rupture.

B. Avoid the application of force if resistance
is met during injection.

C. CORRECT: Cleanse insertion ports with alcohol for 15
seconds and allow it to air dry prior to use. this action
decreases the risk for bacterial contamination.

D. CORRECT: maintain a transparent dressing over the
insertion site to decrease the risk for infection and
allow for visualization. Plan to change the dressing at
least every 7 days and when wet, loose, or soiled.

E. Flush the PICC line with 10 mL 0.9% sodium chloride
before, between, and after medications. A flush
of 5 mL heparin (10 units/mL) is recommended
when the PICC is not actively in use.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

178 CHAPTER 27 CARDIOvAsCULAR DIAGNOstIC AND thERAPEUtIC PROCEDUREs CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 28 ELECtROCARDIOGRAPhY AND DYsRhYthmIA mONItORING 179

UNIT 4 NURSING CARE OF CLIENTS WHO HAVE
CARDIOVASCULAR DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 28 Electrocardiography
and Dysrhythmia
Monitoring

Cardiac electrical activity can be monitored
by using an electrocardiogram (ECG). the
heart’s electrical activity can be monitored by a
standard 12‑lead ECG (resting ECG), ambulatory
ECG (holter monitoring), continuous cardiac
monitoring, or by telemetry.

Cardiac monitoring is used to diagnose
dysrhythmias, chamber enlargement, myocardial
ischemia, injury, or infarction and to monitor
the effects of electrolyte imbalances or
medication administration.

Cardiac dysrhythmias are heartbeat
disturbances (beat formation, beat conduction,
or myocardial response to beat).

Nurses should be familiar with cardioversion and
defibrillation procedures for treating
dysrhythmias. (28.1)

Electrocardiography
Electrocardiography uses an electrocardiograph to
record the electrical activity of the heart over time. The
electrocardiograph is connected by wires (leads) to skin
electrodes placed on the chest and limbs of a client.

● Continuous cardiac monitoring requires the client to be
in close proximity to the monitoring system.

● Telemetry allows the client to ambulate while
maintaining proximity to the monitoring system.

● Inform clients receiving continuous ECG monitoring
that the monitoring will not detect shortness of breath,
chest pain, or other manifestations of acute coronary
syndrome. The client should be instructed to report new
or worsening manifestations.

CHAPTER 28

Online Image: ECG Strip

28.1 ECG strip

180 CHAPTER 28 ELECtROCARDIOGRAPhY AND DYsRhYthmIA mONItORING CONTENT MASTERY SERIES

INDICATIONS
Dysrhythmias

● Sinus bradycardia and tachycardia
● Atrioventricular (AV) blocks
● Atrial fibrillation
● Ventricular asystole
● Premature atrial complexes (PACs) and premature

ventricular complexes (PVCs)
● Supraventricular tachycardia
● Ventricular tachycardia
● Ventricular fibrillation

CLIENt PREsENtAtION
● Cardiovascular disease
● Myocardial infarction (MI)
● Hypoxia
● Acid‑base imbalances
● Electrolyte disturbances
● Kidney failure, liver, or lung disease
● Pericarditis
● Drug or alcohol use
● Hypovolemia
● Shock

CONSIDERATIONS

PREPROCEDURE
NURSING ACTIONS
Prepare the client for a 12‑lead ECG, if prescribed. (28.2)

● Position the client in a supine position with
chest exposed.

● Wash the client’s skin to remove oils.
● If the area on which the electrode is to be placed has

hair on it, clip — do not shave — the area to provide
skin adherence and electrical conduction.

● Attach one electrode to each of the client’s extremities by
applying electrodes to flat surfaces above the wrists and
ankles and the other six electrodes to the chest, avoiding
chest hair. (Chest hair can be clipped if needed.)

INtRAPROCEDURE
NURSING ACTIONS: Monitor for manifestations of
dysrhythmia (chest pain, decreased level of consciousness,
shortness of breath) and hypoxia.

CLIENT EDUCATION: Remain still and breathe normally
while the 12‑lead ECG is performed.

POstPROCEDURE
NURSING ACTIONS

● Remove leads from the client, print the ECG report, and
notify the provider.

● Apply a Holter monitor if the client is on a telemetry
unit and/or needs continuous cardiac monitoring.

● Continue to monitor the client for dysrhythmia.

● To conduct a rhythm analysis, perform the following steps.
◯ Determine the heart rate.
◯ Determine whether the heart rhythm is regular
or irregular.

◯ Analyze the P waves for regularity and shape.
◯ Measure the PR interval for consistency (0.12 to
0.20 seconds).

◯ Measure the QRS duration and for consistency
in appearance.

◯ Examine the ST segment. Depression or elevation
is unexpected.

◯ Assess the T wave.
◯ Measure the QT interval.

Dysrhythmias
● Dysrhythmias are classified by the following:

◯ Site of origin: sinoatrial (SA) node, atria,
atrioventricular (AV) node, or ventricle

■ Electrophysiological study is performed to
determine the area of the heart causing the
dysrhythmia. Ablation of the area is possible.

◯ Effect on the rate and rhythm of the heart:
bradycardia, tachycardia, heart block, premature beat,
flutter, fibrillation, or asystole

● Dysrhythmias can be benign or life‑threatening.
● The life‑threatening effects of dysrhythmias are

generally related to decreased cardiac output and
ineffective tissue perfusion.

● Cardiac dysrhythmias are a primary cause of death
in clients suffering acute MI and other sudden death
disorders.

● Rapid recognition and treatment of serious dysrhythmias is
essential to preserve life. Treatment is based on the cardiac
rhythm, which can require cardioversion, defibrillation or
pacemaker insertion, and/or medications. (28.4)

● Findings of a dysrhythmia in older adults might be
present only with increased activity.

Online Images: Atrial Fibrillation, Premature Atrial Complexes
(PACs), Premature Ventricular Complexes
(PVCs), Ventricular TachycardiaOnline Image: ECG Lead Placement

28.2 ECG lead placement

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 28 ELECtROCARDIOGRAPhY AND DYsRhYthmIA mONItORING 181

● Risks for heart disease, hypertension,
dysrhythmias, and atherosclerosis
increase with age.

● Treatment of dysrhythmias follows
Advanced Cardiac Life Support (ACLS)
evidence‑based protocols. See CHAPTER

2: EMERGENCY NURSING PRINCIPLES AND

MANAGEMENT for further
information.

Cardioversion and
defibrillation

Cardioversion is the delivery of a direct
countershock to the heart synchronized
to the QRS complex. Defibrillation is the
delivery of an unsynchronized, direct
countershock to the heart. Defibrillation
stops all electrical activity of the heart,
allowing the SA node to take over and
reestablish a perfusing rhythm.

INDICATIONS
Cardioversion: Elective treatment of
atrial dysrhythmias, supraventricular
tachycardia, and ventricular tachycardia
with a pulse. Cardioversion is the
treatment of choice for clients who are
symptomatic.

Defibrillation: Ventricular fibrillation or
pulseless ventricular tachycardia.

CONSIDERATIONS

PREPROCEDURE
Clients who have atrial fibrillation
of unknown duration must receive
adequate anticoagulation for 4 to 6
weeks prior to cardioversion therapy to
prevent dislodgement of thrombi into the
bloodstream.

NURSING ACTIONS
● Explain the procedure to the client, and
obtain consent.

● Administer oxygen.
● Document preprocedure rhythm.
● Have emergency equipment available.
● Digoxin is held for 48 hr prior to
elective cardioversion.

INDICATIONS
Dysrhythmias

● Sinus bradycardia and tachycardia
● Atrioventricular (AV) blocks
● Atrial fibrillation
● Ventricular asystole
● Premature atrial complexes (PACs) and premature

ventricular complexes (PVCs)
● Supraventricular tachycardia
● Ventricular tachycardia
● Ventricular fibrillation

CLIENt PREsENtAtION
● Cardiovascular disease
● Myocardial infarction (MI)
● Hypoxia
● Acid‑base imbalances
● Electrolyte disturbances
● Kidney failure, liver, or lung disease
● Pericarditis
● Drug or alcohol use
● Hypovolemia
● Shock

CONSIDERATIONS

PREPROCEDURE
NURSING ACTIONS
Prepare the client for a 12‑lead ECG, if prescribed. (28.2)

● Position the client in a supine position with
chest exposed.

● Wash the client’s skin to remove oils.
● If the area on which the electrode is to be placed has

hair on it, clip — do not shave — the area to provide
skin adherence and electrical conduction.

● Attach one electrode to each of the client’s extremities by
applying electrodes to flat surfaces above the wrists and
ankles and the other six electrodes to the chest, avoiding
chest hair. (Chest hair can be clipped if needed.)

INtRAPROCEDURE
NURSING ACTIONS: Monitor for manifestations of
dysrhythmia (chest pain, decreased level of consciousness,
shortness of breath) and hypoxia.

CLIENT EDUCATION: Remain still and breathe normally
while the 12‑lead ECG is performed.

POstPROCEDURE
NURSING ACTIONS

● Remove leads from the client, print the ECG report, and
notify the provider.

● Apply a Holter monitor if the client is on a telemetry
unit and/or needs continuous cardiac monitoring.

● Continue to monitor the client for dysrhythmia.

Online Images: Atrial Fibrillation, Premature Atrial Complexes
(PACs), Premature Ventricular Complexes
(PVCs), Ventricular TachycardiaOnline Image: ECG Lead Placement

28.3 Dysrhythmias

ATRIAL FIBRILLATION

PREMATURE ATRIAL COMPLEXES

PREMATURE VENTRICULAR COMPLEXES

VENTRICULAR TACHYCARDIA

28.4 Dysrhythmia treatments

MEDICATION
ELECTRICAL
MANAGEMENT

Bradycardia
(any rhythm less than 60/min)

treat if the client is symptomatic

Atropine;
dopamine or
epinephrine
infusion if
unresponsive
to atropine

Pacemaker

Atrial fibrillation
Supraventricular tachycardia

Ventricular tachycardia with pulse

Amiodarone,
adenosine,
and verapamil

synchronized
cardioversion

Ventricular tachycardia without
pulse or ventricular fibrillation

Amiodarone,
lidocaine, and
epinephrine

Defibrillation

182 CHAPTER 28 ELECtROCARDIOGRAPhY AND DYsRhYthmIA mONItORING CONTENT MASTERY SERIES

INtRAPROCEDURE
NURSING ACTIONS

● Administer sedation as prescribed.
● Ensure proper placement of leads and machine settings,

including joules to be delivered.
● Monitor the client in a lead that provides an upright

QRS complex.
● All staff must stand clear of the client, equipment

connected to the client, and the bed when a shock
is delivered.

● Cardioversion requires activation of the synchronizer
button in addition to charging the machine. This allows
the shock to be in sync with the client’s underlying
rhythm. Failure to synchronize can lead to development
of a lethal dysrhythmia, such as ventricular fibrillation.

● Perform CPR for cardiac asystole or other
pulseless rhythms.

● Defibrillate the client immediately for
ventricular fibrillation.

● Administer a prescribed antidysrhythmic agent or other
prescribed medications.

● Monitor the client for pulmonary or systemic emboli
following cardioversion.

POstPROCEDURE
NURSING ACTIONS

● After cardioversion or defibrillation, monitor vital signs,
assess airway patency, and obtain an ECG.

● Provide the client/family with reassurance and
emotional support.

● Document the following:
◯ Postprocedure rhythm
◯ Number of defibrillation or cardioversion attempts,
energy settings, time, and response

◯ The client’s condition and state of consciousness
following the procedure

◯ Skin condition under the electrodes

CLIENT EDUCATION
● Follow instructions on checking your pulse.
● Report palpitations or irregularities.

COMPLICATIONS

Embolism

Cardioversion can dislodge blood clots, potentially causing:
● A pulmonary embolism (evidenced by dyspnea, chest

pain, air hunger, and decreasing SaO2).

● A cerebrovascular accident (evidenced by decreased level
of consciousness, slurred speech, and muscle weakness/
paralysis)

● An MI (evidenced by chest pain and ST segment
depression or elevation)

NURSING ACTIONS: Provide therapeutic anticoagulation
for clients who have dysrhythmias.

Decreased cardiac output and heart failure

Cardioversion might damage heart tissue and impair
heart function.

NURSING ACTIONS
● Monitor for manifestations of decreased cardiac

output (hypotension, syncope, increased heart rate)
and heart failure (dyspnea, productive cough, edema,
venous distention).

● Provide medications to increase output (inotropic
agents) and to decrease cardiac workload.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 28 ELECtROCARDIOGRAPhY AND DYsRhYthmIA mONItORING 183

Active Learning Scenario

A nurse educator is reviewing electrocardiography with
a group of nurses. What information should be included
in this discussion? Use the AtI Active Learning template:
therapeutic Procedure to complete this item.

DESCRIPTION OF PROCEDURE: Describe
electrocardiography and describe the difference between
continuous cardiac monitoring and telemetry.

INDICATIONS: List four dysrhythmias that can be identified.

NURSING INTERVENTIONS (PRE, INTRA,
POST): Identify at least two preprocedure, one
intraprocedure, and two postprocedure.

Application Exercises

1. A nurse on a cardiac unit is caring for a group of
clients. the nurse should recognize which of the
following clients as being at risk for the development
of a dysrhythmia? (select all that apply.)

A. A client who has metabolic alkalosis

B. A client who has a blood potassium
level of 4.3 mEq/L

C. A client who has an saO2 of 96%

D. A client who has COPD

E. A client who underwent stent
placement in a coronary artery

2. A nurse is reviewing the medical record of a
client who is to undergo a scheduled electrical
cardioversion. For which of the following findings
should the nurse notify the provider? (Review the
data below for additional client information.)

MAR

Ferrous sulfate 200 mg PO 0800 and 2000

Diazepam 2 mg PO 0800 and 2000

Isosorbide 2.5 mg PO 4 times a day AC and hs

VITAL SIGNS

0800

t 99° F (37.2° C)

Blood pressure 142/86 mm hg

heart rate 88/min and irregular

Respirations 20/min

HISTORY AND PHYSICAL

Bariatric surgery 10 years ago

Dyspnea with exertion for 3 years

Atrial fibrillation began 3 years ago

Client reports taking the following medications
for the past 6 weeks: iron supplement,
multivitamin, antilipemic, and nitroglycerin

A. Respiratory history

B. vital signs

C. medication history

D. medications to be administered

3. A nurse is caring for a client who experienced
defibrillation. Which of the following should
be included in the documentation of this
procedure? (select all that apply.)

A. Follow‑up ECG

B. Energy settings used

C. Iv fluid intake

D. Urinary output

E. skin condition under electrodes

4. A nurse on a cardiac unit is caring for a client who is on
telemetry. the nurse recognizes the client’s heart rate is
46/min and notifies the provider. Which of the following
prescriptions might be appropriate for this client?

A. Defibrillation

B. Pacemaker insertion

C. synchronized cardioversion

D. Administration of Iv lidocaine

5. A newly licensed nurse is observing a cardioversion
procedure and hears the team leader call out,
“stand clear.” this statement indicates which
of the following events is occurring?

A. the cardioverter is being charged
to the appropriate setting.

B. the team should initiate CPR due to
pulseless electrical activity.

C. team members cannot be in contact with
equipment connected to the client.

D. A time‑out is being called to
verify correct protocols.

184 CHAPTER 28 ELECtROCARDIOGRAPhY AND DYsRhYthmIA mONItORING CONTENT MASTERY SERIES

Application Exercises Key

1. A. CORRECT: A client who has an acid‑base imbalance such
as metabolic alkalosis is at risk for a dysrhythmia.

B. A blood potassium of 4.3 mEq/L is within
the expected reference range and does not
increase the risk of a dysrhythmia.

C. saO2 of 96% is within the expected reference range
and does not increase the risk of a dysrhythmia.

D. CORRECT: A client who has lung disease, such
as COPD, is at risk for a dysrhythmia.

E. CORRECT: A client who has cardiac disease and underwent
a stent placement is at risk for a dysrhythmia.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. A. Client who have a dysrhythmia often have a
history of lung disease, which can make them
candidates for cardioversion.

B. Client who have a dysrhythmia might have an irregular pulse,
which can make them candidates for cardioversion.

C. CORRECT: Because the client has a history of atrial
fibrillation, it is recommended the client take anticoagulant
therapy for 4 to 6 weeks prior to cardioversion to
prevent clot dislodgement. the nurse should contact
the provider regarding this safety concern.

D. Client who have a dysrhythmia often have a
history of cardiac disease and angina, which can
make them candidates for cardioversion.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

3. A. CORRECT: the client’s ECG rhythm is
documented following the procedure.

B. CORRECT: Energy settings used during
the procedure are documented.

C. Iv fluid intake is not documented during defibrillation.
D. Urinary output is not documented during defibrillation.
E. CORRECT: the condition of the client’s skin where

electrodes were placed is documented.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. A. Defibrillation is used when a client has ventricular
fibrillation or pulseless ventricular tachycardia.

B. CORRECT: A client who has bradycardia is a candidate
for a pacemaker to increase his heart rate.

C. synchronized cardioversion is used when a client has a
dysrhythmia such as atrial fibrillation, supraventricular
tachycardia (svt), or ventricular tachycardia with pulse.

D. the administration of Iv lidocaine is used in clients
who have a pulseless ventricular dysrhythmia
to stimulate cardiac electrical function.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

5. A. the cardioverter is charged prior to the delivery
of the shock during cardioversion.

B. the team leader calls out “Initiate CPR” when
members of the team are to begin CPR.

C. CORRECT: A safety concern for personnel performing
cardioversion is to “stand clear” of the client and
equipment connected to the client when a shock is
delivered to prevent them from also receiving a shock.

D. A “time‑out” is called by personnel during a procedure
to verify that proper protocols are being followed.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

DESCRIPTION OF PROCEDURE
● Electrocardiography is the use of an electrocardiograph to record
the electrical activity of the heart over time by connecting wires
(leads) to skin electrodes placed on the chest and limbs of the client.

● Continuous monitoring requires the client to be in close proximity
to the monitoring system. telemetry allows the client to ambulate.

INDICATIONS
● sinus bradycardia and tachycardia
● Atrioventricular (Av) blocks
● Atrial fibrillation
● supraventricular tachycardia
● ventricular fibrillation
● ventricular asystole
● Premature ventricular complexes (PvCs)
● Premature atrial complexes (PACs)

NURSING INTERVENTIONS (PRE, INTRA, POST)

Preprocedure
● Position the client in a supine position with chest exposed.
● Wash the skin to remove oils.
● Attach one electrode to each of the client’s extremities by
applying electrodes to flat surfaces above the wrists and
ankles and the other six electrodes to the chest, avoiding
chest hair, which can be clipped on male clients.

Intraprocedure
● Instruct the client to remain still and breathe normally.
● monitor for manifestations of dysrhythmia (chest pain, decreased
level of consciousness, shortness of breath) and hypoxia.

Postprocedure
● Remove leads, print ECG report, and notify the provider.
● Apply holter monitor if the client is on the telemetry
unit and/or needs continuous monitoring.

● Continue monitoring for manifestations of dysrhythmia and hypoxia.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 29 PACEmAKERs AND ImPLANtABLE CARDIOvERtER/DEFIBRILLAtORs 185

UNIT 4 NURSING CARE OF CLIENTS WHO HAVE
CARDIOVASCULAR DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 29 Pacemakers
and Implantable
Cardioverter/
Defibrillators

An artificial pacemaker is a battery‑operated
device that electrically stimulates the heart when
the natural pacemaker of the heart fails to
maintain an acceptable rhythm.

Pacemakers can be temporary or permanent
and are composed of two parts. the pulse
generator houses the energy source (battery)
and the control center. the electrodes are wires
that attach to the myocardial muscle on one side
and connect to the pulse generator on the other.

Nurses should be familiar with the various types
of pacemakers, how they function, and the care
involved with their placement/insertion.

Conduction of electrical impulses through the
sinoatrial (sA) node can be slowed with aging,
causing bradycardia and conduction defects.

When a pacing stimulus is delivered to the
heart, a pacer spike (or pacemaker artifact) will
be seen on a cardiac monitor or ECG strip. the
pacer spike, a vertical line, should be followed
by a P wave (atrial pacing) or QRs complex
(ventricular pacing).

An implantable cardioverter/defibrillator (ICD)
monitors for life‑threatening changes in cardiac
rhythm and automatically delivers an electrical
shock directly to the heart in an attempt
to restore a normal rhythm. An ICD can be
programmed to deliver a shock and has pacing
capabilities.

Types of pacemakers
tEmPORARY PACEmAKERs
The energy source is provided by an external battery pack.

External (transcutaneous)
● Pacing energy is delivered transcutaneously through

the thoracic musculature to the heart via two electrode
patches placed on the skin.

● It requires large amounts of electricity, which can be
painful for a client.

● Transcutaneous pacing is used when a symptomatic
bradycardia is unresponsive to atropine or other
medications used to increase heart rate.

Epicardial
● Pacemaker leads are attached directly to the heart

during open‑heart surgery. Wires run externally
through the chest incision and can be attached to an
external impulse generator if needed.

● It is commonly used during and immediately following
open‑heart surgery.

Endocardial (transvenous)

Pacing wires are threaded through a large central vein
(subclavian, jugular, or cephalic) and lodged into the wall
of the right ventricle (ventricular pacing), right atrium
(atrial pacing), or both chambers (dual chamber pacing).

CHAPTER 29

Online Image: Pacemaker

29.1 Pacemaker/implantable
cardioverter/defibrillator

186 CHAPTER 29 PACEmAKERs AND ImPLANtABLE CARDIOvERtER/DEFIBRILLAtORs CONTENT MASTERY SERIES

PERmANENt PACEmAKERs
● Contain an internal pacing unit
● Indicated for chronic or recurrent dysrhythmias due to

sinus or atrioventricular (AV) node malfunction
● Can be programmed to pace the atrial (A) or

ventricular (V) chamber, or both (AV)

PACEMAKER MODES
● Fixed rate (asynchronous): Fires at a constant rate

without regard for the heart’s electrical activity.
● Demand mode (synchronous): Detects the heart’s

electrical impulses and fires at a preset rate only if the
heart’s intrinsic rate is below a certain level. Pacemaker
response modes include the following:

◯ Inhibited: Pacemaker activity is inhibited/
does not fire.

◯ Triggered: Pacemaker activity is triggered/fires when
intrinsic activity is sensed.

● Tachydysrhythmia function: Can overpace a
tachydysrhythmia and/or deliver an electrical shock.

29.2 Five‑letter system to identify
pacemaker function

CHAMBER PACED CHAMBER SENSED RESPONSE MODE
O: None
A: Atria
v: ventricle
D: Dual (Av)

O: None
A: Atria
v: ventricle
D: Dual (Av)

O: None
t: triggered
I: Inhibited
D: Dual (Av)

PROGRAMMABLE
FUNCTIONS

TACHYDYSRHYTHMIC
FUNCTIONS

O: None
R: Rate modulation

O: None
P: Pacing (anti‑tachydysrhythmia)
s: shock
D: Dual (P + s)

Often, the first three letters are used to describe the
pacemaker function:

Example: vvI mode

Function: ventricular paced, ventricular
sensed, inhibited. If no QRs detected
within desired time, pacemaker fires. If QRs
detected, pacemaker does not fire.

Implantable cardioverter/
defibrillators

● Contains an internal generator
● Indicated for survivors of sudden cardiac death

syndrome, risk for sudden cardiac death, and
spontaneous or symptomatic ventricular dysrhythmias.

Pacemaker/ICD placement
INDICATIONS

POtENtIAL DIAGNOsEs
Pacemaker

● Symptomatic bradycardia
● Complete heart block
● Sick sinus syndrome
● Sinus arrest
● Asystole
● Atrial tachydysrhythmias

ICD
● Ventricular tachydysrhythmias
● MI with left ventricular dysfunction

CLIENt PREsENtAtION
SUBJECTIVE DATA

● Dizziness
● Palpitations (racing heart)
● Chest pain or pressure
● Anxiety
● Fatigue
● Nausea
● Breathing difficulties

OBJECTIVE DATA
● Bradycardia or tachycardia
● Abnormal ECG
● Dyspnea, tachypnea
● Restlessness
● Jugular venous distention
● Vomiting
● Hypotension
● Diaphoresis
● Decreased cardiac output

CONSIDERATIONS

PREPROCEDURE
NURSING ACTIONS

● Assess the client’s knowledge of the procedure and need
for pacemaker/ICD (if nonemergent situation).

● Obtain signed informed consent form from the client.
● Prepare skin (clean with soap and water; trim excess

hair). Do not shave, rub, or apply alcohol to the skin.

CLIENT EDUCATION
● Understand the type of pacemaker or ICD that is to be

inserted and information about the procedure.

Temporary pacemaker
● Wires and a pacemaker box will be on the client’s chest

after the procedure.
● Dot not to touch the dials on the pacemaker box.
● The wires and box need to be kept dry. Do not shower.
● If transcutaneous pacing is required, large ECG pacing

pads will be placed on the chest and back. Alert clients
should receive sedation and analgesia when being
paced transcutaneously.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 29 PACEmAKERs AND ImPLANtABLE CARDIOvERtER/DEFIBRILLAtORs 187

Permanent pacemaker/ICD
● A small incision is made in the pectoral region using a

local anesthetic and IV sedation.
● The device can be reprogrammed externally after

the procedure.
● The pacemaker battery will last about 10 years. The

pacemaker pulse generator must be replaced when
this occurs.

● The lithium ICD battery can last for about 9 years and
requires replacement of the generator.

POstPROCEDURE
NURSING ACTIONS

● Document the time and date of insertion, model,
settings, rhythm strip, presence of adequate pulse and
blood pressure, and client response.

● Continually monitor heart rate and rhythm. Compare
ECG rhythm to prescribed pacemaker settings. Notify
provider of any discrepancies.

● Obtain chest x‑ray to assess lead placement and for
pneumothorax, hemothorax, or pleural effusion.

● Provide analgesia as prescribed.
● Minimize shoulder movement initially to allow leads to

anchor, and provide a sling (if prescribed).
● Monitor the incision site for bleeding, hematoma

formation, or infection.
● Following pacemaker insertion, assess for hiccups, which

can indicate that the generator is pacing the diaphragm.
● Following transcutaneous pacing, inspect the skin under

the electrodes for thermal burns. Clients who are older,
dehydrated, or have had external pacing for an extended
period of time are most at risk for thermal burns.

● For a permanent pacemaker/ICD: Provide the client with
an identification card including the manufacturer’s
name, model number, mode of function, rate
parameters, and expected battery life.

CLIENT EDUCATION
● Temporary pacemakers are used only in a controlled

facility with telemetry for continuous ECG monitoring.
If needed, a permanent pacemaker is inserted before
discharge to home.

● Permanent pacemaker/ICD discharge teaching
◯ Carry a device identification card at all times.
◯ Prevent wire dislodgement. (Wear sling when out of

bed. Do not raise arm above shoulder for 1 to 2 weeks.)
◯ Take pulse daily at the same time for those with

pacemakers or combination devices. Notify the
provider if heart rate is less than the pacemaker rate.

◯ Report dizziness, fainting, fatigue, weakness, chest
pain, hiccuping, palpitations, difficulty breathing, or
weight gain.

◯ If the ICD device delivers a shock, anyone touching
the client will feel a slight electrical impulse, but the
impulse is not harmful.

◯ Follow activity restrictions as prescribed, including no
contact sports or heavy lifting for 2 months.

◯ Loss of consciousness can occur prior to ICD
shock delivery.

◯ An ICD shock can feel like a blow to the chest.
◯ Avoid direct blows or injury to the generator site.

◯ Resume sexual activity as desired, avoiding positions
that put stress on the incision site.

◯ Never place items that generate a magnetic field directly
over the pacemaker generator. These items can affect
function and settings. This includes garage door
openers, burglar alarms, strong magnets, generators
and other power transmitters, and large stereo speakers.
The use of household items is not prohibited.

◯ Inform providers and dentists about the pacemaker/
ICD. Some tests, such as magnetic resonance imaging
and therapeutic diathermy (heat therapy), can
be contraindicated.

◯ Inform airport security personnel about the presence
of a pacemaker/ICD, because it will set off airport
security detectors. The airport security device should
not affect pacemaker functioning. Airport security
personnel should not place wand detection devices
directly over the pacemaker or ICD.

COMPLICATIONS

Infection or hematoma at insertion site

NURSING ACTIONS
● Assess the incision site for redness, pain, drainage,

or swelling.
● Administer antibiotics as prescribed.
● Monitor PT, PTT, and CBC.

Pneumothorax or hemothorax

NURSING ACTIONS
● Assess breath sounds and chest movement.
● Monitor oxygen saturation.
● Obtain a chest x‑ray after the procedure.

PACEmAKER
● Complications relate to improper sensing or pacing

electrical charge being outside the heart. Causes include
insufficient pacemaker settings, lead wire placement
and function, battery function, myocardial damage, and
electrolyte imbalance.

● Complications often are detectable by ECG.
◯ Monitor ECG to ensure heart rate is within programmed

parameters. Pacer spikes should be adequate in number
and occur directly before P or QRS complexes.

◯ Pacer spikes that occur on the T wave can cause
life‑threatening arrhythmias.

● Treatment of complications is related to identifying
the cause.

● Pacemaker settings should be manipulated only
as prescribed.

Arrhythmias

Related to ventricular irritation from pacemaker electrode

NURSING ACTIONS
● Monitor ECG and blood pressure.
● Administer antiarrhythmics as prescribed.
● Have emergency resuscitation equipment and

medications readily available.

188 CHAPTER 29 PACEmAKERs AND ImPLANtABLE CARDIOvERtER/DEFIBRILLAtORs CONTENT MASTERY SERIES

ICD
● Complications include delivery of inappropriate shocks.

This can be identified through device interrogation and
requires reprogramming of the device.

● The primary complication is risk of infection from the
surgical procedure. This risk is increased during battery
or lead replacement procedures.

Active Learning Scenario

A coronary care nurse is orienting a newly hired nurse
and discussing care of a client who has complications
related to pacemaker insertion. What should be included
in the discussion? Use the AtI Active Learning template:
therapeutic Procedure to complete this item.

POTENTIAL COMPLICATIONS: Describe two. Describe
at least two nursing actions for each complication.

Application Exercises

1. A nurse is admitting a client who has complete heart
block as demonstrated by ECG. the client’s heart rate is
34/min and blood pressure is 83/48 mm hg. the client
is lethargic and unable to complete sentences. Which
of the following actions should the nurse perform first?

A. transport the client to the
cardiovascular laboratory.

B. Prepare the client for insertion of
a permanent pacemaker.

C. Obtain a signed informed consent
form for a pacemaker.

D. Apply transcutaneous pacemaker pads.

2. A nurse is caring for a client following the insertion
of a temporary venous pacemaker via the femoral
artery that is set as a vvI pacemaker rate of 70/min.
Which of the following findings should the nurse
report to the provider? (select all that apply.)

A. Cool and clammy foot with
capillary refill of 5 seconds

B. Observed pacing spike followed by a QRs complex

C. Persistent hiccups

D. heart rate 84/min

E. Blood pressure 104/62 mm hg

3. A nurse is completing discharge teaching
with a client who has a permanent pacemaker.
Which of the following statements by the client
indicates understanding of the teaching?

A. “I will notify the airport screeners
about my pacemaker.”

B. “I will expect to have occasional hiccups.”

C. “I will have to disconnect my garage door opener.”

D. “I will take my pulse every 2 to 3 days.”

4. A cardiac nurse educator is reviewing the use of the
fixed rate mode pacemaker with a group of newly hired
nurses. Which of the following statements by a newly
hired nurse indicates understanding of the review?

A. “this means the pacemaker fires in
an asynchronous pattern.”

B. “this means the pacemaker fires only when
the heart rate is below a certain rate.”

C. “the pacemaker can automatically adjust
to a client’s increased activity level.”

D. “the pacemaker activity is triggered
by heart muscle activity.”

5. A nurse is completing discharge teaching
with a client following placement of an ICD.
Which of the following information should
the nurse include? (select all that apply.)

A. Avoid large magnetic fields.

B. Caution family members that they can receive
harmful unexpected shocks from the ICD.

C. take body temperature at the same time each day.

D. Wear tight clothing to hold the device in place.

E. Perform arm stretching exercises to
strengthen muscles surrounding the ICD.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 29 PACEmAKERs AND ImPLANtABLE CARDIOvERtER/DEFIBRILLAtORs 189

Application Exercises Key

1. A. Plan to transport the client to the cardiovascular
laboratory for placement of a permanent pacemaker
to control the client’s heart; however, there is
another action the nurse should take first.

B. Plan to prepare the client for insertion of a permanent
pacemaker by cleansing the skin and clipping excess hair;
however, there is another action the nurse should take first.

C. Obtain informed consent for placement of a permanent
pacemaker if an individual with authority to make decisions
for the client is present; however, there is another action
the nurse should take first. Emergency procedures can be
performed without consent if the client is not coherent.

D. CORRECT: the greatest risk to this client is injury or death
from inadequate tissue perfusion; therefore, the first
action the nurse should take is to apply transcutaneous
pacemaker pads and begin external pacing of the heart
until a permanent pacemaker can be placed.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

2. A. CORRECT: A cool, clammy foot can be an indication
of a femoral hematoma secondary to insertion of
the lead wires and should be reported.

B. A pacing spike followed by a QRs complex
is an expected finding.

C. CORRECT: Persistent hiccups can indicate
lead wire perforation and stimulation of the
diaphragm and should be reported.

D. A heart rate of 84/min is an expected finding.
E. A blood pressure of 104/62 mm hg is an expected finding.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

3. A. CORRECT: the client should notify airport
screening personnel about a pacemaker.

B. the client should report hiccups to the provider because
they can indicate improper lead placement.

C. the use of household appliances, such as microwaves and
garage door openers, does not affect pacemaker function.

D. the client should check their pulse at the same
time every day to ensure the pacemaker is
maintaining the prescribed heart rate.

NCLEX® Connection: Physiological Adaptation,
Illness Management

4. A. CORRECT: Fixed rate mode is asynchronous,
meaning the pacemaker fires without regard
for electrical activity in the heart.

B. Demand mode detects an electrical impulse,
and the pacemaker will then fire only if this
impulse remains below a certain level.

C. Fixed rate pacemaker mode means the rate does
not change in relation to activity level.

D. Fixed rate mode means the pacemaker fires without
regard for electrical activity in the heart.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. A. CORRECT: Large magnetic fields can deactivate the device,
causing it to be ineffective for dysrhythmias.

B. Family members can feel the shock of an ICD if in contact
with the client, but the shock is not harmful.

C. CORRECT: the client should take their temperature at
the same time each day and report any increase to the
provider. this is done to monitor for infection.

D. the client should avoid wearing tight clothing, as
this can cause friction over the insertion site.

E. the client should restrict arm movement until
healing of the incision occurs. the client should
not raise arms above the head for 2 weeks.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using ATI Active Learning Template: Therapeutic Procedure

POTENTIAL COMPLICATIONS

Infection or hematoma
● Assess incision site for redness, pain, drainage, or swelling.
● Administer antibiotics as prescribed.
● monitor Pt, Ptt, and CBC.

Pneumothorax or hemothorax
● monitor breath sounds and chest movement.
● monitor oxygen saturation.
● Obtain a chest x‑ray following the procedure.

Arrhythmias
● monitor ECG and blood pressure.
● Administer antiarrhythmics as prescribed.
● have emergency resuscitation equipment
and medications readily available.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

190 CHAPTER 29 PACEmAKERs AND ImPLANtABLE CARDIOvERtER/DEFIBRILLAtORs CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 30 INvAsIvE CARDIOvAsCULAR PROCEDUREs 191

UNIT 4 CARDIOVASCULAR DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 30 Invasive
Cardiovascular
Procedures

Cardiovascular procedures include invasive
methods used to improve blood flow for
occluded arteries and veins.

Invasive cardiovascular procedures are indicated
after noninvasive interventions have been tried,
such as diet, exercise, and medications.

Invasive cardiovascular procedures that nurses
should be knowledgeable about include
percutaneous coronary intervention (PCI),
coronary artery bypass grafts (CABG), and
peripheral bypass grafts.

Percutaneous coronary
intervention

PCI is a nonsurgical procedure performed to open coronary
arteries through one of the following means:

● Atherectomy: Used to break up and remove plaques
within cardiac vessels.

● Stent: Placement of a mesh‑wire device that contains no
medication to hold an artery open and prevent restenosis.

● Percutaneous transluminal coronary angioplasty: Also
referred to simply as angioplasty, this involves inflating
a balloon to dilate the arterial lumen and the adhering
plaque, thus widening the arterial lumen. This can
include stent placement.

INDICATIONS
● Can be performed on an elective basis to treat coronary

artery disease when there is occlusion of one to two
coronary arteries. The area of occlusion is confined, not
scattered, and easy to access (proximal).

● Might reduce ischemia during the occurrence of an
acute myocardial infarction (MI) by opening coronary
arteries and restoring perfusion. It is usually performed
within 4 to 6 hr of the onset of manifestations if having
a non‑ST‑elevation (NSTEMI) or myocardial infarction
(MI), or within 60 to 90 min for a ST‑elevation
myocardial infarction (STEMI).

● Might be used as an alternative to coronary artery
bypass graft.

● Angioplasty might be used with stent placement to prevent
artery reocclusion and to dilate the coronary artery.

CLIENt PREsENtAtION
SUBJECTIVE DATA: Chest pain might occur with or without
exertion. Pain might radiate to the jaw, left arm, through
the back, or to the shoulder. Manifestations might increase
in cold weather or with exercise. Other manifestations
might include dyspnea, nausea, fatigue, and diaphoresis.

OBJECTIVE DATA: ECG changes might include ST elevation,
depression, or nonspecific ST changes. Other findings might
include bradycardia, tachycardia, hypotension, elevated
blood pressure, vomiting, and mental disorientation.

CONSIDERATIONS
Refer to CHAPTER 27 CARDIOVASCULAR DIAGNOSTIC AND

THERAPEUTIC PROCEDURES under angiography.

COMPLICATIONS

Artery dissection
● Perforation of an artery by the catheter might cause

cardiac tamponade or require emergency bypass surgery.
● Artery dissection findings include severe hypotension

and tachycardia, and might require extended occlusion
of perforation with a balloon catheter and reversal
of anticoagulants.

Cardiac tamponade

Cardiac tamponade can result from fluid accumulation in
the pericardial sac.

● Findings include hypotension, jugular venous distention,
muffled heart sounds, and paradoxical pulse (variance
of 10 mm Hg or more in systolic blood pressure between
expiration and inspiration).

● Hemodynamic monitoring reveals that intracardiac and
pulmonary artery pressures are similar and elevated
(plateau pressures) and that cardiac output is decreased.

NURSING ACTIONS
● Notify the provider immediately.
● Administer IV fluids to manage hypotension.
● Obtain a chest x‑ray or echocardiogram to

confirm findings.
● Prepare the client for pericardiocentesis or return to

surgical suite (informed consent, gather materials,
administer medications as appropriate).

◯ Monitor hemodynamic pressures and heart rhythm
for reoccurrence of findings after the procedure.

Hematoma formation near insertion site

NURSING ACTIONS
● Monitor for sensation, color, capillary refill, and peripheral

pulses in the extremity distal to the insertion site.
● Assess insertion site for development of a hematoma at

prescribed intervals and as needed.
● Hold pressure for uncontrolled oozing/bleeding.
● Notify the provider.

CHAPTER 30 Online Video: Stent Placement

192 CHAPTER 30 INvAsIvE CARDIOvAsCULAR PROCEDUREs CONTENT MASTERY SERIES

Allergic reaction related to the contrast dye

Manifestations can include chills, fever, rash, wheezing,
tachycardia, and bradycardia.

NURSING ACTIONS
● Monitor for an allergic reaction.
● Have resuscitation equipment readily available.
● Administer diphenhydramine or epinephrine

if prescribed.

External bleeding at the insertion site

NURSING ACTIONS
● Monitor insertion site for bleeding or swelling.
● Apply pressure to site.
● Keep client’s leg or arm straight.

Embolism

Plaque or a clot can become dislodged.

NURSING ACTIONS
● Monitor for chest pain during and after the procedure.
● Monitor vital signs and SaO2.

Retroperitoneal bleeding

Bleeding in the retroperitoneal space (abdominal cavity
behind the peritoneum) can occur due to femoral
artery puncture.

NURSING ACTIONS
● Assess for flank pain and hypotension.
● Notify the provider immediately.
● Administer IV fluids and blood products.

CLIENT EDUCATION
● Pressure will be applied to the insertion site.
● Keep leg straight.
● Report chest pain, shortness of breath, and

cardiac manifestations.

Restenosis of treated vessel

Clot formation can occur in the coronary vessel
immediately or several days after the procedure.

NURSING ACTIONS
● Assess ECG patterns and for report of chest pain.
● Notify the provider immediately.
● Prepare the client for return to the cardiac

catheterization laboratory.

CLIENT EDUCATION: Notify the provider of cardiac
manifestations.

Acute kidney injury

Damage to the kidney can result from use of contrast
agent, which is nephrotoxic.

NURSING ACTIONS
● Monitor urine output, BUN, creatinine, and electrolytes.
● Promote adequate hydration (oral and IV).

Coronary artery
bypass grafts

● CABG is an invasive surgical procedure that aims to
restore vascularization of the myocardium.

◯ Performed to bypass an obstruction in one or more
of the coronary arteries, CABG does not alter the
atherosclerotic process but improves the quality
of life for clients restricted by painful coronary
artery disease.

◯ The procedure is most effective when a client has
sufficient ventricular function (ejection fraction
greater than 50%).

◯ Older adult clients are more likely to experience
transient neurologic changes, toxic effects from
cardiac medications, and dysrhythmias.

● Less invasive revascularization procedures have been
developed to reduce risk and improve client outcomes
(off‑pump coronary artery bypass, robotic heart surgery,
minimally invasive direct coronary artery bypass).
These procedures have characteristics similar to
traditional CABG.

INDICATIONS

POtENtIAL DIAGNOsEs
● More than 50% blockage of left main coronary artery

with anginal episodes (blockage inaccessible to
angioplasty and stenting)

● Significant two‑vessel disease with unstable angina
● Triple‑vessel disease with or without angina
● Persistent ischemia or likely MI following coronary

angiography, PCI, or stent placement
● Heart failure or cardiogenic shock with acute MI or

ischemia (might not be reasonable for clients who have
poor ejection fractions)

● Coronary arteries that are unable to be accessed or
treated by angioplasty and stent placement (narrow
or calcified)

● Coronary artery disease nonresponsive to medical
management

● Heart valve disease

CLIENt PREsENtAtION
SUBJECTIVE DATA: Chest pain can occur with or without
exertion. Pain can radiate to jaw, left arm, through the
back, or to the shoulder. Effects can increase in cold
weather or with exercise. Other findings can include
dyspnea, nausea, fatigue, and diaphoresis.

OBJECTIVE DATA: ECG changes can include ST elevation,
depression, or nonspecific ST changes. Other findings can
include bradycardia, tachycardia, hypotension, elevated
blood pressure, vomiting, and mental disorientation.

Online Image: Bypass Graft

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 30 INvAsIvE CARDIOvAsCULAR PROCEDUREs 193

CONSIDERATIONS

PREPROCEDURE
NURSING ACTIONS

● A CABG can be an elective procedure or done as an
emergency. When planned, preparation begins before
the client comes to the facility for the procedure.

● Verify that the client has signed the informed
consent form.

● Confirm that recent chest x‑ray, ECG, and laboratory
reports are available if needed.

● Complete a baseline assessment of the client’s cognitive
status, identify any health issues that can complicate
postoperative recovery (diabetes, hypertension, stroke)
and the client’s support system.

● Administer preoperative medications.
◯ Anxiolytics, such as lorazepam and diazepam
◯ Prophylactic antibiotics
◯ Anticholinergics, such as scopolamine, to
reduce secretions

● Provide safe transport of the client to the operating
suite. Monitor heart rate and rhythm, oxygenation, and
other vital indicators.

● Ensure the client understands the procedure and
postsurgical environment.

● Assess client and family anxiety levels surrounding the
procedure.

CLIENT EDUCATION
● Understand the importance of coughing and deep

breathing after the procedure to prevent complications.
● Splint the incision when coughing and deep breathing.

Provide a return demonstration to the nurse when
being instructed.

● Perform arm and leg exercises to prevent complications.
● Report pain to the nursing staff. The majority of pain

stems from the harvest site for the vein.
● Expect the following postoperatively.

◯ Endotracheal tube and mechanical ventilator
for airway management for several hours
following surgery

◯ Inability to talk while endotracheal tube
is in place

◯ Sternal incision and possible leg incision
◯ Early ambulation to prevent complications
◯ Administration of analgesics for pain control
◯ One or two mediastinal chest tubes
◯ Indwelling urinary catheter
◯ Pacemaker wires
◯ Hemodynamic monitoring devices (pulmonary
artery catheter, arterial line)

● Alter or discontinue regular medications
as prescribed.

◯ Medications frequently discontinued for CABG
■ Diuretics 2 to 3 days before surgery
■ Aspirin and other anticoagulants 1 week
before surgery

◯ Medications often continued for CABG
■ Potassium supplements
■ Scheduled antidysrhythmics, such as
amiodarone

■ Scheduled antihypertensives (metoprolol, a
beta‑blocker; diltiazem, a calcium‑channel blocker)

■ Insulin (clients who have diabetes mellitus and
are insulin‑dependent usually receive half the
regular insulin dose)

◯ Verbalize any feelings with family and the nurse.

INtRAPROCEDURE
● An extracardiac vein (saphenous vein), artery (usually

the radial or mammary artery), or synthetic graft can
be used to bypass an obstruction in one or more of the
coronary arteries.

● Most often, a median sternotomy incision is made to
visualize the heart and the great vessels.

● The client is placed on cardiopulmonary bypass, and the
client’s core temperature can be lowered to decrease the
rate of metabolism and demand for oxygen. A normal core
temperature can be maintained during cardiopulmonary
bypass to improve postoperative myocardial function and
reduce postoperative complications.

● A cardioplegic solution is used to stop the heart.
This prevents myocardial ischemia and allows for a
motionless operative field.

● The artery or vein to be used is harvested.
● The harvested vessel is anastomosed from the aorta

to the affected coronary artery distal to the occlusion.
When the mammary artery is used as a graft, the
proximal end remains intact, and the distal end is
grafted just past the coronary artery occlusion.

● Once the bypass is complete, the hypothermic client is
rewarmed by heat exchanges on the bypass machine.
Grafts are monitored for patency and leakage as the
client is weaned from the bypass machine and blood is
redirected through coronary vasculature.

● Lastly, pacemaker wires can be sutured into the
myocardium, and chest tubes are placed. The incision is
closed with wire sutures, and the client is transported
to the intensive care unit.

30.1 Bypass graft

194 CHAPTER 30 INvAsIvE CARDIOvAsCULAR PROCEDUREs CONTENT MASTERY SERIES

NURSING ACTIONS
● Provide padding to bony prominences to provide

comfort and prevent skin breakdown.
● Communicate surgical progress to family members,

if appropriate.
● Assist in monitoring urine output and blood loss.
● Document appropriate surgical events.
● Assist in arranging intensive care unit placement and

communicate the client’s postoperative needs.

POstPROCEDURE
NURSING ACTIONS

● Maintain patent airway and adequate ventilation.
◯ Monitor respiratory rate and effort.
◯ Auscultate breath sounds. Report crackles.
◯ Monitor SaO2.
◯ Document ventilator settings.
◯ Suction as needed.
◯ Assist with extubation.

● Dangle the client’s legs and turn the client from side to
side as tolerated within 2 hr following extubation. Assist
the client to a chair within 24 hr. Ambulate the client 25
to 100 ft three times a day by first postoperative day.

● Consult respiratory services to aid in recovery and
client education.

● Consult case management services to initiate discharge
planning: need for home oxygen therapy, transfer to
tertiary care facility.

● Continually monitor heart rate and rhythm. Treat
dysrhythmias per protocol.

● Maintain an adequate circulating blood volume.
◯ Monitor blood pressure.

■ Hypotension can result in graft collapse.
■ Hypertension can result in bleeding from grafts
and sutures.

■ Titrate IV drips (dopamine, dobutamine, milrinone,
sodium nitroprusside) per protocol to control blood
pressure and/or increase cardiac output.

◯ Monitor hemodynamic pressures and catheter
placement. Observe waveforms and markings on
the catheter.

◯ Monitor level of consciousness. Assess neurologic
status every 30 to 60 min until the client awakens
from anesthesia, then every 2 to 4 hr, or per
facility policy.

◯ Notify the surgeon of significant changes in values.
● Monitor chest tube patency and drainage.

◯ Measure drainage at least once an hour.
◯ Volume exceeding 150 mL/hr could be a manifestation
of hemorrhage and should be reported to the surgeon.

◯ Avoid dependent loops in tubing to facilitate drainage.
● Assess and control pain.

◯ Determine source of pain (angina, incisional pain).
■ Anginal pain often radiates and is unaffected

by breathing.
■ Incisional pain is localized, sharp, aching, burning,
and often worsens with deep breathing.

● Administer analgesics (morphine, fentanyl).
◯ Pain will stimulate the sympathetic nervous system,
resulting in increased heart rate and systemic
vascular resistance.

◯ Provide frequent and adequate doses to control pain.
Maintain around‑the‑clock administration.

● Monitor fluid and electrolyte status.
◯ Fluid administration is determined by blood pressure,

pulmonary artery wedge pressure, right atrial
pressure, cardiac output and index, systemic vascular
resistance, blood loss, and urine output.

◯ Follow provider or unit‑specific orders for
fluid administration.

◯ Monitor for electrolyte imbalances, especially for
hypokalemia and hyperkalemia.

● Prevent and monitor for infection.
◯ Practice proper hand hygiene.
◯ Use surgical aseptic technique during procedures such
as dressing changes and suctioning.

◯ Administer antibiotics.
◯ Monitor WBC counts, incisional redness and drainage,
and fever.

◯ Monitor temperature and provide warming measures
if indicated.

● Encourage physical activity. Consult the cardiac
rehabilitation program or a physical therapist to devise
a specific program.

● Discuss home environment and social supports. Consult
case management to assist with home planning needs.

CLIENT EDUCATION
● Splint the incision while deep breathing and coughing.
● Monitor and report manifestations of infection (fever,

incisional drainage, redness).
● Treat angina.

◯ Maintain a fresh supply of sublingual nitroglycerin.
◯ Store nitroglycerin in a light‑resistant container.
◯ Discontinue activity and rest with the onset of pain.
Follow directions for treating anginal pain.

◯ Older female clients might show milder
manifestations (dyspnea, indigestion).

● Adhere to the pharmacological regimen.
● Those who have diabetes mellitus should closely

monitor blood glucose levels.
● Consume a heart‑healthy diet (low fat, low cholesterol,

high fiber, low salt).
● Quit smoking if applicable. Use resources on smoking

cessation provided by nurse.
● Remain home during the first week after surgery and

resume normal activities slowly.
◯ Week 2: possible return to work part time, increase in
social activities

◯ Week 3: lifting of up to 15 lb (avoid heavier lifting for
6 to 8 weeks)

● Resume sexual activity based on provider advice.
◯ Walking one block or climbing two flights of stairs
without shortness of breath or manifestations of
angina generally indicates that it is safe for the client
to resume normal sexual activity.

● Verbalize feelings.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 30 INvAsIvE CARDIOvAsCULAR PROCEDUREs 195

COMPLICATIONS

Pulmonary complications

These include the primary complication of atelectasis, as
well as pneumonia and pulmonary edema.

NURSING ACTIONS
● While the client is intubated, suction every 1 to 2 hr and

as needed.
● Turn the client every 2 hr, and advance them out of bed

as soon as possible.
● Monitor breath sounds, SaO2, ABGs, pulmonary artery

pressures, cardiac output, and urine output and obtain a
chest x‑ray as indicated.

CLIENT EDUCATION: Engage in coughing, deep breathing,
and use of an incentive spirometer. Increasing activity
reduces postoperative complications.

Hypothermia

Hypothermia can cause vasoconstriction, metabolic
acidosis, and hypertension.

NURSING ACTIONS
● Monitor temperature and provide warming measures

(warm blankets, heat lamps).
● Monitor blood pressure.
● Administer vasodilators if prescribed.

CLIENT EDUCATION: Shivering is common
following surgery.

Decreased cardiac output

Decreased cardiac output can result from dysrhythmias,
cardiac tamponade, hypovolemia, left ventricular
failure, or MI.

Cardiac tamponade results from bleeding while chest
tubes are occluded, causing fluid to build up in the
pericardium. Increased pericardial fluid compresses heart
chambers and inhibits effective pumping.

● Indications include a sudden decrease/cessation
of chest‑tube drainage following heavy drainage,
jugular‑venous distention with clear lung sounds, and
equal pulmonary artery wedge pressure and central
venous pressure values.

Hypovolemia can be the result of bleeding, decreased
intravascular volume, or vasodilation; hypotension and
decreased urine output are the results.

Left ventricular heart failure can occur with an MI
or fluid overload.

NURSING ACTIONS
● Monitor ECG, blood pressure, pulmonary artery

pressures, cardiac output, urine output, and bleeding
through the chest tube.

● Administer inotropic medications and fluid and
blood products.

● Treat dysrhythmias.
◯ Use pacemaker wires if heart block is present.

● Treatment of cardiac tamponade involves volume
expansion (fluid administration) and an emergency
sternotomy with drainage. Pericardiocentesis is avoided
because blood can have clotted.

Electrolyte disturbances

Potassium and magnesium depletion is common.

NURSING ACTIONS
● Always dilute potassium in adequate fluid (20 to 40 mEq

in 100 mL of IV solution).
● Administer via infusion pump to control the rate of

delivery. The administration rate is 10 mEq/hr.
● Monitor ECG and electrolytes.

Neurologic deficits

Transient hypertension, hypotension, or a blood clot
might cause an intraoperative cerebrovascular accident.

NURSING ACTIONS
● Assess neurologic status, including pupils, level of

consciousness, and sensory and motor function.
● Maintain the client’s blood pressure within

prescribed parameters.

CLIENT EDUCATION
● Understand the procedures.
● Memory loss and neurologic deficits can be temporary.

Peripheral bypass grafts
Peripheral bypass graft surgery aims to restore
adequate blood flow to the areas affected by peripheral
artery disease.

● A peripheral bypass graft involves suturing graft
material or autogenous saphenous veins proximal and
distal to occluded area of an artery. This procedure
improves blood supply to the area normally served by
the blocked artery.

● If bypass surgery fails to restore circulation, the client
might need to undergo amputation of the limb.

INDICATIONS
● Acute circulatory compromise in limb
● Severe pain at rest that interferes with the

ability to work

CLIENt PREsENtAtION
SUBJECTIVE DATA

● Numbness or burning pain to the lower extremity with
exercise; can stop with rest (intermittent claudication)

● Numbness or burning pain to the lower extremity at
rest; can wake the client at night; pain can be relieved
by lowering the extremity below the level of the heart

196 CHAPTER 30 INvAsIvE CARDIOvAsCULAR PROCEDUREs CONTENT MASTERY SERIES

OBJECTIVE DATA
● Decreased or absent pulses to feet.
● Dry, hairless, shiny skin on calves.
● Muscles can atrophy with advanced disease.
● Skin can be cold and darkened.
● Feet and toes can be mottled and dusky, and toenails

might be thick.
● Skin can become reddened (rubor) when extremity is

dropped to a dependent position.
● Ulcers or lesions can be noted on toes (arterial ulcers) or

ankles (venous ulcers).

CONSIDERATIONS

PREPROCEDURE
NURSING ACTIONS

● Assess client and family understanding of the procedure.
● Verify that the client has signed the informed

consent form.
● Assess for allergies.
● Document baseline vital signs and peripheral pulses.
● Administer prophylactic antibiotic therapy.
● Understand information about postoperative

pain management and deep breathing/incentive
spirometer exercises.

CLIENT EDUCATION
● Maintain NPO status for at least 8 hr prior to surgery.
● Do not to cross legs.
● An arterial line might be inserted for blood and blood

pressure.
● Pedal pulses will be checked frequently.

INtRAPROCEDURE
NURSING ACTIONS

● Provide padding to bony prominences to provide
comfort and to prevent skin breakdown.

● Communicate surgical progress to family members,
if appropriate.

● Assist in monitoring urine output and blood loss.
● Document appropriate surgical events.
● Communicate the client’s postoperative needs to the

postanesthesia care unit.

POstPROCEDURE
NURSING ACTIONS

● Assess vital signs every 15 min for 1 hr and then hourly
after the first hour (or per facility policy).

● Follow standing orders to maintain blood pressure
within the prescribed range. Hypotension might
reduce blood flow to graft, and hypertension might
cause bleeding.

● Assess the operative limb every 15 min for 1 hr and
then hourly after that, paying particular attention to
the following.

◯ Incision site for bleeding.
◯ Peripheral pulses, capillary refill, skin color/
temperature, and sensory and motor function for
indications of bypass graft occlusion. In clients who
have dark skin, assess nail beds and soles of feet to
detect early cyanosis.

◯ Site is marked with an indelible marker.
● Administer IV fluids.
● Assess the type of pain experienced by the client.

◯ Throbbing pain is experienced due to an increase in
blood flow to extremity.

◯ Ischemic pain is often difficult to relieve with
opioid administration.

● Administer analgesics, such as morphine sulfate
and fentanyl.

● Administer antibiotics.
● Use surgical aseptic technique for dressing changes.
● Monitor incision sites for evidence of infection

(erythema, tenderness, drainage).
● Administer anticoagulant therapy (warfarin, heparin,

enoxaparin) to prevent reocclusion.
● Administer antiplatelet therapy (clopidogrel, aspirin).
Alternate medications are tirofiban and eptifibatide.

● Help the client turn, cough, and deep breathe every 2 hr.
● Maintain bed rest for 18 to 24 hr. The leg should be kept

straight during this time.
● Assist the client to get out of bed and ambulate.

Encourage the use of a walker initially.
● Discourage the client from sitting for long

periods of time.
● Apply antiembolic stockings to promote venous return.
● Set up a progressive exercise program that includes

walking. Consider a physical therapy consult.

CLIENT EDUCATION
● Completely abstain from smoking. Consider a

smoking‑cessation program suggested by the nurse.
● Follow activity restrictions.
● Avoid crossing legs.
● Avoid elevating legs above heart level.
● Reduce risk factors for atherosclerosis (smoking,

sedentary lifestyle, uncontrolled diabetes mellitus).
● Learn techniques of foot inspection and care from

the nurse.
◯ Keep feet dry and clean.
◯ Avoid extreme temperatures.
◯ Use lotion.
◯ Avoid socks with tight cuffs.
◯ Wear clean white cotton socks and always wear shoes.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 30 INvAsIvE CARDIOvAsCULAR PROCEDUREs 197

COMPLICATIONS

Graft occlusion

The graft might occlude due to reduced blood flow and
clot formation. Occurs primarily in first 24 hr after
the procedure.

NURSING ACTIONS
● Notify the provider immediately for changes in pedal

pulse, extremity color, or temperature.
● Prepare the client for thrombectomy or

thrombolytic therapy.
● Monitor for bleeding with thrombolytics.
● Monitor coagulation studies.
● Monitor for anaphylaxis.

Compartment syndrome

Pressure from tissue swelling or bleeding within a
compartment or a restricted space causes reduced blood
flow to the area. Untreated, the affected tissue will
become necrotic and die.

NURSING ACTIONS
● Assess for worsening pain, swelling, and tense or

taut skin.
● Report unusual findings to the provider immediately.
● Prepare the client for a fasciotomy to relieve

compartmental pressure.

Infection

Infection of the surgical site might result in the loss of the
graft and increased ischemia.

NURSING ACTIONS
● Assess the wound for increased redness, swelling,

and drainage.
● Monitor WBC count and temperature.
● Collect specimens (wound or blood cultures).
● Administer antibiotic therapy.

CLIENT EDUCATION: Notify the provider of decreased
sensation, increased ischemic pain, redness, or swelling at
the incisional site or in the affected limb.

Application Exercises

1. A nurse is caring for a client who is 4 hr postoperative
following coronary artery bypass grafting (CABG)
surgery. the client is able to inspire 200 mL with
the incentive spirometer, then declines to try to
cough because of fatigue and pain. Which of
the following actions should the nurse take?

A. Allow the client to rest, and return in 1 hr.

B. Administer Iv bolus analgesic, and return in 15 min.

C. Document the 200 mL as an
appropriate inspired volume.

D. tell the client coughing after incentive
spirometry is required.

2. A nurse is caring for a client following peripheral
bypass graft surgery of the left lower extremity.
Which of the following findings pose an
immediate concern? (select all that apply.)

A. trace of bloody drainage on dressing

B. Capillary refill of affected limb of 6 seconds

C. mottled appearance of the limb

D. throbbing pain of affected limb that is
decreased following Iv bolus analgesic

E. Pulse of 2+ in the affected limb

3. A nurse educator is reviewing the use of
cardiopulmonary bypass during surgery for coronary
artery bypass grafting with a group of nurses.
Which of the following statements should the nurse
include in the discussion? (select all that apply.)

A. “the client’s demand for oxygen is lowered.”

B. “motion of the heart ceases.”

C. “Rewarming of the client takes place.”

D. “the client’s metabolic rate is increased.”

E. “Blood flow to the heart is stopped.”

4. A nurse is caring for a client following an angioplasty
that was inserted through the femoral artery.
While turning the client, the nurse discovers blood
underneath the client’s lower back. Which of the
following findings should the nurse suspect?

A. Retroperitoneal bleeding

B. Cardiac tamponade

C. Bleeding from the incisional site

D. heart failure

5. A nurse is completing the admission assessment
of a client who will undergo peripheral bypass
graft surgery on the left leg. Which of the
following findings should the nurse expect?

A. Rubor of the affected leg when elevated

B. 3+ dorsal pedal pulse in left foot

C. thin, peeling toenails of left foot

D. Report of intermittent claudication
in the affected leg

Active Learning Scenario

A nurse is developing the plan of care for a client who is
returning to the unit following angioplasty. What should be
included in the plan of care? Use the AtI Active Learning
template: therapeutic Procedure to complete this item.

NURSING INTERVENTIONS: Describe five
postprocedure nursing actions.

POTENTIAL COMPLICATIONS:
● Describe at least two.
● Describe at least two actions related to
each of these complications.

198 CHAPTER 30 INvAsIvE CARDIOvAsCULAR PROCEDUREs CONTENT MASTERY SERIES

Application Exercises Key

1. A. turning, coughing, and deep breathing should be performed
every 2 hr to promote oxygenation and circulation.

B. CORRECT: Providing adequate analgesia and returning in
15 min will reduce pain and improve coughing effectiveness.

C. this is not an adequate inspired air volume
to promote effective oxygenation.

D. this intervention is non‑therapeutic communication.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

2. A. A trace of bloody drainage on the dressing is an expected
finding and does not require immediate concern.

B. CORRECT: Capillary refill greater than 3 seconds
is outside the expected reference range and
should be reported to the provider.

C. CORRECT: mottled appearance of the affected extremity is an
unexpected finding and should be reported to the provider.

D. Pain that is decreased following Iv bolus analgesia is an
expected finding and does not require immediate concern.

E. Pulse of 2+ in the affected extremity is an expected
finding and does not require immediate concern.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

3. A. CORRECT: the use of cardiopulmonary bypass reduces
the client’s demand for oxygen, which reduces the risk
of inadequate oxygenation of vital organs.

B. CORRECT: motion of the heart ceases during
cardiopulmonary bypass to allow for placement of
the graft near the affected coronary artery.

C. CORRECT: the core body temperature is lowered for
the procedure, and rewarming then occurs through heat
exchanges on the cardiopulmonary bypass machine.

D. the use of cardiopulmonary bypass
decreases the rate of metabolism.

E. Blood flow to the heart is maintained by the action
of the cardiopulmonary bypass machine.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

4. A. Retroperitoneal bleeding is internal bleeding.
B. Cardiac tamponade includes manifestations of

bleeding in the pericardial sac, which is internal.
C. CORRECT: Bleeding is occurring from the incision site

and then draining under the client. the nurse should
assess the incision for hematoma, apply pressure,
monitor the client, and notify the provider.

D. heart failure does not including findings of blood
underneath the client’s lower back.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

5. A. Reddening (rubor) of a leg affected by peripheral artery
disease occurs when it is placed in a dependent position.

B. Pulses are decreased or absent in the feet in
cases of peripheral artery disease.

C. toenails are thickened in cases of peripheral artery disease.
D. CORRECT: A client who has peripheral artery disease

might report that numbness or burning pain in the
extremity ceases with rest (intermittent claudication).

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

Active Learning Scenario Key

Using ATI Active Learning Template: Therapeutic Procedure

NURSING INTERVENTIONS
● Assess vital signs every 15 min × 4, every 30 min × 2, every
hour × 4, and then every 4 hr (or per facility protocol).

● Assess the groin site with vital signs.
● maintain bed rest in supine position with
leg straight for prescribed time.

● Conduct continuous cardiac monitoring for dysrhythmia.
● Administer antiplatelet or thrombolytic agents.
● Administer anxiolytics and analgesics.
● monitor urine output and administer Iv fluids for hydration.
● Assist with sheath removal from insertion site.

POTENTIAL COMPLICATIONS
● Cardiac tamponade: Notify the provider; administer
Iv fluids to manage hypotension; obtain chest x‑ray or
echocardiogram; prepare for pericardiocentesis.

● hematoma formation: monitor sensation, color, capillary refill,
and pulse in extremity distal to insertion site; hold pressure
for uncontrolled oozing/bleeding; notify the provider.

● Allergic reaction: monitor the client; have resuscitation equipment
available; administer diphenhydramine or epinephrine as needed.

● External bleeding: monitor insertion site for bleeding or swelling;
apply pressure to insertion site; keep client’s leg straight.

● Embolism: monitor for chest pain; monitor vital signs and saO2.
● Retroperitoneal bleeding: Assess for flank pain and hypotension;
notify the provider; administer Iv fluids and blood products.

● Restenosis of vessel: Assess ECG pattern and for
report of chest pain; notify the provider; prepare for
return to cardiac catheterization laboratory.

NCLEX® Connection: Physiological Adaptation, Alterations in
Body Systems

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 31 ANGINA AND mYOCARDIAL INFARCtION 199

UNIT 4 CARDIOVASCULAR DISORDERS
SECTION: CARDIAC DISORDERS

CHAPTER 31 Angina and
Myocardial
Infarction

the continuum from angina to myocardial infarction
(mI) is acute coronary syndrome. manifestations of
acute coronary syndrome are due to an imbalance
between myocardial oxygen supply and demand.

When blood flow to the heart is compromised,
ischemia causes chest pain. Anginal pain is often
described as a tight squeezing, heavy pressure,
or constricting feeling in the chest. the pain can
radiate to the jaw, neck, or arm. Pain unrelieved
by rest or nitroglycerin and lasting for more than
15 min differentiates an mI from angina. Females
and older adults do not always experience
manifestations typically associated with
angina or mI.

the area of infarction in clients experiencing a
myocardial infarction (mI) develops over minutes
to hours. Early recognition and treatment of an
acute mI is essential to prevent death.

Research shows improved outcomes following an
mI in clients treated with aspirin, beta‑blockers,
and angiotensin‑converting
enzyme inhibitors or angiotensin
receptor blockers.

An abrupt interruption of oxygen to the heart
muscle produces myocardial ischemia. Ischemia
can lead to tissue necrosis (infarction) if blood
supply and oxygen are not restored. Ischemia
is reversible. An infarction results in permanent
damage. When the cardiac muscle suffers
ischemic injury, cardiac enzymes are released into
the bloodstream, providing specific markers of mI.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Maintain an exercise routine to remain physically
active. Consult with a provider before starting any
exercise regimen.

● Have cholesterol level and blood pressure checked regularly.
● Consume a diet low in saturated fats and sodium.

Consult with a provider regarding diet restrictions.
● Promote smoking cessation.

ASSESSMENT

Types of angina

Stable (exertional) angina occurs with exercise or
emotional stress and is relieved by rest or nitroglycerin.

Unstable (preinfarction) angina occurs with exercise or
at rest, but increases in occurrence, severity, and duration
over time.

Variant (Prinzmetal’s) angina is due to a coronary artery
spasm, often occurring during periods of rest.

CHAPTER 31

Online Image: Myocardial Infarction

31.1 Myocardial infarction

200 CHAPTER 31 ANGINA AND mYOCARDIAL INFARCtION CONTENT MASTERY SERIES

RIsK FACtORs
● Male sex or postmenopausal clients
● Ethnic background
● Sedentary lifestyle
● Hypertension
● Tobacco use
● Hyperlipidemia
● Obesity
● Excessive alcohol consumption
● Metabolic disorders (diabetes mellitus, hyperthyroidism)
● Methamphetamine or cocaine use
● Stress (with ineffective coping skills)
● An increased risk of coronary artery disease exists for

older adult clients who are physically inactive, have one
or more chronic diseases (hypertension, heart failure,
and diabetes mellitus), or have lifestyle habits (smoking
and diet) that contribute to atherosclerosis.
Atherosclerotic changes related to aging predispose the
heart to poor blood perfusion and oxygen delivery.

● Incidence of cardiac disease increases with age,
especially in the presence of hypertension, diabetes
mellitus, hypercholesterolemia, elevated homocysteine,
and highly sensitive C‑reactive protein (hs‑CRP).

EXPECtED FINDINGs
● Anxiety, feeling of impending doom
● Chest pain: substernal or precordial

◯ Can radiate down the shoulder or arm, or present
as jaw pain

◯ Can be described as a crushing or aching pressure
● Nausea
● Dizziness
● Females can experience atypical angina, which is

characterized by pain between the shoulders, ache in
the jaw, or sensation of choking with exertion.

PHYSICAL ASSESSMENT FINDINGS
● Pallor, and cool, clammy skin
● Tachycardia and heart palpitations
● Tachypnea and shortness of breath
● Diaphoresis
● Vomiting
● Decreased level of consciousness

LABORAtORY tEsts
Cardiac enzymes released with cardiac muscle injury:

● Myoglobin: Earliest marker of injury to cardiac or
skeletal muscle. Levels no longer evident after 24 hr.

● Creatine kinase‑MB: Peaks around 24 hr after onset of
chest pain. Levels no longer evident after 3 days.

● Troponin I or T: Any positive value indicates damage to
cardiac tissue and should be reported.

◯ Troponin I: Levels no longer evident after 7 to 10 days.
◯ Troponin T: Levels no longer evident after 10 to 14 days.

DIAGNOstIC PROCEDUREs
Refer to CHAPTER 27: CARDIOVASCULAR DIAGNOSTIC AND

THERAPEUTIC PROCEDURES.

Electrocardiogram (ECG)

Recording of electrical activity of the heart over time

NURSING ACTIONS
● Assess for changes on serial ECGs.
● Angina: ST depression and/or T‑wave inversion indicates

presence of ischemia.
● MI: T‑wave inversion indicates ischemia; ST‑segment

elevation indicates injury; abnormal Q‑wave
indicates necrosis.

Stress test

Also known as exercise electrocardiography. Client
tolerance of activity is tested using a treadmill, bicycle, or
medication to evaluate response to increased heart rate.

Thallium scan

Assesses for ischemia or necrosis. Radioisotopes cannot
reach areas with decreased or absent perfusion, and the
areas appear as “cold spots.”

CLIENT EDUCATION: Avoid smoking and consuming
caffeinated beverages 4 hr prior to the procedure. These
can affect the test.

31.3 Assessment

Stable angina
Precipitated by
exertion or stress
Relieved by rest or
nitroglycerin
manifestations last
less than 15 min
Not associated with nausea,
epigastric distress, dyspnea,
anxiety, diaphoresis

Myocardial
infarction
Can occur without
cause, often in the
morning after rest
Relieved only by opioids
manifestations last
more than 30 min
Associated with nausea,
epigastric distress, dyspnea,
anxiety, diaphoresis

31.2 Anginal pain

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 31 ANGINA AND mYOCARDIAL INFARCtION 201

Cardiac catheterization
● A coronary angiogram, also called a cardiac

catheterization, is an invasive diagnostic procedure
used to evaluate the presence and degree of coronary
artery blockage.

● Angiography involves the insertion of a catheter into a
femoral (sometimes a brachial) vessel and threading it
into the right or left side of the heart. Coronary artery
narrowing and occlusions are identified by the injection
of contrast media under fluoroscopy.

NURSING ACTIONS
● Ensure the client understands the procedure prior to

signing informed consent.
● Ensure that the client remains NPO 8 hr prior

to procedure.
● Assess for iodine/shellfish allergy (contrast media).

mI CLAssIFICAtION
MIs are classified based on:

● Affected area of the heart: anterior, lateral, inferior,
or posterior

● ECG changes produced: ST elevation myocardial
infarction (STEMI) vs. non‑ST elevation myocardial
infarction (NSTEMI)

● The time frame within the progression of the infarction:
acute, evolving, old

PATIENT‑CENTERED CARE

NURsING CARE
● Monitor the following.

◯ Vital signs every 5 min until stable, then every hour
◯ Serial ECG, continuous cardiac monitoring
◯ Location, precipitating factors, severity, quality, and
duration of pain

◯ Hourly urine output: greater than 30 mL/hr indicates
renal perfusion

◯ Laboratory data: cardiac enzymes, electrolytes, ABGs
● Administer oxygen: 2 to 4 L/min.
● Obtain and maintain IV access.
● Promote energy conservation. Cluster

nursing interventions.

mEDICAtIONs

Vasodilators

Nitroglycerin prevents coronary artery vasospasm and
reduces preload and afterload, decreasing myocardial
oxygen demand.

NURSING ACTIONS
● Use to treat angina and help control blood pressure.
● Use cautiously with other antihypertensive medications.
● Monitor for orthostatic hypotension.
● Ensure the client has not taken a phosphodiesterase

inhibitor for erectile dysfunction within 24 to 48 hr, as
severe hypotension can result.

CLIENT EDUCATION FOR CHEST PAIN
● Stop activity and rest.
● Place a nitroglycerin tablet under the tongue to dissolve

(quick absorption).
● If pain is unrelieved in 5 min, call 911 or be driven to an

emergency department.
● Up to two more doses of nitroglycerin can be taken at
5‑min intervals.

● Headache is a common adverse effect of this medication.
● Change positions slowly.

Analgesics

Morphine sulfate is an opioid analgesic used to treat
moderate to severe pain. Analgesics act on the mu and
kappa receptors that help alleviate pain. Activation of
these receptors produces analgesia (pain relief), respiratory
depression, euphoria, sedation, and decreases in myocardial
oxygen consumption and gastrointestinal (GI) motility.

! Use cautiously with clients who have asthma or
emphysema due to the risk of respiratory depression.

NURSING ACTIONS
● For the client having chest pain, assess pain every
5 to 15 min.

● Watch for manifestations of respiratory depression,
especially in older adults. If respirations are less than
12/min, stop medication, and notify the provider
immediately.

● Monitor vital signs for hypotension and
decreased respirations.

● Assess for nausea and vomiting.

CLIENT EDUCATION
● If nausea and vomiting persist, notify a nurse.
● If a PCA pump is prescribed, the client is the only

person who should push the medication administration
button. The safety lockout mechanism on the PCA pump
prevents overdosing of the medication.

Beta‑blockers
● Metoprolol has antidysrhythmic and antihypertensive

properties that decrease the imbalance between
myocardial oxygen supply and demand by reducing
afterload and slowing heart rate.

● In an acute MI, beta‑blockers decrease infarct size and
improve short‑ and long‑term survival rates.

NURSING ACTIONS
● Beta‑blockers can cause bradycardia and hypotension.

Hold the medication if the apical pulse rate is less than
60/min, and notify the provider.

● Avoid giving to clients who have asthma. Cardioselective
beta blockers (which affect only beta1 receptors), such
as metoprolol, are preferred because they minimize the
effects on the respiratory system.

● Use with caution in clients who have heart failure.
● Monitor for decreased level of consciousness, crackles in

the lungs, and chest discomfort.

CLIENT EDUCATION
● Change positions slowly.
● Notify the provider immediately of shortness of breath,

edema, weight gain, or cough.

202 CHAPTER 31 ANGINA AND mYOCARDIAL INFARCtION CONTENT MASTERY SERIES

Thrombolytic agents
● Alteplase and reteplase are used to break up blood clots.
● Thrombolytic agents have similar adverse effects and

contraindications as anticoagulants.
● For best results, give within 6 hr of infarction.

NURSING ACTIONS
● Assess for contraindications (active bleeding, peptic

ulcer disease, history of stroke, recent trauma).
● Monitor for effects of bleeding (mental status changes,

hematuria).
● Monitor bleeding times: PT, aPTT, INR, fibrinogen

levels, and CBC.
● Monitor for the same adverse effects as anticoagulants

(thrombocytopenia, anemia, hemorrhage).
● Administer streptokinase slowly to prevent hypotension.

CLIENT EDUCATION: There is a risk for bruising and
bleeding while on this medication.

Antiplatelet agents
● Aspirin and clopidogrel prevent platelets from forming

together, which can produce arterial clotting.
● Aspirin prevents vasoconstriction. Due to this and

antiplatelet effects, it should be administered with
nitroglycerin at the onset of chest pain.

● Antiplatelet agents can cause GI upset.

NURSING ACTIONS
● Use cautiously with clients who have a history of

GI ulcers.
● Tinnitus (ringing in the ears) can be a manifestation of

aspirin toxicity.

CLIENT EDUCATION
● There is risk for bruising and bleeding while on

this medication.
● If aspirin is prescribed, choose the enteric‑coated form

and take with food to minimize GI upset.
● Report ringing in the ears.

Anticoagulants

Heparin and enoxaparin are used to prevent clots from
becoming larger or other clots from forming.

NURSING ACTIONS
● Assess for contraindications (active bleeding, peptic

ulcer disease, history of stroke, recent trauma).
● Monitor platelet levels and bleeding times: PT, aPTT,

INR, and CBC.
● Monitor for adverse effects of anticoagulants

(thrombocytopenia, anemia, hemorrhage).

CLIENT EDUCATION: There is risk for bruising and
bleeding while on this medication.

Glycoprotein IIB/IIIA inhibitors

Eptifibatide is used to prevent binding of fibrinogen to
platelets, in turn blocking platelet aggregation.

● In combination with aspirin therapy, IIB/IIIA inhibitors
are standard therapy.

● This medication can cause active bleeding.

NURSING ACTIONS: Monitor platelet levels.

CLIENT EDUCATION: Report evidence of bleeding during
medication therapy.

INtERPROFEssIONAL CARE
● Pain management services can be consulted if pain

persists or is uncontrolled.
● Cardiac rehabilitation care can be consulted if the client

has prolonged weakness and needs assistance with
increasing level of activity.

● Nutritional services can be consulted for diet modification
to promote food choices low in sodium and saturated fat.

thERAPEUtIC PROCEDUREs
● Percutaneous transluminal coronary angioplasty (PTCA)
● Bypass graft (also known as CABG)

CLIENt EDUCAtION
● Cardiac rehabilitation should be consulted for a specific

exercise program related to the heart.
● Nutritional services, such as a dietitian, can be

consulted for diet modification or weight management.
● Monitor and report findings of infection (fever,

incisional drainage, redness).
● Avoid straining, strenuous exercise, or emotional stress

when possible.
● Regarding response to chest pain: follow instructions on

use of sublingual nitroglycerin.
● Consider smoking cessation, if applicable.
● Remain active and to exercise regularly.

COMPLICATIONS

Acute MI

A complication of angina not relieved by rest or nitroglycerin

NURSING ACTIONS
● Administer oxygen.
● Notify the provider immediately.

Heart failure/cardiogenic shock

Injury to the left ventricle can lead to decreased cardiac
output and heart failure. Progressive heart failure can lead
to cardiogenic shock.

● This is a serious complication of pump failure,
commonly following an MI of 40% blockage.

● Manifestations include tachycardia; hypotension;
inadequate urinary output; altered level of consciousness;
respiratory distress (crackles and tachypnea); cool,
clammy skin; decreased peripheral pulses; and chest pain.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 31 ANGINA AND mYOCARDIAL INFARCtION 203

NURSING ACTIONS
● Administer oxygen. Intubation and ventilation can be

required.
● Administer IV morphine, diuretics, and/or nitroglycerin

to decrease preload. Administer IV vasopressors and/
or positive inotropes to increase cardiac output and
maintain organ perfusion.

● Maintain continuous hemodynamic monitoring.

Ischemic mitral regurgitation

Evidenced by development of a new cardiac murmur

NURSING ACTIONS
● Administer oxygen.
● Notify the provider immediately.

Ventricular aneurysms/rupture

Can be due to necrosis from MI. Can present as sudden
chest pain, dysrhythmias, and severe hypotension

NURSING ACTIONS
● Administer oxygen.
● Notify the provider immediately.

Dysrhythmias
● An inferior wall MI can lead to an injury to the AV

node, resulting in bradycardia and second‑degree
AV heart block.

● An anterior wall MI can lead to an injury to the ventricle,
resulting in premature ventricular contractions, bundle
branch block, or complete heart block.

NURSING ACTIONS
● Monitor ECG and vital signs.
● Administer oxygen.
● Administer antidysrhythmic medications.
● Prepare for cardiac pacemaker or implantable

cardioverter defibrillator if needed.

Active Learning Scenario

A nurse is teaching a client who has new diagnosis of angina
about coronary syndrome. What information should the
nurse include in the teaching? Use the AtI Active Learning
template: system Disorder to complete this item.

RISK FACTORS: Describe five.

CLIENT EDUCATION: Describe at least two
teaching points the nurse can use to help the
client decrease risk of having angina or an mI.

EXPECTED FINDINGS

LIST FIVE SUBJECTIVE FINDINGS.

DESCRIBE FOUR PHYSICAL ASSESSMENT FINDINGS.

Application Exercises

1. A nurse is admitting a client who has a suspected
myocardial infarction (mI) and a history of angina.
Which of the following findings will help the
nurse distinguish stable angina from an mI?

A. stable angina can be relieved
with rest and nitroglycerin.

B. the pain of an mI resolves in less than 15 min.

C. the type of activity that causes
an mI can be identified.

D. stable angina can occur for longer than 30 min.

2. A nurse on a cardiac unit is reviewing the laboratory
findings of a client who has a diagnosis of myocardial
infarction (mI) and reports that his dyspnea began
2 weeks ago. Which of the following cardiac enzymes
would confirm the mI occurred 14 days ago?

A. CK‑mB

B. troponin I

C. troponin t

D. myoglobin

3. A nurse is caring for a client who asks why the
provider prescribed a daily aspirin. Which of the
following responses should the nurse make?

A. “Aspirin reduces the formation of blood
clots that could cause a heart attack.”

B. “Aspirin relieves the pain due to
myocardial ischemia.”

C. “Aspirin dissolves clots that are forming
in your coronary arteries.”

D. “Aspirin relieves headaches that are
caused by other medications.”

4. A nurse is teaching a client who has angina
about a new prescription for metoprolol.
Which of the following statements by the client
indicates understanding of the teaching?

A. “I should place the tablet under my tongue.”

B. “I should have my clotting time checked weekly.”

C. “I will report any ringing in my ears.”

D. “I will call my doctor if my pulse
rate is less than 60.”

5. A nurse is presenting a community education program
on recommended lifestyle changes to prevent angina
and myocardial infarction. Which of the following
changes should the nurse recommend be made first?

A. Diet modification

B. Relaxation exercises

C. smoking cessation

D. taking omega‑3 capsules

204 CHAPTER 31 ANGINA AND mYOCARDIAL INFARCtION CONTENT MASTERY SERIES

Application Exercises Key

1. A. CORRECT: stable angina can be relieved
by rest and nitroglycerin.

B. Pain associated with an mI usually lasts longer than
30 min and requires opioid analgesics for relief.

C. there is no specific type of activity that causes
an mI. It can occur following rest.

D. the pain of stable angina usually occurs for 15 min or less.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

2. A. the creatinine kinase mB levels are no
longer evident after 3 days.

B. troponin I levels are no longer evident after 7 to 10 days.
C. CORRECT: the troponin t level will still be

evident 10 to 14 days following an mI.
D. myoglobin levels are no longer evident after 24 hr.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

3. A. CORRECT: Aspirin decreases platelet aggregation
that can cause a myocardial infarction.

B. One aspirin per day is not sufficient
to alleviate ischemic pain.

C. Aspirin does not dissolve clots.
D. Other medications can cause headaches, but one

aspirin per day is not administered as an analgesic.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. A. metoprolol is administered orally, not sublingually.
B. metoprolol does not affect bleeding or

clotting time. the client should have CBC and
blood glucose checked periodically.

C. Ringing in the ears is not an adverse effect of the medication.
Dry mouth and mucous membranes can occur.

D. CORRECT: the client is advised to notify the provider
if bradycardia (pulse rate less than 60) occurs.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

5. A. Recommend changing the diet to decrease consumption
of sodium and saturated fat; however, there is another
change the clients should plan to make first.

B. Recommend using relaxation exercise to cope
with stress; however, there is another change
the clients should plan to make first.

C. CORRECT: According to the airway, breathing, and
circulation (ABC) priority‑setting framework, the first
step is to recommend the clients to stop smoking.
Nicotine causes vasoconstriction, elevates blood
pressure, and narrows coronary arteries.

D. Recommend taking omega‑3 capsules to increase
consumption of good cholesterol; however, there is
another change the clients should plan to make first.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS
● male sex or postmenopausal clients
● sedentary lifestyle
● hypertension
● substance use (tobacco, cocaine,
methamphetamine, excessive alcohol)

● hyperlipidemia
● metabolic disorders (diabetes mellitus, hyperthyroidism)
● stress (with ineffective coping skills)

CLIENT EDUCATION
● have routine cholesterol, blood pressure,
and blood sugar screenings.

● Participate in regular physical activity for
exercise and stress reduction.

EXPECTED FINDINGS
● subjective findings: Feeling of impending doom;
chest pain, pressure, or crushing radiating to the
arm or jaw; nausea; dizziness; anxiety

● Physical assessment findings: Pale, cool, clammy
skin; tachycardia; tachypnea; diaphoresis

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 32 hEARt FAILURE AND PULmONARY EDEmA 205

UNIT 4 CARDIOVASCULAR DISORDERS
SECTION: CARDIAC DISORDERS

CHAPTER 32 Heart Failure and
Pulmonary Edema

heart failure occurs when the heart muscle
is unable to pump effectively, resulting
in inadequate cardiac output, myocardial
hypertrophy, and pulmonary/systemic
congestion. the heart is unable to maintain
adequate circulation to meet tissue needs.

heart failure is the result of an acute or
chronic cardiopulmonary problem, such as
systemic hypertension, myocardial infarction
(mI), pulmonary hypertension, dysrhythmias,
valvular heart disease, pericarditis, or
cardiomyopathy. (32.1)

Pulmonary edema is a severe, life‑threatening
accumulation of fluid in the alveoli and
interstitial spaces of the lung that can result from
severe heart failure.

Heart failure
New York Heart Association’s
functional classification scale

The severity of heart failure is graded on the
New York Heart Association’s (NYHA) functional
classification scale indicating the level of activity it
takes to induce manifestations of impaired function
(chest pain, shortness of breath).

CLASS I: Client exhibits no manifestations
with activity.

CLASS II: Client has manifestations with
ordinary exertion.

CLASS III: Client displays manifestations with
minimal exertion.

CLASS IV: Client has manifestations at rest.

American College of Cardiology and American
Heart Association staging heart failure

American College of Cardiology and American Heart
Association developed evidence‑based guidelines for
staging and managing heart failure in comparison with
the NYHA system.

A: High risk for developing heart failure

B: Cardiac structural abnormalities or remodeling but no
manifestations of heart failure

C: Current or prior manifestations of heart failure

D: Refractory end‑stage heart failure

Low‑output heart failure

Low‑output heart failure can initially occur on either the
left or right side of the heart.

● Left‑sided heart (ventricular) failure results in
inadequate left ventricle (cardiac) output and
consequently in inadequate tissue perfusion.

◯ Systolic heart (ventricular) failure (ejection fraction
below 40%, pulmonary and systemic congestion)

◯ Diastolic heart (ventricular) failure (inadequate
relaxation or “stiffening” prevents ventricular filling)

● Right‑sided heart (ventricular) failure results in
inadequate right ventricle output and systemic venous
congestion (peripheral edema).

High‑output heart failure

An uncommon form of heart failure is high‑output failure,
in which cardiac output is normal or above normal.

CHAPTER 32

32.1 Cardiomyopathy

206 CHAPTER 32 hEARt FAILURE AND PULmONARY EDEmA CONTENT MASTERY SERIES

HEALTH PROMOTION AND
DISEASE PREVENTION

● Maintain an exercise routine to remain physically
active, and consult with the provider before starting any
exercise regimen.

● Consume a diet low in sodium, along with fluid
restrictions, and consult with the provider regarding
diet specifications.

● Refrain from smoking.
● Follow medication regimen, and follow up with the

provider as needed.

ASSESSMENT

RIsK FACtORs
Older adults have an increased risk for heart failure and
can have worse manifestations due to increased systolic
blood pressure and some medications.

Left‑sided heart (ventricular) failure
● Hypertension
● Coronary artery disease, angina, MI
● Valvular disease (mitral and aortic)

Right‑sided heart (ventricular) failure
● Left‑sided heart (ventricular) failure
● Right ventricular MI
● Pulmonary problems (COPD, pulmonary fibrosis)

High‑output heart failure
● Increased metabolic needs
● Septicemia (fever)
● Anemia
● Hyperthyroidism

Cardiomyopathy (leading to heart failure)
● Coronary artery disease
● Infection or inflammation of the heart muscle
● Various cancer treatments
● Prolonged alcohol use
● Heredity

EXPECtED FINDINGs
The presence of other chronic illnesses (lung disease,
kidney failure) can mask the presence of heart failure in
older adult clients.

Left‑sided failure
● Dyspnea, orthopnea (shortness of breath while lying

down), nocturnal dyspnea
● Fatigue
● Displaced apical pulse (hypertrophy)
● S3 heart sound (gallop)
● Pulmonary congestion (dyspnea, cough, bibasilar crackles)
● Frothy sputum (can be blood‑tinged)

● Altered mental status
● Manifestations of organ failure, such as oliguria

(decrease in urine output)
● Nocturia

Right‑sided failure
● Jugular vein distention
● Ascending dependent edema (legs, ankles, sacrum)
● Abdominal distention, ascites
● Fatigue, weakness
● Nausea and anorexia
● Polyuria at rest (nocturnal)
● Liver enlargement (hepatomegaly) and tenderness
● Weight gain

Cardiomyopathy (leading to heart failure)

Blood circulation to the lungs is impaired when the
cardiac pump is compromised. (32.1)

FOUR TYPES
● Dilated (most common)
● Hypertrophic
● Arrhythmogenic right ventricular
● Restrictive

MANIFESTATIONS
● Fatigue, weakness
● Heart failure (left with dilated type, right with

restrictive type)
● Dysrhythmias (heart block)
● S3 gallop
● Cardiomegaly (enlarged heart), more severe with

dilated type
● Angina (hypertrophic type)

LABORAtORY tEsts

Human B‑type natriuretic peptides (hBNP)

In clients who have dyspnea, elevated hBNP confirms
a diagnosis of heart failure rather than a problem
originating in the respiratory system. hBNP levels direct
the aggressiveness of treatment interventions.

● Less than 100 pg/mL indicates no heart failure.
● 100 to 300 pg/mL suggests heart failure is present.
● Greater than 300 pg/mL indicates mild heart failure.
● Greater than 600 pg/mL indicates moderate heart failure.
● Greater than 900 pg/mL indicates severe heart failure.

DIAGNOstIC PROCEDUREs

Hemodynamic monitoring
● Heart failure generally results in increased central

venous pressure (CVP), increased pulmonary wedge
pressure (PAWP), increased pulmonary artery pressure
(PAP), and decreased cardiac output (CO). See CHAPTER 30:

INVASIVE CARDIOVASCULAR PROCEDURES for detailed
information related to hemodynamic monitoring.

● Mixed venous oxygen saturation (SvO2) is directly
related to cardiac output. A drop in SvO2 indicates
worsening cardiac function.

View Image: Cardiomyopathy

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 32 hEARt FAILURE AND PULmONARY EDEmA 207

Ultrasound

Two‑dimensional or three‑dimensional ultrasound (also
called cardiac ultrasound or echocardiogram) is used to
measure the systolic and diastolic functioning of the heart.

Left ventricular ejection fraction: The volume of blood
pumped from the left ventricle into the arteries upon each
beat. Expected reference range is 55% to 70%.

Right ventricular ejection fraction: The volume of blood
pumped from the right ventricle to the lungs upon each
beat. Expected reference range is 45% to 60%.

Transesophageal echocardiography (TEE)

Uses a transducer placed in the esophagus behind the
heart to obtain a detailed view of cardiac structures. The
nurse prepares the client for a TEE in the same manner as
for an upper endoscopy.

Chest x‑ray

A chest x‑ray can reveal cardiomegaly and pleural effusions.

ECG, cardiac enzymes, electrolytes, and ABGs

Used to assess factors contributing to heart failure and/or
the impact of heart failure. Monitor potassium level
closely if the client is taking antibiotics.

PATIENT‑CENTERED CARE

NURsING CARE
● Monitor daily weight and I&O.
● Assess for shortness of breath and dyspnea on exertion.
● Administer oxygen as prescribed.
● Monitor vital signs and hemodynamic pressures.
● Position the client to maximize ventilation

(high‑Fowler’s).
● Monitor diagnostic results to track progress.
● Assess for manifestations of medication toxicity

(digoxin toxicity).
● Encourage bed rest until the client is stable.
● Encourage energy conservation by assisting with

care and ADLs.
● Maintain dietary restrictions as prescribed (restricted

fluid intake, restricted sodium intake).
● Provide emotional support to the client and family.

mEDICAtIONs
Herbal medications and supplements can interact with
medications taken for disorders of the cardiovascular
system. Obtain a list of herbal supplements the client takes,
and advise the client of potential contraindications.

Diuretics

Diuretics are used to decrease preload.

Loop diuretics , such as furosemide and bumetanide

Thiazide diuretics , such as hydrochlorothiazide

Potassium‑sparing diuretics , such as spironolactone

NURSING ACTIONS
● Administer furosemide IV no faster than 20 mg/min.
● Loop and thiazide diuretics can cause hypokalemia, and

potassium supplementation can be required.

CLIENT EDUCATION: If taking loop or thiazide diuretics,
ingest foods and beverages that are high in potassium to
counter the effects of hypokalemia. If taking potassium‑
sparing diuretics, watch for hidden sources of potassium,
such as salt substitutes.

Afterload‑reducing agents

Afterload‑reducing agents help the heart pump more
easily by altering the resistance to contraction. These are
contraindicated for clients who have renal deficiency.

Angiotensin‑converting enzyme (ACE) inhibitors , such as
enalapril and captopril

Angiotensin receptor II blockers , such as losartan

Calcium channel blockers , such as diltiazem
and nifedipine

Phosphodiesterase‑3 inhibitors , such as milrinone

NURSING ACTIONS
● Monitor clients taking ACE inhibitors for hypotension

following the initial dose.
● ACE inhibitors can cause angioedema (swelling of

the tongue and throat), decreased sense of taste, or
skin rash.

● Monitor for increased levels of potassium.

CLIENT EDUCATION: ACE INHIBITORS
● This medication can cause a dry cough.
● Notify the provider if a rash or decreased sense of

taste occurs.
● Notify the provider if swelling of the face or

extremities occurs.
● Blood pressure needs to be monitored for 2 hr after the

initial dose to detect hypotension.

Inotropic agents

Inotropic agents (digoxin, dopamine, dobutamine,
milrinone, levosimendan) are used to increase
contractility and thereby improve cardiac output.

NURSING ACTIONS
● For a client taking digoxin, take the apical heart rate

for 1 min. Hold the medication if apical pulse is less
than 60/min, and notify the provider. For some clients,
the provider might allow the heart rate to be as low
as 50/min.

● Observe the client for nausea and vomiting.
● Dopamine, dobutamine, and milrinone are administered

via IV. The ECG, blood pressure, and urine output must
be closely monitored.

208 CHAPTER 32 hEARt FAILURE AND PULmONARY EDEmA CONTENT MASTERY SERIES

CLIENT EDUCATION
If self‑administering digoxin, be sure to:

● Count pulse for 1 min before taking the medication. If
the pulse rate is irregular or the pulse rate is outside of
the limitations set by the provider (usually less than
60/min or greater than 100/min), hold the dose and
contact the provider.

● Take the digoxin dose at the same time each day.
● Do not take digoxin at the same time as antacids.

Separate the two medications by at least 2 hr.
● Report manifestations of toxicity, including fatigue,

muscle weakness, confusion, and loss of appetite.
● Have blood digoxin and potassium levels

checked regularly.

Beta adrenergic blockers (beta blockers)

Medications such as carvedilol and metoprolol can be
used to improve the condition of the client who has
sustained increased levels of sympathetic stimulation and
catecholamines. This includes clients who have chronic
heart failure.

NURSING ACTIONS
● Monitor blood pressure, pulse, activity tolerance,

and orthopnea.
● Check orthostatic blood pressure readings.

CLIENT EDUCATION
● Weigh daily.
● Check blood pressure daily.
● Follow the provider’s instructions for increasing

medication dosage.

Vasodilators

Nitroglycerin and isosorbide mononitrate prevent coronary
artery vasospasm and reduce preload and afterload,
decreasing myocardial oxygen demand.

NURSING ACTIONS
● Vasodilators are given to treat angina and help control

blood pressure.
● Use cautiously with other antihypertensive mediations.
● Vasodilators can cause orthostatic hypotension.

CLIENT EDUCATION
● A headache is a common adverse effect of

this medication.
● Change positions down slowly.

Hyperpolarization‑activated cyclic nucleotide‑
gated channel blocker (HCN channel blocker)

● Slows heart rate by inhibiting sinus node channel
● Used for clients who can not take beta blockers or are

receiving the maximum dose

Human B‑type natriuretic peptides

hBNPs, such as nesiritide, are used to treat acute heart
failure by causing natriuresis (loss of sodium and
vasodilation). They are administered IV.

NURSING ACTIONS
● hBNPs can cause hypotension, as well as a number

of cardiac effects, including ventricular tachycardia
and bradycardia.

● BNP levels will increase while on this medication.
● Monitor ECG, blood pressure, and other parameters.

CLIENT EDUCATION
● This medication can decrease the blood pressure,

sometimes without warning.
● Sit and lie down slowly.

Anticoagulants

Anticoagulants, such as warfarin, can be prescribed if the
client has a history of thrombus formation.

NURSING ACTIONS
● Assess for contraindications: active bleeding, peptic

ulcer disease, history of cerebrovascular accident, and
recent trauma.

● Monitor bleeding times: PT, aPTT, INR, and CBC.

CLIENT EDUCATION
● Remember the risk for bruising and bleeding while on

this medication.
● Have blood monitored routinely to check bleeding times.

INtERPROFEssIONAL CARE
Cardiology and pulmonary services should be consulted
to manage heart failure.

Respiratory services should be consulted for inhalers,
breathing treatments, and suctioning for airway
management.

Cardiac rehabilitation services can be consulted if the
client has prolonged weakness and needs assistance with
increasing level of activity.

Nutritional services can be consulted for diet modification
to promote low‑sodium and low‑saturated fat food choices.

thERAPEUtIC PROCEDUREs

Ventricular assist device (VAD)

A VAD is a mechanical pump that assists a heart that is
too weak to pump blood through the body. It is used in
clients who are awaiting heart transplants or who have
severe end‑stage heart failure and are not candidates for
heart transplants.

● Heart transplantation is the treatment of choice for
clients who have severe dilated cardiomyopathy.

● Contraindications to VAD surgery include severe
chronic lung disease, end‑stage kidney disease,
clotting disorders, and infections unresponsive to
antibiotic therapy.

NURSING ACTIONS
● Prepare the client for the procedure (NPO status and

informed consent).
● Monitor postoperatively: vital signs, SaO2, incision

drainage, and pain management.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 32 hEARt FAILURE AND PULmONARY EDEmA 209

Heart transplantation
● Heart transplantation is a possible option for clients who

have end‑stage heart failure. Immunosuppressant therapy
is required post‑transplantation to prevent rejection.

● Eligibility for transplantation depends on several factors,
including life expectancy, age, psychosocial status, and
absence of substance use disorders.

NURSING ACTIONS
● Prepare the client for the procedure (NPO status and

informed consent).
● Monitor postoperatively: vital signs, SaO2, incision

drainage, and pain management.
● Monitor for complications. Organ transplant recipients

are at risk for infection, thrombosis, and rejection. See
CHAPTER 58: KIDNEY TRANSPLANT for details related to
these complications.

CLIENT EDUCATION
● Take diuretics in the early morning and early afternoon.
● Restrict fluid and sodium as instructed. Regulate

potassium intake as instructed to prevent high
or low potassium levels. A dietitian can help with
menu planning.

● Check weight daily at the same time, and notify the
provider for a weight gain of 2 lb in 24 hr or 5 lb in 1 week.

● Schedule regular follow‑up visits with the provider.
● Obtain the pneumococcal and yearly influenza vaccines.

COMPLICATIONS

Acute pulmonary edema

Acute pulmonary edema is a life‑threatening
medical emergency. Effective intervention should result
in diuresis (carefully monitor output), reduction in
respiratory distress, improved lung sounds, and adequate
oxygenation.

EXPECTED FINDINGS: Anxiety, tachycardia, acute
respiratory distress, dyspnea at rest, change in level of
consciousness, and an ascending fluid level within the lungs
(crackles, cough productive of frothy, blood‑tinged sputum).

NURSING ACTIONS
● Prompt response to this emergency includes the following.

◯ Positioning the client in high‑Fowler’s position
◯ Administration of oxygen, positive airway pressure,
intubation and mechanical ventilation

◯ IV morphine (to decrease anxiety, respiratory distress,
and decrease venous return)

● IV administration of rapid‑acting loop diuretics, such
as furosemide. Administer prescribed medications to
improve cardiac output.

● Teach the client about measures to improve tolerance
to activity, such as alternating periods of activity with
periods of rest.

Cardiogenic shock

This is a serious complication of pump failure that occurs
commonly following an MI with injury to greater than
40% of the left ventricle.

EXPECTED FINDINGS: Tachycardia, hypotension,
inadequate urinary output, altered level of consciousness,
respiratory distress (crackles, tachypnea), cool, clammy
skin, decreased peripheral pulses, chest pain

NURSING ACTIONS
● Monitor breath sounds. Assess for crackles or wheezing.
● Monitor heart sounds.
● Administration of oxygen, intubation, and ventilation

can be required.
● Administer IV morphine, diuretics, and/or nitroglycerin

to decrease preload. Administer IV vasopressors
and/or positive inotropes to increase cardiac output and
maintain organ perfusion.

● Provide continuous hemodynamic monitoring.

Pericardial tamponade

Cardiac tamponade can result from fluid accumulation in
the pericardial sac.

EXPECTED FINDINGS: Hypotension, jugular venous
distention, muffled heart sounds, and paradoxical pulse
(variance of 10 mm Hg or more in systolic blood pressure
between expiration and inspiration)

DIAGNOSTIC PROCEDURES: Hemodynamic monitoring
will reveal intracardiac and pulmonary artery pressures
similar and elevated (plateau pressures).

NURSING ACTIONS
● Notify the provider immediately.
● Administer IV fluids to combat hypotension while

monitoring for fluid overload.
● Obtain a chest x‑ray or echocardiogram to

confirm diagnosis.
● Prepare the client for pericardiocentesis (informed

consent, gather materials, administer medications
as appropriate).

● Monitor hemodynamic pressures to ensure
they normalize.

● Monitor heart rhythm; changes can indicate improper
positioning of the needle.

● Monitor for reoccurrence of findings after the procedure.

Pulmonary edema
Cardiogenic factors are the most common cause of
pulmonary edema. It is a complication of various heart and
lung diseases and usually occurs from increased pulmonary
vascular pressure secondary to severe cardiac dysfunction.

Noncardiac pulmonary edema can occur due to
barbiturate or opiate toxicity, inhalation of irritating
gases, rapid administration of IV fluids, and after a
pneumonectomy evacuation of pleural effusion.

Neurogenic pulmonary edema develops following a
head injury.

210 CHAPTER 32 hEARt FAILURE AND PULmONARY EDEmA CONTENT MASTERY SERIES

OLDER ADULTS: Increased risk for pulmonary edema
related to decreased cardiac output and heart failure

● Increased risk for fluid and electrolyte imbalances
occurs when the older adult client receives treatment
with diuretics.

● IV infusions must be administered at a slower rate to
prevent circulatory overload.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Remain physically active, but consult with the provider
before starting any exercise regimen.

● Consume a diet low in sodium; some clients require
fluid restrictions. (Consult with the provider regarding
diet specifications.)

● Refrain from tobacco use.

ASSESSMENT

RIsK FACtORs
● Acute MI
● Fluid volume overload
● Hypertension
● Valvular heart disease
● Postpneumonectomy
● Postevacuation of pleural effusion
● Acute respiratory failure
● Left‑sided heart failure
● High altitude exposure or deep‑sea diving
● Trauma
● Sepsis
● Medication toxicity

EXPECtED FINDINGs
● Anxiety
● Inability to sleep
● Persistent cough with pink, frothy sputum (key finding)
● Tachypnea, dyspnea, and orthopnea
● Hypoxemia
● Cyanosis (later stage)
● Crackles
● Tachycardia
● Reduced urine output
● Confusion, stupor
● S3 heart sound (gallop)
● Increased pulmonary artery occlusion pressure

PATIENT‑CENTERED CARE

NURsING CARE
● Position the client in high‑Fowler’s position with feet

and legs dependent or sitting on the side of the bed to
decrease preload.

● Administer high‑flow oxygen using a face mask or
non‑rebreather mask. Bilevel positive airway pressure
or intubation/ventilation can become necessary. Be
prepared to intervene quickly.

● Monitor vital signs every 15 min until stable.
● Monitor intake and output.
● Monitor hemodynamic status (pulmonary wedge

pressures, cardiac output).
● Check ABGs, electrolytes (especially potassium if on

diuretics), SaO2, and chest x‑ray findings.
● Maintain a patent airway. Suction as needed.
● Restrict fluid intake (slow or discontinue infusing

IV fluids).
● Monitor hourly urine output. Watch for intake greater

than output or hourly urine less than 30 mL/hr.
● Provide emotional support for the client and family.

mEDICAtIONs
Rapid‑acting diuretics , such as furosemide and
bumetanide, promote fluid excretion.

Morphine decreases sympathetic nervous system response
and anxiety and promotes mild vasodilation.

Vasodilators (nitroglycerin, sodium nitroprusside)
decrease preload and afterload.

Inotropic agents , such as digoxin and dobutamine,
improve cardiac output.

Antihypertensives , such as ACE inhibitors and
beta‑blockers, decrease afterload.

CLIENt EDUCAtION
● Use techniques to promote effective

breathing techniques.
● Understand prescribed medications and how to

administer them.
● Continue to take medications even if feeling better.
● Follow instructions for reasons to contact the provider.
● Remain on a low‑sodium diet and restrict fluids

as prescribed.
● Measure weight daily at the same time. Notify the

provider of a gain of more than 2 lb in 1 day or 5 lb
in 1 week.

● Report swelling of feet or ankles or any shortness of
breath or angina.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 32 hEARt FAILURE AND PULmONARY EDEmA 211

Active Learning Scenario

A nurse in a cardiac rehabilitation program is teaching a
class on heart failure to a group of clients. What should
the nurse include in this presentation? Use the AtI Active
Learning template: system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS): Describe the
difference between left‑ and right‑sided heart failure.

LABORATORY TESTS: Describe one and its importance.

DIAGNOSTIC PROCEDURES: Describe two.

MEDICATIONS: Describe two groups of medications
and an example of one medication for each group.

Application Exercises

1. A nurse is caring for a client who has heart failure
and reports increased shortness of breath. Which of
the following actions should the nurse take first?

A. Obtain the client’s weight.

B. Assist the client into high‑Fowler’s position.

C. Auscultate lungs sounds.

D. Check oxygen saturation with pulse oximeter.

2. A nurse is teaching a client who heart failure and
new prescriptions for furosemide and digoxin.
Which of the following information should
the nurse include? (select all that apply).

A. Weigh daily, first thing each morning.

B. Decrease intake of potassium.

C. Expect muscle weakness while taking digoxin.

D. hold digoxin if heart rate is less than 70/min.

E. Decrease sodium intake.

3. A nurse is completing the admission assessment
of a client who has suspected pulmonary edema.
Which of the following manifestations are
expected findings? (select all that apply.)

A. tachypnea

B. Persistent cough

C. Increased urinary output

D. thick, yellow sputum

E. Orthopnea

4. A nurse is talking with a client who has class
I heart failure and asks about obtaining a
ventricular assist device (vAD). Which of the
following statement should the nurse make?

A. ”vADs are only implanted during
heart transplantation.”

B. “A vAD helps to pace the heart.”

C. “vADs are used when heart failure is
not responsive to medications.”

D. “A vAD is useful for clients who also
have a chronic lung issue.”

5. A nurse is providing discharge teaching for a client
who has heart failure and is on a fluid restriction
of 2,000 mL/day. the client asks the nurse how to
determine the appropriate amount of fluids they
are allowed. Which of the following statements
is an appropriate response by the nurse?

A. “Pour the amount of fluid you drink into an empty
2‑liter bottle to keep track of how much you drink.”

B. “Each glass contains 8 ounces. there are
30 milliliters per ounce, so you can have a
total of 8 glasses or cups of fluid each day.”

C. “this is the same as 2 quarts, or about
the same as two pots of coffee.”

D. “take sips of water or ice chips so you
will not take in too much fluid.”

212 CHAPTER 32 hEARt FAILURE AND PULmONARY EDEmA CONTENT MASTERY SERIES

Application Exercises Key

1. A. Check the client’s weight to monitor for weight gain.
however, another action is the priority.

B. CORRECT: Using the airway, breathing, and circulation
(ABC) priority approach to client care, the first action
to take is to assist the client into high‑Fowler’s
position. this will decrease venous return to the heart
(preload) and help relieve lung congestion.

C. Auscultate lung sounds to monitor for adventitious sounds,
such as crackles. however, another action is the priority.

D. Check the client’s oxygen saturation to monitor for a
decrease. however, another action is the priority.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

2. A. CORRECT: Weighing daily when first getting out of bed
will assist the client in tracking fluid loss and gain.

B. Increase intake of potassium to prevent
hypokalemia while taking furosemide, which
increases the risk for digoxin toxicity.

C. Report muscle weakness while taking digoxin
as an indication of possible toxicity.

D. hold digoxin if heart rate less than 50 to 60/min. the
provider will prescribe the parameters for the client.

E. CORRECT: Decrease sodium intake to prevent fluid retention,
which could worsen heart failure manifestations.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

3. A. CORRECT: tachypnea is an expected finding in
a client who has pulmonary edema.

B. CORRECT: A persistent cough with pink, frothy sputum is an
expected finding in a client who has pulmonary edema.

C. Decreased urinary output is an expected finding
in a client who has pulmonary edema.

D. Pink, frothy sputum is an expected finding in
a client who has pulmonary edema.

E. CORRECT: Orthopnea is an expected finding
in a client who has pulmonary edema.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. A. A vAD is often placed for clients awaiting heart
transplant, to maintain adequate circulation.

B. A vAD is a pump that promotes blood
circulation throughout the body.

C. CORRECT: One use for a vAD is to prolong life for clients who
have become unresponsive to heart failure medications.

D. Implantation of a vAD is contraindicated for
clients who also have a chronic lung issue.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

5. A. CORRECT: Pouring the amount of fluid consumed into an
empty 2 L bottle provides a visual guide for the client as to
the amount consumed and how to plan daily intake.

B. Glasses and cups vary in size and can
contain more than 8 oz.

C. Offering a vague frame of reference does not
assist with accurate fluid measurement.

D. suggesting that the client take sips of water or ice chips
does not assist with accurate fluid measurement.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): Left‑sided heart failure results
in inadequate output from the left ventricle, leading to poor tissue
perfusion. systolic failure includes an ejection fraction below 40%
with pulmonary and systemic congestion. Diastolic failure includes
stiffening or inadequate relaxation of the ventricle. Right‑sided
heart failure results in inadequate output from the right ventricle,
leading to systemic venous congestion and peripheral edema.

LABORATORY TESTS: human B‑type natriuretic
peptides (hBNP) confirms a diagnosis of heart failure, and
findings direct the aggressiveness of the treatment.

DIAGNOSTIC PROCEDURES
● hemodynamic monitoring
● Ultrasound
● Chest x‑ray
● Electrocardiogram

MEDICATIONS
● Diuretics: furosemide, bumetanide,
hydrochlorothiazide, spironolactone

● Afterload‑reducing agents: enalapril, captopril,
losartan, diltiazem, nifedipine, milrinone

NCLEX® Connection: Physiological Adaptation, Alterations in
Body Systems

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 33 vALvULAR hEARt DIsEAsE 213

UNIT 4 CARDIOVASCULAR DISORDERS
SECTION: CARDIAC DISORDERS

CHAPTER 33 Valvular Heart
Disease

valvular heart disease describes an abnormality
or dysfunction of any of the heart’s four valves:
the mitral and aortic valves (left side), the
tricuspid, and pulmonic valves (right side).
tricuspid valve dysfunction occurs secondary to
endocarditis or Iv illicit drug use, and is rare.

valve dysfunction affects the efficiency of the
heart as a pump and reduces stroke volume.
Over time, there might be remodeling of the
heart itself (hypertrophy) and heart failure.

With age, fibrotic thickening occurs in the
mitral and aortic valves. the aorta is stiffer in
older adult clients, increasing systolic blood
pressure and stress on the mitral valve. (33.1)

HEALTH PROMOTION AND
DISEASE PREVENTION

● Prevent and treat bacterial infections.
● Encourage clients to consume a diet
low in sodium and to follow fluid
restrictions prescribed by the provider
to prevent heart failure.

● Control chronic illnesses
(diabetes mellitus, hypertension,
hypercholesterolemia).

● Encourage increased activity and
exercise to boost high‑density
lipoprotein (HDL) levels.

ASSESSMENT
● Valvular heart disease is classified as:

◯ Stenosis: Narrowed opening impedes blood
moving forward.

◯ Insufficiency/Improper closure: Some blood flows
backward (regurgitation).

● Valvular heart disease can have congenital or
acquired causes.

◯ Congenital valvular heart disease can affect all four
valves and cause either stenosis or insufficiency.

◯ Acquired valvular heart disease is classified as one of
three types:

■ Degenerative disease: Due to damage over time
from mechanical stress, atherosclerosis, and
hypertension. Most common in developed countries.

■ Rheumatic disease: Gradual fibrotic changes,
calcification of valve cusps. Most common in
developing countries.

■ Infective endocarditis: Infectious organisms
destroy the valve. Streptococcal infections are a
common cause.

RIsK FACtORs
● Hypertension
● Rheumatic fever (mitral stenosis and insufficiency)
● Infective endocarditis
● Congenital malformations
● Marfan syndrome (connective tissue disorder that

affects the heart and other areas of the body)
● In older adult clients, the predominant causes of

valvular heart disease are degenerative calcification and
atherosclerosis, papillary muscle dysfunction, and
infective endocarditis.

CHAPTER 33

33.1 Heart valve blood flow comparison

214 CHAPTER 33 vALvULAR hEARt DIsEAsE CONTENT MASTERY SERIES

EXPECtED FINDINGs
● Clients who have valvular heart disease often do not

have manifestations until late in the progression of
the disease.

● A murmur is heard with turbulent blood flow. The
location of the murmur and timing (diastolic
versus systolic) help determine the valve involved.
Murmurs are graded on a scale of I (very faint) to VI
(extremely loud).

● Left‑sided valve damage causes increased pulmonary
artery pressure, left ventricular hypertrophy, and
decreased cardiac output, resulting in orthopnea,
paroxysmal nocturnal dyspnea (PND), and fatigue. (33.2)

DIAGNOstIC PROCEDUREs
Chest x‑ray shows chamber enlargement (with stenosis
and insufficiencies) and pulmonary congestion (with
aortic stenosis).

12‑lead electrocardiogram (ECG) shows chamber
hypertrophy.

Echocardiogram shows chamber size, hypertrophy,
specific valve dysfunction, ejection function, and amount
of regurgitant flow.

Transesophageal echocardiography (TEE) provides
visualization of the mitral and aortic valves; can be used
intraoperatively during valve replacement and repair.

Exercise tolerance testing/stress echocardiography is
used to assess the impact of the valve problem on cardiac
functioning during stress.

Radionuclide studies determine ejection fraction during
activity and rest.

Angiography is used to evaluate the coronary arteries
and the degree of atherosclerosis. Cardiac catheterization
might be used as a diagnostic tool in valvular disease.

PATIENT‑CENTERED CARE

NURsING CARE
● Monitor current weight and note recent changes.
● Assess heart rhythm (can be irregular or bradycardic,

assess for murmur).
● Administer oxygen and medications.
● Assess hemodynamic monitoring. Maintain fluid and

sodium restrictions.
● Assist the client to conserve energy.

mEDICAtIONs

Diuretics

Diuretics are used to treat heart failure by removing
excessive extracellular fluid.

● Loop diuretics, such as furosemide
● Thiazide diuretics, such as hydrochlorothiazide
● Potassium‑sparing diuretics, such as spironolactone

NURSING ACTIONS
● Administer furosemide IV slowly over 1 to 2 minutes.
● Monitor for hypokalemia with loop and thiazide diuretics,

and administer potassium supplements as indicated.

CLIENT EDUCATION: If taking loop or thiazide diuretics,
ingest foods (dried fruits, nuts, spinach, citrus fruits,
bananas and potatoes) and beverages that are high in
potassium to decrease the risk of developing
hypokalemia.

Afterload‑reducing agents

Afterload‑reducing agents help the heart pump more
easily by altering the resistance to contraction.

● Angiotensin‑converting enzyme (ACE) inhibitors
(enalapril , captopril, lisinopril)

● Angiotensin‑receptor blockers (losartan, valsartan)

33.2 Left‑sided valve damage

Mitral stenosis
Apical diastolic murmur
Dyspnea on exertion
Orthopnea
Atrial fibrillation
Palpitations
Fatigue
Jugular venous distention
Pitting edema
hemoptysis
Dry cough
PND
hepatomegaly

Mitral insufficiency
systolic murmur at the apex
s3 sounds
Fatigue and weakness
Atrial fibrillation
Dyspnea on exertion
Orthopnea
Atypical chest pain
Palpitations
Jugular venous distention
Pitting edema
Possible diminished
lung sounds
PND
hepatomegaly

Aortic stenosis
systolic murmur
Dyspnea on exertion
s4 sounds
Angina
syncope on exertion
Fatigue
Orthopnea
PND
Narrowed pulse pressure

Aortic insufficiency
Diastolic murmur
sinus tachycardia
Exertional dyspnea
Orthopnea
Palpitations
Fatigue
Nocturnal angina
with diaphoresis
Widened pulse pressure
Bounding arterial pulse on
palpation (Corrigan’s pulse)
Elevated systolic and
diminished diastolic pressures
PND

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 33 vALvULAR hEARt DIsEAsE 215

● Beta‑blockers, metoprolol, carvedilol
● Calcium‑channel blockers (felodipine,

nifedipine, amlodipine)
● Vasodilators, such as hydralazine

NURSING ACTIONS: Monitor clients taking ACE inhibitors
for initial dose hypotension.

Inotropic agents

Inotropic agents, such as digoxin, are used to increase
contractility and thereby improve cardiac output.

CLIENT EDUCATION
If self‑administering digoxin:

● Count pulse for 1 min before taking the medication. If
the pulse rate is irregular or the pulse rate is outside
of the limitations set by the provider (usually less than
60/min or greater than 100/min), the hold the dose and
contact the provider.

● Take the dose of digoxin at the same time every day.
● Do not take digoxin at the same time as antacids.

Separate the two medications by at least 2 hr
● Report manifestations of toxicity, including fatigue,

muscle weakness, confusion, visual changes, and loss
of appetite.

Anticoagulants

Anticoagulation therapy is used for clients who have a
mechanical valve replacement, atrial fibrillation, or severe
left ventricle dysfunction.

thERAPEUtIC PROCEDUREs
NURSING ACTIONS: Postsurgery care is similar to coronary
artery bypass surgery (care for sternal incision, activity
limited for 6 weeks, report fever).

Percutaneous balloon valvuloplasty

This procedure can open aortic or mitral valves affected
by stenosis. A catheter is inserted through the femoral
artery and advanced to the heart. A balloon is inflated at
the stenotic lesion to open the fused commissures and
improve leaflet mobility.

Valve replacement

This procedure replaces damaged heart valves with
mechanical, xenografts (from other species), allografts
(from cadavers), or autografts (formed from the client’s
pulmonic valve and a portion of the pulmonary artery).
It is often done with an open‑heart approach, although
minimally invasive surgery is also performed in
some instances.

● Mechanical valves require lifelong
anticoagulant therapy.

● Tissue valves need to be replaced every 7 to 10 years.

Miscellaneous surgical management
● Other surgeries used in the treatment of valvular

disorders include chordae tendineae reconstruction,
commissurotomy (relieve stenosis on leaflets),
annuloplasty ring insertion (correct dilatation of valve
annulus by narrowing the opening), and leaflet repair.

● Medical management is appropriate for many older
adult clients; surgery is indicated when manifestations
interfere with daily activities. The goal of surgery can
be to improve the quality of life rather than to
prolong life.

INtERPROFEssIONAL CARE
● Respiratory services should be consulted for

inhalers, breathing treatments, and suctioning for
airway management.

● Cardiology can be consulted for cardiac management.
● Nutritional services can be contacted for weight loss or

gain related to medications or diagnosis.
● Rehabilitative care might need to be consulted if the

client has prolonged weakness and needs assistance
with increasing level of activity.

CLIENt EDUCAtION
● Prophylactic antibiotic use is important before any

invasive dental or respiratory procedure.
● Weigh daily and notify the provider of 3 lb (1.4 kg) gain

in 1 day or 5 lb (2.3 kg) gain in 1 week.
● Coordinate activities with planned rest periods.
● Follow the prescribed exercise program.
● Adhere to dietary restrictions, including avoidance of

caffeine and alcohol; consider nutritional consultation.
● Perform energy conservation.
● Open wounds need to be cleaned carefully and antibiotic

ointment should be used.
● Read labels of over‑the‑counter medication to avoid

those which include alcohol, ephedrine, or epinephrine
(might cause dysrhythmias).

● Report manifestations of heart failure, fever, or
petechial rash to the provider immediately.

COMPLICATIONS

Heart failure

Heart failure is the inability of the heart to maintain
adequate circulation to meet tissue needs for oxygen and
nutrients. Ineffective valves result in heart failure.

NURSING ACTIONS: Monitoring the client’s heart failure
class (I to IV) is often the gauge for surgical intervention
for valvular problems.

216 CHAPTER 33 vALvULAR hEARt DIsEAsE CONTENT MASTERY SERIES

Active Learning Scenario

A nurse educator is preparing a poster on valvular heart
disease to be displayed at a health fair. What content should
be included on the poster? Use the AtI Active Learning
template: system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)
● Describe the difference between valve
stenosis and insufficiency.

● Describe the difference between acquired
and congenital valvular heart disease.

CLIENT EDUCATION: Describe two
actions to prevent valvular disease.

Application Exercises

1. A nurse is completing discharge teaching with a
client who had a surgical placement of a mechanical
heart valve. Which of the following statements by
the client indicates understanding of the teaching?

A. “I will be glad to get back to my
exercise routine right away.”

B. “I will have my prothrombin time
checked on a regular basis.”

C. “I will talk to my dentist about no longer
needing antibiotics before dental exams.”

D. “I will continue to limit my intake of
foods containing potassium.”

2. A nurse is completing the admission physical
assessment of a client who has mitral
valve insufficiency. Which of the following
findings should the nurse expect?

A. s4 heart sound

B. Petechiae

C. Neck vein distention

D. splenomegaly

3. A nurse is reviewing the health record of a client who
is being evaluated for possible valvular heart disease.
the nurse should recognize which of the following data
as risk factors for this condition? (select all that apply.)

A. surgical repair of an atrial septal defect at age 2

B. measles infection during childhood

C. hypertension for 5 years

D. Weight gain of 10 lb in past year

E. Diastolic murmur present

4. A nurse is caring for an older adult client who is to
undergo a percutaneous balloon valvuloplasty. the
client’s family member asks the nurse to explain
the expected outcome of this procedure. Which of
the following responses should the nurse give?

A. “this will improve blood flow of
the coronary arteries.”

B. “this will assist with the ability to
perform activities of daily living.”

C. “this will prolong the life span of
living with this valve disorder.”

D. “this will reverse the effects to the damaged area.”

5. A nurse educator is reviewing expected findings
in a client who has right‑sided valvular heart
disease with a group of nurses. Which of the
following findings should the nurse include
in the discussion? (select all that apply.)

A. Dyspnea

B. Client report of fatigue

C. Bradycardia

D. Pleural friction rub

E. Peripheral edema

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 33 vALvULAR hEARt DIsEAsE 217

Application Exercises Key

1. A. the client will be on activity limitation for 6 weeks
following surgery for a heart valve replacement.

B. CORRECT: Anticoagulant therapy with warfarin is
necessary for the client following placement of a
mechanical heart valve; the client’s prothrombin
time will be checked on a regular basis.

C. Antibiotic therapy is recommended prior to dental
work following placement of a heart valve.

D. Dietary recommendations include limiting
foods containing sodium.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

2. A. An s3 heart sound is an expected finding in a client who
has mitral valve insufficiency. An s4 heart sound is an
expected finding for a client who has aortic stenosis.

B. Petechiae is an expected finding in a client
who has infective endocarditis.

C. CORRECT: Neck vein distention is an expected
finding in a client who has pulmonary congestion
due to mitral valve insufficiency.

D. hepatomegaly, not splenomegaly, is an expected finding
in a client who has left‑sided heart valve damage.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. A. CORRECT: A history of congenital malformations
is a risk factor for valvular heart disease.

B. having a streptococcal infection or rheumatic fever during
childhood is a risk factor for valvular heart disease.

C. CORRECT: hypertension places a client
at risk for valvular heart disease.

D. A sudden weight gain of 10 lb could indicate fluid
collection related to left‑sided valvular heart disease.

E. CORRECT: A murmur indicates turbulent blood flow,
which is often due to valvular heart disease.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

4. A. A valvuloplasty improves blood flow through a
heart valve by opening the fused commissures and
allowing valve leaflets greater mobility. It does not
improve blood flow in the coronary arteries.

B. CORRECT: surgery is indicated for older adult clients when
manifestations interfere with activities of daily living.

C. surgical interventions can improve the client’s quality
of life, but they will not necessarily prolong life.

D. A valvuloplasty improves blood flow through a heart
valve by opening the fused commissures and allowing
valve leaflets greater mobility. It does not reverse the
damage that has already occurred to the valve.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. A. CORRECT: Dyspnea is a manifestation of
right‑sided valvular heart disease.

B. CORRECT: A client’s report of fatigue is a manifestation
of right‑sided valvular heart disease.

C. A normal or rapid pulse and an irregular rhythm are
manifestations of right‑sided valvular heart disease.

D. A pleural friction rub is a manifestation
of pleurisy or pneumonia.

E. CORRECT: Peripheral edema is a manifestation
of right‑sided valvular heart disease.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS)
● stenosis is the narrowed opening of a heart valve, which
prevents blood from moving forward. Insufficiency is the
improper closure of a valve resulting in blood flowing
backward (regurgitation) through the valve.

● Congenital valvular heart disease can affect all four valves and
can cause either stenosis or insufficiency. Acquired valvular heart
disease occurs due to degenerative changes from mechanical
stress over time; rheumatic disease, which causes calcifications
and fibrotic changes, often to the mitral valve; and infective
endocarditis, in which infectious organisms destroy the valve.

CLIENT EDUCATION
● Prevent and manage hypertension.
● Prevent and seek early treatment of bacterial infections.
● Consume a low‑sodium diet.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

218 CHAPTER 33 vALvULAR hEARt DIsEAsE CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 34 INFLAmmAtORY DIsORDERs 219

UNIT 4 CARDIOVASCULAR DISORDERS
SECTION: CARDIAC DISORDERS

CHAPTER 34 Inflammatory
Disorders

Inflammation related to the heart is an extended
inflammatory response that often leads to the
destruction of healthy tissue. this primarily
includes the layers of the heart.

Inflammatory disorders related to the
cardiovascular system that nurses should be
familiar with include pericarditis, myocarditis,
rheumatic endocarditis, and infective endocarditis.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Early treatment of streptococcal infections can prevent
rheumatic fever.

● Prophylactic treatments (including antibiotics
for clients who have cardiac defects) can prevent
infective endocarditis.

● Influenza and pneumonia immunizations are important
for all clients (especially older adults) in order to
decrease the incidence of myocarditis.

ASSESSMENT

RIsK FACtORs
● Congenital heart defect/cardiac anomalies
● Intravenous substance use
● Heart valve replacement
● Immunosuppression
● Rheumatic fever and other infections
● School‑age children who have a long duration of

streptococcus infection
● Malnutrition
● Overcrowding
● Lower socioeconomic status

EXPECtED FINDINGs
Pericarditis: Inflammation of the pericardium

● Commonly follows a respiratory infection.
● Can be due to a myocardial infarction.
● Can be due to acute exacerbation of a systemic

connective tissue disease.
● Findings include chest pressure/pain aggravated

by breathing (mainly inspiration), coughing, and
swallowing; pericardial friction rub auscultated at left
lower sternal border; shortness of breath; and relief of
pain when sitting and leaning forward.

Myocarditis: Inflammation of the myocardium
● Can be due to a viral, fungal, or bacterial infection, or a

systemic inflammatory disease (Crohn’s disease).
● Findings include tachycardia, murmur, friction rub

auscultated in the lungs, cardiomegaly, chest pain,
and dysrhythmias.

Rheumatic endocarditis: An infection of the endocardium
due to a complication of rheumatic fever.

● Preceded by group A beta‑hemolytic streptococcal
pharyngitis

● Produces lesions in the heart
● Findings include fever, chest pain, joint pain,

tachycardia, shortness of breath, rash on trunk and
extremities, friction rub, murmur, muscle spasms

Infective endocarditis: Infection of the endocardium
due to staphylococci, streptococci, fungi or other
infectious organisms

● Most common in clients who have structural cardiac
malformations, cardiac devices (pacemaker), prosthetic
heart valves, or IV substance use disorder.

● Invasive procedures (dental procedures, body piercing,
tattooing) can cause bacteremia, which can lead to
infective endocarditis in at‑risk clients.

● Findings include fever, flu‑like manifestations, murmur,
petechiae (on the trunk and mucous membranes),
positive blood cultures, and splinter hemorrhages (red
streaks under the nail beds).

LABORAtORY tEsts
● Blood cultures can detect a bacterial infection.
● An elevated WBC count can be indicative of a

bacterial infection.
● Cardiac enzymes can be elevated with pericarditis.
● Elevated ESR and CRP indicate inflammation in the body.
● Throat cultures can detect a streptococcal infection,

which can lead to rheumatic fever.

DIAGNOstIC PROCEDUREs

Electrocardiography (ECG)

Can detect a heart block, which is associated with
rheumatic fever or demonstrate ST segment elevation in
almost all leads in the case of pericarditis

Echocardiography

Can reveal inflamed heart layers or pericardial effusion

PATIENT‑CENTERED CARE

NURsING CARE
● Auscultate heart sounds. (Listen for murmur or

friction rub.)
● Review ABGs, SaO2, and chest x‑ray results.
● Administer oxygen.
● Monitor vital signs. (Watch for fever.)
● Monitor ECG, and notify the provider of changes.
● Monitor for cardiac tamponade and heart failure.

CHAPTER 34

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220 CHAPTER 34 INFLAmmAtORY DIsORDERs CONTENT MASTERY SERIES

● Obtain throat cultures to identify bacteria to be treated
by antibiotic therapy.

● Administer antibiotics.
● Administer antipyretics.
● Assess onset, quality, duration, and severity of pain.
● Administer pain medication.
● Encourage bed rest.
● Provide emotional support to the client and family, and

encourage verbalization of feelings regarding the illness.

mEDICAtIONs

Penicillin

Antibiotic given to treat infection

NURSING ACTIONS
● Monitor for skin rash and hives.
● Monitor electrolyte and kidney levels.

CLIENT EDUCATION
● Report skin rash or hives.
● The medication can cause gastrointestinal (GI) distress.

Ibuprofen

NSAIDs are given to treat fever and inflammation
associated with pericarditis. No longer used for treatment
of pain and inflammation with myocarditis.

NURSING ACTIONS
● Do not use with clients who have peptic ulcer disease.
● Watch for indications of GI distress.
● Monitor platelets, and liver and kidney function levels.

CLIENT EDUCATION
● The medication can cause GI distress. Taking with food

reduces the risk.
● Avoid alcohol consumption while taking the medication.

Prednisone

Glucocorticosteroid given to treat inflammation

NURSING ACTIONS
● Use in low doses.
● Monitor blood pressure.
● Monitor electrolytes and blood sugar levels.
● Monitor for impaired healing in clients taking

this medication.

CLIENT EDUCATION
● Take the medication with food.
● Avoid stopping the medication abruptly.
● Report unexpected weight gain.

Amphotericin B

Antifungal given to treat fungal infection

NURSING ACTIONS: Monitor liver and kidney
function levels.

CLIENT EDUCATION: The medication can cause GI distress.

INtERPROFEssIONAL CARE
● Cardiology services are consulted to manage

cardiac dysfunction.
● Infectious disease services can be consulted to

manage infection.
● Physical therapy can be consulted to increase the

client’s level of activity once prescribed.

thERAPEUtIC PROCEDUREs

Pericarditis

Pericardiocentesis is the insertion of a needle into the
pericardium to aspirate pericardial fluid. This can be done
in the emergency department or a procedure room.

NURSING ACTIONS
● Pericardial fluid can be sent to the laboratory for culture

and sensitivity.
● Monitor for reoccurrence of cardiac tamponade.

Infective endocarditis

Valve debridement, draining of abscess, and repairing
congenital shunts are procedures involved with infective
endocarditis.

NURSING ACTIONS: Monitor for indications of bleeding,
infection, and alteration in cardiac output.

CLIENt EDUCAtION
● Take rest periods as needed.
● Wash hands to prevent infection.
● Avoid crowded areas to reduce the risk of infection.
● Good oral hygiene and the prevention of infection

is important.
● Taking medications as prescribed is important.
● Demonstrate the administration of intravenous

antibiotics and management before discharge.
● Participate in cessation of tobacco use if applicable.
● Understand the illness, and express any feelings.
● Advise all providers, including dentists, of history of

endocarditis so that antibiotic prophylaxis is prescribed
if needed.

CARE AFTER DISCHARGE
● Home health services can be indicated if the client

had surgery.
● Intravenous antibiotic therapy can be given by the home

health service.
● Pharmaceutical services can be indicated for IV supplies

and medications.
● Rehabilitation services can be indicated to help the

client increase the level of activity.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 34 INFLAmmAtORY DIsORDERs 221

COMPLICATIONS

Cardiac tamponade

Cardiac tamponade, considered a medical emergency, can
result from fluid accumulation in the pericardial sac.

● Manifestations include dyspnea, dizziness, report of
“tightness” in the chest, increasing restlessness, pulsus
paradoxus (a decrease of 10 mm Hg or more in systolic
blood pressure during inspiration), tachycardia, muffled
heart sounds, and jugular venous distention.

● Hemodynamic monitoring reveals intracardiac and
pulmonary artery pressures similar and elevated
(plateau pressures).

NURSING ACTIONS
● Notify the provider immediately.
● Administer IV fluids to combat hypotension.
● Obtain a chest x‑ray or echocardiogram to confirm

the diagnosis.
● Prepare the client for pericardiocentesis (informed consent,

gather materials, administer medications as prescribed).
◯ Monitor hemodynamic pressures to ensure
they normalize.

◯ Monitor heart rhythm as changes indicate improper
positioning of the needle.

◯ Monitor for reoccurrence of manifestations after the
procedure.

Active Learning Scenario

A nurse is reviewing discharge teaching with a client
who has myocarditis. What should the nurse include in
the teaching? Use the AtI Active Learning template:
system Disorder to complete this item.

CLIENT EDUCATION
● Identify at least two referral facilities and
the services they can provide.

● Describe at least four actions the client
should take when at home.

Application Exercises

1. A nurse is caring for a client who has pericarditis. Which
of the following findings should the nurse expect?

A. Petechiae

B. murmur

C. Rash

D. Friction rub

2. A nurse is caring for four clients. Which of the
following clients should the nurse identify as being
at risk of developing rheumatic endocarditis?

A. Older adult who has chronic
obstructive pulmonary disease

B. Child who has streptococcal pharyngitis

C. middle‑aged adult who has lupus erythematosus

D. Young adult who recently received a body tattoo

3. A nurse in a clinic is caring for a client who has
been on long‑term NsAID therapy to treat
pericarditis. Which of the following laboratory
findings should the nurse report to the provider?

A. Platelets 100,000/mm3

B. serum glucose 110 mg/dL

C. serum creatinine 0.7 mg/dL

D. Amino alanine transferase (ALt) 30 IU/L

4. A nurse is assessing a client who has splinter
hemorrhages of the nail beds and reports a
fever. the nurse should identify these findings as
manifestations of which of the following disorders?

A. Infective endocarditis

B. Pericarditis

C. myocarditis

D. Rheumatic endocarditis

5. A nurse is admitting a client who has suspected
rheumatic endocarditis. the nurse should expect
a prescription for which of the following laboratory
tests to assist in confirmation of this diagnosis?

A. Arterial blood gases

B. serum albumin

C. Liver enzymes

D. throat culture

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222 CHAPTER 34 INFLAmmAtORY DIsORDERs CONTENT MASTERY SERIES

Application Exercises Key

1. A. Petechiae are an expected finding in a
client who has endocarditis.

B. A murmur is an expected finding in a client
who has myocarditis and endocarditis.

C. Rash is an expected finding in a client who
has rheumatic endocarditis.

D. CORRECT: A friction rub can be heard during
auscultation of a client who has pericarditis.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. A. An older adult who has chronic obstructive pulmonary
disease is not at risk for rheumatic endocarditis
unless they develop rheumatic fever.

B. CORRECT: A child who has streptococcal pharyngitis
is at risk for developing rheumatic fever, which
could result in rheumatic endocarditis.

C. A middle‑age adult who has lupus erythematosus
is not at risk for rheumatic endocarditis unless
they develop rheumatic fever.

D. A young adult who receives a body tattoo is at increased
risk for infective endocarditis but is not at risk for rheumatic
endocarditis unless they develop rheumatic fever.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

3. A. CORRECT: Long‑term NsAID therapy can lower platelets.
this finding is outside the expected reference range
and should be reported to the provider.

B. Blood glucose is not affected by long‑term NsAID therapy.
this finding is within the expected reference range.

C. Kidney function, which is monitored by blood creatinine
level, is affected by long‑term NsAID therapy. this
finding is within the expected reference range.

D. Liver function, which is monitored by the ALt level,
is affected by long‑term NsAID therapy. this finding
is within the expected reference range.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

4. A. CORRECT: splinter hemorrhages in nail beds and a report of
fever are findings associated with infective endocarditis.

B. A client who has pericarditis would report chest pain.
C. A client who has myocarditis would report a rapid heart rate.
D. A client who has rheumatic endocarditis

would report joint pain.

NCLEX® Connection: Physiological Adaptation,
Illness Management

5. A. Arterial blood gases are used to monitor the respiratory
status of a client who has suspected rheumatic endocarditis,
but they do not confirm the diagnosis.

B. Blood albumin monitors the nutrition status of a
client who has a suspected inflammatory disorder,
but it does not confirm the diagnosis.

C. Liver enzymes monitor a client’s response to antibiotic
therapy, which is used to treat rheumatic endocarditis,
but they do not confirm the diagnosis.

D. CORRECT: A throat culture can reveal the
presence of streptococcus, which is the leading
cause of rheumatic endocarditis.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

CLIENT EDUCATION

Referral facilities
● home health: postoperative care, home administration
of intravenous antibiotic therapy

● Pharmaceutical services: intravenous antibiotic
therapy, provision of supplies and medications

● Rehabilitation services: assistance with
monitoring and increasing activity level

Client discharge activities
● Rest as needed.
● Wash hands to prevent infection.
● Avoid crowded areas to reduce the risk of infection.
● maintain good oral hygiene to prevent infection.
● take medications as prescribed.
● Administer and manage Iv antibiotics.
● Participate in a tobacco use cessation program.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 35 PERIPhERAL vAsCULAR DIsEAsEs 223

UNIT 4 CARDIOVASCULAR DISORDERS
SECTION: VASCULAR DISORDERS

CHAPTER 35 Peripheral Vascular
Diseases

Peripheral vascular diseases include peripheral
arterial disease (PAD) and peripheral venous
disorders, both of which interfere with normal
blood flow. PAD affects arteries (blood vessels
that carry blood away from the heart), and
peripheral venous disease affects veins (blood
vessels that carry blood toward the heart).

Peripheral arterial disease
● PAD results from atherosclerosis that usually occurs

in the arteries of the lower extremities and is
characterized by inadequate flow of blood.

● Atherosclerosis is caused by a gradual thickening
of the intima and media of the arteries, ultimately
resulting in the progressive narrowing of the
vessel lumen. Plaques can form on the walls of
the arteries, making them rough and fragile.

● Progressive stiffening of the arteries and narrowing
of the lumen decreases the blood supply to affected
tissues and increases resistance to blood flow.

● Atherosclerosis is a type of arteriosclerosis,
which means “hardening of the arteries” and
alludes to the loss of elasticity of arteries over
time due to thickening of their walls.

● PAD is classified as inflow (distal aorta and iliac
arteries) or outflow (femoral, popliteal, and tibial
arteries) and can range from mild to severe. Tissue
damage occurs below the arterial obstruction.

● Buerger’s disease, subclavian steal syndrome, thoracic
outlet syndrome, Raynaud’s disease, and popliteal
entrapment are examples of PAD.

ASSESSMENT

RIsK FACtORs
● Hypertension
● Hyperlipidemia
● Diabetes mellitus
● Cigarette smoking
● Obesity
● Sedentary lifestyle
● Familial predisposition
● Female sex
● Age older than 65
● Elevated C‑reactive protein
● Hyperhomocysteinemia

EXPECtED FINDINGs
● Burning, cramping, and pain in the legs during exercise

(intermittent claudication)
● Numbness or burning pain primarily in the feet

when in bed
● Pain that is relieved by placing legs at rest in a

dependent position

PHYSICAL ASSESSMENT FINDINGS
● Bruit over femoral and aortic arteries
● Decreased capillary refill of toes (greater than
3 seconds)

● Decreased or nonpalpable pulses
● Loss of hair on lower calf, ankle, and foot
● Dry, scaly, mottled skin
● Thick toenails
● Cold and cyanotic extremity
● Pallor of extremity with elevation
● Dependent rubor (redness) of the extremity
● Muscle atrophy
● Ulcers and possible gangrene of toes

CHAPTER 35

35.1 Rubor

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224 CHAPTER 35 PERIPhERAL vAsCULAR DIsEAsEs CONTENT MASTERY SERIES

DIAGNOstIC PROCEDUREs

Arteriography
● Arteriography of the lower extremities involves arterial

injection of contrast medium to visualize areas of
decreased arterial flow on an x‑ray.

● It is usually done only to determine isolated areas of
occlusion that can be treated during the procedure with
percutaneous transluminal angioplasty and possible
stent placement.

NURSING ACTIONS
● Observe for bleeding and hemorrhage.
● Palpate pedal pulses to identify possible occlusions.

Exercise tolerance testing

A stress test is done with or without the use of a treadmill
(medications such as dipyridamole and adenosine can be
given to mimic the effects of exercise in clients who cannot
tolerate a treadmill) with measurement of pulse volumes
and blood pressures prior to and following the onset of
manifestations or 5 min of exercise. Delays in return to
normal pressures and pulse waveforms indicate arterial
disease. It is used to evaluate claudication during exercise.

Plethysmography
● Plethysmography is used to determine the variations

of blood passing through an artery, thus identifying
abnormal arterial flow in the affected limb.

● Blood pressure cuffs are attached to the client’s upper
extremities, a lower extremity, and the plethysmograph
machine. Variations in peripheral pulses between the
upper and lower extremity are recorded.

● A decrease in pulse pressure of the lower extremity
indicates a possible blockage in the leg.

Segmental systolic blood pressure measurements
● A Doppler probe is used to take various blood pressure

measurements (thigh, calf, ankle, brachial) for comparison.
In the absence of PAD, pressures in the lower extremities
are higher than those of the upper extremities.

● With arterial disease, the pressures in the thigh, calf,
and ankle are lower.

Magnetic resonance angiography

A contrast medium, such as gadolinium, is injected to help
visualize blood flow through peripheral arteries.

Ankle‑brachial index (ABI)

The ankle pressure is compared to the brachial pressure.
The expected finding for ABI is 0.9 to 1.3. ABI less than 0.9
in either leg is diagnostic for PAD.

Doppler‑derived maximal systolic acceleration

A technique that is especially helpful for evaluating PAD in
clients who have diabetes mellitus.

PATIENT‑CENTERED CARE

NURsING CARE
● Encourage the client to exercise to build up

collateral circulation.
◯ Initiate exercise gradually and increase slowly.
◯ Instruct the client to walk until the point of pain, stop
and rest, and then walk a little farther.

● Promote vasodilation and avoid vasoconstriction.
◯ Provide a warm environment for the client.
◯ Have the client wear insulated socks.
◯ Tell the client to never apply direct heat, such as
a heating pad, to the affected extremity because
sensitivity is decreased, and this can cause a burn.

◯ Instruct the client to avoid exposure to cold (causes
vasoconstriction and decreased arterial flow).

◯ Instruct the client to avoid stress, caffeine, and
nicotine, which also cause vasoconstriction.

■ Vasoconstriction is avoided when the client completely
abstains from smoking or chewing tobacco.

■ Vasoconstriction of vessels lasts up to 1 hr after
smoking or chewing tobacco.

POSITIONING
● Instruct the client to avoid crossing the legs.
● Tell the client to refrain from wearing restrictive garments.
● Tell the client to elevate the legs to reduce swelling, but

not to elevate them above the level of the heart because
extreme elevation slows arterial blood flow to the feet.

mEDICAtIONs

Antiplatelet medications

Aspirin, clopidogrel, pentoxifylline
Antiplatelet medications reduce blood viscosity by
decreasing blood fibrinogen levels, enhancing erythrocyte
flexibility, and increasing blood flow in the extremities.
Medications such as aspirin and clopidogrel can be
prescribed. Pentoxifylline, sometimes referred to as
a hemorheologic medication, was one of the first to
be used and is still used, but less commonly than
other medications. It can be given to specifically treat
intermittent claudication in clients who have PAD.

CLIENT EDUCATION
● The medication’s effects might not be apparent for

several weeks.
● Monitor for evidence of bleeding (abdominal pain;

coffee‑ground emesis; black, tarry stools).
● Avoid taking herbal supplements with clopidogrel

because they can increase the risk of bleeding.

Statins

Simvastatin, atorvastatin: Can relieve manifestations
associated with PAD (intermittent claudication)

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 35 PERIPhERAL vAsCULAR DIsEAsEs 225

thERAPEUtIC PROCEDUREs

Percutaneous transluminal angioplasty
and laser‑assisted angioplasty

● Percutaneous transluminal angioplasty is an invasive
intra‑arterial procedure using a balloon and stent to
open and help maintain the patency of the vessel.

● Laser‑assisted angioplasty is an invasive procedure in
which a laser probe is advanced through a cannula to
the site of stenosis.

◯ The laser is used to vaporize atherosclerotic plaque
and open the artery.

NURSING ACTIONS
● The priority action is to observe for bleeding at the

puncture site.
● Monitor vital signs, peripheral pulses, and capillary refill.
● Keep the client on bed rest with their limb straight for 2

to 6 hr before ambulation.
● Anticoagulant therapy is used during the procedure,

followed by antiplatelet therapy for 1 to 3 months.

Mechanical rotational abrasive atherectomy

Uses a rotational device to scrape plaque from the inside
of the client’s peripheral artery. The device is designed to
cause minimal damage to the surface of the artery.

NURSING ACTIONS
● The priority action is to observe for bleeding at the

puncture site.
● Monitor vital signs, peripheral pulses, and capillary refill.
● Keep the client on bed rest with their limb straight for
2 to 6 hr before ambulation.

● Anticoagulant therapy is used during the procedure,
followed by antiplatelet therapy for 1 to 3 months.

Arterial revascularization surgery

Used with clients who have severe claudication and/or
limb pain at rest, or with clients who are at risk for losing
a limb due to poor arterial circulation.

● Bypass grafts are used to reroute the circulation around
the arterial occlusion.

● Grafts can be harvested from the client (autologous) or
made from synthetic materials.

NURSING ACTIONS
● The priority action is to maintain adequate circulation

in the repaired artery. The location of the pedal or
dorsalis pulse should be marked, and its pulsatile
strength compared with the contralateral leg on a
scheduled basis using a Doppler.

● Color, temperature, sensation, and capillary refill should
be compared with the contralateral extremity on a
scheduled basis.

● Assess for warmth, redness, and possibly edema of the
affected limb as a result of increased blood flow.

● Monitor for pain. Pain can be severe due to the
reestablishment of blood flow to the extremity.

● Monitor blood pressure. Hypotension can result in
an increased risk of clotting or graft collapse, while
hypertension increases the risk for bleeding from sutures.

CLIENT EDUCATION
● Limit bending of the hip and knee to decrease the risk

of clot formation.
● Avoid crossing or raising legs above the level of the heart.
● Wear loose clothing.
● Perform wound care if revascularization surgery was done.
● Avoid smoking and cold temperatures.
● Perform foot care (keep feet clean and dry, wear

good‑fitting shoes, never go barefoot, cut toenails
straight across or have the podiatrist cut nails).

COMPLICATIONS

Graft occlusion

Graft occlusion is a serious complication of arterial
revascularization and often occurs within the first 24 hr
following surgery.

NURSING ACTIONS
● Promptly notify the surgeon of manifestations of

occlusion (absent or reduced pedal pulses, increased
pain, change in extremity color or temperature).

● Prepare to assist with treatment, which can include
an emergency thrombectomy (removal of a clot), local
intra‑arterial thrombolytic therapy with an agent
such as tissue plasminogen activator, infusion of a
platelet inhibitor, or a combination of these. With these
treatments, assess for indications of bleeding.

Wound or graft infection

An infection of the surgical wound or graft is a potentially
life‑threatening complication.

NURSING ACTIONS
● Use sterile technique when changing the surgical

dressing or providing wound care.
● Indications of infection include localized induration,

warmth, tenderness, erythema, edema, purulent
drainage, and an elevated WBC. Promptly report
findings to the provider.

Compartment syndrome

Compartment syndrome is considered a medical
emergency. Tissue pressure within a confined body space
can restrict blood flow, and the resulting ischemia can
lead to irreversible tissue damage.

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NURSING ACTIONS
● Manifestations of compartment syndrome include

tingling, numbness, worsening pain, edema, pain on
passive movement, and unequal pulses. Immediately
report findings to the provider.

● Loosen dressings.
● Prepare to assist with fasciotomy (surgical opening into

the tissues), which can be necessary to prevent further
injury and to save the limb.

● Monitor for comfort, impaired mobility, and decreased
sensory perception of the affected extremity by
following the assessment of the “6 P’s” (pain, pressure,
paralysis, paresthesia, pallor, pulselessness). Paresthesia
(numbness, tingling) is often the first manifestation of
compartment syndrome. Then the distal area becomes
pale and cool, with pulselessness, pain, and inability to
move the distal area (hand, foot).

Peripheral venous disorders
Peripheral venous disorders are problems with the veins
that interfere with adequate return of blood flow from
the extremities, and can result in blood stasis.

● There are superficial and deep veins in the lower
extremities that have valves that prevent backflow
of blood as it returns to the heart. The action
of the skeletal muscles of the lower extremities
during walking and other activities also promotes
venous return.

● Three peripheral venous disorders that nurses should
be familiar with are venous thromboembolism (VTE),
venous insufficiency, and varicose veins.

35.4 Thrombophlebitis35.3 Deep‑vein thrombosis

35.2 Compartment syndrome

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 35 PERIPhERAL vAsCULAR DIsEAsEs 227

VTE is a blood clot believed to form as a result of
venous stasis, endothelial injury, or hypercoagulability.
Thrombus formation can lead to a pulmonary embolism,
a life‑threatening complication. Thrombophlebitis
refers to a thrombus that is associated with
inflammation. (35.3, 35.4)

Venous insufficiency occurs secondary to incompetent
valves in the deeper veins of the lower extremities, which
allows pooling of blood and dilation of the veins. The
veins’ inability to carry fluid and wastes from the lower
extremities precipitates the development of swelling,
venous stasis ulcers, and in advanced cases, cellulitis.

Varicose veins are enlarged, twisted, and superficial veins
that can occur in any part of the body; however, they
are commonly observed in the lower extremities and in
the esophagus. (35.5)

ASSESSMENT

RIsK FACtORs
Venous thromboembolism: Associated with Virchow’s
triad (hypercoagulability, impaired blood flow, damage to
blood vessels)

● Hip surgery, total‑knee replacement, open
prostate surgery

● Heart failure
● Immobility
● Pregnancy
● Oral contraceptives
● Active cancer
● Ulcerative colitis
● Central venous and dialysis access catheters
● Factor V Leiden defect

Venous insufficiency: Results from periods of prolonged
venous hypertension that results in damage to the valve,
causing backup of blood, edema, and damage to the
deep tissue

● Sitting or standing in one position for a long
period of time

● Obesity
● Pregnancy
● Thrombophlebitis

Varicose veins
● Female sex
● Age older than 30 years and an occupation requiring

prolonged standing
● Pregnancy
● Obesity
● Systemic diseases (heart disease)
● Family history

EXPECtED FINDINGs
Limb pain: Aching pain and feeling of fullness or
heaviness in the legs after standing

PHYSICAL ASSESSMENT FINDINGS
● Deep vein thrombosis (DVT) and thrombophlebitis

◯ Client can be asymptomatic.
◯ Calf or groin pain, tenderness, and a sudden onset of
edema of the extremity.

◯ Warmth, edema, and induration and hardness over
the involved blood vessel.

◯ Changes in circumferences of right and left calf
and thigh over time; localized edema over the
affected area.

! shortness of breath and chest pain can
indicate that the embolus has moved to
the lungs (pulmonary embolism).

● Venous insufficiency
◯ Stasis dermatitis is a brown discoloration along the
ankles that extends up the calf relative to the level
of insufficiency.

◯ Edema
◯ Stasis ulcers (typically found around ankles)

● Varicose veins
◯ Distended, superficial veins that are visible just below
the skin and are tortuous in nature

◯ Clients often report muscle cramping and aches, pain
after sitting, and pruritus.

LABORAtORY tEsts
D‑dimer test measures fibrin degradation products
present in the blood produced from fibrinolysis. A
positive test indicates that thrombus formation has
possibly occurred.

35.5 Varicose veins

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228 CHAPTER 35 PERIPhERAL vAsCULAR DIsEAsEs CONTENT MASTERY SERIES

DIAGNOstIC PROCEDUREs

DVT and thrombophlebitis
● Venous duplex ultrasonography uses high‑frequency

sound waves to provide a real‑time picture of the blood
flow through a blood vessel.

● Doppler flow study produces an audible sound when
venous circulation is normal and little or no sound
when veins are thrombosed.

● Impedance plethysmography can be used to determine
the variations of blood passing through a vein, thus
identifying abnormal venous flow in the affected limb.

● If the above tests are negative for a DVT, but one is still
suspected, a venogram, which uses contrast material,
or magnetic resonance imaging might be needed for
accurate diagnosis.

Varicose veins: Trendelenburg test

NURSING ACTIONS
● Place the client in a supine position with legs elevated.
● When the client sits up, the veins will fill from the

proximal end if varicosities are present (veins normally
fill from the distal end).

PATIENT‑CENTERED CARE

NURsING CARE

DVT and thrombophlebitis
● Encourage ambulation following initiation of

anticoagulant therapy.
◯ Encourage dorsiflexion/plantar flexion exercises of
the foot when in bed.

◯ Occasionally elevate the legs above the level of the
heart while the client is in bed. (Avoid using a knee
gatch or pillow under the knees.)

● Administer intermittent or continuous warm moist
compresses as prescribed.

● Do not massage the affected limb.
● Provide thigh‑high compression or

anti‑embolism stockings.
● Prepare the client for an inferior vena cava interruption

surgery (a filter traps emboli and prevents them from
reaching the heart) as indicated.

Venous insufficiency
● Elevate legs for at least 20 min, four to five times a day.
● Elevate the legs above the heart when in bed.

CLIENT EDUCATION
● Avoid crossing legs and wearing constrictive clothing

or stockings.
● Wear elastic compression stockings. Apply them after

the legs have been elevated and when swelling is at
a minimum.

mEDICAtIONs

DVT and thrombophlebitis: anticoagulants

Unfractionated heparin
● Given IV to prevent formation of other clots and to

prevent enlargement of the existing clot.
● It has significant adverse effects and must be given

in the facility. Prior to discharge, the client will be
converted to oral anticoagulation therapy with warfarin.

● NURSING ACTIONS
◯ Monitor aPTT to allow for adjustments of

heparin dosage.
◯ Monitor platelet counts for heparin‑induced
thrombocytopenia.

◯ Ensure that protamine sulfate, the antidote for
heparin, is available if needed for excessive bleeding.

◯ Monitor for hazards and adverse effects associated
with anticoagulant therapy.

Low‑molecular weight heparin
● Given subcutaneously and is based on a client’s weight.
● Enoxaparin is used for the prevention and treatment

of DVT. It is usually given in the facility, but the
twice‑daily injections can be given in the home setting.

● CLIENT EDUCATION
◯ Observe for evidence of bleeding.
◯ Take bleeding precautions (use electric instead of

bladed razor, brush teeth with a soft toothbrush).

Warfarin
● Inhibits synthesis of the four vitamin K‑dependent

clotting factors.
● The therapeutic effect takes 3 to 4 days to develop, so

administration of the medication is begun while the
client is still on heparin.

● NURSING ACTIONS
◯ Monitor for bleeding.
◯ Monitor PT and INR.
◯ Ensure that vitamin K (the antidote for warfarin) is
available in case of excessive bleeding.

● CLIENT EDUCATION
◯ Be aware of food sources of vitamin K (green leafy
vegetables) and avoid fluctuations in the amount and
frequency of consumption.

◯ Observe for evidence of bleeding.
◯ Take bleeding precautions (use electric instead of

bladed razor, and brush teeth with soft toothbrush).

Factor Xa inhibitors: Inhibit Factor Xa in prevention of
development of thromboses (fondaparinux, rivaroxaban,
apixaban)

Direct thrombin inhibitor
● Acts as a direct inhibitor of thrombin to prevent

thrombus formation (dabigatran).
● Idarucizumab is the antidote to reverse dabigatran in

life‑threatening events by preventing dabigatran from
inhibiting thrombin.

● Initial lab values are PT and aPTT. Recurrent laboratory
monitoring is not necessary.

● Not recommended if the client has renal insufficiency.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 35 PERIPhERAL vAsCULAR DIsEAsEs 229

DVT and thrombophlebitis: thrombolytic therapy

Thrombolytic therapy dissolves clots that have already
developed. Therapy must be started within 5 days after
the development of the clot for the therapy to be effective.
Tissue plasminogen activator, a thrombolytic agent, and
platelet inhibitors (such as abciximab and eptifibatide) can
be effective in dissolving a clot or preventing new clots
during the first 24 hr. Administering the medication in a
manner that provides direct contact with the thrombus
can be more effective and lessen the chance of bleeding.

NURSING ACTIONS: Monitor for bleeding (such as
intracerebral bleeding).

CLIENT EDUCATION: Take bleeding precautions (use
electric instead of bladed razor and brush teeth with a soft
toothbrush).

thERAPEUtIC PROCEDUREs

DVT

An inferior vena cava filter can be inserted when a
client is unresponsive to medical therapy or when
anticoagulation is contraindicated. It is inserted via the
femoral vein and passed into the inferior vena cava where
it traps emboli before they progress to the lungs.

Varicose veins

Sclerotherapy
● A sclerosing irritating chemical solution is injected into

the varicose vein to produce localized inflammation,
which will close the lumen of the vessel over time.

● For larger vessels, an incision and drainage of the
trapped blood in a sclerosed vein might need to be
performed 2 to 3 weeks after the injection.

● Pressure dressings are applied for approximately 1 week
after each procedure to keep the vessel free of blood.

CLIENT EDUCATION
◯ Wear elastic stockings for the prescribed time.
◯ Mild analgesics, such as acetaminophen, can be taken
for discomfort.

Vein stripping
● Vein stripping is the removal of large varicose veins that

cannot be treated with less‑invasive procedures.
● PREOPERATIVE NURSING ACTIONS

◯ Assist the provider with vein marking.
◯ Evaluate pulses as a baseline for

postoperative comparison.
● POSTOPERATIVE NURSING ACTIONS

◯ Maintain elastic bandages on the legs.
◯ Monitor groin and leg for bleeding through the
elastic bandages.

◯ Monitor extremity for edema, warmth, color, and pulses.
◯ Elevate legs above the level of the heart.

CLIENT EDUCATION
◯ Understand the importance of wearing elastic
stockings after bandage removal.

◯ Elevate the legs when sitting, and avoid dangling
them over the side of the bed.

◯ Engage in range‑of‑motion exercises of the legs.

Endovenous laser treatment: This type of treatment uses
a laser fiber that is inserted into the vessel proximal to the
area to be treated and then threaded to the involved area,
where heat from the laser is used to close the dilated vein.

Application of radio frequency energy: This type of
treatment uses a small catheter with a radio frequency
electrode, instead of a laser, that is inserted into the vessel
proximal to the area to be treated that scars and closes a
dilated vein.

INtERPROFEssIONAL CARE

Venous insufficiency
● Care of venous stasis ulcers requires

long‑term management.
● Consultation with a dietitian and wound care specialist

facilitate the healing process.

COMPLICATIONS

Ulcer formation
● Venous stasis ulcers often form over the medial

malleolus. Venous ulcers are chronic, hard to heal, and
often recur. They can lead to amputation or death. (35.6)

● Clients who have neuropathy might not feel as much
discomfort from the ulcer as its appearance can warrant.

NURSING ACTIONS
● Administer and assist with treatments to improve

circulation (wound vacuum, hyperbaric chamber).
● Assess and treat pain as prescribed.
● Apply oxygen‑permeable polyethylene films to

superficial ulcers.
● Apply occlusive hydrocolloid dressings on deeper ulcers to

promote granulation tissue and reepithelialization.
● Leave a dressing on for 3 to 7 days.
● If a wound needs chemical debridement, apply

prescribed topical enzymatic agents to debride the ulcer,
eliminate necrotic tissue, and promote healing.

● Administer systemic antibiotics as prescribed.
● Prepare for oxygen therapy and blood gas analysis

while continuing to monitor and assess the client for
other manifestations.

35.6 Venous stasis ulcers

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230 CHAPTER 35 PERIPhERAL vAsCULAR DIsEAsEs CONTENT MASTERY SERIES

CLIENT EDUCATION
● Adhere to a diet high in zinc, protein, iron, and

vitamins A and C.
● Understand the use of compression stockings.
● Prepare to administer prescribed anticoagulation.

Pulmonary embolism

A pulmonary embolism occurs when a thrombus
is dislodged, becomes an embolus, and lodges in a
pulmonary vessel. This can lead to obstruction of
pulmonary blood flow, decreased systemic oxygenation,
pulmonary tissue hypoxia, and possible death.

NURSING ACTIONS
● Manifestations include sudden onset dyspnea, pleuritic

chest pain, restlessness, apprehension, feelings of
impending doom, cough, and hemoptysis.

● Findings include tachypnea, crackles, pleural friction
rub, tachycardia, S3 or S4 heart sounds, diaphoresis,
low‑grade fever, petechiae over chest and axillae, and
decreased arterial oxygen saturation.

● Notify the provider immediately. Reassure the client.
Assist the client to a position of comfort with the head
of the bed elevated.

● Prepare for oxygen therapy and blood gas analysis
while continuing to monitor and assess the client for
other manifestations.

● Prepare to administer prescribed anticoagulation.

Active Learning Scenario

A nurse is developing a poster presentation on
peripheral arterial disease (PAD) for a community
health fair. What content should the nurse include on
the poster? Use the AtI Active Learning template:
system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)

RISK FACTORS: Describe at least six.

EXPECTED FINDINGS: Describe at least six findings.

CLIENT EDUCATION: Describe at least two actions
by the client related to proper positioning and
two actions related to promoting vasodilation.

Application Exercises

1. A nurse is caring for a client who has chronic
venous insufficiency and a prescription for
thigh‑high compression stockings. Which of the
following actions should the nurse take?

A. Elevate the client’s legs for 10 min, two to
three times daily while wearing stockings.

B. Apply the stockings in the morning upon
awakening and before getting out of bed.

C. Roll the stockings down to the knees
to relieve discomfort on the legs.

D. Remove the stockings while out of bed for 1 hr,
four times a day, to allow the legs to rest.

2. A nurse is assessing a client who has chronic
peripheral arterial disease (PAD). Which of the
following findings should the nurse expect?

A. Edema around the ankles and feet
B. Ulceration around the medial malleoli
C. scaling eczema of the lower legs

with stasis dermatitis
D. Pallor on elevation of the limbs, and

rubor when the limbs are dependent

3. A nurse is teaching a client who has a new diagnosis
of severe peripheral arterial disease. Which of the
following instructions should the nurse include?

A. Wear tightly‑fitted insulated socks
with shoes when going outside.

B. Elevate both legs above the heart when resting.
C. Apply a heating pad to both legs for comfort.
D. Place both legs in dependent

position while sleeping.

4. A nurse is teaching a client who has a new prescription
for clopidogrel. Which of the following instructions
should the nurse include? (select all that apply.)

A. “Avoid taking herbal supplements
while taking this medication.”

B. “monitor for the presence of black, tarry stools.”
C. “take this medication when you have pain.”
D. “schedule a weekly Pt test.”
E. “Limit food sources containing vitamin

K while taking this medication.”

5. A nurse is caring for a client who has a deep‑vein
thrombosis (Dvt) and has been taking
unfractionated heparin for 1 week. two days
ago, the provider also prescribed warfarin. the
client asks the nurse about receiving both heparin
and warfarin at the same time. Which of the
following statements should the nurse give?

A. “I will remind your provider that you
are already receiving heparin.”

B. “Your laboratory findings indicated that
two anticoagulants were needed.”

C. “It takes 3 to 4 days before the therapeutic
effects of warfarin are achieved, and then
the heparin can be discontinued.”

D. “Only one of these medications is being
given to treat your deep‑vein thrombosis.”

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 35 PERIPhERAL vAsCULAR DIsEAsEs 231

Application Exercises Key

1. A. the client who has venous insufficiency should sit with legs
elevated for at least 20 min, four to five times daily.

B. CORRECT: Applying stockings in the morning upon
awakening and before getting out of bed reduces
venous stasis and assists in the venous return of blood
to the heart. Legs are less edematous at this time.

C. Rolling stockings down can restrict
circulation and cause edema.

D. stockings should remain in place throughout the day
and are removed before going to bed to provide
continuous venous support. If the stockings are removed,
such as for a bath or shower, then the legs should be
elevated before the stockings are reapplied.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

2. A. Edema around the ankles and feet is an expected
finding in a client who has venous stasis.

B. Ulceration around the medial malleoli is an expected
finding in a client who has venous stasis.

C. scaling eczema of the lower legs with stasis dermatitis is
an expected finding in a client who has venous stasis.

D. CORRECT: In a client who has chronic PAD, pallor is
seen in the extremities when the limbs are elevated,
and rubor occurs when they are lowered.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. A. While insulated socks can promote warmth, they should
be loose‑fitting to promote circulation.

B. the client should avoid elevating the legs
above the heart while resting. this can cause a
restriction in arterial blood flow to the feet.

C. the client should not apply a heating pad to the legs
due to the loss in sensation as a result of the disease.
Applying direct heat to the legs can burn the client.

D. CORRECT: Instruct the client to place their legs
in a dependent position, such as hanging off the
edge of the bed while sleeping. this can alleviate
swelling and discomfort of the legs.

NCLEX® Connection: Physiological Adaptation,
Illness Management

4. A. CORRECT: Instruct the client to avoid herbal supplements
while taking clopidogrel. herbal supplements (garlic, ginger,
ginkgo, ginseng) can increase the risk of bleeding.

B. CORRECT: Instruct the client to monitor for evidence
of GI bleeding (abdominal pain; coffee‑ground
emesis; black, tarry stools). If this occurs, the
client should report this to the provider.

C. the client should take clopidogrel routinely as prescribed
because it can take several weeks to be effective.

D. Pt and INR levels are monitored regularly
in a client taking warfarin.

E. A client who is taking warfarin should be advised
about food sources containing vitamin K.

NCLEX® Connection: Pharmacological and Parenteral Therapies
, Adverse Effects/Contraindications/Side Effects/Interactions

5. A. Warfarin is prescribed for 3 to 4 days before
discontinuing Iv heparin.

B. Iv heparin is monitored to achieve adequate
therapeutic levels in treating a Dvt.

C. CORRECT: Warfarin depresses synthesis of clotting
factors but does not have an effect on clotting
factors that are present. It takes 3 to 4 days for the
clotting factors that are present to decay and for
the therapeutic effects of warfarin to occur.

D. heparin and warfarin are both effective in treating Dvt.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): PAD is inadequate blood
flow of the lower extremities due to atherosclerosis. the intima
and media of the arteries become thickened, and plaque can form
on the walls of the arteries, making them rough and fragile. the
arteries progressively stiffen and the lumen narrows, decreasing
blood supply to tissues and increasing resistance to blood flow.
It is classified as either an inflow or outflow type of PAD.

RISK FACTORS
● hypertension
● hyperlipidemia
● Diabetes mellitus
● Cigarette smoking
● Obesity
● sedentary lifestyle
● Familial predisposition
● Age: older adult clients
● Female sex

EXPECTED FINDINGS
● Bruits over femoral and aortic arteries
● Decreased capillary refill of toes (greater than 3 seconds)
● Decreased or nonpalpable pulses
● Loss of hair on the lower extremities
● Dry, scaly, mottled skin
● thick toenails
● Cold, cyanotic extremity
● Pallor of extremity with elevation
● Dependent rubor
● muscle atrophy
● Ulcers and possible gangrene of toes

CLIENT EDUCATION
● Adhere to the following positions.

◯ Avoid crossing the legs.
◯ Avoid wearing restrictive garments.
◯ Keep legs elevated to reduce swelling, but
not above the level of the heart.

● Promote vasodilation.
◯ maintain a warm environment.
◯ Wear insulated socks.
◯ Avoid applying direct heat to the extremity.
◯ Avoid exposure to cold.
◯ Avoid stress, caffeine, and nicotine.

NCLEX® Connection: Physiological Adaptation, Illness
Management

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232 CHAPTER 35 PERIPhERAL vAsCULAR DIsEAsEs CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 36 hYPERtENsION 233

UNIT 4 CARDIOVASCULAR DISORDERS
SECTION: VASCULAR DISORDERS

CHAPTER 36 Hypertension
For an adult client, hypertension occurs when
systolic blood pressure is at or greater than
140 mm hg or diastolic blood pressure is at
or greater than 90 mm hg for two or more
assessments of blood pressure. For clients older
than 60 years, blood pressure should be equal
to or less than 150/90 mm hg.

Essential hypertension, also called primary
hypertension, accounts for most cases of
hypertension. there is no known cause.
secondary hypertension can be caused by
disease states, such as kidney disease, or as an
adverse effect of some medications. treatment
for secondary hypertension occurs by removing
the cause (adrenal tumor, medication).

Clients who have a systolic blood pressure
of 120 to 139 mm hg or a diastolic blood
pressure of 80 to 89 mm hg are considered
to have prehypertension. Lifestyle changes
are necessary for these clients to help prevent
cardiovascular disease.

Prolonged, untreated, or poorly controlled
hypertension can cause peripheral
vascular disease that primarily affects the
heart, brain, eyes, and kidneys. the risk of
developing complications increases as blood
pressure increases.

hypertrophy of the left ventricle can develop as
the heart pumps against resistance caused by
the hypertension.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Maintain body mass index of less than 30.
● Clients who have diabetes mellitus should keep blood

glucose within a recommended reference range.
● Limit caffeine and alcohol intake.
● Use stress‑management techniques during times

of stress.
● Stop smoking. Nicotine patches or engaging in a

smoking cessation class are potential strategies.
● Engage in exercise that provides aerobic benefits at least
3 times a week.

● Limit sodium and fat intake.

ASSESSMENT
Four bodily mechanisms regulate blood pressure.

Arterial baroreceptors
● Baroreceptors are located in the carotid sinus, aorta, and

left ventricle.
● They control blood pressure by altering the heart rate.

They also cause vasoconstriction or vasodilation.

Regulation of body‑fluid volume: Properly functioning
kidneys retain fluid when a client is hypotensive and
excrete fluid when a client is hypertensive.

Renin‑angiotensin‑aldosterone system: Renin
is converted into angiotensin II, which causes
vasoconstriction and controls aldosterone release, causing
the kidneys to reabsorb sodium and inhibit fluid loss.

Vascular autoregulation: This maintains consistent levels
of tissue perfusion.

RIsK FACtORs
Essential hypertension

● Positive family history
● Excessive sodium intake
● Physical inactivity
● Obesity
● High alcohol consumption
● African American
● Smoking
● Hyperlipidemia
● Stress
● Age greater than 60 or postmenopausal

Secondary hypertension
● Kidney disease
● Cushing’s disease (excessive glucocorticoid secretion)
● Primary aldosteronism (causes hypertension

and hypokalemia)
● Pheochromocytoma (excessive catecholamine release)
● Brain tumors, encephalitis
● Medications (estrogen, steroids, sympathomimetics)
● Pregnancy

CHAPTER 36

234 CHAPTER 36 hYPERtENsION CONTENT MASTERY SERIES

EXPECtED FINDINGs
● Clients who have hypertension can experience few or no

manifestations. Monitor for the following.
◯ Headaches, particularly in the morning
◯ Facial flushing
◯ Dizziness
◯ Fainting
◯ Retinal changes, visual disturbances
◯ Nocturia

PHYSICAL ASSESSMENT FINDINGS
● When a blood pressure reading is elevated, take it in

both arms and with the client sitting and standing.
● There are levels of hypertension, as defined by the

Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure.

◯ Prehypertension: systolic 120 to 139 mm Hg; diastolic
80 to 89 mm Hg

◯ Stage I hypertension: systolic 140 to 159 mm Hg;
diastolic 90 to 99 mm Hg

◯ Stage II hypertension: systolic greater than or equal to
160 mm Hg; diastolic greater than or equal to 100 mm Hg

LABORAtORY tEsts
No laboratory tests exist to diagnose hypertension.
However, several laboratory tests can identify the causes
of secondary hypertension and target organ damage.

● BUN, creatinine elevation is indicative of kidney disease.
● Elevated blood corticoids can indicate Cushing’s disease.
● Blood glucose and cholesterol studies can identify

contributing factors related to blood vessel changes.

DIAGNOstIC PROCEDUREs
ECG evaluates cardiac function. Tall R‑waves are often
seen with left‑ventricular hypertrophy.

Chest x‑ray can show cardiomegaly.

PATIENT‑CENTERED CARE

NURsING CARE
Discuss with the client factors that increase the risk of
hypertension and how the client can manage them.

mEDICAtIONs
Medications are added to treat hypertension that is not
responsive to lifestyle changes alone. Diuretics are often
first‑line medications. However, clients can require a
combination of medications to control hypertension.

CLIENT EDUCATION: If taking antihypertensives, change
positions slowly, and be careful when getting out of bed,
driving, and climbing stairs until the medication’s effects
are fully known.

Diuretics
● Thiazide diuretics, such as hydrochlorothiazide,

inhibit water and sodium reabsorption, and increase
potassium excretion.

● Other diuretics can treat hypertension that is not
responsive to thiazide diuretics.

◯ Loop diuretics, such as furosemide, decrease sodium
reabsorption and increase potassium excretion.
Potassium‑sparing diuretics, such as spironolactone,
affect the distal tubule and prevent reabsorption of
sodium in exchange for potassium.

NURSING ACTIONS: Monitor potassium levels and watch
for muscle weakness, irregular pulse, and dehydration.
Thiazide and loop diuretics can cause hypokalemia, and
potassium‑sparing diuretics can cause hyperkalemia.

CLIENT EDUCATION
● Keep all appointments with the provider to monitor

efficacy of pharmacological treatment and possible
electrolyte imbalance (hyponatremia, hyperkalemia).

● If taking a potassium‑depleting diuretic, increase
consumption of potassium‑rich foods, such as bananas.

Calcium‑channel blockers

Verapamil, amlodipine, and diltiazem alter the movement
of calcium ions through the cell membrane, causing
vasodilation and lowering blood pressure.

NURSING ACTIONS
● Monitor blood pressure and pulse, and change the client’s

position slowly. Hypotension is a common adverse effect.
● Use calcium‑channel blockers cautiously with clients

who have heart failure.

CLIENT EDUCATION
● Constipation can occur with verapamil, so intake foods

that are high in fiber.
● A decrease or increase in heart rate and atrioventricular

(AV) block can occur. Take pulse and call the provider if
it is irregular or lower than the established rate.

● Avoid grapefruit juice, which potentiates the
medication’s effects, increases hypotensive effects, and
increases the risk of medication toxicity.

36.1 Classifications of blood pressure

SYSTOLIC BP
(mm HG)

DIASTOLIC BP
(mm HG)

EXPECTED Less than 120 Less than 80

PREHYPERTENSION 120 to 139 80 to 89

STAGE 1
HYPERTENSION 140 to 159 90 to 99

STAGE 2
HYPERTENSION

Equal to or
greater than 160

Equal to or
greater than 100

source: the Eighth Report of the Joint National
Committee on Prevention, Detection, Evaluation,and
treatment of high Blood Pressure

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 36 hYPERtENsION 235

Angiotensin‑converting enzyme (ACE) inhibitors

ACE inhibitors, such as lisinopril and enalapril, prevent
the conversion of angiotensin I to angiotensin II, which
prevents vasoconstriction.

NURSING ACTIONS
● Monitor blood pressure and pulse. Hypotension is a

common adverse effect.
● Monitor for evidence of heart failure, such as edema.
ACE inhibitors can cause heart and kidney complications.

CLIENT EDUCATION
● Report a cough, which is an adverse effect of ACE

inhibitors. Notify the provider of this adverse effect, as
the medication can be discontinued due to its persistent
nature and occasional relationship to angioedema
(swelling of the tissues under the skin) that affects the
lips, tongue and glottis, and can progress to a
life‑threatening obstruction).

● Report manifestations of heart failure (edema).

Angiotensin‑II receptor antagonists

Also called angiotensin‑receptor blockers (ARBs), these
medications, such as valsartan and losartan, are a good
option for clients taking ACE inhibitors who report a cough
or have hyperkalemia. ARBs block the effects of angiotensin
II at the receptor and decrease peripheral resistance. ARBs
do not require a dosage adjustment for older adult clients.

NURSING ACTIONS: Monitor for manifestations of
angioedema or heart failure. Angioedema is a serious, but
uncommon, adverse effect, and heart failure can result
from taking this medication.

CLIENT EDUCATION
● Change positions slowly.
● Report findings of angioedema (swollen lips or face) or

heart failure (edema).
● Avoid foods that are high in potassium and have potassium

levels monitored because ARBS can cause hyperkalemia.

Aldosterone‑receptor antagonists

Aldosterone‑receptor antagonists (eplerenone,
spironolactone) block aldosterone action. The blocking
effect of eplerenone on aldosterone receptors promotes the
retention of potassium and excretion of sodium and water.

NURSING ACTIONS
● Monitor kidney function, triglycerides, sodium,

and potassium levels. The risk of adverse effects
increases with deteriorating kidney function.
Hypertriglyceridemia, hyponatremia, and hyperkalemia
can occur as the dose increases.

● Monitor potassium levels every 2 weeks for the first
few months and every 2 months thereafter. The
client should avoid taking potassium supplements or
potassium‑sparing diuretics.

CLIENT EDUCATION
● Be aware of potential food, medication, and herbal

interactions. Grapefruit juice and St. John’s wort can
increase adverse effects.

● Do not to take salt substitutes with potassium or other
foods that are rich in potassium.

Beta blockers

Beta blockers (metoprolol, atenolol) block the sympathetic
nervous system (beta adrenergic receptors) and produce a
slower heart rate and lowered blood pressure.

NURSING ACTIONS: Monitor blood pressure and pulse.

CLIENT EDUCATION
● These medications can cause fatigue, weakness,

depression, and sexual dysfunction.
● Do not suddenly stop taking the medication without

consulting with the provider. Stopping suddenly can
cause rebound hypertension.

● Beta blockers can reduce some manifestations of
hypoglycemia, such as tachycardia. Monitor for
other indicators.

Central‑alpha2 agonists

Central‑alpha2 agonists, such as clonidine, reduce
peripheral vascular resistance and decrease blood pressure
by inhibiting the reuptake of norepinephrine.

NURSING ACTIONS
● Monitor blood pressure and pulse.
● This medication is not for first‑line management

of hypertension.

CLIENT EDUCATION: Adverse effects include sedation,
orthostatic hypotension, and impotence.

Alpha‑adrenergic Antagonists

Alpha‑adrenergic antagonists (prazosin, doxazosin)
reduce blood pressure by causing vasodilation.

NURSING ACTIONS
● Start treatment with a low dose of the medication,

usually given at night.
● Monitor blood pressure for 2 hr after initiation of treatment.

CLIENT EDUCATION: Rise slowly to prevent postural
hypotension. Use caution when driving until the effects of
the medication are known.

CLIENT EDUCATION
● Report manifestations of electrolyte imbalance

(hyperkalemia, hypokalemia, hyponatremia).
● Understand the importance of adhering to the

medication regimen, even if there are no manifestations
of hypertension.

● Understand the prescribed medications and their
adverse effects.

● Have the resources necessary to pay for and obtain
prescribed antihypertensive medication.

● Schedule regular provider appointments to monitor
hypertension and cardiovascular status.

● Monitor blood pressure at home.
● Report findings and adverse effects, as they can be

indicative of additional problems. Medications can often
be changed to alleviate adverse effects.

● Older adult clients are more likely to experience
medication interactions and orthostatic hypotension.

● Treatment involves making lifestyle changes.

236 CHAPTER 36 hYPERtENsION CONTENT MASTERY SERIES

Nutrition
● Monitor for hyperkalemia with salt substitute use.
● Consume less than 2.3 g/day of sodium.
● Consume a diet low in fat, saturated fat, and cholesterol.
● Limit alcohol intake to 2 servings per day for men and
1 serving per day for women. A serving of alcohol is
equivalent to 1.5 oz liquor, 5 oz wine, or 12 oz beer.

● Dietary approaches to stop hypertension (DASH) are
effective in the prevention and treatment of
hypertension.

● The DASH diet is high in fruits, vegetables, and low‑fat
dairy foods.

● Avoid foods high in sodium and fat (trans and
saturated fat).

● Consume foods rich in calcium and magnesium.
● If not taking a potassium‑sparing medication, increase

potassium consumption.

Weight reduction and maintenance
● Begin slowly and gradually advance the program with

the guidance of the provider and physical therapist.
● Exercise at least three times a week in a manner that

provides aerobic benefits.

Smoking cessation: Explore smoking cessation options
such as nicotine replacement therapy, medications such as
bupropion or varenicline, and support groups.

Stress reduction: Try yoga, massage, hypnosis, or other
forms of relaxation.

COMPLICATIONS

Hypertensive crisis

Hypertensive crisis often occurs when clients do not
follow the medication therapy regimen.

NURSING ACTIONS
● Recognize manifestations.

◯ Severe headache
◯ Extremely high blood pressure (generally, systolic

blood pressure greater than 180 mm Hg, diastolic
greater than 120 mm Hg)

◯ Blurred vision, dizziness, and disorientation
◯ Epistaxis

● Administer IV antihypertensive therapies (nitroprusside,
nicardipine, labetalol).

● The goal is to lower the blood pressure by 20% to 25%
the first hour but not to drop the blood pressure to less
than 140/90 mm Hg.

● Before, during, and after administration of an IV
antihypertensive, monitor blood pressure every
5 to 15 min.

● Assess neurologic status (pupils, level of consciousness,
muscle strength) to monitor for cerebrovascular change.

● Monitor the ECG to assess cardiac status.

Application Exercises

1. A nurse is screening a client for hypertension.
the nurse should identify that which of the
following actions by the client increase the risk
for hypertension? (select all that apply.)

A. Drinking 8 oz nonfat milk daily
B. Eating popcorn at the movie theater
C. Walking 1 mile daily at 12 min/mile pace
D. Consuming 36 oz beer daily
E. Getting a massage once a week

2. A nurse in an urgent care clinic is obtaining a history
from a client who has type 2 diabetes mellitus
and a recent diagnosis of hypertension. this is the
second time in 2 weeks that the client experienced
hypoglycemia. Which of the following client data
should the nurse report to the provider?

A. takes psyllium daily as a fiber laxative
B. Drinks skim milk daily as a bedtime snack
C. takes metoprolol daily after meals
D. Drinks grapefruit juice daily with breakfast

3. A nurse is caring for a client who is admitted
to the emergency department with a blood
pressure of 266/147 mm hg. the client reports
a headache and double vision. the client states,
“I ran out of my diltiazem 3 days ago, and I
am unable to purchase more.” Which of the
following actions should the nurse take first?

A. Administer acetaminophen for headache.
B. Provide teaching regarding the importance of

not abruptly stopping an antihypertensive.
C. Obtain Iv access and prepare to

administer an Iv antihypertensive.
D. Call social services for a referral for financial

assistance in obtaining prescribed medication.

4. A nurse is providing teaching for a client who
has a new diagnosis of hypertension and a new
prescription for spironolactone 25 mg/day.
Which of the following statements by the client
indicates an understanding of the teaching?

A. “I should eat a lot of fruits and vegetables,
especially bananas and potatoes.”

B. “I will report any changes in heart
rate to my provider.”

C. “I should replace the salt shaker on
my table with a salt substitute.”

D. “I will decrease the dose of this medication when
I no longer have headaches and facial redness.”

5. A nurse is providing discharge teaching for a client
who has a prescription for furosemide 40 mg PO
daily. the nurse should instruct the client to take this
medication at which of the following times of day?

A. morning
B. Immediately after lunch
C. Immediately before dinner
D. Bedtime

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 36 hYPERtENsION 237

Active Learning Scenario

A nurse is preparing a community education presentation
on hypertension. What information should the nurse
include in the presentation? Use the AtI Active Learning
template: system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS):
Describe hypertension to include essential,
secondary, and prehypertension.

RISK FACTORS: Describe at least four risk factors
each for essential and secondary hypertension.

EXPECTED FINDINGS
● Describe at least three expected subjective
data findings for hypertension.

● Describe the objective data stages of hypertension.

Application Exercises Key

1. A. Consuming low‑fat beverages and foods lowers
the risk for developing hypertension.

B. CORRECT: Popcorn at a movie theater contains
a large quantity of sodium and fat, which
increases the risk for hypertension.

C. Engaging in regular exercise, such as walking,
lowers the risk of developing hypertension.

D. CORRECT: Consuming more than 24 oz beer
per day for a male client or 12 oz for a female
client increases the risk for hypertension.

E. stress management activities, such as a
massage, lower the risk of hypertension.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

2. A. Adverse effects of psyllium do not
include hypoglycemia.

B. skim milk increases blood glucose levels
and lowers cholesterol.

C. CORRECT: metoprolol can mask the effects of
hypoglycemia in clients who have diabetes mellitus.

D. Grapefruit juice increases blood glucose levels.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

3. A. Administering acetaminophen will treat the client’s
pain, but there is another action to take first.

B. Providing teaching regarding medication administration
can help promote future compliance with taking
medication, but there is another action to take first.

C. CORRECT: the greatest risk to the client is injury
due to a blood pressure of 266/147 mm hg, which
can be life‑threatening and should be lowered as
soon as possible. Obtaining Iv access will permit
administration of an Iv hypertensive, which will
act more rapidly than by the oral route.

D. Calling social services will help connect the client with
financial resources, but there is another action to take first.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. A. teach the client that potatoes and bananas are high in
potassium, and can lead to hyperkalemia when taken with a
potassium‑sparing diuretic such as spironolactone.

B. CORRECT: teach the client to monitor their heart
rate and report any changes to the provider.

C. teach the client that salt substitutes are commonly high in
potassium and can lead to hyperkalemia when taken with
a potassium‑sparing diuretic such as spironolactone.

D. teach the client to continue taking their
medication as prescribed even if they do not
have any manifestations of hypertension.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

5. A. CORRECT: the client should take furosemide, a diuretic,
in the morning so that the peak action and duration of
the medication occurs during waking hours.

B. taking furosemide at this time increases the likelihood of
interruption of the client’s sleep due to the need to urinate.

C. taking furosemide at this time increases the likelihood of
interruption of the client’s sleep due to the need to urinate.

D. taking furosemide at this time increases the likelihood of
interruption of the client’s sleep due to the need to urinate.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS)
● hypertension is when systolic blood pressure is at or above 140 mm
hg or diastolic blood pressure is at or greater than 90 mm hg for an
adult client or greater than 150/90 mm hg for a client older than 60.

● Essential (primary) hypertension has no known cause.
● secondary hypertension is caused by diseases such as
kidney disorders, or as an adverse effect of a medication.
treatment occurs by removing the cause.

● Prehypertension is when a client has a systolic blood pressure of
120 to 139 mm hg or a diastolic blood pressure of 80 to 89 hg.

RISK FACTORS
● Primary hypertension: Positive family history, excessive
sodium intake, physical inactivity, obesity, high alcohol
consumption, African‑American, nicotine use, hyperlipidemia,
stress, age greater than 60, postmenopausal

● secondary hypertension: Kidney disease, Cushing’s disease,
primary aldosteronism (caused by hypertension and hypokalemia),
pheochromocytoma (excessive catecholamine release), brain tumors,
encephalitis, and medications (estrogen, steroids, sympathomimetics)

EXPECTED FINDINGS

subjective data: Few or no manifestations
● Can include headaches, particularly in the morning
● Dizziness, fainting, retinal changes, visual
disturbances, nocturia, facial flushing

Objective data stages: Obtain blood pressure readings
in both arms with the client sitting and standing:

● Prehypertension: systolic 120 to 139 mm hg, diastolic 80 to 89 mm hg
● stage I: systolic 140 to 159 mm hg, diastolic 90 to 99 mm hg
● stage II: systolic greater than or equal to 160 mm hg,
diastolic greater than or equal to 100 mm hg

NCLEX® Connection: Physiological Adaptation, Illness
Management

238 CHAPTER 36 hYPERtENsION CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 37 hEmODYNAmIC shOCK 239

UNIT 4 CARDIOVASCULAR DISORDERS
SECTION: VASCULAR DISORDERS

CHAPTER 37 Hemodynamic Shock
shock is a state of inadequate tissue perfusion
that impairs cellular function and can lead to organ
failure. Any condition that compromises oxygen
delivery to organs and tissues can lead to shock.
shock is a rapidly‑progressing, life‑threatening
process. Early detection with rapid response is
necessary to improve client outcome.

Older adult clients can have reduced
compensatory mechanisms and rapidly progress
through the stages of shock. Catecholamine
secretions might not improve cardiac contractility
or cause vasoconstriction as in younger adults due
to decreased baroreceptor response. Decreased
ability to compensate can cause sustained low
cardiac output and blood pressure.

the type and stage of shock guide treatment.

tYPEs OF shOCK
The type of shock is identified by its underlying cause.

Cardiogenic: Failure of the heart to pump effectively due
to a cardiac factor

Hypovolemic: A decrease in intravascular volume of at
least 15% to 30%

Obstructive: Impairment of the heart to pump effectively
as a result of a noncardiac factor

Distributive: Widespread vasodilation and increased
capillary permeability, including neurogenic, septic, and
anaphylactic shock

stAGEs
All types of shock progress through the same stages and
produce similar effects on body systems

Initial: No visible changes in client parameters; only
changes on the cellular level

Compensatory (non‑progressive): Measures to increase
cardiac output to restore tissue perfusion and oxygenation

Progressive: Compensatory mechanisms beginning to fail

Refractory: Irreversible shock and total body failure

HEALTH PROMOTION AND
DISEASE PREVENTION

Cardiogenic shock

Educate the client about ways to reduce the risk of a
myocardial infarction (MI), such as exercise, diet, stress
reduction, and smoking cessation.

Hypovolemic shock
● Advise the client to drink plenty of fluids when

exercising or when in hot weather.
● Advise the client to obtain early medical attention with

illness or trauma and with any evidence of dehydration
or bleeding.

● Educate the client about the manifestations of dehydration,
including thirst, decreased urine output, and dizziness.

Obstructive/neurogenic/hypovolemic shock

Educate the client about wearing seat belts and helmets,
and the use of caution with dangerous equipment,
machinery, or activities.

Septic shock
● Advise the client to obtain early medical attention with

evidence of an infection (localized redness, swelling,
drainage, fever, urinary frequency and burning).

● Advise the client to complete the entire course of
antibiotics as directed.

Anaphylactic shock
● Advise the client to wear a medical identification

wristband, avoid allergens, and to have an epinephrine
pen available at all times.

● Teach the client and family how to use the epinephrine
pen and to be alert to early manifestations of an
allergic reaction.

ASSESSMENT

RIsK FACtORs

Cardiogenic shock
● Cardiac pump failure occurs due to a direct cardiac

cause, such as MI (especially anterior wall infarction),
heart failure, cardiomyopathy, dysrhythmias, and
valvular rupture or stenosis.

● Older adult clients are at increased risk for MI
and cardiomyopathy.

Hypovolemic shock
● Excessive fluid loss from diuresis, vomiting, or diarrhea;

or blood loss secondary to surgery, trauma, gynecologic/
obstetric causes, burns, and diabetic ketoacidosis.

● Older adult clients are more prone to dehydration due to
decreased fluid and protein intake and the use of
medications, such as diuretics. Minimal amounts of
fluid loss (vomiting, diarrhea) can cause the older adult
client to become dehydrated.

CHAPTER 37

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240 CHAPTER 37 hEmODYNAmIC shOCK CONTENT MASTERY SERIES

Obstructive shock

Cardiac pump failure occurs due to an indirect cardiac
factor (blockage of great vessels, pulmonary artery
stenosis, pulmonary embolism, cardiac tamponade,
tension pneumothorax, aortic dissection).

Distributive shock

Divided into three types:

Neurogenic: Loss of sympathetic tone causing massive
vasodilation. Head trauma, spinal cord injury, and epidural
anesthesia are among the causes.

Septic: Endotoxins and other mediators causing massive
vasodilation. Most common cause is gram‑negative bacteria.

Urosepsis is more frequent in older adult clients due
to increased use of catheters in long‑term care
facilities and late detection of urinary tract infection
(decreased sensation of burning, urgency).

Anaphylactic: Allergen exposure results in an
antigen‑antibody reaction causing massive vasodilation.
Common causes include antibiotics, foods (such as
peanuts), latex, and bee stings.

EXPECtED FINDINGs
Manifestations can include chest pain, lethargy,
somnolence, restlessness, anxiousness, dyspnea,
diaphoresis, thirst, muscle weakness, nausea,
and constipation.

PHYSICAL ASSESSMENT FINDINGS
● Hypoxia, tachypnea progressing to greater than 40/min,

hypocarbia
● Skin moist and cool or cold. Pallor and cyanosis (first in

mucous membranes, then extremities the trunk). Skin
mottling (clients who have dark skin tones appear darker
and lack reddish undertones; clients who have light skin
tones appear grayish‑blue). Skin can be flushed initially
with anaphylactic and septic shock.

● Angioedema (anaphylactic shock)
● Wheezing
● Decreased blood pressure with narrowed pulse pressure.
● Postural hypotension
● Tachycardia
● Pulse that is weak, thready
● Decreased cardiac output
● Central venous pressure decreased (hypovolemic shock)
● Central venous pressure increased with increased

systemic vascular resistance (cardiogenic shock)
● Decreased urine output
● Seizures

LABORAtORY tEsts
ABGs: Decreased tissue oxygenation (decreased pH,
decreased PaO2, increased PaCO2)

Blood lactic acid: Increases due to anaerobic metabolism

Blood glucose and electrolytes: Blood glucose can increase
during shock due to hypermetabolism; electrolyte balance
can be altered depending on cause (dehydration).

Cardiogenic shock

Cardiac enzymes: elevation can indicate cardiac ischemia
or infarction.

B‑type natriuretic peptide: elevated in response to
increased left ventricular pressures.

Hypovolemic shock

Hgb and Hct: Decreased with hemorrhage, increased with
dehydration

Septic shock

Cultures: Blood, urine, wound

Coagulation tests: PT, INR, aPTT

DIAGNOstIC PROCEDUREs

Hemodynamic monitoring

Arterial line insertion: Needed for continuous blood
pressure monitoring and blood specimens for ABGs and
other tests

Pulmonary artery catheter insertion: A pulmonary
artery catheter is inserted to measure central venous
pressure, pulmonary artery pressures, and cardiac output.
Continuous hemodynamic monitoring is important to
manage fluids and dosage of inotropic medications.

NURSING ACTIONS
● Monitor ECG during catheter insertion.
● Have resuscitation medications and equipment ready.
● Monitor hemodynamic waveforms and readings.
● Confirm catheter placement using a chest x‑ray.
● Explain all procedures to the client. The client can be

anxious and scared.

Cardiogenic and obstructive shock

ECG: Assess for ECG changes associated with MI and
dysrhythmias.

Echocardiogram: Used for cardiomegaly, cardiomyopathy,
evaluation of cardiac contractility and function, ejection
fraction, and valve function

Computerized tomography (CT): Used for cardiomegaly,
cardiac tamponade, pulmonary emboli, cardiomyopathy,
aortic dissection or aneurysm, and pericardial effusion

Cardiac catheterization: Used to identify coronary
artery blockage

Chest x‑ray: Used to diagnose cardiomegaly and
pneumothorax, and to evaluate lungs

Hypovolemic shock: miscellaneous
diagnostic procedures

Investigate possible sources of bleeding.
● Blood in nasogastric drainage or stools
● Esophagogastroduodenoscopy
● CT scan of abdomen

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 37 hEmODYNAmIC shOCK 241

NURSING ACTIONS
● Continuously monitor airway and vital signs.
● Provide hemodynamic support by administration

of fluids and medications because a client who has
suspected shock can be hemodynamically unstable.

● Have resuscitation equipment available when
transporting the client to and from procedures.

● Explain all procedures to the client.

PATIENT‑CENTERED CARE

NURsING CARE
● Monitor the following.

◯ Oxygenation status (priority)
◯ Vital signs
◯ Cardiac rhythm with continuous cardiac monitoring
◯ Urine output: hourly, report if less than 20 mL/hr
◯ Level of consciousness
◯ Skin color, temperature, moisture, capillary
refill, turgor

● Explain procedures and findings to the client and family
while providing reassurance.

● Place the client on high‑flow oxygen, such as a 100%
non‑rebreather face mask. If the client has COPD, insert
a 2 L/min nasal cannula and increase the oxygen flow
as needed.

● Be prepared to intubate the client. Have emergency
resuscitation equipment ready.

● Maintain patent IV access.
● For hypotension, place the client flat with both legs

elevated to increase venous return.
● If change in status occurs, notify the rapid response

team and provider of the findings.
● Prepare for and maintain client care during transfer to

the intensive care unit, surgery, other specialty unit, or
diagnostic area.

● Prepare for and perform hemodynamic monitoring.
◯ Monitor central venous pressure, pulmonary artery

pressures, cardiac output, and pulse pressure.
◯ Titrate continuous IV drips to maintain hemodynamic

parameters as prescribed.
● Educate and reassure the client and family.

Experiencing shock can be frightening.

mEDICAtIONs

Inotropic agents

Milrinone lactate, dobutamine

ACTIONS: Strengthens cardiac contraction and increases
cardiac output

NURSING ACTIONS
● Administer by continuous IV infusion with constant

hemodynamic monitoring.
● Can titrate to maintain prescribed

hemodynamic parameters.
● Can cause vasodilation in some clients.
● Often administered in combination with a vasopressor.

Vasopressors

Dopamine hydrochloride, norepinephrine

ACTIONS
● Strengthens cardiac contraction and increases

cardiac output
● Increases kidney perfusion at low doses
● Decreases kidney perfusion at high doses

NURSING ACTIONS
● Administer by continuous IV infusion with constant

hemodynamic monitoring.
● Can titrate vasopressor to maintain prescribed

hemodynamic parameters.
● Monitor urine output.
● Administer through a central line to prevent

extravasation. Rapid onset occurs in 5 min, and short
duration occurs in 10 min.

Pituitary hormone: Vasopressin

ACTIONS: Causes vasoconstriction, increases systemic
vascular resistance, increases blood pressure

NURSING ACTIONS
● Administer by continuous IV infusion with constant

hemodynamic monitoring.
● Can titrate to maintain prescribed

hemodynamic parameters.
● Monitor urine output.
● Administer through a central line to

prevent extravasation.

Sympathomimetics: Epinephrine

ACTIONS
● Rapid‑acting bronchodilator
● Increases heart rate and cardiac output

NURSING ACTIONS
● Monitor blood pressure, pulse, and cardiac output.
● Epinephrine can cause sloughing if it infiltrates tissue.

Opioid analgesics: Morphine sulfate

ACTIONS: Pain management

NURSING ACTIONS
● Monitor respirations of clients who are nonventilated.
● Monitor blood pressure, heart rate, and SaO2.
● Monitor ABGs.
● Use opioid analgesics cautiously in conjunction with

hypnotic sedatives.
● Use cautiously due to risk of increased vasodilation

and hypotension.
● Have naloxone and resuscitation equipment available for

severe respiratory depression in a client who is
nonventilated.

Proton‑pump inhibitors: Pantoprazole

ACTIONS: Protects against stress ulcer development

NURSING ACTIONS: Do not mix with other medications.

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242 CHAPTER 37 hEmODYNAmIC shOCK CONTENT MASTERY SERIES

Anticoagulants

Low‑molecular weight heparin, enoxaparin sodium

ACTIONS: Deep‑vein thrombosis prophylaxis

NURSING ACTIONS
● Administer subcutaneously, usually in abdomen.
● Do not rub injection site.

Isotonic crystalloids or colloids
(including blood products)

0.9% sodium chloride or lactated Ringer’s

ACTIONS: Hypovolemic shock: volume replacement

NURSING ACTIONS: Replace fluid volume before using
vasopressor medications, and only if blood pressure
remains low after volume is replaced.

! During hypovolemic shock, replace volume first.

Antihistamines: Diphenhydramine

ACTIONS
● Used as a secondary medication to treat angioedema

and urticaria associated with anaphylactic shock
● Blocks histamine at receptor sites

NURSING ACTIONS: Can cause drowsiness, hypotension,
and tachycardia.

Vasodilator: Sodium nitroprusside

ACTIONS
● Used to treat cardiogenic shock
● Reduces afterload and preload
● Causes vasodilation
● Decreases cardiac output and afterload

NURSING ACTIONS
● Continuous arterial blood pressure monitoring is

recommended.
● Titrate as needed. If blood pressure does not decrease

after 10 minutes of infusion at maximum rate
(10 mcg/kg/min), discontinue the medication.

● Administer with caution because it is a
potent vasodilator.

● Protect the solution from light.

Corticosteroids: Hydrocortisone, methylprednisolone

ACTIONS: Reduces WBC migration and
decreases inflammation

NURSING ACTIONS
● Hydrocortisone can cause hypertension.
● Discontinue medication gradually.
● Administer hydrocortisone with an antiulcer medication

to prevent peptic ulcer formation.
● Monitor weight and blood pressure.
● Monitor blood glucose and electrolytes.

Antibiotics sensitive to cultured organism(s)

Because septic shock is most commonly caused by
gram‑negative bacteria, the Joint Commission’s National
Patient Safety Goals recommends the administration of IV
antibiotics that are effective against gram‑negative
bacteria within 1 hr of a septic shock diagnosis.

Vancomycin
Antibiotics sensitive to the cultured organism, such as
vancomycin, can then be prescribed once the causative
organism is identified.

ACTIONS
● Used to treat septic shock
● Inhibits cell growth or reproduction of

causative organism

NURSING ACTIONS
● Monitor for hypersensitivity reaction.
● Administer IV vancomycin slowly.
● Culture infected area prior to administration of the first

dose of vancomycin.
● Monitor the IV site for infiltration.
● Do not administer vancomycin with other medications.
● Monitor coagulopathy and kidney function.

thERAPEUtIC PROCEDUREs

Intubation and mechanical ventilation

An artificial airway is inserted, and the client’s
respirations are controlled by mechanical ventilation.

PREINTUBATION NURSING ACTIONS
● Monitor ECG, SaO2, breath sounds, and color.
● Sedate the client as needed.
● Preoxygenate with 100% oxygen.
● Assist with ventilation using a manual resuscitation bag

and a face mask.
● Have suction equipment, manual emergency

resuscitation, and a face mask readily available.
● Suction secretions as needed.

POSTINTUBATION NURSING ACTIONS
● Assess bilateral breath sounds, symmetrical chest

movement, and a chest x‑ray to confirm placement of
the endotracheal tube.

● Secure the endotracheal tube per facility guidelines.
● Assess the balloon cuff for air leak periodically.

Positive end expiratory pressure (PEEP)
● Positive pressure is applied at the end of expiration to

keep the alveoli expanded to promote gas exchange.
● PEEP is added to the ventilator setting to increase

oxygenation and improve lung expansion.

CLIENT EDUCATION: You will be unable to talk with the
endotracheal tube in place.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 37 hEmODYNAmIC shOCK 243

Needle decompression and chest tube insertion

This procedure is used to relieve pressure from a tension
pneumothorax that can be causing obstructive shock.

NURSING ACTIONS
● Monitor ECG, SaO2, breath sounds, and color.
● Sedate as needed.
● Set up a water seal chest‑drainage system and attach it

to suction.
● Apply a dressing.
● Assess the chest tube for air leaks.
● Monitor and document the drainage.
● Obtain a chest x‑ray postprocedure.

CLIENT EDUCATION: Needle decompression provides
temporary relief while chest tube insertion allows for lung
reinflation.

Pericardiocentesis

Pericardial fluid that is causing cardiac tamponade and
obstructive shock is drained.

NURSING ACTIONS
● Monitor ECG, SaO2, breath sounds, and color.
● Sedate as needed.
● Obtain a postprocedure chest x‑ray.

CLIENT EDUCATION: Additional procedures are often
necessary to resolve acute tamponade (pericardial window,
pericardiectomy).

Surgical interventions

Surgery might be needed to correct the cause of shock
(hemorrhaging ulcer, wound, artery, vein).

PREPROCEDURE NURSING ACTIONS
● Manage the airway and provide supplemental oxygen

and intubation if needed.
● Provide hemodynamic support with fluids and

medications to stabilize the client prior to surgical
intervention, if possible.

POSTPROCEDURE NURSING ACTIONS
● Continue to monitor blood pressure, ECG, pulmonary

artery pressures, cardiac output, central venous
pressure, and urine output.

● Titrate and administer medications as prescribed.
● Assess the surgical site for bleeding.
● Monitor airway, breath sounds, and ABGs.
● Monitor CBC.
● Explain all procedures to the client.

INtERPROFEssIONAL CARE
Respiratory therapy: The respiratory therapist typically
manages the ventilator, adjusts the settings, and provides
chest physical therapy to improve ventilation and chest
expansion. The respiratory therapist can also suction the
endotracheal tube and administer inhalation medications,
such as bronchodilators.

COMPLICATIONS

Multiple organ dysfunction syndrome (MODS)

MODS occurs from the release of toxic metabolites and
destructive enzymes in response to inadequate oxygenation.

● MODS can develop from inadequate tissue perfusion
(severe hypotension) and reperfusion of ischemic
cells, causing further tissue injury. Organ failure
usually first occurs in the lungs (adult respiratory
distress syndrome), but can occur in the kidneys, heart
(decreased coronary artery perfusion, decreased cardiac
contractility), and the gastrointestinal tract (necrosis).

● MODS is most commonly associated with sepsis. Other
risk factors include malnutrition, coexisting disease,
and advanced age.

NURSING ACTIONS
● Assess organ function, and provide support measures

that can increase tissue perfusion and improve organ
function (ventilatory support, inotropic medications).

● Implement measures to compensate for dysfunction
(administration of clotting factors, dialysis).

Disseminated intravascular coagulation (DIC)

DIC is a complication of septic shock. Thousands of small
clots form within organ capillaries (liver, kidney, heart,
brain), creating hypoxia and anaerobic metabolism. As a
result of massive, multiple clot formation, platelets and
other clotting factors such as fibrinogen are depleted and
the client is at increased risk for hemorrhage. The client
can develop diffuse petechiae and ecchymoses, and blood
can leak from membranes and puncture sites.

NURSING ACTIONS
● Assess client preference related to transfusion of blood

products. Some clients might not accept this treatment
for various reasons (religion, fear of contamination).

● Administer platelets, clotting factors, and other blood
products as prescribed.

● Monitor hemodynamic levels.
● Monitor results of laboratory tests (PT, PTT, blood

fibrinogen, fibrin degradation products).
● Assess for further indications of bleeding from mucous

membranes, venipuncture sites, gums, and around
IV catheters.

● Apply pressure to leaking IV/central line/arterial
line sites.

● Explain procedures and care to the client and family.

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244 CHAPTER 37 hEmODYNAmIC shOCK CONTENT MASTERY SERIES

Application Exercises

1. A nurse is caring for a client who has a prescription
for an afterload‑reducing medication. the nurse
should identify that this medication is administered
for which of the following types of shock?

A. Cardiogenic

B. Obstructive

C. hypovolemic

D. Distributive

2. A nurse is planning care for a client who has
septic shock. Which of the following actions
is the priority for the nurse to take?

A. maintain adequate fluid volume with Iv infusions.

B. Administer antibiotic therapy.

C. monitor hemodynamic status.

D. Administer vasopressor medication.

3. A nurse is caring for a client who is experiencing
wheezing and swelling of the tongue. Which
of the following medications should the
nurse anticipate administering first?

A. methylprednisolone

B. Diphenhydramine

C. Epinephrine

D. Dobutamine

4. A nurse in the emergency department is
completing an assessment on a client who is in
shock. Which of the following findings should
the nurse expect? (select all that apply.)

A. heart rate 60/min

B. seizure activity

C. Respiratory rate 42/min

D. Increased urine output

E. Weak, thready pulse

5. A nurse is caring for a group of clients. Which of the
following clients is at risk for obstructive shock?

A. A client who is having occasional
PvCs on the ECG monitor

B. A client who has been experiencing
vomiting and diarrhea for several days

C. A client who has a gram‑negative bacterial infection

D. A client who has a pulmonary arterial stenosis

Active Learning Scenario

A nurse educator is reviewing care of a client who is in shock
with a group of newly hired nurse. What should the nurse
educator include in this discussion? Use the AtI Active
Learning template: system Disorder to complete this item.

RISK FACTORS: List each type of shock
and at least one risk factor for each.

EXPECTED FINDINGS: Describe expected findings related
to blood pressure, pulse, respirations, and urine output.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 37 hEmODYNAmIC shOCK 245

Application Exercises Key

1. A. CORRECT: Identify that a prescription to reduce afterload
will allow the heart to pump more effectively, which is
needed for the client who has cardiogenic shock.

B. In obstructive shock, the high afterload is due
to obstruction of blood flow. Afterload‑reducing
agents will not remove the obstruction.

C. Fluid replacement and reduction of further fluid loss are
the focus of management of hypovolemic shock.

D. Afterload‑reducing medication is not administered
to a client who has distributive shock because the
client already has decreased afterload.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Expected Actions/Outcomes

2. A. maintain the client’s fluid volume by administration of Iv
fluids. however, another action is the priority.

B. CORRECT: the greatest risk to the client is injury
from elimination endotoxins and mediators from
bacteria. the priority intervention is to administer
antibiotics, which will reduce vasodilation.

C. monitor hemodynamic status to monitor the blood
pressure inside the veins, arteries and heart.
however, another action is the priority.

D. Administer vasopressor medication to increase
the contractility of the heart muscle and to cause
vasoconstriction. however, another action is the priority.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

3. A. Administer methylprednisolone to treat the inflammatory
response. however, administer another medication first.

B. Administer diphenhydramine to treat urticaria.
however, administer another medication first.

C. CORRECT: When using the airway, breathing,
circulation approach to client care, place the priority
on administering epinephrine to the client. this is
a rapid‑acting medication that promotes effective
oxygenation and is used to treat anaphylactic shock.

D. Administer dobutamine or other medications to improve
cardiac status if Iv fluid replacement is not successful.
however, administer another medication first.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. A. tachycardia is an expected finding in
a client who is in shock.

B. CORRECT: seizure activity caused by progressive
hypoxia can be present in a client who is in shock.

C. CORRECT: tachypnea is an expected finding
in a client who is in shock due to the body’s
attempt to increase oxygen intake.

D. Decreased urine output is in expected
finding in a client who is in shock.

E. CORRECT: A weak, thready pulse caused by low
fluid volume, vasoconstriction, and hypotension is
an expected finding in a client who is in shock.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

5. A. ventricular dysrhythmia is a risk factor
for cardiogenic shock.

B. Dehydration from vomiting and diarrhea for several
days is a risk factor for hypovolemic shock.

C. Presence of a gram‑negative bacterial infection
is a risk factor for septic shock.

D. CORRECT: Obstructive shock results from decreased cardiac
function by a noncardiac cause, such as with pulmonary
arterial stenosis or hypertension, or thoracic tumor.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS
● Cardiogenic: Pump failure due to myocardial infarction, heart failure,
cardiomyopathy, dysrhythmia, and valvular rupture or stenosis

● hypovolemic: Excessive fluid loss from diuresis,
vomiting, diarrhea, blood loss

● Obstructive: Blockage of great vessels, pulmonary artery
stenosis, pulmonary embolism, cardiac tamponade,
tension pneumothorax, and aortic dissection

● septic: Endotoxins (gram‑negative bacteria) and
mediators causing massive vasodilation

● Neurogenic: Loss of sympathetic tone causing massive
vasodilation due to trauma, spinal shock, epidural anesthesia

● Anaphylactic: Antigen‑antibody reaction causing
massive vasodilation due to allergens (inhaled,
swallowed, contacted, or introduced Iv)

EXPECTED FINDINGS
● Blood pressure: Decreased blood pressure with
narrowed pulse pressure, postural hypotension

● Pulse: tachycardia, can be weak or thready,
bounding with distributive shock

● Respirations: tachypnea progressing to greater
than 40/min, hypocarbia, hypoxia

● Urine output: Decreased

NCLEX® Connection: Physiological Adaptation, Medical
Emergencies

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246 CHAPTER 37 hEmODYNAmIC shOCK CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 38 ANEURYsms 247

UNIT 4 CARDIOVASCULAR DISORDERS
SECTION: VASCULAR DISORDERS

CHAPTER 38 Aneurysms
A weakness in a section of a dilated artery
that causes a widening or ballooning in the
wall of the blood vessel is called an aneurysm.
Aneurysms can occur in two forms. they can be
saccular (only affecting one side of the artery), or
fusiform (involving the complete circumference
of the artery).

Aortic dissection (also known as a dissecting
aneurysm) can occur when blood accumulates
within the artery wall (hematoma) following a
tear in the lining of the artery (usually due to
hypertension). this is a life‑threatening condition.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Promote smoking cessation.
● Maintain appropriate weight for height and body frame.
● Encourage a healthy diet and physical activity.
● Control blood pressure with regular monitoring and

medication if needed.

ASSESSMENT

RIsK FACtORs
● Male sex
● Atherosclerosis (most common cause)
● Uncontrolled hypertension
● Tobacco use
● Hyperlipidemia
● Family history
● Blunt force trauma
● History of syphilis
● With age, arterial stiffening caused by loss of elastin
in arterial walls, thickening of intima of arteries,
and progressive fibrosis of media occurs. Older adult
clients are more prone to aneurysms and have a
higher mortality rate from aneurysms than younger
individuals.

EXPECtED FINDINGs
Initially, clients are often asymptomatic.

Abdominal aortic aneurysm (AAA)

Most common, related to atherosclerosis
● Constant gnawing feeling in abdomen
● Low back pain (due to pressure on lumbar nerves

by aneurysm)
● Pulsating abdominal mass (do not palpate; can

cause rupture )
● Bruit over the area of the aneurysm
● Elevated blood pressure (unless in cardiac tamponade or

rupture of aneurysm)

Thoracic aortic aneurysm
● Severe back pain (most common)
● Hoarseness, cough, shortness of breath, and

difficulty swallowing
● Decrease in urinary output (secondary to

hypovolemic shock)

Aortic dissections

Often associated with Marfan syndrome
● Sudden onset of “tearing,” “ripping,” and “stabbing”

abdominal or back pain
● Hypovolemic shock

◯ Diaphoresis, nausea, vomiting, faintness,
apprehension

◯ Decreased or absent peripheral pulses
◯ Neurologic deficits
◯ Hypotension and tachycardia (initial)
◯ Oliguria

DIAGNOstIC PROCEDUREs
X‑ray: Can be used to detect the presence of an aneurysm.

Computed tomography (CT) and ultrasonography: Used
to assess the size and location of aneurysms. Often
repeated at periodic intervals to monitor the progression
of an aneurysm.

Transesophageal echocardiography (TEE): Useful in
diagnosing thoracic aneurysms and aortic dissections.

CHAPTER 38
38.1 Types of aneurysms

38.1 Common aneurysm sites

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248 CHAPTER 38 ANEURYsms CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

NURsING CARE
● Take vital signs every 15 min until stable, then every

hour. Monitor for an increase in blood pressure.
● Assess the onset, quality, duration, and severity of pain.
● Assess temperature, circulation, and range of motion

of extremities.
● Continuously monitor cardiac rhythm.
● Monitor hemodynamic findings.
● Monitor ABGs, SaO2, electrolytes, and CBC findings.
● Monitor hourly urine output. Greater than 30 mL/hr

indicates adequate kidney perfusion.
● Administer oxygen as prescribed.
● Obtain and maintain IV access.
● Administer medications as prescribed.

! All aneurysms can be life‑threatening
and require medical attention.

mEDICAtIONs
● The priority intervention is to reduce systolic blood
pressure to between 100 and 120 mm Hg during an
emergency. Long‑term goal includes maintaining
systolic blood pressure at or less than 130 to
140 mm Hg.

● Administer antihypertensive agents as prescribed.
Often, more than one is prescribed (beta blockers and
calcium blockers).

thERAPEUtIC PROCEDUREs

Abdominal aortic aneurysm resection

Excision of the aneurysm and the placement of a
synthetic graft (elective or emergency)

● Elective surgery is used to manage AAA of 5.5 cm
diameter or greater (2% to 5% mortality rate).

● Emergency surgery is indicated for a
rupturing aneurysm.

● Risks include significant blood loss and the
consequences of reduced cardiac output and tissue
ischemia (myocardial infarction, acute kidney injury,
respiratory distress, and paralytic ileus).

NURSING ACTIONS
● Priority interventions include monitoring
the arterial pressure, heart rhythm, and
hemodynamic findings, as well as
monitoring for evidence of graft occlusion or
rupture postoperatively.

● Monitor vital signs and circulation (pulses distal
to graft) every 15 min.

● Maintain the head of the bed below 45° to prevent
flexion of the graft.

● Report evidence of graft occlusion or rupture
immediately (changes in pulses, coolness of
extremity below graft, white or blue extremities
or flanks, severe pain, abdominal distention,
decreased urine output).

● Monitor and maintain blood pressure within the
prescribed parameters. Prolonged hypotension
can cause thrombi to form within the graft; severe
hypertension can cause leakage or rupture at the
arterial anastomosis suture line.

● Maintain a warm environment to prevent
temperature‑induced vasoconstriction.

● Administer IV fluids at prescribed rates to ensure
adequate hydration and kidney perfusion.

● Monitor for altered kidney perfusion and acute kidney
injury caused by clamping aorta during surgery (urine
output less than 30 mL/hr, weight gain, elevated BUN or
blood creatinine).

● Auscultate lung sounds. Encourage coughing and
deep breathing every 2 hr. Encourage splinting
with coughing.

● Assess onset, quality, duration, and severity of pain.
Administer pain medication as prescribed.

38.3 Graft

38.2 Aneurysm types

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 38 ANEURYsms 249

● Monitor bowel sounds, and observe for abdominal
distention. Maintain nasogastric suction as prescribed.

● Prevent thromboembolism. Maintain sequential
compression devices. Encourage early ambulation.

● Monitor for infection.
● Administer antibiotics as prescribed to maintain

adequate blood levels of the medication.

Percutaneous aneurysm repair

Insertion of endothelial stent grafts for aneurysm repair
avoids abdominal incision and shortens the postoperative
period (can be used to repair thoracic and abdominal
aortic aneurysms).

NURSING ACTIONS: Nursing care after the procedure
is similar to care following an arteriogram or cardiac
catheterization (monitor pedal pulse). Refer to CHAPTER 30:

INVASIVE CARDIOVASCULAR PROCEDURES.

Thoracic aortic aneurysm repair

Procedure similar to thoracic surgery, such as open
heart. The course of action depends on the location of the
aneurysm. Cardiopulmonary bypass is commonly used for
this procedure.

NURSING ACTIONS
● Nursing care after the procedure is similar to care

following coronary artery bypass graft surgery. (Monitor
respiratory status. Respiratory distress is common after
this type of procedure.)

● Cardiac rehabilitation services are often consulted for
prolonged weakness and assistance in increasing the
client’s level of activity.

● Nutritional services can be consulted for food choices
that are low in fat and cholesterol.

CLIENT EDUCATION
● Monitor and maintain blood pressure. Stay within

parameters set by the provider. Taking medications as
prescribed prevents complications (rupture).

● Perform follow‑up on scheduled CT scans or
ultrasounds to monitor aneurysm size (nonsurgical
client). Collaborate with case management services to
assist with transportation needs.

● Consider smoking cessation if the client smokes.
● Prevent infection (good hand hygiene, wound care

management). Report evidence of infection following
surgical intervention (wound redness, edema, drainage;
elevated temperature).

● Adhere to a proper diet (low‑fat, high‑protein, vitamins
A and C, zinc to promote wound healing).

● Review manifestations of aneurysm rupture (abdominal
fullness or pain, chest or back pain, shortness of breath,
cough, difficulty swallowing, hoarseness). Report
these immediately.

● Avoid strenuous activity, and restrict heavy lifting to
less than 15 lb (surgical client).

INtERPROFEssIONAL CARE
● Cardiology services can assist in managing and

treating hypertension.
● Radiology should be consulted for diagnostic studies to

diagnose and monitor an aneurysm.
● Vascular services may be consulted for

surgical intervention.

COMPLICATIONS

Rupture
● Aneurysm rupture is a life‑threatening emergency,

often resulting in massive hemorrhage, shock,
and death.

● Treatment requires simultaneous resuscitation and
immediate surgical repair.

● Older adult clients who have an aneurysm greater than
6 cm (2.4 in) along with hypertension are at greater risk
of death due to spontaneous rupture than of dying
during surgical repair.

Thrombus formation
● A thrombus can form inside the aneurysm. Emboli

can be dislodged, blocking arteries distal to the
aneurysm, which causes ischemia and shuts down other
body systems.

● Assess circulation distal to aneurysm, including pulses
and color and temperature of the lower extremities.
Monitor urine output.

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250 CHAPTER 38 ANEURYsms CONTENT MASTERY SERIES

Application Exercises

1. A nurse in the emergency department is
admitting a client who has a possible dissecting
abdominal aortic aneurysm. Which of the following
actions is the priority for the nurse to take?

A. Administer pain medication as prescribed.

B. Provide a warm environment.

C. Administer Iv fluids as prescribed.

D. Initiate a 12‑lead ECG.

2. A nurse is reviewing manifestations of a thoracic
aortic aneurysm with a newly hired nurse. Which
of the following findings should the nurse include
in the discussion? (select all that apply.)

A. Cough

B. shortness of breath

C. Upper chest pain

D. Diaphoresis

E. Altered swallowing

3. A nurse is planning postoperative care for a client
following a surgical placement of an endovascular
stent graft to repair an aneurysm. Which of the
following interventions should the nurse include
in the plan of care? (select all that apply.)

A. Assess pedal pulses.

B. monitor for an increase in pain below the graft site.

C. maintain the client in high‑Fowler’s position.

D. monitor the femoral site for bleeding.

E. Report hourly urine output of 60 mL.

4. A nurse is teaching a client who has a new diagnosis
of an aneurysm. the client asks the nurse to explain
what causes an aneurysm to rupture. Which of the
following statements should the nurse give?

A. “this can occur when the wall of an
artery becomes thin and flexible.”

B. “this can occur when there is turbulence
in blood flow in the artery.”

C. “It is due to abdominal enlargement.”

D. “It is due to hypertension.”

5. A nurse is admitting a client who has a suspected
occlusion of a graft of the abdominal aorta. Which of
the following manifestations should the nurse expect?

A. Increase in urine output

B. Bounding pedal pulse

C. Increase in abdominal girth

D. Lower extremities have irregularly
shaped cyanotic areas

Active Learning Scenario

A nurse manager is presenting an in‑service to a
group of nurses about care of the client who has an
aneurysm. What information should the nurse manager
include in the in‑service? Use the AtI Active Learning
template: system Disorder to complete this item.

RISK FACTORS: Describe three.

DIAGNOSTIC PROCEDURES: Describe two.

NURSING CARE: Describe at least four nursing actions.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 38 ANEURYsms 251

Application Exercises Key

1. A. Administer pain medication to alleviate the client’s
pain and discomfort related to the aneurysm.
however, another action is the priority.

B. Provide a warm environment due to impaired blood
flow and decreasing blood pressure related to the
aneurysm. however, another action is the priority.

C. CORRECT: When using the airway, breathing,
circulation approach to client care, determine that
the priority is on administering Iv fluids to the client.
the client is at risk of inadequate circulatory volume
due to profuse sweating related to the pain and
feeling of fullness related to the aneurysm and to
possible leaking or rupture of the aneurysm.

D. Initiate a 12‑lead ECG to determine the cardiac rhythm related
to the aneurysm. however, another action is the priority.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

2. A. CORRECT: Cough is a manifestation of a
thoracic aortic aneurysm.

B. CORRECT: shortness of breath is a manifestation
of a thoracic aortic aneurysm.

C. Report of severe back pain is a finding
of thoracic aortic aneurysm.

D. Diaphoresis is a finding of dissecting aortic aneurysm.
E. CORRECT: Difficulty swallowing is a manifestation

of a thoracic aortic aneurysm.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. A. CORRECT: Assess the pulses distal to the graft site
to detect possible occlusion of the graft.

B. CORRECT: monitor for an increase pain below the graft site.
this can be an indication of graft occlusion or rupture.

C. the head of the bed should be maintained at less
than 45° to prevent flexion of the graft.

D. CORRECT: Check the femoral insertion site for
bleeding and for a thrombus formation.

E. Urine output of 60 mL/hr is an expected finding.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. A. An aneurysm ruptures as a result of thickening in the intima
of the artery and a lack of elasticity in the vessel wall, which
is typically under pressure due to hypertension.

B. A bruit is objective data that indicates the presence
of an aneurysm, not the cause of rupture.

C. Abdominal distention can occur when an aneurysm
ruptures, but it is not the cause of the rupture.

D. CORRECT: Explain to the client that aneurysm
ruptures as a result of hypertension increasing
pressure within the arterial walls.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

5. A. Decreased urine output is an expected finding
with occlusion of a graft of the aorta.

B. Decreased or absent pedal pulse is an expected
finding with occlusion of a graft of the aorta.

C. CORRECT: the client who has a graft embolism can
have irregularly shaped cyanotic areas, tenderness,
and decrease pulses in the lower extremities due to
the occlusion of blood flow from the thrombus.

D. Pallor or cyanosis of the extremities is an expected
finding with occlusion of a graft of the aorta.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS
● male sex
● Atherosclerosis
● Uncontrolled hypertension
● tobacco use
● hyperlipidemia
● Family history
● Blunt force trauma
● history of syphilis
● Age‑related changes to the artery (loss of elastin,
thickening of the intima, progressive fibrosis)

DIAGNOSTIC PROCEDURES
● X‑rays
● Ct scans
● Ultrasonography
● transesophageal echocardiography

NURSING CARE
● take vital signs every 15 min until stable. then
monitor for increased blood pressure hourly.

● Assess pain (onset, quality, duration, severity).
● Assess temperature, circulation, and range of motion of extremities.
● monitor cardiac rhythm continuously.
● monitor hemodynamic findings.
● monitor ABGs, saO2, electrolytes, and CBC laboratory findings.
● monitor hourly urine output.
● Administer oxygen as prescribed.
● Obtain and maintain Iv access.
● Administer medications as prescribed.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

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252 CHAPTER 38 ANEURYsms CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING NCLEX® CONNECtIONs 253

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Basic Care and Comfort
HYDRATION: Evaluate the impact of disease/illness on nutrition.

Pharmacological and Parenteral Therapies
BLOOD AND BLOOD PRODUCTS
Identify the client according to facility/agency policy prior
to administration of red blood cells/ blood products.

Administer blood products and evaluate client response.

MEDICATION ADMINISTRATION: Review pertinent
data prior to medication administration.

Reduction of Risk Potential
LABORATORY VALUES
Identify laboratory values for ABGs, BUN, cholesterol, glucose,
hematocrit, hemoglobin, glycosylated hemoglobin, platelets,
potassium, sodium, WBC, creatinine, PT, PTT & APTT, INR.

POTENTIAL FOR ALTERATIONS IN BODY SYSTEMS: Identify
client with increased risk for insufficient vascular perfusion.

POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC TESTS/
TREATMENTS/PROCEDURES: Monitor the client for signs of bleeding.

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS: Apply knowledge of
nursing procedures, pathophysiology and psychomotor skills
when caring for a client with an alteration in body systems.

HEMODYNAMICS: Mange the care of a client with alteration
in hemodynamics, tissue perfusion, and/or hemostasis.

UNEXPECTED RESPONSE TO THERAPIES: Recognize signs
and symptoms of client complications and intervene.

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254 NCLEX® CONNECtIONs CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 39 Hematologic Diagnostic ProceDures 255

UNIT 5 HEMATOLOGIC DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 39 Hematologic
Diagnostic
Procedures

Hematologic assessment and diagnostic
procedures evaluate blood function by
testing indicators such as erythrocytes
(rBcs), leukocytes (WBcs), platelets, and
coagulation times. By testing the blood,
diagnosis of a disease and efficacy of treatment
can be determined.

Bone marrow is responsible for the production
of many blood cells including rBcs, WBcs,
and platelets. a bone marrow biopsy provides
diagnostic information about how the bone
marrow is functioning.

Blood collection/testing
● Hematologic diagnostic procedures of blood components

that nurses should be knowledgeable about include the
following. (39.1)

◯ RBC count
◯ WBC count
◯ Mean corpuscular volume (MCV)
◯ Mean corpuscular Hgb (MCH)
◯ Total iron‑binding count (TIBC)
◯ Iron
◯ Platelets
◯ Hemoglobin (Hgb)
◯ Hematocrit (Hct)
◯ Coagulation studies

■ Prothrombin time (PT)
■ Partial thromboplastin time (aPTT)
■ International normalized ratio (INR)
■ D‑dimer
■ Fibrinogen levels
■ Fibrin degradation products

● CBC is a series of tests that includes RBC, WBC, MCV,
MCH, Hgb, and Hct.

CONSIDERATIONS

PreProceDure
NURSING ACTIONS: Use standard precautions in collecting
and handling blood for specimen collection.

intraProceDure
NURSING ACTIONS: For coagulation studies, draw blood
at specific times and immediately send to the laboratory.
Adjust the dose of anticoagulant therapy based on the
results and prescription.

PostProceDure
NURSING ACTIONS

● Results of hematologic tests are usually available
preliminarily within 24 to 48 hr, with final results in 72 hr.

● If results are out of the expected reference range, it is
the nurse’s responsibility to report the results to the
provider for further intervention.

Bone marrow
aspiration/biopsy

● A biopsy is the extraction of a very small amount of
tissue, such as bone marrow, to definitively diagnose
cell type and to confirm or rule out malignancy. A bone
marrow tissue sample is removed by needle aspiration
for cytological (histological) examination. (39.2)

● Biopsies are commonly performed with local anesthesia
or conscious sedation in an ambulatory setting,
intraoperatively, or during endoscopic procedures.

INDICATIONS
A bone marrow biopsy is commonly performed to
diagnose causes of blood disorders, such as anemia or
thrombocytopenia; to diagnose diseases of the bone
marrow, such as leukemia, and infection; or to stage
lymphoma or other forms of cancer.

CONSIDERATIONS

PreProceDure
NURSING ACTIONS

● Ensure that the client has provided informed consent.
● Place the client in a prone or side‑lying position to

expose the iliac crest for the procedure.
● Explain the procedure to the client.

CLIENT EDUCATION
● The biopsy site will be anesthetized with a local

anesthetic, and there can be a feeling pressure and brief
pain during the aspiration.

● There will be a sensation of pressure as the biopsy
needle is inserted, and a crunching sound might be
heard when the needle enters the bone.

CHAPTER 39

Online Image: Bone Marrow Biopsy

256 CHAPTER 39 Hematologic Diagnostic ProceDures CONTENT MASTERY SERIES

39.1 Expected reference ranges for blood diagnostic procedures

EXPECTED REFERENCE RANGE INTERPRETATION OF FINDINGS

RBC
Females: 4.2 to 5.4 million/ul
males: 4.7 to 6.1 million/ul

elevated level: erythrocytosis, polycythemia vera, severe dehydration
Decreased level: anemia, hemorrhage, kidney disease

WBC 5,000 to 10,000/mm3
elevated level: infection, inflammation.
Decreased level: immunosuppression, autoimmune disease

MCV 80 to 95 fl
elevated level: macrocytic (large) rBcs, megaloblastic anemia.
Decreased level: microcytic (small) rBcs, iron deficiency anemia.

MCH 27 to 31 pg/cell elevated/decreased level: same as above for mcV

TIBC 250 to 460 mcg/dl
elevated level: iron deficiency anemia, polycythemia vera
Decreased level: malnutrition, cirrhosis, pernicious anemia

IRON
Females: 60 to 160 mcg/dl
males: 80 to 180 mcg/dl

elevated level: Hemochromatosis, iron excess, liver disorder, or lead toxicity.
Decreased level: iron deficiency anemia, chronic blood
loss, inadequate dietary intake of iron.

PLATELETS 150,000 to 400,000 mm3
increased level: malignancy, polycythemia vera, rheumatoid arthritis.
Decreased level: enlarged spleen, hemorrhage, leukemia

HGB
Females: 12 to 16 g/dl
males: 14 to 18 g/dl

elevated level: erythrocytosis, coPD, severe dehydration
Decreased level: anemia, hemorrhage, kidney disease

HCT
Females: 37% to 47%
males: 42% to 52%

elevated /decreased level: same as above for Hgb

APTT
30 to 40 seconds (1.5 to
2.5 times the control value if
receiving heparin therapy)

increased time: Vitamin K deficiency, disseminated intravascular
coagulation (Dic), liver disease, heparin administration
Decreased time: extensive cancer

PT 11 to 12.5 seconds, 85% to 100%,
or 1:1.1 client‑control ratio

increased time: clotting factors ii, V, Vii, or X, liver disease,
warfarin therapy, disseminated intravascular coagulation
Decreased time: Vitamin K excess, pulmonary embolus, thrombophlebitis

INR 0.8 to 1.1 (desired goal of
2 to 3 on warfarin therapy)

measures the mean of Pt to provide a universally recognized value.
elevated level: Warfarin therapy
Decreased level: cancer disorders

D‑DIMER less than 0.4 mcg/ml
Positive result: Disseminated intravascular coagulation, malignancy
negative result: can rule out pulmonary embolus or deep vein thrombosis

FIBRINOGEN
LEVELS 200 to 400 mg/dl

elevated level: acute inflammation, acute infection, heart disease
Decreased levels: liver disease, advanced cancer, malnutrition

FIBRIN
DEGRADATION

PRODUCTS
less than 10 mcg/ml

elevated level: Disseminated intravascular coagulation,
massive trauma resulting in fibrinolysis
Decreased level: anticoagulation therapy

39.2 Bone marrow biopsy

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 39 Hematologic Diagnostic ProceDures 257

intraProceDure
NURSING ACTIONS

● Administer a sedative if prescribed.
◯ Older adult clients are at greater risk for
complications associated with sedation for biopsy
procedures due to chronic illnesses.

◯ The nurse should take an older adult’s kidney function
into consideration when using analgesics for sedation.

● Cleanse the site with an antiseptic solution.
● Maintain sterility of equipment and supplies.
● Assist the provider with the procedure as needed.

CLIENT EDUCATION: The test will last about 20 min.

PostProceDure
NURSING ACTIONS

● Apply pressure to the biopsy site to control bleeding.
● Place a sterile dressing over the biopsy site.
● Maintain the client on bed rest for 30 to 60 min.
● Monitor for manifestations of infection (fever, increased

WBCs, pain, and swelling at the site) and bleeding.
● Apply ice to the biopsy site to minimize bleeding

and bruising.
● Postprocedure discomfort is usually relieved by

mild analgesics.
● Avoid aspirin and other medications that affect clotting.

CLIENT EDUCATION
● Report excessive bleeding and evidence of infection to

the provider.
● Check the biopsy site daily. Keep the dressing clean, dry,

and intact.
● If sutures are in place, return in 7 to 10 days to have

them removed.

INTERPRETATION OF FINDINGS
After a procedure is completed, the tissue sample is sent to
pathology for interpretation.

COMPLICATIONS

Infection

Infection can occur at the aspiration site.

NURSING ACTIONS: Monitor the site, and keep the
dressing clean and dry.

Bleeding

Bleeding can occur from the site.

NURSING ACTIONS
● Report bleeding to the provider immediately.
● Apply a pressure dressing over the site.

Active Learning Scenario

a nurse is caring for a client who is having a bone
marrow biopsy. What actions should the nurse
take? use the ati active learning template:
Diagnostic Procedure to complete this item.

NURSING INTERVENTIONS (PRE, INTRA, POST): Describe
two for each of the pre‑, intra‑, and postprocedure periods.

POTENTIAL COMPLICATIONS: identify two.

CLIENT EDUCATION: Describe two
discharge teaching points.

Application Exercises

1. a nurse in a clinic is caring for a client who
has suspected anemia. Which of the following
laboratory test results should the nurse expect?

a. iron 90 mcg/dl

B. rBc 6.5 million/ul

c. WBc 4,800 mm³

D. Hgb 10 g/dl

2. a nurse is caring for a client who is receiving warfarin
for anticoagulation therapy. Which of the following
laboratory test results indicates to the nurse that
the client needs an increase in the dosage?

a. aPtt 38 seconds

B. inr 1.1

c. Pt 22 seconds

D. D‑dimer negative

3. a nurse is providing teaching for a client who is
scheduled for a bone marrow biopsy of the iliac
crest. Which of the following statements made by the
client indicates an understanding of the teaching?

a. “this test will be performed while
i am lying flat on my back.”

B. “i will need to stay in bed for about
an hour after the test.”

c. “this test will determine which antibiotic
i should take for treatment.”

D. “i will receive general anesthesia for the test.”

258 CHAPTER 39 Hematologic Diagnostic ProceDures CONTENT MASTERY SERIES

Application Exercises Key

1. a. an iron level of 90 mcg/dl is within the expected reference
range and is not an expected finding of anemia.

B. rBc count of 6.5 million/ul is above the
expected reference range. a decreased rBc
count is an expected finding of anemia.

c. WBc count of 4800 mm3 is below the expected reference
range and is not an expected finding of anemia.

D. CORRECT: Hgb of 10 g/dl is below the expected
reference range and is an expected finding of anemia.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. aPtt is monitored for clients receiving heparin therapy.
an aPtt of 38 seconds is within the expected reference
range for clients not receiving heparin therapy.

B. CORRECT: inr of 1.1 is within the expected reference
range for a client who is not receiving warfarin.
However, this value is subtherapeutic for anticoagulation
therapy. expect the client to receive an increased
dosage of warfarin until the inr is 2 to 3.

c. Pt of 22 seconds is above the expected reference range
for a client receiving warfarin therapy. this result indicates
the client is at an increased risk for bleeding.

D. a negative D‑dimer test indicates the absence of a
pulmonary embolus or deep vein thrombosis and is not used
to determine the dosage needs for warfarin therapy.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

3. a. inform the client that they will be placed in a
prone or side‑lying position during the test
in order to expose the iliac crest.

B. CORRECT: inform the client of the need to
stay on bed rest for 30 to 60 min following the
test to reduce the risk for bleeding.

c. inform the client that a culture and sensitivity test determines
the type of antibiotics needed to treat an infection.

D. inform the client that they will receive a sedative prior to the
test and that a local anesthetic will be used at the site.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

NURSING INTERVENTIONS (PRE, INTRA, POST)

Preprocedure
● ensure that the client has signed the informed consent form.
● Position the client in a prone or side‑lying position.
● explain the procedure to the client. inform the client that they might
feel pressure and brief pain during the bone marrow aspiration.

intraprocedure
● administer sedative medication.
● assist with the procedure.
● inform the client that the procedure lasts about 20 min.
● cleanse the site with an antiseptic solution.
● maintain sterility of equipment and supplies.

Postprocedure
● apply pressure to the biopsy site.
● Place a sterile dressing over the biopsy site.
● monitor for evidence of infection and bleeding.
● apply ice to the biopsy site.
● administer mild analgesics. avoid aspirin or
medications that affect clotting.

POTENTIAL COMPLICATIONS
● Bleeding and infection
● older adults at greater risk for complications
associated with anesthesia

CLIENT EDUCATION
● report excessive bleeding and evidence of infection to the provider.
● check the biopsy site daily. Keep the dressing clean, dry and intact.
● if there are sutures, return in 7 to 10 days for removal.

NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 40 BlooD anD BlooD ProDuct transFusions 259

UNIT 5 HEMATOLOGIC DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 40 Blood and
Blood Product
Transfusions

clients can receive transfusions of whole blood
or components of whole blood for replacement
due to blood loss or blood disease.

Blood components include packed rBcs,
washed red blood cells (WBc‑poor rBcs), white
blood cells (WBcs), fresh frozen plasma, albumin,
clotting factors, cryoprecipitate, and platelets.

TRANSFUSION TYPES
Standard donation: Transfusion from compatible
donor blood.

Autologous transfusions: The client’s blood is collected in
anticipation of future transfusions (elective surgery). This
blood is designated for and used only by the client. Clients
can donate up to 6 weeks prior to the scheduled surgery.
If the client’s hemoglobin and hematocrit remain stable,
donation can occur weekly until the desired amount of
blood for the anticipated transfusion is collected.

Intraoperative blood salvage: Sterile blood lost during
a procedure is saved or retrieved into a device that
filters and drains the blood into a bag for transfusion
intraoperatively or postoperatively. Reinfusion must occur
within 6 hr of salvaged blood collection.

INDICATIONS

Potential Diagnoses
Excessive blood loss: packed RBCs

Anemia (Hgb less than 6, or 6 to 10 g/dL,
depending on findings): packed RBCs

Kidney failure: packed RBCs

Coagulation factor deficiencies such as hemophilia:
fresh frozen plasma

Thrombocytopenia/platelet dysfunction: platelets

Hemophilia A: cryoprecipitate

Burns, hypoproteinemia: albumin

CONSIDERATIONS

Platelet transfusion

Platelets do not need to match the client blood type.
Platelet infusion bags contain 200 to 300 mL.

NURSING ACTIONS
● Platelets are fragile and must be immediately infused

once brought to the client’s room, and given over 15 to
30 min using a special transfusion set with a small filter
and short tubing.

● Vital signs are taken before the infusion, 15 min after
the infusion starts, and upon completion.

Plasma transfusion
● Plasma is frozen immediately following donation and is

then in the form of fresh frozen plasma (FFP).
● FFP is transfused as soon as the unit is thawed while

clotting factors are still active.
● The client can react to the FFP transfusion if the ABO

compatibility is not matched.

NURSING ACTIONS: Infuse the unit of 200 mL of FFP
rapidly over 30 to 60 min through a regular Y‑set or
straight filtered tubing.

White blood cell transfusion (Granulocyte)
● Immunocompromised clients rarely receive WBC

transfusions because of the risk for severe reaction.
● If the client is receiving amphotericin B antibiotics,

4 to 6 hr should be between the administration of
the antibiotic and the WBC transfusion because
amphotericin B can hemolyze the WBCs.

NURSING ACTIONS : Infuse WBCs suspended in 400 mL
plasma over 45 to 60 min and vital signs are taken every
15 min. The presence of the provider may be required
according to agency policy.

Washed RBCs (WBC-poor packed RBCs)

NURSING ACTIONS
● Infuse a unit of 200 mL over 2 to 4 hr.
● Administer to a client who has a history of transfusion

reactions or to a client who has had a hematopoietic
stem cell transplant.

PreProceDure
● Incompatibility is a major concern when administering

blood or blood products. Preventing incompatibility
requires strict adherence to blood transfusion protocols.

● Type and cross match is necessary for packed red blood
cells. Blood products containing RBCs are typed and
cross‑matched for antigens.

● Plasma products are typed for ABO compatibility but
not cross‑matched for antigens. The other cells (WBCs,
platelets) in the plasma products can carry ABO antigens.

● Blood is typed based on the presence of antigens.

CHAPTER 40

260 CHAPTER 40 BlooD anD BlooD ProDuct transFusions CONTENT MASTERY SERIES

40.1 Blood type compatibility

BLOOD TYPE ANTIGEN
ANTIBODIES

AGAINST COMPATIBLE WITH

a a B a, o
B B a B, o

aB aB none a, B, aB, o
o none a, B o

● Another consideration is the Rh factor. Clients who are
Rh‑negative are born without the Rh antigen in their
RBCs. As a result, they do not develop antibodies unless
sensitization occurs. Once this occurs, any transfusion
with Rh‑positive blood will cause a reaction.

NURSING ACTIONS
● Explain the procedure to the client.
● Assess vital signs and the client’s temperature prior

to transfusion.
● Remain with the client during the initial 15 to 30 min of

the transfusion. Most severe reactions occur within this
time frame.

● Review laboratory values to ensure the client requires
transfusion and to compare to post‑transfusion values.

● Verify the prescription for a specific blood product.
● Obtain consent for procedure if required.
● Obtain blood samples for compatibility determination,

such as type and cross‑match.
● Assess for a history of blood‑transfusion reactions.
● Initiate large‑bore IV access. An 18‑ or 20‑gauge needle

is standard for administering blood products.
● Obtain blood products from the blood bank. Inspect the

blood for discoloration, excessive bubbles, or cloudiness.
● Prior to transfusion, two RNs (or an RN and a PN,

depending on facility policy) must identify the correct
blood product and client by looking at the hospital
identification number (noted on the blood product) and
the number identified on the client’s identification band
to make sure the numbers match.

● The nurse completing the blood product verification must
be one of the nurses who administers the blood product.

● Prime the blood administration set with 0.9% sodium
chloride only. Never add medications to blood products.
Y‑tubing with a filter is used to transfuse blood.

● Begin the transfusion, and use a blood warmer if indicated.
Initiate the transfusion within 30 min of obtaining the
blood product to reduce the risk of bacterial growth.

● OLDER ADULT CLIENTS
◯ No larger than a 19‑gauge needle is used.
◯ Assess kidney function, fluid status, and circulation

prior to blood product administration. Older adult
clients are at an increased risk for fluid overload.

◯ Use blood products that are less than 1 week old.
◯ Explain to the client the reason for the

blood transfusion.

intraProceDure
NURSING ACTIONS

● Remain with the client for the first 15 to 30 min of the
infusion (reactions occur most often during the first
15 min) and monitor vital signs and rate of infusion per
facility policy.

● OLDER ADULT CLIENTS: Assess vital signs every 15 min
throughout the transfusion because changes in pulse,
blood pressure, and respiratory rate can indicate fluid
overload, or can be the sole indicators of a transfusion
reaction. Older adult clients who have cardiac or renal
dysfunction are at an increased risk for heart failure and
fluid‑volume excess when receiving a blood transfusion.
Administer the blood transfusion over 2 to 4 hr for older
adult clients. Withhold administration of other IV fluids
during blood product administration to prevent
fluid overload.

● Notify the provider immediately if indications of a
reaction occur.

PostProceDure
NURSING ACTIONS

● Obtain vital signs upon completion of the transfusion.
● Dispose of the blood‑administration set according to

facility policy.
● Complete paperwork, and file in the appropriate places.
● Document the client’s response.

COMPLICATIONS

Acute hemolytic transfusion reaction

ONSET: Immediate or can manifest during subsequent
transfusions

FINDINGS
● Results from a transfusion of blood products that are

incompatible with the client’s blood type or Rh factor.
Can occur following the transfusion of as few as 10 mL
of a blood product.

● Can be mild or life‑threatening, resulting in
disseminated intravascular coagulation (DIC) or
circulatory collapse.

● Findings include chills, fever, low‑back pain,
tachycardia, flushing, hypotension, chest tightening or
pain, tachypnea, nausea, anxiety, hemoglobinuria, and
an impending sense of doom.

NURSING ACTIONS
● Stop the transfusion.
● Remove the blood tubing from the IV access.

Avoid infusing further blood products into the
circulatory system.

● Initiate an infusion of 0.9% sodium chloride using
new tubing.

● Monitor vital signs and fluid status.
● Send the blood bag and administration set to the lab

for testing.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 40 BlooD anD BlooD ProDuct transFusions 261

Febrile transfusion reaction

ONSET: Commonly occurs within 2 hr of starting
the transfusion

FINDINGS
● Results from the development of anti‑WBC

antibodies. Can be seen when the client has received
multiple transfusions.

● Findings include chills, increase of 1° F (0.5° C) or
greater from the pretransfusion temperature, flushing,
hypotension, and tachycardia.

NURSING ACTIONS
● Use WBC filter for administration to catch the WBCs and

prevent the reaction from occurring.
● Stop the transfusion and administer antipyretics.
● Initiate an infusion of 0.9% sodium chloride using

new tubing.

Allergic transfusion reaction

ONSET: During or up to 24 hr after transfusion

FINDINGS
● Results from a sensitivity reaction to a component of the

transfused blood products.
● Findings are usually mild and include itching, urticaria,

and flushing.
● The client can develop an anaphylactic transfusion

reaction resulting in bronchospasm, laryngeal edema,
hypotension, and shock.

NURSING ACTIONS

Mild reaction
● Stop the transfusion.
● Initiate an infusion of 0.9% sodium chloride using

new tubing.
● Administer an antihistamine, such as diphenhydramine.
● If the provider prescribes to restart the transfusion, do

so slowly.

Anaphylactic reaction
● Stop the transfusion.
● Administer epinephrine, corticosteroids, vasopressors,

oxygen, or CPR if indicated.
● Remove the blood tubing from the client’s IV access.
● Initiate an infusion of 0.9% sodium chloride using

new tubing.

Bacterial transfusion reaction

ONSET: During or up to several hours after transfusion

FINDINGS
● Results from a transfusion of contaminated

blood products.
● Findings include wheezing, dyspnea, chest tightness,

cyanosis, hypotension, and shock.

NURSING ACTIONS
● Stop the transfusion.
● Administer antibiotics and an IV infusion of

0.9% sodium chloride using new tubing.
● Send a blood culture specimen to the lab for analysis.

Circulatory overload

ONSET: Can occur any time during the transfusion

FINDINGS
● Results from a transfusion rate that is too rapid for

the client. Older adult clients or those who have a
preexisting increased circulatory volume are at an
increased risk.

● Findings include crackles, dyspnea, cough, anxiety,
jugular vein distention, and tachycardia. Manifestations
can progress to pulmonary edema.

NURSING ACTIONS
● Slow or stop the transfusion depending on the severity

of manifestations.
● Position the client upright with feet lower than the level

of the heart.
● Administer oxygen, diuretics, and morphine

as prescribed.

262 CHAPTER 40 BlooD anD BlooD ProDuct transFusions CONTENT MASTERY SERIES

Application Exercises

1. a nurse is preparing to administer packed rBcs
to a client who has a Hgb of 8 g/dl. Which of the
following actions should the nurse plan to take
during the first 15 min of the transfusion?

a. obtain consent from the client for the transfusion.
B. assess for an acute hemolytic reaction.
c. explain the transfusion procedure to the client.
D. obtain blood culture specimens to send to the lab.

2. a nurse is caring for a client who is receiving a blood
transfusion. Which of the following actions should
the nurse plan to take if an allergic transfusion
reaction is suspected? (select all that apply.)

a. stop the transfusion.
B. monitor for hypertension.
c. maintain an iV infusion with 0.9% sodium chloride.
D. Position the client in an upright position

with the feet lower than the heart.
e. administer diphenhydramine.

3. a nurse is monitoring a client who began receiving a
unit of packed rBcs 10 min ago. Which of the following
findings should the nurse identify as an indication of
a febrile transfusion reaction? (select all that apply.)

a. temperature change from 37° c (98.6° F)
pretransfusion to 37.2° c (99.0° F)

B. current blood pressure 178/90 mm Hg
c. Heart rate change from 88/min

pretransfusion to 120/min
D. client report of itching
e. client appears flushed

4. a nurse is providing preoperative teaching for
a client who requests autologous donation in
preparation for a scheduled orthopedic surgical
procedure. Which of the following statements
should the nurse include in the teaching?

a. “You should make an appointment to donate
blood 8 weeks prior to the surgery.”

B. “if you need an autologous transfusion, the
blood your brother donates can be used.”

c. “You can donate blood each week
if your hemoglobin is stable.”

D. “any unused blood that is donated
can be used for other clients.”

5. a nurse preceptor is observing a newly licensed
nurse on the unit who is preparing to administer a
blood transfusion to an older adult client. Which of
the following actions by the newly licensed nurse
indicates an understanding of the procedure?

a. inserts an 18‑gauge iV catheter in the client
B. Verifies blood compatibility and expiration date

of the blood with an assistive personnel (aP)
c. administers dextrose 5% in 0.9% sodium

chloride iV with the transfusion
D. obtains vital signs every 15 min

throughout the procedure.

Active Learning Scenario

a nurse is caring for a client who is receiving a blood
transfusion. What nursing actions should the nurse plan to
take if a transfusion reaction is suspected? use the ati active
learning template: nursing skill to complete this item.

INDICATIONS
● Describe the types of reactions and the time of onset.
● Describe three medications that can be
administered and for which reaction.

NURSING INTERVENTIONS: Describe
actions for each type of reaction.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 40 BlooD anD BlooD ProDuct transFusions 263

Application Exercises Key

1. a. obtain consent from the client for the transfusion
prior to initiating the transfusion.

B. CORRECT: assess for an acute hemolytic reaction
during the first 15 min of the transfusion. this form
of a reaction can occur following the transfusion
of as little as 10 ml of blood product.

c. explain the transfusion procedure to the client
prior to initiating the transfusion.

D. obtain blood culture specimens from the client
if a bacterial reaction is suspected.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Blood and Blood Products

2. a. CORRECT: immediately stop the infusion if an
allergic transfusion reaction is suspected.

B. monitor for hypotension if an allergic transfusion
reaction is suspected due to the risk for shock.

c. CORRECT: administer 0.9% sodium chloride solution through
new iV tubing if an allergic transfusion reaction is suspected.

D. Position the client with the feet elevated and the head
flat or elevated no more than 30° to prevent or treat
hypotension associated with an allergic reaction.

e. CORRECT: administer an antihistamine,
such as diphenhydramine, if an allergic
transfusion reaction is suspected.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Blood and Blood Products

3. a. a temperature increase of 1° F (0.5° c) is an
indication of a febrile transfusion reaction.

B. Hypotension is an indication of a febrile transfusion reaction.
c. CORRECT: tachycardia is an indication of

a febrile transfusion reaction.
D. itching is an indication of an allergic transfusion reaction.
e. CORRECT: a flushed appearance of the client

can indicate a febrile transfusion reaction.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Blood and Blood Products

4. a. the client should donate blood for an autologous
transfusion 6 weeks prior to surgery.

B. an autologous donation refers to the client’s
donation of blood for their own personal use.

c. CORRECT: Beginning 6 weeks prior to surgery, the
client can donate blood each week for autologous
transfusion if their Hgb and Hct remain stable.

D. an autologous donation is for use only by the client.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. a. use no larger than a 19‑gauge needle
in the older adult client.

B. Verify the client’s identity and blood compatibility, and
expiration date of the blood with another nurse. this task is
beyond the scope of practice for an assistive personnel.

c. administer blood products with 0.9% sodium chloride.
iV solutions containing dextrose cannot be used.

D. CORRECT: check the older adult client’s vital signs every
15 min throughout the transfusion to allow for early
detection of fluid overload or other transfusion reaction.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Blood and Blood Products

Active Learning Scenario Key

Using the ATI Active Learning Template: Nursing Skill

INDICATIONS

types of reactions and onset
● acute hemolytic: immediate or during subsequent transfusions
● Febrile: within 2 hr of starting the transfusion
● allergic: during or up to 24 hr after transfusion
● Bacterial: during or up to several hours after the transfusion
● circulatory overload: any time during the transfusion

medications
● antipyretics (acetaminophen): febrile
● antihistamines (diphenhydramine): mild allergic
● antihistamines, corticosteroids, vasopressors,
epinephrine: anaphylactic

● antibiotics: bacterial
● Diuretics, morphine: circulatory overload

NURSING ACTIONS

acute hemolytic
● stop the transfusion.
● remove the blood tubing.
● initiate an infusion of 0.9% sodium chloride.
● monitor vital signs and fluid status.
● send the blood bag and administration set to the lab for testing.

Febrile
● use a WBc filter to help prevent a febrile reaction.
● stop the transfusion.
● administer antipyretics.
● initiate an infusion of 0.9% sodium chloride.

mild allergic reaction
● stop the transfusion.
● initiate an infusion of 0.9% sodium chloride.
● administer an antihistamine.
● if prescribed, restart the transfusion slowly to continue.

anaphylactic reaction
● stop the transfusion.
● administer epinephrine, corticosteroids, vasopressors, and oxygen.
● administer cPr if indicated.
● remove the blood tubing from the client’s iV access.
● initiate an infusion of 0.9% sodium chloride.

circulatory overload
● slow or stop the transfusion depending on the severity.
● Position the client upright with feet lower than the level of the heart.
● administer oxygen, diuretics, and morphine.

Bacterial
● stop the transfusion.
● administer antibiotics as prescribed.
● initiate an infusion of 0.9% sodium chloride.
● obtain blood samples for culture.

NCLEX® Connection: Physiological Adaptation, Unexpected
Response to Therapies

264 CHAPTER 40 BlooD anD BlooD ProDuct transFusions CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 41 anemias 265

UNIT 5 HEMATOLOGIC DISORDERS
SECTION: HEMATOLOGIC DISORDERS

CHAPTER 41 Anemias
anemia is an abnormally low amount of
circulating rBcs, Hgb concentration, or both.
it is an indicator of an underlying disease
or disorder. anemia results in diminished
oxygen‑carrying capacity and delivery to tissues
and organs. the goal of treatment is to restore
and maintain adequate tissue oxygenation.

iron‑deficiency anemia due to inadequate
intake is the most common cause of anemia
in children, adolescents, and pregnant clients.
iron‑deficiency anemia due to blood loss (such
as from a gastrointestinal ulcer) is the most
common cause of anemia in clients who are
postmenopausal, as well as males. clients who
are menstruating can develop anemia secondary
to menorrhagia.

causes oF anemia
● Blood loss
● Inadequate RBC production (hypoproliferative)
● Increased RBC destruction (hemolytic)
● Deficiency of necessary components (folic acid, iron,

erythropoietin, vitamin B12)

HEALTH PROMOTION AND
DISEASE PREVENTION

● Clients who are pregnant or menstruating should ensure
that their diet contains adequate amounts of iron‑rich
foods. Otherwise, they should take an iron supplement.

● Individuals who are iron‑deficient and have elevated
cholesterol levels should integrate iron‑rich foods
that are not red or organ meats into their diets
(iron‑fortified cereal and breads, fish, poultry, and dried
peas and beans).

● Clients should regularly consume foods high in folate
(spinach, lentils, bananas) and folic acid fortified grains
and juices.

ASSESSMENT

risK Factors
Acute or chronic blood loss

● Trauma
● Menorrhagia
● Gastrointestinal bleed (ulcers, tumor)
● Intra or postsurgical blood loss or hemorrhage
● Chemical or radiation exposure

Rapid metabolic activity
● Pregnancy
● Adolescence
● Infection

Increased hemolysis
● Defective Hgb (sickle‑cell disease): RBCs become

malformed during periods of hypoxia and obstruct
capillaries in joints and organs

● Impaired glycolysis: glucose‑6‑phosphate‑dehydrogenase
(G6PD) deficiency anemia

● Immune disorder or destruction (transfusion reactions,
autoimmune diseases)

● Mechanical trauma to RBCs (mechanical heart valve,
cardiopulmonary bypass)

Inadequate dietary intake or malabsorption
● Iron deficiency
● Vitamin B12 deficiency: pernicious anemia due to

deficiency of intrinsic factor produced by gastric mucosa,
which is necessary for absorption of vitamin B12

● Folic acid deficiency
● Pica, or a persistent eating of substances not normally

considered food (nonnutritive substances), such as
soil or chalk, for at least 1 month, which can limit the
amount of healthy food choices a client makes

Bone‑marrow suppression
● Exposure to radiation or chemicals (such as insecticides

or solvents)
● Aplastic anemia, which results in a decreased number of

RBCs as well as decreased platelets and WBCs

Age
● Older adult clients are at risk for nutrition‑deficient

anemias (iron, vitamin B12, folate).
● Anemia can be misdiagnosed as depression or

debilitation in older adult clients.
● Gastrointestinal bleeding is a common cause of anemia

in older adult clients. Check stools for occult blood.

eXPecteD FinDings
● Little to no manifestations in mild cases
● Pallor
● Fatigue, somnolence, and headache
● Irritability
● Numbness and tingling of extremities
● Dyspnea on exertion
● Sensitivity to cold
● Pain and hypoxia with sickle‑cell crisis

CHAPTER 41

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266 CHAPTER 41 anemias CONTENT MASTERY SERIES

PHYSICAL ASSESSMENT FINDINGS
● Shortness of breath/fatigue, especially upon exertion
● Tachycardia and palpitations
● Dizziness or syncope upon standing or with exertion
● Pallor of the nail beds and mucous membranes
● Nail bed deformities (spoon‑shaped nails)
● Smooth, sore, bright‑red tongue (vitamin B12 deficiency)
● Paresthesias in hands and feet with possible loss of

balance (vitamin B12 deficiency)

laBoratorY tests

CBC count
● RBCs are the major carriers of hemoglobin in the blood.
● Hgb transports oxygen and carbon dioxide to and

from the cells and can be used as an index of the
oxygen‑carrying capacity of the blood.

● Hct is the percentage of RBCs in relation to the total
blood volume.

RBC indices

Used to determine the type and cause of most anemias

Mean corpuscular volume (MCV): Size of red blood cells
● Normocytic: Normal size
● Microcytic: Small cells
● Macrocytic: Large cells

Mean corpuscular Hgb (MCH): Determines the amount of
Hgb per RBC

● Normochromic: Normal amount of Hgb per cell
● Hypochromic: Decreased Hgb per cell

Mean corpuscular Hgb concentration (MCHC): Indicates
Hgb amount relative to the size of the cell

Iron studies
● Total iron‑binding capacity (TIBC) reflects an indirect

measurement of transferrin, a protein that binds with
iron and transports it for storage.

● Ferritin is an indicator of total iron stores in the body.
● Low blood iron levels and elevated TIBC indicate

iron‑deficiency anemia.

Hgb electrophoresis

Separates normal Hgb from abnormal. It is used to detect
thalassemia and sickle‑cell disease.

Sickle-cell test

Evaluates the sickling of RBCs in the presence of decreased
oxygen tension

Schilling test

Measures vitamin B12 absorption with and without
intrinsic factor. It is used to differentiate between
malabsorption and pernicious anemia.

Diagnostic ProceDures
Bone‑marrow aspiration/biopsy is used to diagnose
aplastic anemia (failure of bone marrow to produce RBCs
as well as platelets and WBCs).

PATIENT‑CENTERED CARE

nursing care
● Encourage increased dietary intake of the deficient

nutrient (iron, vitamin B12, folic acid).
● Monitor oxygen saturation to determine a need for

oxygen therapy.
● Administer medications, as prescribed, at the

proper time for optimal absorption, and using an
appropriate technique.

● Teach the client and family about energy conservation
and the risk of the client experiencing dizziness
upon standing.

● Teach the client about the time frame for resolution.

meDications

Iron supplements

Ferrous sulfate, ferrous fumarate, ferrous gluconate
● Oral iron supplements are used to replenish iron in the

blood and iron stores. Iron is an essential component of
Hgb, and subsequently, oxygen transport.

● Parenteral iron supplements (iron dextran) are only
given for severe anemia.

NURSING ACTIONS: Administer parenteral iron using the
Z‑track method.

41.1 Sickled blood cells

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 41 anemias 267

CLIENT EDUCATION
● Have hemoglobin checked in 4 to 6 weeks to

determine efficacy.
● Vitamin C can increase oral iron absorption.
● Take iron supplements between meals to increase

absorption, if tolerated.
● Stools can appear green to black in color while taking iron.

Erythropoietin: epoetin alfa

A hematopoietic growth factor used to increase
production of RBCs

NURSING ACTIONS
● Monitor for an increase in blood pressure.
● Monitor Hgb and Hct twice per week.
● Monitor for a cardiovascular event if Hgb increases too

rapidly (greater than 1 g/dL in 2 weeks).

CLIENT EDUCATION: Understand the importance of having
Hgb and Hct evaluated on a twice‑per‑week basis until
targeted levels are reached.

Vitamin B12 supplementation (cyanocobalamin)
● Vitamin B12 is necessary to convert folic acid from its

inactive form to its active form. All cells rely on folic
acid for DNA production.

● Vitamin B12 supplementation can be given orally if the
deficit is due to inadequate dietary intake. However,
if deficiency is due to lack of intrinsic factor being
produced by the parietal cells of the stomach or
malabsorption syndrome, it must be administered
parenterally or intranasally to be absorbed.

NURSING ACTIONS
● Administer vitamin B12 according to appropriate route

related to cause of vitamin B12 anemia (parenteral vs. oral).
● Administer parenteral forms of vitamin B12 IM or deep

subcutaneous to decrease irritation. Do not mix other
medications in the syringe.

CLIENT EDUCATION
● If lacking intrinsic factor or have an irreversible

malabsorption syndrome, this therapy must be
continued for the rest of their life.

● Receive vitamin B12 injections on a monthly basis.

Folic acid supplements

Folic acid is a water‑soluble, B‑complex vitamin. It is
necessary for the production of new RBCs.

NURSING ACTIONS: Folic acid can be given orally or
parenterally.

CLIENT EDUCATION
● Large doses of folic acid can mask vitamin B12 deficiency.
● Large doses of folic acid will turn urine dark yellow.

tHeraPeutic ProceDures

Blood transfusions
● Blood transfusions lead to an immediate improvement

in blood‑cell counts and manifestations of anemia.
● Typically only used when the client has significant

manifestations of anemia, because of the risk of
blood‑borne infections.

COMPLICATIONS

Heart failure

Heart failure can develop due to the increased demand
on the heart to provide oxygen to tissues. A low Hct
decreases the amount of oxygen carried to tissues in the
body, which makes the heart work harder and beat faster
(tachycardia, palpitations).

NURSING ACTIONS
● Administer oxygen, and monitor oxygen saturation.
● Monitor cardiac rhythm.
● Obtain daily weight.
● Administer blood transfusion as prescribed.
● Administer cardiac medications as prescribed (diuretics,

antidysrhythmics).
● Administer antianemia medications as prescribed.

41.2 RBC indices

NORMAL MCV, MCH, MCHC DECREASED MCV, MCH, MCHC INCREASED MCV

CLASSIFICATION normocytic, normochromic anemia microcytic, hypochromic anemia macrocytic anemia,
normochromic anemia

POSSIBLE CAUSES

acute blood loss
sickle‑cell disease
chronic illness (kidney
disease, sepsis, tumor)
aplastic anemia
iron deficiency anemia
(early detection)

iron‑deficiency anemia
(late detection)
thalassemia
chronic blood loss

Vitamin B12 deficiency
Folic acid deficiency

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268 CHAPTER 41 anemias CONTENT MASTERY SERIES

Active Learning Scenario

a nurse educator is presenting a community education
program on anemia to a group of clients. What should be
included in this presentation? use the ati active learning
template: system Disorder to complete this item.

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM:
Describe at least three causes of the disorder.

EXPECTED FINDINGS: identify at least six.

LABORATORY TESTS: Describe the importance
of the total iron‑binding capacity (tiBc) test.

Application Exercises

1. a nurse is planning care for a client who has
Hgb 7.5 g/dl and Hct 21.5%. Which of the
following actions should the nurse include in
the plan of care? (select all that apply.)

a. Provide assistance with ambulation.

B. monitor oxygen saturation.

c. Weigh the client weekly.

D. obtain stool specimen for occult blood.

e. schedule daily rest periods.

2. a nurse is teaching a client who has a new prescription
for ferrous sulfate. Which of the following information
should the nurse include in the teaching?

a. stools will be dark red.

B. take with a glass of milk if
gastrointestinal distress occurs.

c. Foods high in vitamin c will promote absorption.

D. take for 14 days.

3. a nurse is providing discharge teaching to a client
who had a gastrectomy for stomach cancer. Which
of the following information should the nurse
include in the teaching? (select all that apply.)

a. “You will need a monthly injection of
vitamin B12 for the rest of your life.”

B. “using the nasal spray form of vitamin B12
on a daily basis can be an option.”

c. “an oral supplement of vitamin B12 taken
on a daily basis can be an option.”

D. “You should increase your intake of animal
proteins, legumes, and dairy products
to increase vitamin B12 in your diet.”

e. “add soy milk fortified with vitamin B12 to your
diet to decrease the risk of pernicious anemia.”

4. a nurse is completing an integumentary
assessment of a client who has anemia. Which of
the following findings should the nurse expect?

a. absent turgor

B. spoon‑shaped nails

c. shiny, hairless legs

D. Yellow mucous membranes

5. a nurse in a clinic receives a phone call from a client
seeking information about a new prescription for
erythropoietin. Which of the following information
should the nurse review with the client?

a. the client needs an erythrocyte
sedimentation rate (esr) test weekly.

B. the client should have their hemoglobin
checked twice a week.

c. oxygen saturation levels should be monitored.

D. Folic acid production will increase.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 41 anemias 269

Application Exercises Key

1. a. CORRECT: assist the client when ambulating
to prevent a fall because the client who has
anemia can experience dizziness.

B. CORRECT: monitor oxygen saturation when
the client has anemia due to the decreased
oxygen‑carrying capacity of the blood.

c. Weigh the client daily to determine if the client is losing
weight from inadequate oral intake or gaining weight,
which can indicate a complication of heart failure due
to lack of oxygen from low hemoglobin level.

D. CORRECT: obtain the client’s stool to test for
occult blood, which can identify a possible cause of
anemia caused from gastrointestinal bleeding.

e. CORRECT: schedule the client to rest throughout the day
because the client who has anemia can experience fatigue.
rest periods should be planned to conserve energy.

NCLEX® Connection: Physiological Adaptation,
Illness Management

2. a. stools will be dark green to black in
color when taking iron.

B. milk binds with iron and decreases its absorption.
c. CORRECT: Vitamin c enhances the absorption

of iron by the intestinal tract.
D. iron therapy usually takes 4 to 6 weeks for Hgb and

Hct to return to the expected reference range.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

3. a. CORRECT: the client who had a gastrectomy will
require monthly injections of vitamin B12 for the
rest of their life due to lack of intrinsic factor being
produced by the parietal cells of the stomach.

B. CORRECT: cyanocobalamin nasal spray used daily is
an option for a client who had a gastrectomy.

c. oral supplements of vitamin B12 will not be
absorbed due to the lack of intrinsic factor produced
by the parietal cells of the stomach.

D. Dietary sources of vitamin B12 will not be absorbed
due to the lack of intrinsic factor produced
by the parietal cells of the stomach.

e. Dietary sources of vitamin B12 will not be absorbed
due to the lack of intrinsic factor produced
by the parietal cells of the stomach.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. a. absent skin turgor is a finding in a client
who has dehydration.

B. CORRECT: Deformities of the nails, such as being
spoon‑shaped, are findings in a client who has anemia.

c. shiny, hairless legs are present in a client who
has peripheral vascular disease.

D. Yellow mucous membranes are found in a client
who has jaundice. the client who has anemia will
have pale nail beds and mucous membranes.

NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessment

5. a. include in the teaching that the effectiveness of erythropoietin
is evaluated by changes in the hematocrit.

B. CORRECT: include in the teaching that hemoglobin
and hematocrit are monitored twice a week
until the targeted levels are reached.

c. monitor the client’s blood pressure for an
increase and determine if the provider should
prescribe an antihypertensive.

D. inform the client that erythropoietin promotes
increased production of rBcs.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM: anemia is
an abnormally low amount of circulating red blood cells, hemoglobin
concentration, or both. it can be due to blood loss, inadequate
production or increased destruction of red blood cells, and dietary
deficiencies of folic acid, iron, erythropoietin, and/or vitamin B12.

EXPECTED FINDINGS
● shortness of breath and fatigue with exertion
● tachycardia, palpitations, dizziness, or syncope
upon standing or with exertion

● Pallor of the nail beds and mucous membranes, nail bed deformities
● smooth, sore, bright‑red tongue
● irritability, numbness and tingling of extremities, dyspnea on
exertion, sensitivity to cold, pain, and hypoxia with sickle‑cell crisis

LABORATORY TESTS: a total iron‑binding capacity (tiBc)
test is an indirect measurement of transferrin, a protein that
binds with iron and transports it for storage. transferrin
is an indicator of the total iron stores in the body.

NCLEX® Connection: Physiological Adaptation, Alterations in
Body Systems

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270 CHAPTER 41 anemias CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 42 coagulation DisorDers 271

UNIT 5 HEMATOLOGIC DISORDERS
SECTION: HEMATOLOGIC DISORDERS

CHAPTER 42 Coagulation
Disorders

coagulation disorders occur secondary to an
alteration in platelets, clotting factors, or both.
coagulopathy is the term for any condition
that affects an individual’s ability to coagulate.
coagulopathies are suspected when the usual
measures used to stop bleeding fail.

coagulopathy can occur secondary to an
autoimmune disorder or extensive blood loss in
which platelets and clotting factors are lost. in
some cases, the development of microemboli in
the circulatory system paradoxically uses up the
clotting factors that cause hemorrhages to occur
at the same time intravascular clotting occurs.

Idiopathic or immune thrombocytopenic
purpura (ITP) is a coagulopathy that is an
autoimmune disorder in which the life span of
platelets is decreased by antiplatelet antibodies
although platelet production is normal. this
can result in severe hemorrhage following a
cesarean birth or lacerations.

Thrombotic thrombocytopenic purpura (TTP)
is a coagulopathy in which platelets abnormally
clump together in capillaries due to an
autoimmune reaction from platelet aggregation,
resulting in an insufficient quantity in circulation.
inappropriate clotting occurs, and clotting fails
to occur with trauma. this can lead to kidney
failure, myocardial infarction, and stroke, and
can be fatal within 3 months if untreated.

Heparin‑induced thrombocytopenia (HIT) is an
immunity‑mediated clotting disorder that causes
unexplained low blood platelet count as a result
of treatment with heparin.

Disseminated intravascular coagulation (DIC) is a
life‑threatening coagulopathy in which clotting and
anticlotting mechanisms occur at the same time. a
client who has Dic is at risk for both internal and
external bleeding, as well as damage to organs
resulting from ischemia caused by microclots.

ASSESSMENT

risK Factors

ITP
● Female sex (ages 20 to 50 years)
● Secondary conditions (medications, viruses [HIV,

hepatitis C])
● Other autoimmune disorders
● Recent virus (children only)

TTP

Other autoimmune disorders

HIT
● Female sex
● Receiving heparin longer than 1 week
● Exposure to unfractionated heparin
● Postsurgical thromboprophylaxis (prevention of

thromboembolic disease)

DIC secondary to other complications
● Septicemia
● Cardiopulmonary arrest
● Trauma (hemorrhage, burns, crush injuries)
● Obstetric complications (toxemia, amniotic fluid

embolus, placental abruption)
● Cancer
● Allergic reaction

eXPecteD FinDings
● Unusual spontaneous bleeding from the gums and

nose (epistaxis)
● Oozing, trickling, or flow of blood from incisions

or lacerations
● Petechiae and ecchymoses
● Hematuria
● Excessive bleeding from venipuncture, injection sites, or

slight traumas
● Tachycardia, hypotension, and diaphoresis
● Organ failure secondary to microemboli
● Respiratory distress
● Redness, pain, warmth and swelling of lower

extremities (HIT)

CHAPTER 42

272 CHAPTER 42 coagulation DisorDers CONTENT MASTERY SERIES

laBoratorY tests
● Hemoglobin (decreased with DIC and ITP):

Expected reference range males, 14 to 18 g/dL;
females, 12 to 16 g/dL

● Platelet levels (thrombocytopenia; decreased with DIC,
TTP, and ITP): Expected reference range 150,000 to
400,000 mm3

● Fibrinogen levels (decreased with DIC): Expected
reference range 200 to 400 mg/dL

● Prothrombin time (increased with DIC): Expected
reference range 11.0 to 12.5 seconds

● Partial thromboplastin (increased with DIC): Expected
reference range aPTT, 30 to 40 seconds; PTT, 60 to
70 seconds

● Thrombin time (increased with DIC): 8 to 11 seconds
● Fibrin split product levels/fibrin degradation products

(increased with DIC): Expected reference range less
than 10 mcg/mL

● D‑dimer (increased with DIC): Expected reference range
less than 0.4 mcg/mL

● Blood typing and cross‑match

PATIENT‑CENTERED CARE

nursing care
DIC

● Nursing interventions for DIC initially focus on
assessing for and correcting the underlying cause
(sepsis, malignancy, hemorrhage). Focus then turns to
preventing organ damage secondary to microemboli and
replacing the blood’s clotting components.

● Monitor for manifestations of microemboli (cyanotic
nail beds, pain).

DIC, HIT, ITP, and TTP
● Regularly assess vital signs and hemodynamic status.
● Monitor for manifestations of organ failure or

intracranial bleed (oliguria, decreased level of
consciousness).

● Monitor laboratory values for clotting factors.
● Administer fluid volume replacement.
● Transfuse blood, platelets, and other clotting products.
● Monitor for complications from administration of blood

and blood products.
● Avoid use of NSAIDs.
● Administer supplemental oxygen.
● Provide protection from injury.
● Instruct client to avoid Valsalva maneuver (could cause

cerebral hemorrhage).
● Implement bleeding precautions (avoid use of needles).

meDications
ITP: Corticosteroids and immunosuppressants

TTP
● Antiplatelet medications (aspirin, alprostadil,

plicamycin)
● Immunosuppressive therapy decreases the intensity

of complications.

HIT: Anticoagulants with direct thrombin inhibitor
(argatroban, lepirudin, bivalirudin)

DIC: Anticoagulants (heparin) can be used to decrease
microclots from forming and using up clotting factors.

tHeraPeutic ProceDures
ITP: Splenectomy can be performed if the client does not
respond to medical management.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 42 coagulation DisorDers 273

Application Exercises

1. a nurse is caring for a client who has disseminated
intravascular coagulation (Dic). Which of the following
laboratory values indicates the client’s clotting
factors are depleted? (select all that apply.)

a. Platelets 100,000/mm3

B. Fibrinogen levels 120 mg/dl

c. Fibrin degradation products 4.3 mcg/ml

D. D‑dimer 0.03 mcg/ml

e. sedimentation rate 38 mm/hr

2. a nurse is assessing a client and suspects the
client is experiencing Dic. Which of the following
physical findings should the nurse anticipate?

a. Bradycardia

B. Hypertension

c. epistaxis

D. Xerostomia

3. a nurse is caring for a client who has idiopathic
thrombocytopenic purpura (itP). the nurse should
notify the provider and report possible small‑vessel
clotting when which of the following is assessed?

a. Petechiae on the upper chest

B. Hypotension

c. cyanotic nail beds

D. severe headache

4. a nurse is caring for a client who has Dic.
Which of the following medications should
the nurse anticipate administering?

a. Heparin

B. Vitamin K

c. mefoxin

D. simvastatin

5. a nurse is teaching a newly licensed nurse about
heparin‑induced thrombocytopenia. Which
of the following risk factors for this disorder
should the nurse include in the teaching?

a. Warfarin therapy for atrial fibrillation

B. Placental abruption

c. systemic lupus erythematosus

D. Heparin therapy for deep‑vein thrombosis

Active Learning Scenario

a nurse is developing a plan of care for a client who
has disseminated intravascular coagulation (Dic).
What interventions should the nurse include in the
plan of care? use the ati active learning template:
system Disorder to complete this item.

NURSING CARE: Describe five interventions.

274 CHAPTER 42 coagulation DisorDers CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: in Dic, platelet levels are decreased, causing
clotting factors to become depleted. clotting times are
increased, which raises the risk for fatal hemorrhage.

B. CORRECT: in Dic, fibrinogen levels are decreased, causing
clotting factors to become depleted. clotting times are
increased, which raises the risk for fatal hemorrhage.

c. Fibrin degradation products are increased when Dic occurs.
D. a D‑dimer level is increased when Dic occurs.
e. the sedimentation rate is increased, but

it is not an indicator of Dic.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. tachycardia is a finding that is indicative of Dic.
B. Hypotension is a finding that is indicative of Dic.
c. CORRECT: epistaxis is unexpected bleeding of the

gums and nose and is a finding indicative of Dic.
D. Xerostomia is dryness of the mouth

and is not indicative of Dic.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. a. Petechiae on the upper chest can
indicate impaired clotting.

B. Hypotension can indicate impaired clotting.
c. CORRECT: cyanotic nail beds indicate microvascular

clotting is occurring and should be immediately reported
to avoid ischemic loss of the fingers or toes.

D. severe headache can indicate cerebral bleeding.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

4. a. CORRECT: Heparin can be administered to decrease the
formation of microclots, which deplete clotting factors.

B. Vitamin K promotes blood coagulation and is
not prescribed for a client who has Dic.

c. mefoxin is an antibiotic given to treat bacterial
infection and is not a medication that should be
administered to a client who has Dic.

D. simvastatin is an antilipemic given to treat
hyperlipidemia and is not a medication that should
be administered to a client who has Dic.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

5. a. Warfarin therapy and atrial fibrillation are not
related to development of Hit.

B. Placental abruption is a risk factor for development of Dic.
c. systemic lupus erythematosus is an autoimmune disorder

that places the client at risk for development of itP.
D. CORRECT: the client who is receiving heparin

therapy for longer than 1 week is at increased
risk for the development of Hit.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

NURSING CARE
● monitor for manifestations of microemboli (cyanotic nail beds, pain).
● regularly assess vital signs and hemodynamic status.
● monitor for manifestations of organ failure or intracranial
bleed (oliguria, decreased level of consciousness).

● monitor laboratory values for clotting factors.
● administer fluid volume replacement.
● transfuse blood, platelets, and other clotting products.
● monitor for complications from the administration
of blood and blood products.

● avoid use of nsaiDs.
● administer supplemental oxygen.
● Provide protection from injury.
● instruct client to avoid Valsalva maneuver
(could cause cerebral hemorrhage).

● implement bleeding precautions (avoid use of needles).

NCLEX® Connection: Physiological Adaptation, Hemodynamics

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RN ADULT MEDICAL SURGICAL NURSING ncleX® connections 275

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Reduction of Risk Potential
SYSTEM SPECIFIC ASSESSMENTS: Perform focused assessments.

Physiological Adaptation
FLUID AND ELECTROLYTE IMBALANCES
Evaluate the client’s response to interventions to
correct fluid or electrolyte imbalance.

Apply knowledge of pathophysiology when caring for
the client with fluid and electrolyte imbalances.

HEMODYNAMICS: Apply knowledge of pathophysiology to
interventions in response to client abnormal hemodynamics.

MEDICAL EMERGENCIES: Evaluate and document the
client’s response to emergency interventions.

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276 ncleX® connections CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 43 FluiD imBalances 277

UNIT 6 FLUID/ELECTROLYTE/ACID‑BASE IMBALANCES

CHAPTER 43 Fluid Imbalances
the body maintains homeostasis when the
characteristics of body fluid remain in balance:
volume, concentration (osmolality), composition
(electrolyte concentration), and acidity (pH). in the
healthy adult client, 55% to 60% of body weight
is comprised of body fluid. this decreases to
about 50% to 55% in a healthy older adult client.

Fluid moves between compartments through
selectively permeable membranes by a variety
of methods (diffusion, active transport, filtration,
osmosis) to maintain homeostasis.

Balance is maintained through input and output.
thirst sensation, social factors, and personal
habits can impact fluid intakes. Fluid output
occurs in all of the following organs, the kidneys,
skin, lungs, and gi tract. the kidneys are the
major regulator of fluid output.

Volume imbalances occur when too little or
too much isotonic fluid is present. osmolality
imbalances occur when body fluid becomes
either hypertonic or hypotonic. Hypernatremia
(water deficit) and hyponatremia (water excess or
intoxication) are good examples of this type of
imbalance.

BoDY FluiDs
Body fluids are distributed between two compartments.

Intracellular (ICF)
● Two thirds of body water
● Body fluids within the cell

Extracellular (ECF)
● One third of body water
● Body fluids outside of the cell membrane
● Further divided into parts

◯ Intravascular fluid: The liquid part of blood or
the plasma

◯ Interstitial fluid: Located between the cells and
outside of the blood vessels

◯ Transcellular body fluids: Secreted by epithelial cells
(cerebrospinal, pleural, peritoneal, synovial fluids)

Dehydration
A lack of fluid in the body, from insufficient intake or
excessive loss

● Actual dehydration is a lack of fluid in the body; relative
dehydration involves a shift of water from the plasma
(blood) to the interstitial space.

● Hypovolemia, or isotonic dehydration, is a lack of both
water and electrolytes, causing a decrease in circulating
blood volume. This is also called fluid volume deficit.

ASSESSMENT

risK Factors

Causes of isotonic fluid volume deficit (hypovolemia)
● Excessive gastrointestinal (GI) loss: vomiting,

nasogastric suctioning, diarrhea
● Excessive skin loss: diaphoresis without sodium and

water replacement
● Excessive renal system losses: diuretic therapy, kidney

disease, adrenal insufficiency
● Third spacing: burns
● Hemorrhage or plasma loss
● Altered intake: anorexia, nausea, impaired swallowing,

confusion, nothing by mouth (NPO) (decreased intake of
water and sodium)

Causes of dehydration
● Hyperventilation or excessive perspiration without

water treatment
● Prolonged fever
● Diabetic ketoacidosis
● Insufficient water intake (enteral feeding without water

administration, decreased thirst sensation, aphasia)
● Diabetes insipidus
● Osmotic diuresis
● Excessive intake of salt, salt tablets, or

hypertonic IV fluids

eXPecteD FinDings

Hypovolemia

VITAL SIGNS: Hyperthermia, tachycardia (in an attempt
to maintain a normal blood pressure), thready pulse,
hypotension, orthostatic hypotension, decreased central
venous pressure, tachypnea (increased respirations
to compensate for lack of fluid volume within the
body), hypoxia

NEUROMUSCULOSKELETAL: Dizziness, syncope, confusion,
weakness, fatigue

GASTROINTESTINAL: Thirst, dry furrowed tongue, nausea,
vomiting, anorexia, acute weight loss

RENAL: Oliguria (decreased production and
concentration of urine)

CHAPTER 43

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278 CHAPTER 43 FluiD imBalances CONTENT MASTERY SERIES

OTHER FINDINGS:
● Diminished capillary refill, cool clammy skin, diaphoresis,

sunken eyeballs, flattened neck veins, poor skin turgor
and tenting, weight loss, low central venous pressure

● The effect of fluid imbalance in older adults is greater
due to the loss of elasticity of the skin, decrease in
glomerular filtration and concentrating ability of the
kidneys, loss of muscle mass (muscle tissue holds more
body water), and diminished thirst reflex.

● In dehydration, the client can have an elevated
temperature (cause or finding). Rapid/severe
dehydration can induce seizures.

laBoratorY tests
With fluid loss due to hemorrhage, hemoconcentration
does not occur.

Hematocrit (Hct): Increased in hypovolemia

BUN: Increased (greater 25 mg/dL) due to
hemoconcentration

Urine specific gravity: Greater than 1.030

Blood sodium: Greater than 145 mEq/L with dehydration

Blood osmolality: Greater than 295 mOsm/kg with
dehydration/hypernatremia

PATIENT‑CENTERED CARE

nursing care
● Provide oral or IV rehydration therapy.
● Monitor I&O.
● Monitor vital signs (orthostatic blood pressure, heart rate).
● Monitor for changes in mentation and confusion (an

indication of worsening fluid imbalance).
● Monitor weight every 8 hr while fluid replacement is

in progress.
● Assess level of gait stability. Encourage the client to use

call light and ask for assistance because of the increased
risk for falls.

● Encourage the client to change positions, rolling from
side to side or standing up slowly.

interProFessional care
Collaborate with other members of the health care team
to determine appropriate fluid volume replacement and
oxygen management.

client eDucation
● Drink plenty of liquids to promote hydration.
● Causes of dehydration include vomiting; large, draining

wounds; and diarrhea or excessive ostomy losses.

COMPLICATIONS

Hypovolemic shock
● Occurs with significant loss of body fluid.
● The client’s mean arterial pressure decreases (which

slows blood flow and perfusion to tissues of the body)
and the cells are no longer able to carry oxygen to the
blood adequately (due to the loss of red blood cells).

NURSING ACTIONS
● Administer oxygen, and monitor oxygen

saturation. Oxygen saturation less than 70% is a
medical emergency.

● Stay with an unstable client suffering from
hypovolemic shock.

● Monitor vital signs at least every 15 min.
● Provide fluid replacement with the following.

◯ Colloids: whole blood, packed RBCs, plasma, synthetic
plasma expanders

◯ Crystalloids: lactated Ringer’s, normal saline
● Administer vasoconstrictors (dopamine, norepinephrine,

phenylephrine), agents to improve myocardial perfusion
(sodium nitroprusside), and/or positive inotropic
medications (dobutamine, milrinone).

● Perform hemodynamic monitoring.

Overhydration
Too much fluid in the body from excessive intake or
ineffective removal from the body

● Fluid overload is an excess of fluid or water, such as
with water intoxication. This includes hemodilution,
which makes the amount of blood components (blood
cells, electrolytes) seem lower.

● Hypervolemia, or fluid volume excess, involves an
excess of water and electrolytes, so that the two are still
in the right proportions. For example, excessive sodium
intake causes the body to retain water, so that there is
too much of both.

● Clients who have fluid overload are at risk for
developing pulmonary edema or congestive heart failure.

● In older adult clients, the risk of fluid imbalance is
greater due to changes in the body with age (such as
reduced kidney function).

HEALTH PROMOTION AND
DISEASE PREVENTION

When clients have known heart disease and impairment
of kidney function, it important to instruct the client
regarding the following.

● Consume a diet low in sodium. Consult with the
provider regarding diet restrictions.

● Restrict fluid intake. Consult with provider regarding
prescribed restrictions.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 43 FluiD imBalances 279

ASSESSMENT

risK Factors

Causes of hypervolemia
● Compromised regulatory systems (heart failure, kidney

disease, cirrhosis)
● Overdose of fluids (oral, enteral, IV)
● Fluid shifts that occur following burns
● Prolonged use of corticosteroids
● Severe stress
● Hyperaldosteronism

Causes of overhydration
● Water replacement without electrolyte replacement,

excessive water intake (forced or psychogenic polydipsia)
● Syndrome of inappropriate antidiuretic hormone (SIADH)
● Excessive administration of IV D5W; use of hypotonic

solutions for irrigations

eXPecteD FinDings

Fluid volume overload

VITAL SIGNS: Tachycardia, bounding pulse, hypertension,
tachypnea, increased central venous pressure

NEUROMUSCULAR: Weakness, visual changes,
paresthesias, altered level of consciousness, seizures (if
severe, sudden hyponatremia/water excess)

GASTROINTESTINAL: Ascites, increased motility,
liver enlargement

RESPIRATORY: Crackles, cough, dyspnea

OTHER SIGNS: Peripheral edema due to an excess of fluids
within the body and lungs, resulting in weight gain,
distended neck veins, and increased urine output, skin
cool to touch with pallor

laBoratorY tests
● Decreased Hct and Hgb
● Decreased blood osmolarity with water/fluid excess
● Decreased urine sodium and specific gravity
● Decreased BUN due to plasma dilution

Diagnostic ProceDures
Chest x‑ray: Reveals possible pulmonary congestion

PATIENT‑CENTERED CARE

nursing care
● Monitor I&O.
● Monitor daily weight. A weight gain or loss of 1 kg

(2.2 lb) in 24 hr is equivalent to 1 L of fluid.
● Assess breath sounds.
● Monitor peripheral edema.
● Maintain sodium‑restricted diet as prescribed (indicated

for isotonic/fluid volume excess).
● Maintain fluid restrictions if prescribed.
● Encourage rest.
● Monitor clients receiving diuretics.
● Encourage the client to discuss use of over‑the‑counter

medications with the provider, as some of these
contain sodium.

● Position the client in the semi‑Fowler’s or Fowler’s
position, and reposition to prevent tissue breakdown in
edematous skin.

● Use a pressure‑reducing mattress, and assess bony
prominence on a regular basis.

● Monitor blood sodium and potassium levels.

interProFessional care
● Respiratory services can be consulted for

oxygen management.
● Pulmonology can be consulted if fluid moves into lungs.

client eDucation
● Weigh daily. Notify the provider if there is a 1‑ to 2‑lb

gain in 24 hr, or a 3‑lb gain in 1 week.
● If excessive sodium intake is the cause of fluid volume

excess, consume a low‑sodium diet, read food labels to
check sodium content, and keep a record of daily
sodium intake.

● Adhere to fluid restriction. Consult with the provider
regarding prescribed restrictions, and divide the 24‑hr
fluid allotment to allow for fluid intake throughout the day.

43.1 Pitting edema

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280 CHAPTER 43 FluiD imBalances CONTENT MASTERY SERIES

COMPLICATIONS

Pulmonary edema
● Pulmonary edema can be caused by severe

fluid overload.
● Manifestations include anxiety, tachycardia, increased

vein distention, premature ventricular contractions,
dyspnea at rest, change in level of consciousness,
restlessness, lethargy, ascending crackles (fluid
level within lungs), and cough productive of frothy
pink‑tinged sputum.

NURSING ACTIONS
● Position the client in high‑Fowler’s to

maximize ventilation.
● Administer oxygen, positive airway pressure, and/or

possible intubation and mechanical ventilation.
● Administer morphine, nitrates, and diuretic as

prescribed if blood pressure is adequate.

Active Learning Scenario

a nurse is planning care for a client who is experiencing
fluid volume excess. What nursing actions should the nurse
include in the plan of care? use the ati active learning
template: system Disorder to complete this item.

NURSING CARE: Describe three
interventions the nurse should take.

Application Exercises

1. a nurse is admitting a client who reports nausea,
vomiting, and weakness. the client has dry
oral mucous membranes and blood pressure
102/64 mm Hg. Which of the following findings
should the nurse identify as manifestations of
fluid volume deficit? (select all that apply.)

a. Decreased skin turgor

B. concentrated urine

c. Bradycardia

D. low‑grade fever

e. tachypnea

2. a nurse is admitting an older adult client who reports
a weight gain of 2.3 kg (5 lb) in 48 hr. Which of the
following manifestations of fluid volume excess
should the nurse expect? (select all that apply.)

a. Dyspnea

B. edema

c. Bradycardia

D. Hypertension

e. Weakness

3. a nurse is assessing a client who is dehydrated. Which
of the following findings should the nurse expect?

a. moist skin

B. Distended neck veins

c. increased urinary output

D. tachycardia

4. a nurse is caring for a client in a long‑term care facility
who has become weak, confused, and experienced
dizziness when standing. the client’s temperature
is 38.3° c (100.9° F), pulse 92/min, respirations
20/min, and blood pressure 108/60 mm Hg. Which
of the following actions should the nurse take?

a. initiate fluid restrictions to limit intake.

B. check for peripheral edema.

c. encourage the client to ambulate
to promote oxygenation.

D. monitor for orthostatic hypotension.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 43 FluiD imBalances 281

Application Exercises Key

1. a. CORRECT: Decreased skin turgor is a manifestation
present with fluid volume deficit. skin turgor is
decreased due to the lack of fluid within the body
and results in dryness of the skin.

B. CORRECT: concentrated urine is a manifestation present with
fluid volume deficit. urine is concentrated due to lack of fluid
in the vascular system, causing a decreased profusion of the
kidneys and resulting in an increased urine specific gravity.

c. tachycardia is a manifestation present with fluid volume deficit
due to an attempt to maintain a normal blood pressure.

D. CORRECT: low‑grade fever is a manifestation
present with fluid volume deficit. low‑grade fever is
one of the body’s ways to maintain homeostasis to
compensate for lack of fluid within the body.

e. CORRECT: tachypnea is a manifestation present
with fluid volume deficit. increased respirations
are the body’s way to obtain oxygen due to the
lack of fluid volume within the body.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

2. a. CORRECT: Dyspnea is a manifestation present with
fluid volume excess. Dyspnea is due to an excess
of fluids within the body and lungs, and the client is
struggling to breathe to obtain oxygen.

B. CORRECT: edema is a manifestation present with fluid
volume excess. Weight gain can be a result of edema.

c. tachycardia and bounding pulses are manifestations
related to fluid volume excess.

D. CORRECT: Hypertension is a manifestation related
to fluid volume excess. Blood pressure rises as the
heart must work harder due to the excess fluid.

e. CORRECT: Weakness is a manifestation present
with fluid volume excess. Weakness is due to the
excess fluid that is retained, which depletes energy
and increases the workload for the body.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

3. a. moist skin is a manifestation of fluid volume excess.
B. Distended neck veins are a manifestation

of fluid volume excess.
c. increased urinary output is a manifestation

of fluid volume excess.
D. CORRECT: tachycardia is an attempt to maintain blood

pressure, a manifestation of fluid volume deficit.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

4. a. offer fluids when the client has
manifestations of dehydration.

B. monitor for poor skin turgor when the client has
manifestations of fluid volume deficit.

c. Keep the client in bed and assist them to the
bathroom as needed because they are at risk for
falling due to manifestations of dehydration.

D. CORRECT: monitor for orthostatic hypotension
because they have manifestations of dehydration
due to decreased circulatory volume.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

NURSING CARE
● check aBgs, sao2, cBc, and chest x‑ray results.
● Position the client in semi‑Fowler’s to Fowler’s position as tolerated.
● obtain daily weight.
● monitor intake and output.
● administer supplemental oxygen as prescribed.
● reduce iV flow rates.
● administer diuretics (osmotic, loop) as prescribed.
● limit fluid and sodium intake as prescribed.
● monitor and document presence of edema
(pretibial, sacral, periorbital).

● reposition the client at least every 2 hr.
● support arms and legs to decrease dependent edema as appropriate.
● monitor vital signs and heart rhythm.
● auscultate lung sounds for crackles.

NCLEX® Connection: Physiological Adaptation, Fluid and
Electrolyte Imbalances

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UNIT 6 FLUID/ELECTROLYTE/ACID‑BASE IMBALANCES

CHAPTER 44 Electrolyte
Imbalances

electrolytes are charged ions dissolved in body
fluids. cations are positively charged, and
anions are negatively charged. electrolytes
are distributed between intracellular (icF) and
extracellular (ecF) fluid compartments. the
distributions of ions differs in icF and ecF. the
difference in the concentration of electrolytes in
the icF and ecF maintains cell excitability and
allows for the transmission of nerve impulses.

Body fluids should be electrically neutral; the
negative and positive ions in the body fluids are
equal in number. electrolytes conduct either a
positive (cations: magnesium, potassium, sodium,
calcium, and hydrogen ions) or negative (anions:
phosphate, sulfate, chloride, bicarbonate, and
proteinate ions) electrical current.

clients can develop an imbalance of electrolytes
from an imbalance of intake and output. ill and
older adult clients are at higher risk of electrolyte
imbalance. although laboratory tests can
accurately reflect the electrolyte concentrations
in plasma, it is not possible to directly measure
electrolyte concentrations within cells.

eXPecteD reFerence ranges
Sodium: 136 to 145 mEq/L

Calcium: 9.0 to 10.5 mg/dL

Potassium: 3.5 to 5.0 mEq/L

Magnesium: 1.3 to 2.1 mEq/L

Chloride: 98 to 106 mEq/L

Phosphorus: 3.0 to 4.5 mg/dL

Sodium imbalances
● Sodium (Na+) is the major electrolyte (cation) found in

ECF, and maintains ECF osmolarity.
● Sodium within ICF is low (14 mEq/L). The difference

in ICF and ECF sodium levels is very important in
maintaining skeletal muscle contraction, cardiac
contraction, and nerve impulse transmission.

● Water flows in the direction of sodium concentration. The
ECF sodium level influences fluid retention, excretion,
and movement of fluid from one body space to another.

● The kidneys regulate sodium levels with the assistance
of aldosterone, antidiuretic hormone (ADH), and
natriuretic peptide.

Hyponatremia
Hyponatremia is a net gain of water or loss of sodium‑rich
fluids that results in sodium levels less than 136 mEq/L.

● Hyponatremia delays and slows the depolarization
of membranes.

● Water moves from the ECF into the ICF, causing cells to
swell (cellular edema).

● Urine sodium levels helps to differentiate between
non‑kidney fluid loss (vomiting, diarrhea, and sweating)
and kidney salt wasting, which can occur with diuretic use.

● Hyponatremia generally is caused by fluid imbalance,
which results in sodium loss.

● Compensatory mechanisms include the kidney excretion
of sodium‑free water.

ASSESSMENT

risK Factors
Actual sodium deficits

● Excessive sweating
● Diuretics
● Wound drainage (especially gastrointestinal)
● Nasogastric tube suction of isotonic gastric contents
● Decreased secretion of aldosterone
● Hyperlipidemia
● Kidney disease
● Inadequate sodium intake (nothing by mouth [NPO] status)
● Hyperglycemia
● Low‑sodium diet
● Cerebral salt wasting syndrome

Relative sodium deficits due to dilution
● Hypotonic fluid excess (forced oral intake, psychogenic

polydipsia, irrigation with hypotonic solutions)
● Freshwater submersion accident
● Kidney failure (nephrotic syndrome)
● Heart failure
● Syndrome of inappropriate ADH secretion
● Anticonvulsant medications, SSRIs, or desmopressin
● Older adult clients at a greater risk due to increased

incidence of chronic illnesses, use of diuretic
medications, and risk for insufficient sodium intake

CHAPTER 44

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284 CHAPTER 44 electrolYte imBalances CONTENT MASTERY SERIES

eXPecteD FinDings
● Clinical indicators depend on whether the ECF volume

is normal (euvolemic), decreased (hypovolemic), or
increased (hypervolemic).

● If the client is hypervolemic with hyponatremia, the pulse
quality is usually bounding. The client’s blood pressure
can be within or above the expected reference range.

VITAL SIGNS (WITH HYPOVOLEMIA): Hypothermia,
tachycardia, rapid thready pulse, hypotension, orthostatic
hypotension, diminished peripheral pulses

NEUROMUSCULOSKELETAL: Headache, confusion,
lethargy, muscle weakness to the point of possible
respiratory compromise, fatigue, decreased deep‑tendon
reflexes (DTRs), seizures, lightheadedness, dizziness

GASTROINTESTINAL: Increased motility, hyperactive
bowel sounds, abdominal cramping, nausea

laBoratorY tests
Blood sodium: Decreased, less than 136 mEq/L

Blood osmolarity: Decreased (except in azotemia with
toxin accumulation)

Urine sodium: Less than 20 mEq/L (in sodium loss);
greater than 20 mEq/L (in SIADH)

Urine specific gravity: Decreased (1.002 to 1.004 in sodium
loss; greater than 1.012 in SIADH)

PATIENT‑CENTERED CARE

nursing care
● If the client can tolerate PO fluids, sodium can be easily

replaced by intake of foods and fluids. Encourage foods
and fluids high in sodium (beef broth, tomato juice).

● Administer IV fluids (lactated Ringer’s,
0.9% isotonic saline).

● Replacement of sodium should not exceed 12 mEq/L in a
24‑hr period because rapid rise in sodium level risks
development of neurologic damage due to
demyelination.

● For fluid overload, restrict water intake as prescribed.
● Monitor I&O and daily weight.
● Monitor vital signs and level of consciousness.

Report abnormal findings to the provider.

interProFessional care
● Nephrology can be consulted for electrolyte and

fluid replacement.
● Respiratory services can be consulted for

oxygen management.
● Nutritional services can be consulted for high‑sodium

food choices and restricting fluid intake.

client eDucation
● Weigh daily and notify the provider of a 1‑ to 2‑lb gain

in 24 hr, or 3‑lb (1.4 kg) gain in 1 week.
● Consume a high‑sodium diet, including reading food

labels to check sodium content and keeping a daily
record of sodium intake.

COMPLICATIONS

Severe hyponatremia

Complications (coma, seizures, respiratory arrest) can
result from acute hyponatremia if not treated immediately.

NURSING ACTIONS
● The goal is to elevate the blood sodium level enough

to decrease neurologic manifestations associated with
hyponatremia (lethargy, confusion, seizures).

● Maintain an open airway, and monitor vital signs.
● Implement seizure precautions, and take appropriate

action if seizures occur.
● Monitor level of consciousness.
● Administer hypertonic oral and IV fluids as prescribed.
● Administer 3% sodium chloride slowly, and monitor

sodium levels frequently. When using hypertonic
solutions, the blood sodium level should not be greater
than 125 mEq/L.

● Administer medications as prescribed (such as
conivaptan or tolvaptan, which promote excretion of
excess fluid).

Hypernatremia
Increased sodium causes hypertonicity of the blood.
This causes a shift of water out of the cells, resulting in
dehydrated cells.

● Hypernatremia is a blood sodium level greater
than 145 mEq/L.

● Hypernatremia is a serious electrolyte imbalance.
It can cause significant neurologic, endocrine, and
cardiac disturbances.

ASSESSMENT

risK Factors

Actual sodium excess
● Kidney failure
● Cushing’s syndrome
● Aldosteronism
● Some medications (such as glucocorticosteroids)
● Excessive intake of oral sodium

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 44 electrolYte imBalances 285

Relative sodium excess due to
decreased fluid volume

● Water deprivation (NPO)
● Hypertonic enteral feedings without adequate water

supplement
● Diabetes insipidus
● Heatstroke
● Hyperventilation
● Watery stools
● Burns
● Excessive sweating

eXPecteD FinDings
Thirst

VITAL SIGNS: Hyperthermia, tachycardia,
orthostatic hypotension

NEUROMUSCULOSKELETAL: Restlessness; irritability;
muscle twitching to the point of muscle weakness,
including respiratory compromise; decreased or absent
DTRs; seizures; coma

GASTROINTESTINAL: Thirst, dry mucous membranes,
nausea, vomiting, anorexia, occasional diarrhea

laBoratorY tests
Blood sodium: Increased to greater than 145 mEq/L

Blood osmolarity: Increased to greater than 300 mOsm/L

Urine specific gravity and osmolarity: Increased

PATIENT‑CENTERED CARE

nursing care
● Monitor level of consciousness, and ensure safety.
● Monitor vital signs and heart rhythm.
● Auscultate lung sounds.
● Provide oral hygiene and other comfort measures to

decrease thirst.
● Monitor I&O, and alert the provider of inadequate

urinary output.

Fluid loss

Based on blood osmolarity and hemodynamic stability
● Dextrose 5% in 0.45% sodium chloride is a hypertonic

solution prior to infusion. However, once infused,
the glucose rapidly metabolizes and it becomes a
hypotonic solution.

● 0.3% sodium chloride can be prescribed as a hypotonic
solution, which provides a more gradual reduction in
blood sodium levels and reduces the risk of cerebral
edema. This is the preferred IV solution if the client also
has severe hyperglycemia.

● Dextrose 5% in water and 0.9% sodium chloride are
isotonic solutions.

Excess sodium
● Encourage water intake, and discourage sodium intake.
● Administer diuretics (loop diuretics) for clients who

have poor kidney excretion.

interProFessional care
Nutritional services can be consulted for low‑sodium food
choices and to restrict fluid intake.

client eDucation
● Weigh daily. Notify the provider of a 1‑ to 2‑lb gain in
24 hr, or 3‑lb (1.4 kg) gain in 1 week.

● Consume a low‑sodium diet, read food labels for sodium
content, and keep a record of daily sodium intake.

● Adhere to fluid intake as prescribed.
● Over‑the‑counter medications that contain sodium

bicarbonate can increase sodium levels.

COMPLICATIONS

Severe hypernatremia

Seizures, convulsion, and death can result from severe
hypernatremia if not treated immediately.

NURSING ACTIONS
● Maintain open airway, and monitor vital signs.
● Implement seizure precautions, and take appropriate

action if seizures occur.
● Monitor level of consciousness.

Potassium imbalances
● Potassium (K+) is the major cation in ICF. 98% of the

body’s potassium is within the cells.
● Potassium plays a vital role in cell metabolism;

transmission of nerve impulses; functioning of cardiac,
lung, and muscle tissues; and acid‑base balance.

● Potassium has a reciprocal action with sodium.
● Minor variations in the level of potassium in the body is

a significant finding.

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286 CHAPTER 44 electrolYte imBalances CONTENT MASTERY SERIES

Hypokalemia
Hypokalemia is the result of an increased loss of
potassium from the body or movement of potassium
into the cells, resulting in a blood potassium
less than 3.5 mEq/L.

ASSESSMENT

risK Factors
Actual potassium deficits

● Overuse of diuretics, digitalis, corticosteroids
● Increased secretion of aldosterone
● Cushing’s syndrome
● Loss via GI tract: vomiting, diarrhea, prolonged

nasogastric suctioning, and excessive use of laxatives or
tap water enema administered repeatedly because tap
water is hypotonic, and gastrointestinal losses are isotonic

● NPO status
● Kidney disease, which impairs the reabsorption

of potassium

Relative potassium deficit
● Alkalosis
● Hyperinsulinism
● Hyperalimentation
● Total parental nutrition
● Water intoxication
● Older adult clients due to increased use of diuretics

and laxatives

eXPecteD FinDings
VITAL SIGNS: Decreased blood pressure, thready weak
pulse, orthostatic hypotension

NEUROLOGIC: Altered mental status, anxiety, and
lethargy that progresses to acute confusion and coma

ECG: Flattened T wave, prominent U waves, ST depression,
prolonged PR interval

GASTROINTESTINAL: Hypoactive bowel sounds, nausea,
vomiting, constipation, abdominal distention. Paralytic
ileus can develop.

MUSCULAR: Weakness. Deep‑tendon reflexes can
be reduced.

RESPIRATORY: Shallow breathing

laBoratorY tests
Blood potassium: Decreased to less than 3.5 mEq/L

Diagnostic ProceDures
Electrocardiogram (ECG): Inverted/flat T waves, ST
depression. An elevated U wave is a finding specific to
hypokalemia. Other dysrhythmias possible.

PATIENT‑CENTERED CARE

nursing care
● Administer prescribed potassium replacement. Never

give potassium via IM or subcutaneous route, which can
cause necrosis of the tissues.

● Monitor and maintain adequate urine output.
● Observe for shallow ineffective respirations and

diminished breath sounds.
● Monitor cardiac rhythm, and intervene promptly as needed.
● Monitor clients receiving digoxin. Hypokalemia

increases the risk for digoxin toxicity.
● Monitor level of consciousness, and maintain client safety.
● Monitor bowel sounds and abdominal distention, and

intervene as needed.
● Monitor oxygen saturation levels, which should remain

greater than 95%.
● Assess hand grasps for muscle weakness.
● Assess DTRs.
● Implement fall precautions due to muscle weakness.

Oral replacement of potassium
● Encourage foods high in potassium: avocados, broccoli,

dairy products, dried fruit, cantaloupe, bananas, juices,
melon, lean meats, milk, whole grains, and citrus fruits.
Salt substitutes are high in potassium and can facilitate
increased oral potassium intake.

● Provide oral potassium medications.

IV potassium supplementation
● Never administer by IV bolus (high risk of cardiac arrest).
● The maximum recommended rate is 10 mEq/hr with a

concentration of no more than 1 mEq of potassium per
10 mL of solution.

● Assess for phlebitis (tissue irritant).

interProFessional care
● Nephrology can be consulted for electrolyte and

fluid management.
● Respiratory services can be consulted for

oxygen management.
● Nutritional services can be consulted for food choices

and potassium‑rich foods.
● Cardiology can be consulted for dysrhythmias.

client eDucation
● Understand which potassium‑rich foods to consume.
● Prevent a decrease in potassium by avoiding excessive

use of diuretics and laxatives.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 44 electrolYte imBalances 287

COMPLICATIONS

Respiratory failure

NURSING ACTIONS
● Maintain an open airway, and monitor vital signs.
● Monitor level of consciousness.
● Monitor for hypoxemia and hypercapnia.
● Assist with intubation and mechanical ventilation

if indicated.

Cardiac arrest

NURSING ACTIONS
● Perform continuous cardiac monitoring.
● Treat dysrhythmias promptly.

Hyperkalemia
Hyperkalemia is the result of an increased intake of
potassium, movement of potassium out of the cells,
or inadequate kidney excretion resulting in a blood
potassium level greater than 5.0 mEq/L.

● Increased risk of cardiac arrest
● Rare in clients who have normal kidney function.

ASSESSMENT

risK Factors
Clients who are chronically ill

Actual potassium excess
● Older adult clients due to decreases in renin and

aldosterone, and increased use of salt substitutes,
ACE inhibitors, and potassium‑sparing diuretics

● Overconsumption of high‑potassium foods or
salt substitutes

● Excessive or rapid potassium replacement (oral or IV)
● RBC transfusions
● Adrenal insufficiency
● ACE inhibitors or potassium‑sparing diuretics
● Kidney failure

Relative potassium excess
● Extracellular shift caused from decreased insulin

production
● Acidosis (diabetic ketoacidosis)
● Tissue damage (sepsis, trauma, surgery, fever,

myocardial infarction)
● Hyperuricemia

eXPecteD FinDings
Vital signs: Slow irregular pulse, hypotension

Neuromusculoskeletal: Restlessness, irritability, weakness
to the point of ascending flaccid paralysis, paresthesia

ECG: Premature ventricular contractions, ventricular
fibrillation, peaked T waves, widened QRS

Gastrointestinal: Increased motility, diarrhea, hyperactive
bowel sounds

Other manifestations: Oliguria

laBoratorY tests
Blood potassium: Increased to greater than 5.0 mEq/L

Hemoglobin and hematocrit
● Increased with dehydration
● Decreased with kidney failure

BUN and creatinine: Increased with kidney failure

Arterial blood gases: Metabolic acidosis (pH less than 7.35)
with kidney failure

Diagnostic ProceDures
Electrocardiogram: Peaked T waves, widened PR and QRS,
absent/flat P waves, ST depression, possible dysrhythmias
(heart block, ventricular fibrillation, asystole)

PATIENT‑CENTERED CARE

nursing care
Priority nursing care is to prevent falls, assessing for
cardiac complications, and health teaching.

● Monitor cardiac rhythm, and intervene promptly as needed.
● Monitor I&O.
● Assess for muscle weakness.
● Observe for GI manifestations, such as nausea and

intestinal colic.
● For clients who have elevated potassium levels, report

and stop IV infusion of potassium, maintain IV access,
stop all potassium supplements, and promote a
potassium‑restricted diet.

● Monitor for manifestations of hypokalemia while
receiving medications to reduce the potassium level.

● Monitor blood potassium levels.
● Severe hyperkalemia can require administration of

calcium gluconate. Chronic or severe hyperkalemia can
require dialysis.

● Promote movement of potassium from ECF to ICF.
◯ Administer IV fluids with dextrose and regular insulin.
◯ Administer sodium bicarbonate to reverse acidosis.

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288 CHAPTER 44 electrolYte imBalances CONTENT MASTERY SERIES

Prevention of hyperkalemia
● Avoid administering “aged” blood in clients who have

impaired kidney function because the deterioration of
red blood cells releases potassium into the stored blood.

● Encourage the client to avoid foods high in potassium
(citrus fruits, legumes, whole‑grain foods, lean meat,
milk, eggs, cocoa, some cola beverages). Encourage the
client to read food labels for potassium content.

● Fruits and juices low in potassium include raw apples,
cranberries, grapes, canned peaches, and cranberry and
grape juice. Vegetables low in potassium include lettuce,
cabbage, cucumbers, green peppers, sweet onions,
green peas, and green beans. It is possible to reduce the
content of most vegetables by leaching them (slice, peel,
soak overnight, drain water, and boil). Refined grains
have less potassium than whole grains and cereals.
Beverages low in potassium include brewed tea and
coffee, ginger ale, and root beer. Other food items with
low potassium content include applesauce, angel food
cake, butter, margarine, hard candy, sugar, and honey.

● Clients who have impaired kidney function and are
taking potassium‑conserving diuretics should not
receive potassium replacement or salt substitutes.

meDications
To increase potassium excretion

Loop diuretics (furosemide)
● Administer if kidney function is adequate.
● Loop diuretics increase the depletion of potassium from

the renal system.

NURSING ACTIONS: Monitor intake and output.

Cation exchange resins

Sodium polystyrene sulfonate works as a laxative and
excretes excess potassium from the body.

NURSING ACTIONS: If potassium levels are extremely
high, dialysis can be required.

CLIENT EDUCATION
● Adhere to a potassium‑restricted diet.
● Hold oral potassium supplements until advised by

the provider.

Beta-2 agonists (albuterol)

NURSING ACTIONS: Monitor for tachycardia and chest pain.

Patiromer

Used for chronic hyperkalemia

interProFessional care
● Nephrology can be consulted if dialysis is needed and

for electrolyte and fluid management.
● Nutritional services can be consulted for food choices

containing potassium‑restricted foods.
● Cardiology can be consulted for dysrhythmias.

client eDucation
● Remember which potassium‑restricted foods to consume.
● Prevent an increase in potassium by reading food labels

and avoiding salt substitutes containing potassium.

COMPLICATIONS

Cardiac arrest

NURSING ACTIONS
● Treat dysrhythmias.
● Perform continuous cardiac monitoring.

Other electrolyte
imbalances

CALCIUM: Hypocalcemia, hypercalcemia

CHLORIDE: Hypochloremia, hyperchloremia

MAGNESIUM: Hypomagnesemia, hypermagnesemia

PHOSPHORUS: Hypophosphatemia, hyperphosphatemia

In particular, nurses should be aware of the implications
of hypocalcemia and hypomagnesemia.

Hypocalcemia
Hypocalcemia is a total blood calcium less than 9.0 mg/dL.

ASSESSMENT

risK Factors

Actual calcium deficit
● Inadequate intake of calcium, including lactose

intolerance, malabsorption issues
● Diarrhea or steatorrhea
● Inadequate vitamin D intake
● End‑stage kidney disease
● Wound drainage

Relative calcium deficit
● Conditions: alkalosis, acute pancreatitis,

hyperproteinemia, hyperphosphatemia, immobility
● Treatments: calcium chelators, citrate, mithramycin,

sodium cellulose phosphate, penicillamine, pamidronate
● Immobility
● Parathyroid removal or damage

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 44 electrolYte imBalances 289

eXPecteD FinDings
Tetany is the most common manifestation seen in
clients in a hypocalcemic state. It is caused by neural
excitability‑spontaneous discharges from both the
sensory and motor fibers (peripheral nerves).

● Paresthesia of the fingers and lips (early manifestation)
● Muscle twitches as hypocalcemia progresses
● Seizure due to irritability of the central nervous system
● Frequent, painful muscle spasms at rest in the foot or

calf (Charley horses)
● Hyperactive DTRs
● Positive Chvostek’s sign (tapping on the facial nerve

triggering facial twitching)
● Positive Trousseau’s sign (hand/finger spasms with

sustained blood pressure cuff inflation)
● History of thyroid surgery or irradiation of the

upper chest or neck, which places a client at risk for
developing hypocalcemia

CARDIOVASCULAR: Prolonged QT interval as a result
of a prolonged ST segment. Risk of torsades de pointes.
Decreased myocardial contractility (decreased heart rate
and hypotension when hypocalcemia is severe).

GASTROINTESTINAL: Hyperactive bowel sounds, diarrhea,
and abdominal cramps

laBoratorY tests
● Calcium level less than 9.0 mg/dL
● Decreased blood albumin level can make the total blood

calcium level falsely low.
● The ionized calcium level should give the true calcium

level when the client appears to have hypocalcemia
with hypoalbuminemia.

Diagnostic ProceDures
Electrocardiogram changes: Prolonged QT and ST interval

PATIENT‑CENTERED CARE

nursing care
● Administer oral or IV calcium supplements. Vitamin D

supplements enhance the absorption of calcium.
● Implement seizure and fall precautions.
● Avoid overstimulation. Keep the client’s room quiet,

limit visitors, and use soft lighting in the room.
● Have emergency equipment on standby.
● Encourage foods high in calcium, including dairy

products, canned salmon, sardines, fresh oysters, and
dark leafy green vegetables.

● A client exhibiting life‑threatening manifestations of
hypocalcemia will require rapid treatment with calcium
gluconate or calcium chloride (not used as often due to
risk of tissue damage if infiltrated). IV administration
should be diluted in dextrose 5% and water and
given as a bolus infusion (using an infusion pump). If
administered too quickly, cardiac arrest could occur.

interProFessional care
● Endocrinology can be consulted for electrolyte and

fluid management.
● Respiratory services can be consulted for

oxygen management.
● Nutritional services can be consulted for food choices

high in calcium.
● Cardiology can be consulted for dysrhythmias.

client eDucation
● Consume foods high in calcium (yogurt, milk).
● Increase calcium in diet by reading food labels.

Hypomagnesemia
Hypomagnesemia is a blood magnesium level
less than 1.3 mg/dL.

ASSESSMENT

risK Factors
● Celiac disease or Crohn’s disease
● Malnutrition (insufficient magnesium intake)
● Ethanol ingestion (magnesium excretion)
● Diarrhea, steatorrhea, or chronic laxative use
● Citrate from blood products
● Steatorrhea
● Myocardial infarction or heart failure
● Concurrent hypokalemia and hypocalcemia
● Medication therapy (aminoglycoside antibiotics,

cisplatin, cyclosporine, amphotericin B)

eXPecteD FinDings
Cardiovascular: Risk for increased blood pressure
and dysrhythmias or ECG changes (presence of PVCs,
flat/inverted T waves, ST depression, prolonged PR,
widened QRS)

Neuromuscular: Increased nerve impulse transmission
(hyperactive DTRs, paresthesias, muscle tetany, seizures),
positive Chvostek’s and Trousseau’s signs

Gastrointestinal: Hypoactive bowel sounds, constipation,
abdominal distention, paralytic ileus

Other: Possible depressed mood, apathy, or agitation

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290 CHAPTER 44 electrolYte imBalances CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

nursing care
● Correct concurrent imbalance of other electrolytes to

prevent worsening of either condition.
● Encourage foods high in magnesium (dark green

vegetables, nuts, whole grains, seafood, peanut butter,
cocoa). If there is mild hypomagnesemia, dietary
changes can be used to correct it.

● Discontinue magnesium‑depleting medications (loop
diuretics, osmotic diuretics, medications that contain
phosphorus).

● Administer oral magnesium sulfate for mild
hypomagnesemia. Oral magnesium can cause diarrhea
and increase magnesium depletion.

● IV magnesium sulfate is prescribed if hypomagnesemia
is severe. Administer via an infusion pump not to
exceed 150 mg/min, or 67 mEq over an 8‑hr period.
Monitor DTRs hourly during administration.

● Monitor clients taking digitalis closely if magnesium is
low because it predisposes the client to digitalis toxicity.

● Have calcium gluconate readily available to
reverse hypermagnesemia.

interProFessional care
● Endocrinology can be consulted for electrolyte and

fluid management.
● Respiratory services can be consulted for

oxygen management.
● Nutritional services can be consulted for food choices

high in magnesium.
● Cardiology can be consulted for dysrhythmias.

client eDucation
● Intake foods that are high in magnesium.
● Increase magnesium in diet by reading food labels.

Active Learning Scenario

a nurse is caring for a client who has hypokalemia.
use the ati active learning template: system
Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)

NURSING CARE: Describe at least six actions.

INTERPROFESSIONAL CARE: Describe one action.

CLIENT EDUCATION: Describe one teaching point.

COMPLICATIONS: Describe one.

Application Exercises

1. a nurse is caring for a client who has a blood sodium
level 133 meq/l and blood potassium level 3.4 meq/l.
the nurse should recognize that which of the following
treatments can result in these laboratory findings?

a. three tap water enemas

B. 0.9% sodium chloride solution iV at 50 ml/hr

c. 5% dextrose with 0.45% sodium chloride
solution with 20 meq of K+ iV at 80 ml/hr

D. antibiotic therapy

2. a nurse is caring for a client who has a blood
potassium 5.4 meq/l. the nurse should assess
for which of the following manifestations?

a. ecg changes

B. constipation

c. Polyuria

D. Paresthesia

3. a nurse is caring for a client who has a
nasogastric tube attached to low intermittent
suctioning. the nurse should monitor for which
of the following electrolyte imbalances?

a. Hypercalcemia

B. Hyponatremia

c. Hyperphosphatemia

D. Hyperkalemia

4. a nurse is assessing a client who has hyperkalemia. the
nurse should identify which of the following conditions
as being associated with this electrolyte imbalance?

a. Diabetic ketoacidosis

B. Heart failure

c. cushing’s syndrome

D. thyroidectomy

5. a nurse is assessing a client for chvostek’s
sign. Which of the following techniques
should the nurse use to perform this test?

a. apply a blood pressure cuff to the client’s arm.

B. Place the stethoscope bell over
the client’s carotid artery.

c. tap lightly on the client’s cheek.

D. ask the client to lower their chin to their chest.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 44 electrolYte imBalances 291

Application Exercises Key

1. a. CORRECT: three tap water enemas can result in a
decrease in blood sodium and potassium. tap water
is hypotonic, and gastrointestinal losses are isotonic.
this creates an imbalance and solute dilution.

B. 0.9% sodium chloride is an isotonic solution
and will not produce these results.

c. 5% dextrose with 0.45% sodium chloride is an
isotonic solution with 20 meq of K+ at 80 ml/hr
and would not produce these results.

D. antibiotic therapy would not produce these results.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

2. a. CORRECT: assess for ecg changes. Potassium levels
can affect the heart and result in arrhythmias.

B. constipation is a manifestation of hypokalemia.
c. Polyuria is a manifestation of hypokalemia.
D. Paresthesia is a manifestation of hypokalemia.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

3. a. an increase in calcium is not indicated with
nasogastric losses due to suctioning.

B. CORRECT: monitor the client for hyponatremia.
nasogastric losses are isotonic and contain sodium.

c. Hyperphosphatemia is not indicated with
nasogastric losses due to suctioning.

D. a decrease in potassium can occur from
nasogastric losses due to suctioning.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

4. a. CORRECT: Hyperkalemia, an increase in blood potassium, is a
laboratory finding associated with diabetic ketoacidosis.

B. Hyponatremia, a decrease in blood sodium, is a
laboratory finding associated with heart failure.

c. Hypernatremia, an increase in blood sodium, is a laboratory
finding associated with cushing’s syndrome.

D. Hypocalcemia, a decrease in blood calcium, is a laboratory
finding that is found in clients following a thyroidectomy.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

5. a. applying a blood pressure cuff to the client’s arm is
performed to assess for trousseau’s sign.

B. Placing the stethoscope bell over the client’s carotid
artery is performed to auscultate a carotid bruit.

c. CORRECT: tap the client’s cheek over the facial nerve
just below and anterior to the ear to elicit chvostek’s
sign. a positive response is indicated when the client
exhibits facial twitching on this side of the face.

D. asking the client to lower their chin to their chest is
performed to assess for range of motion of the neck.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): Hypokalemia
is the result of an increased loss of potassium from the
body or movement of potassium into the cells, resulting
in a blood potassium less than 3.5 meq/l.

NURSING CARE
● report abnormal findings to the provider.
● replacement of potassium

◯ encourage foods high in potassium (avocados, broccoli,
dairy products, dried fruit, cantaloupe, bananas, juices,
melon, lean meats, milk, whole grains, and citrus fruits).

◯ Provide oral potassium supplementation.
● iV potassium supplementation

◯ never administer by iV bolus (high risk of cardiac arrest).
◯ the maximum recommended rate is 10 meq/hr.
◯ assess for phlebitis (tissue irritant).

● Potassium must never be given by im or subcutaneous
route, which can cause necrosis of the tissues.

● monitor and maintain adequate urine output.
● observe for shallow ineffective respirations
and diminished breath sounds.

● monitor cardiac rhythm, and intervene promptly as needed.
● monitor clients receiving digoxin. Hypokalemia
increases the risk for digoxin toxicity.

● monitor level of consciousness, and maintain client safety.
● monitor bowel sounds and abdominal
distention, and intervene as needed.

● monitor oxygen saturation levels, which
should remain greater than 95%.

● assess hand grasps for muscle weakness.
● assess deep‑tendon reflexes.

INTERPROFESSIONAL CARE
● nephrology can be consulted for electrolyte and fluid management.
● respiratory services can be consulted for oxygen management.
● nutritional services can be consulted for food
choices and potassium‑rich foods.

● cardiology can be consulted for dysrhythmias.

CLIENT EDUCATION
● understand which potassium‑rich foods to consume.
● Prevent a decrease in potassium by avoiding
excessive use of diuretics and laxatives.

COMPLICATIONS
● respiratory failure
● cardiac arrest

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

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292 CHAPTER 44 electrolYte imBalances CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 45 aciD‑Base imBalances 293

UNIT 6 FLUID/ELECTROLYTE/ACID‑BASE IMBALANCES

CHAPTER 45 Acid‑Base
Imbalances

For cells to function optimally, metabolic
processes must maintain a steady balance
between the acids and bases found in the body.
acid‑base balance represents homeostasis of
hydrogen (H+) ion concentration in body fluids.
Hydrogen shifts between the extracellular and
intracellular compartments to compensate
for acid‑base imbalances. minor changes in
hydrogen concentration have major effects on
normal cellular function.

arterial pH is an indirect measurement of hydrogen
ion concentration and is a result of respiratory
and kidney compensation function. arterial blood
gases (aBgs) are mos t commonly used to evaluate
acid‑base balance. the pH is the expression of the
balance between carbon dioxide (co2), which is
regulated by the lungs, and bicarbonate (Hco3

‑),
a base regulated by the kidneys. the greater the
concentration of hydrogen, the more acidic the
body fluids and the lower the pH. the lower the
concentration of hydrogen, the more alkaline the
body fluids and the higher the pH.

MAINTENANCE OF ACID‑BASE BALANCE
Acid‑base balance is maintained by chemical, respiratory,
and kidney function.

Chemical (bicarbonate and intracellular fluid) and
protein buffers (albumin and globulins)

● First line of defense
● Either bind or release hydrogen ions as needed
● Respond quickly to changes in pH

Respiratory buffers
● Second line of defense
● Control the level of hydrogen ions in the blood through

the control of CO2 levels
● When a chemoreceptor senses a change in the level of

CO2, a signal is sent to the brain to alter the rate and
depth of respirations.

◯ Hyperventilation: Decrease in hydrogen ions (helps to
blow off excess hydrogen ions)

◯ Hypoventilation: Increase in hydrogen ions

Kidney buffers
● Kidneys are the third line of defense.
● This buffering system is much slower to respond, but

it is the most effective buffering system with the
longest duration.

● Kidneys control the movement of bicarbonate in
the urine. Bicarbonate can be reabsorbed into the
bloodstream or excreted in the urine in response to
blood levels of hydrogen.

● Kidneys can also produce more bicarbonate when needed.
◯ High hydrogen ions: Bicarbonate reabsorption
and production

◯ Low hydrogen ions: Bicarbonate excretion

comPensation
Compensation refers to the process by which the body
attempts to correct changes and imbalances in pH levels.

● Full compensation occurs when the pH level of the
blood returns to normal (7.35 to 7.45).

● If the pH level is not able to normalize, it is referred to
as partial compensation.

CHAPTER 45

45.1 Insufficient compensation

Respiratory compensation Metabolic compensation

H2O + CO2 H2CO3 H+ + HCO3
‑

Water carbon
dioxide

carbonic acid Hydrogen ion Bicarbonate

expelled by lungs expelled by kidneys

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294 CHAPTER 45 aciD‑Base imBalances CONTENT MASTERY SERIES

eXamPles
● Metabolic alkalosis, metabolic acidosis, respiratory

alkalosis, and respiratory acidosis are examples of
acid‑base imbalances.

● Acid‑base imbalances are a result of insufficient
compensation. Respiratory and kidney function play a
large role in the body’s ability to effectively compensate
for acid‑base alterations. Organ dysfunction negatively
affects acid‑base compensation. (45.1)

HEALTH PROMOTION AND
DISEASE PREVENTION

● Encourage a healthy diet and physical activity.
● Limit the consumption of alcohol.
● Encourage drinking six to eight cups of water daily.
● Maintain an appropriate weight for height and

body frame.
● Promote smoking cessation.

ASSESSMENT

risK Factors

Respiratory acidosis: Hypoventilation

RESULTS FROM
● Respiratory depression from opioids, poisons, anesthetics
● Clients who have brain tumors, cerebral

aneurysm, stroke or overhydration, trauma,
or neurologic diseases (myasthenia gravis,
Guillain‑Barré when respiratory effort is affected)

● Inadequate chest expansion due to muscle weakness,
pneumothorax/hemothorax, flail chest, obesity, sleep
apnea, tumors, or deformities

● Airway obstruction that occurs from neck edema, or
localized lymph node enlargement, foreign bodies or mucus

● Alveolar‑capillary blockage secondary to a pulmonary
embolus, thrombus, acute respiratory distress syndrome,
chest trauma, drowning, or pulmonary edema

● Inadequate mechanical ventilation

RESULTS IN
● Increased CO2

● Increased or normal H+ concentration

MANIFESTATIONS
● Vital signs: Initial tachycardia and hypertension;

bradycardia and hypotension develop as acidosis worsens
● Dysrhythmias: Ventricular fibrillation can be the first

indication in a client receiving anesthesia.
● Neurologic: Initial anxiety, irritability, and confusion;

lethargy and possibly coma develop as acidosis worsens
● Respiratory: Ineffective, shallow, rapid breathing
● Skin: Pale or cyanotic
● Chronic respiratory acidosis seen in clients who have

pulmonary disease, sleep apnea, and obesity

NURSING CARE: Oxygen therapy, maintain patent
airway, and enhance gas exchange (positioning
and breathing techniques, ventilatory support,
bronchodilators, mucolytics).

Respiratory alkalosis: Hyperventilation

RESULTS FROM
● Hyperventilation due to fear, anxiety, intracerebral trauma,

salicylate toxicity, or excessive mechanical ventilation
● Hypoxemia from asphyxiation, high altitudes, shock, or

early‑stage asthma or pneumonia

RESULTS IN
● Decreased CO2

● Decreased or normal H+ concentration

MANIFESTATIONS
● Vital signs: Tachypnea
● Neurologic: Inability to concentrate, numbness, tingling,

tinnitus, and possible loss of consciousness
● Cardiovascular: Tachycardia, ventricular, and atrial

dysrhythmias
● Respiratory: Rapid, deep respirations

NURSING CARE: Oxygen therapy, anxiety reduction
interventions, and rebreathing techniques

Metabolic acidosis

RESULTS FROM
● Excess production of hydrogen ions
● Diabetic ketoacidosis (DKA)
● Starvation
● Lactic acidosis can result from:

◯ Heavy exercise
◯ Seizure activity
◯ Hypoxia

● Excessive intake of acids
◯ Ethyl alcohol
◯ Methyl alcohol
◯ Acetylsalicylic acid (aspirin)

● Inadequate elimination of hydrogen ions
◯ Kidney failure
◯ Severe lung problems

● Inadequate production of bicarbonate
◯ Kidney failure
◯ Pancreatitis

● Impaired liver or pancreatic function: Liver failure
● Excess elimination of bicarbonate: Diarrhea

RESULTS IN
● Decreased HCO3

‑

● Increased H+ concentration

MANIFESTATIONS
● Dysrhythmias
● Vital signs: Bradycardia, weak peripheral pulses,

hypotension, tachypnea
● Neurologic: Headache, drowsiness, confusion
● Respiratory: Rapid, deep respirations

(Kussmaul respirations)
● Skin: Warm, dry, pink

NURSING CARE: Varies with causes. If DKA, administer
insulin. If related to GI losses, administer antidiarrheals
and provide rehydration. If blood bicarbonate is low,
administer sodium bicarbonate 1 mEq/kg.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 45 aciD‑Base imBalances 295

Metabolic alkalosis

RESULTS FROM
● Base excess
● Oral ingestion of excess amount of bases (antacids)
● Venous administration of bases (blood transfusions,

total parenteral nutrition, or sodium bicarbonate)
● Acid deficit

◯ Loss of gastric secretions (through prolonged
vomiting, nasogastric suction)

◯ Potassium depletion (due to thiazide diuretics,
laxative overuse, Cushing’s syndrome,
hyperaldosteronism)

● Increased digitalis toxicity

RESULTS IN
● Increased HCO3

‑

● Decreased H+ concentration

MANIFESTATIONS
● Vital signs: Tachycardia, normotensive or hypotensive
● Dysrhythmias: Atrial tachycardia, ventricular issues

when pH increases
● Neurologic: Numbness, tingling, tetany, muscle

weakness, hyperreflexia, confusion, convulsion
● Respiratory: Depressed skeletal muscles resulting in

ineffective breathing

NURSING CARE: Varies with causes (GI losses: administer
antiemetics, fluids, and electrolyte replacements). If related
to potassium depletion, discontinue causative agent.

Diagnostic ProceDures
To determine the type of imbalance, follow these steps. (45.2)

STEP 1: Look at pH.
● If less than 7.35, identify as acidosis.
● If greater than 7.45, identify as alkalosis.

STEP 2: Look at PaCO2 and HCO3‑ simultaneously.
● Determine which is in the expected reference range.
● Conclude that the other is the indicator of imbalance.
● Identify PaCO2 less than 35 or greater than 45 mm Hg as

respiratory in origin.
● Identify HCO3

‑ less than 22 or greater than 26 mEq/L as
metabolic in origin.

STEP 3: Combine diagnoses of Steps 1 and 2 to name the
type of imbalance.

STEP 4: Evaluate the PaO2 and SaO2. If the results are less
than the expected reference range, the client is hypoxic.

STEP 5: Determine compensation as follows.
● Uncompensated: The pH is outside the expected

reference range, and either the HCO3
‑ or the PaCO2 is

outside the expected reference range.
● Partially compensated: The pH, HCO3

‑, and PaCO2 are
outside the expected reference range.

● Fully compensated: The pH is within the expected
reference range, but the PaCO2 and HCO3

‑ are both outside
the expected reference range. Looking at the pH will
provide a clue as to which system initiated the problem,
respiratory or metabolic. If the pH is less than 7.40, think

“acidosis,” and determine which system has the acidosis
value. If the pH is greater than 7.40, think “alkalosis,”
and determine which system has the alkalosis value.

PATIENT‑CENTERED CARE

nursing care
● For all acid‑base imbalances, it is imperative to treat

the underlying cause.
● Education can vary in relation to the client’s condition.

interProFessional care
● Respiratory services can be consulted for oxygen

therapy, breathing treatments, and ABGs.
● Pulmonology services can be consulted for

respiratory management.

client eDucation
● Adhere to the prescribed diet and dialysis regimen, if

with kidney dysfunction.
● Weigh daily and notify the provider if there is a 1‑ to 2‑lb

(0.5 to 0.9 kg) gain in 24 hr or a 3‑lb (1.4 kg) gain in 1 week.
● Consider smoking cessation if a smoker.
● Take medication as prescribed. Adhere to the medication

regimen if with COPD.
● Set up referral services (home oxygen).

45.2 Types of results

the following are the five classic types of aBg
results demonstrating balance and imbalance.

Step 1:
Look at pH

Step 2:
Determine which is
in the normal range

Step 3:
Combine

names
pH PaCO2 HCO3

− DIAGNOSIS
7.35 to 7.45 35 to 45 21 to 28 Homeostasis
less
than 7.35

greater
than 45 22 to 26 respiratory

acidosis
less
than 7.35 35 to 45 less than 22 metabolic

acidosis
greater
than 7.45 less than 35 22 to 26 respiratory

alkalosis
greater
than 7.45 35 to 45 greater

than 26
metabolic
alkalosis

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296 CHAPTER 45 aciD‑Base imBalances CONTENT MASTERY SERIES

COMPLICATIONS

Convulsions, coma, and respiratory arrest

NURSING ACTIONS
● Implement seizure precautions, and perform

management interventions if necessary.
● Provide life‑support interventions if necessary.

Active Learning Scenario

a nurse is caring for a client who has liver cancer.
the client’s arterial blood gases reveal metabolic
acidosis. use the ati active learning template:
system Disorder to complete this item.

RISK FACTORS: include three conditions
related to metabolic acidosis.

NURSING CARE: include two nursing actions.

COMPLICATIONS: identify one.

Application Exercises

1. a nurse is caring for a client admitted with
confusion and lethargy. the client was found
at home unresponsive with an empty bottle of
aspirin lying next to the bed. Vital signs reveal
blood pressure 104/72 mm Hg, heart rate 116/min
with regular rhythm, and respiratory rate 42/min
and deep. Which of the following arterial blood
gas findings should the nurse expect?

a. pH 7.68
Pao2 96 mm Hg
Paco2 38 mm Hg
Hco3

− 28 meq/l

B. pH 7.48
Pao2 100 mm Hg
Paco2 28 mm Hg
Hco3

− 23 meq/l

c. pH 6.98
Pao2 100 mm Hg
Paco2 30 mm Hg
Hco3

− 18 meq/l

D. pH 7.58
Pao2 96 mm Hg
Paco2 38 mm Hg
Hco3

− 29 meq/l

2. a nurse is caring for a client who was in a motor‑vehicle
accident. the client reports chest pain and difficulty
breathing. a chest x‑ray reveals the client has a
pneumothorax. Which of the following arterial
blood gas findings should the nurse expect?

a. pH 7.06
Pao2 86 mm Hg
Paco2 52 mm Hg
Hco3

− 24 meq/l

B. pH 7.42
Pao2 100 mm Hg
Paco2 38 mm Hg
Hco3

− 23 meq/l

c. pH 6.98
Pao2 100 mm Hg
Paco2 30 mm Hg
Hco3

− 18 meq/l

D. pH 7.58
Pao2 96 mm Hg
Paco2 38 mm Hg
Hco3

− 29 meq/l

3. a nurse is obtaining arterial blood gases for
a client who has vomited for 24 hr. the nurse
should expect which of the following acid‑base
imbalances to result from vomiting for 24 hr?

a. respiratory acidosis

B. respiratory alkalosis

c. metabolic acidosis

D. metabolic alkalosis

4. a charge nurse is teaching a group of nurses
about conditions related to metabolic acidosis.
Which of the following statements by a unit nurse
indicates the teaching has been effective?

a. “metabolic acidosis can occur due
to diabetic ketoacidosis.”

B. “metabolic acidosis can occur in a
client who has myasthenia gravis.”

c. “metabolic acidosis can occur in
a client who has asthma.”

D. “metabolic acidosis can occur due to cancer.”

5. a nurse is assessing a client who has pancreatitis.
the client’s arterial blood gases reveal
metabolic acidosis. Which of the following are
expected findings? (select all that apply.)

a. tachycardia

B. Hypertension

c. Bounding pulses

D. Hyperreflexia

e. Dysrhythmia

F. tachypnea

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 45 aciD‑Base imBalances 297

Application Exercises Key

1. a. these arterial blood gases indicate metabolic alkalosis.
B. these arterial blood gases indicate respiratory alkalosis.
c. CORRECT: an aspirin toxicity would result in arterial

blood gas findings of metabolic acidosis.
D. these arterial blood gases indicate metabolic alkalosis.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. CORRECT: a pneumothorax can cause alveolar
hypoventilation and increased carbon dioxide levels,
resulting in a state of respiratory acidosis.

B. these aBgs are within the expected reference
range and reflect homeostasis.

c. metabolic acidosis is not indicated for this client.
D. metabolic alkalosis is not indicated for this client.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

3. a. respiratory acidosis is not indicated for this client.
B. respiratory alkalosis is not indicated for this client.
c. metabolic acidosis is not indicated for this client.
D. CORRECT: excessive vomiting causes a loss of

gastric acids and an accumulation of bicarbonate
in the blood, resulting in metabolic alkalosis.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

4. a. CORRECT: metabolic acidosis results from an
excess production of hydrogen ions, which
occurs in diabetic ketoacidosis.

B. respiratory acidosis can occur in a client
who has myasthenia gravis.

c. respiratory acidosis can occur in a client who has asthma.
D. respiratory acidosis can occur due to cancer.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

5. a. tachycardia is an expected finding for a client who has
respiratory acidosis or metabolic alkalosis.

B. Hypertension is an expected finding of respiratory acidosis.
c. Bounding pulses is an expected finding for

respiratory acidosis due to hypertension.
D. Hyperreflexia is an expected finding for a

client who has metabolic alkalosis.
e. CORRECT: Dysrhythmia is an expected finding in a

client who has pancreatitis and metabolic acidosis.
F. CORRECT: tachypnea is an expected finding in a client

who has pancreatitis and metabolic acidosis.

NCLEX® Connection: Physiological Adaptation,
Illness Management

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS

metabolic acidosis results from:
● excess production of hydrogen ions
● Diabetic ketoacidosis (DKa)
● starvation

lactic acidosis can result from:
● Heavy exercise
● seizure activity
● Hypoxia
● excessive intake of acids such as the following:

◯ ethyl alcohol
◯ methyl alcohol
◯ acetylsalicylic acid (aspirin)

● inadequate elimination of hydrogen ions
◯ Kidney failure
◯ severe lung problems

● inadequate production of bicarbonate
◯ Kidney failure
◯ Pancreatitis
◯ impaired liver or pancreatic function
◯ liver failure

● excess elimination of bicarbonate (diarrhea)

metabolic acidosis results in:
● Decreased Hco3

‑

● increased H+ concentration

NURSING CARE: Varies with causes. if DKa, administer insulin. if
related to gi losses, administer antidiarrheals and provide rehydration.
if blood bicarbonate is low, administer sodium bicarbonate 1 meq/kg.

COMPLICATIONS: convulsions, coma, and respiratory arrest

nursing actions
● implement seizure precautions, and perform
management interventions if necessary.

● Provide life‑support interventions if necessary.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

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298 CHAPTER 45 aciD‑Base imBalances CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING ncleX® connections 299

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Basic Care and Comfort
ELIMINATION: Assess and manage the client
with an alteration in elimination.

NUTRITION AND ORAL HYDRATION: Evaluate side
effects of client tube feedings and intervene, as needed.

Pharmacological and Parenteral Therapies
MEDICATION ADMINISTRATION: Use clinical decision making/critical
thinking when addressing expected effects/outcomes of medications.

PHARMACOLOGICAL PAIN MANAGEMENT: Assess client
need for administration of a PRN pain medication.

TOTAL PARENTERAL NUTRITION: Administer parenteral
nutrition and evaluate client response.

Reduction of Risk Potential
DIAGNOSTIC TESTS: Perform diagnostic testing.

LABORATORY VALUES: Monitor client laboratory values.

POTENTIAL FOR COMPLICATIONS OF
DIAGNOSTIC TESTS/TREATMENTS/PROCEDURES
Insert, maintain, or remove a nasal/oral gastrointestinal tube.

THERAPEUTIC PROCEDURES: Manage client
following a procedure with moderate sedation.

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS: Educate
client about managing health problems.

ILLNESS MANAGEMENT: Apply knowledge of client
pathophysiology to illness management.

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300 ncleX® connections CONTENT MASTERY SERIES

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UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 46 Gastrointestinal
Diagnostic
Procedures

gastrointestinal diagnostic procedures often
involve endoscopes and x‑rays to visualize
parts of the gastrointestinal system and to
evaluate gastrointestinal contents. Procedures
include liver function tests, other blood tests,
urobilinogen, fecal occult blood test (FoBt),
stool samples, endoscopy, and gastrointestinal
(gi) series.

Liver function tests and
other blood tests

● Liver function tests are aspartate aminotransferase
(AST), alanine aminotransferase (ALT), alkaline
phosphatase (ALP), bilirubin, and albumin.

● Other blood tests that provide information on the
functioning of the GI system include amylase, lipase,
alpha‑fetoprotein, and ammonia.

INDICATIONS
Suspected liver, pancreatic, or biliary
tract disorder

CONSIDERATIONS
PREPROCEDURE: Explain to the
client how blood is obtained and what
information this will provide.

Urine bilirubin
Also known as urobilinogen, this is a urine test to
determine the presence of bilirubin in the urine.

INDICATIONS
Suspected liver or biliary tract disorder

CONSIDERATIONS

PreProceDure
NURSING ACTIONS: The test can be performed by using
a dipstick (urine bilirubin) or a 24‑hr urine collection
(urobilinogen).

CLIENT EDUCATION: Collect urine using the provided
proper collection container.

PostProceDure
NURSING ACTIONS: Inform the client when and how
results are provided.

INTERPRETATION OF FINDINGS
A positive or elevated finding indicates possible liver
disorder (cirrhosis, hepatitis), biliary obstruction,
hemolytic anemia, or pernicious anemia.

CHAPTER 46

46.1 Blood tests: Interpretation of findings

BLOOD TEST
EXPECTED
REFERENCE RANGE

INTERPRETATION
OF FINDINGS

aspartate aminotransferase 0 to 35 units/l elevation occurs with
hepatitis or cirrhosis.alanine aminotransferase 4 to 36 units/l

alkaline phosphatase 30 to 120 units/l elevation indicates
liver damage.

amylase 30 to 220 units/l elevation occurs
with pancreatitis.lipase 0 to 160 units/l

total bilirubin 0.3 to 1 mg/dl elevations indicate
altered liver function, bile
duct obstruction, or other
hepatobiliary disorder.

Direct (conjugated) bilirubin 0.1 to 0.3 mg/dl

indirect (unconjugated) bilirubin 0.2 to 0.8 mg/dl

albumin 3.5 to 5 g/dl Decrease can indicate
hepatic disease.

alpha‑fetoprotein less than 40 mcg/l elevated in liver cancer,
cirrhosis, hepatitis.

ammonia 10 to 80 mcg/dl elevated in liver disease.

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302 CHAPTER 46 gastrointestinal Diagnostic ProceDures CONTENT MASTERY SERIES

Fecal occult blood test
and stool samples

A stool sample is collected and tested for blood, ova and
parasites (Giardia lamblia), and bacteria (Clostridium difficile).
Stool also can be collected to assess for DNA changes in
the vimentin gene, which can predispose a client to cancer
of the intestine.

INDICATIONS
CLIENT PRESENTATION

● GI bleeding
● Unexplained diarrhea

CONSIDERATIONS

PreProceDure
NURSING ACTIONS

● Occult blood: Provide the client with cards impregnated
with guaiac that can be mailed to provider or with a
specimen collection cup. If the cards are used, three
samples are usually required.

● Stool for ova and parasites and bacteria: Provide the
client with a specimen collection cup.

CLIENT EDUCATION
● Occult blood: Adhere to the proper collection technique.

Be aware of any medication restrictions (anticoagulants,
NSAIDs) for 7 days before the testing starts, and dietary
restrictions to follow (vitamin C rich foods, red meat,
chicken, fish) prior to obtaining samples.

● Stool for ova and parasites and bacteria: Adhere to the
proper collection technique (time frame for submission
to laboratory, need for refrigeration).

PostProceDure
NURSING ACTIONS: Inform the client when and how the
results are provided.

INTERPRETATION OF FINDINGS
● At least three repeats of a positive guaiac FOBT confirms

GI bleeding.
● A positive finding for blood is indicative of GI bleeding

(ulcer, colitis, cancer).

Stool samples
● A positive finding for ova and parasites is indicative of a

GI parasitic infection.
● A positive finding for Clostridium difficile is

indicative of this opportunistic infection, which
usually becomes established secondary to use of
broad‑spectrum antibiotics.

● A change in the vimentin gene can be an indicator of
colorectal cancer.

Endoscopy
● Endoscopic procedures allow direct visualization of body

cavities, tissues, and organs through the use of a
flexible, lighted tube (endoscope). They are performed
for diagnostic and therapeutic purposes.

● Endoscopic procedures are performed in a variety of
facilities. The provider can perform biopsies, remove
abnormal tissue, and perform minor surgery, such as
cauterizing a bleeding ulcer. A contrast medium can be
injected to allow visualization of structures beyond the
capabilities of the scope.

GASTROINTESTINAL SCOPE PROCEDURES
● Colonoscopy
● Esophagogastroduodenoscopy (EGD)
● Endoscopic retrograde cholangiopancreatography (ERCP)
● Small bowel capsule endoscopy (M2A)
● Sigmoidoscopy

INDICATIONS
POTENTIAL DIAGNOSES: GI bleeding, ulcerations,
inflammation, polyps, malignant tumors

CLIENT PRESENTATION
● Anemia (secondary to bleeding)
● Abdominal discomfort
● Abdominal distention or mass

CONSIDERATIONS

General endoscopic procedures

PREPROCEDURE
● NURSING ACTIONS

◯ Evaluate the client’s understanding of the procedure.
◯ Verify that a consent form has been signed.
◯ Assess vital signs, and verify the client’s allergies.
◯ Evaluate baseline laboratory tests and report
unexpected findings to the provider (CBC, electrolyte
panel, BUN, creatinine, PT, aPTT, and liver function
studies). Evaluate chest x‑ray, ECG, and ABGs,
as indicated.

◯ Evaluate the client’s medical history for increased risk
of complications.

◯ Age can influence the client’s ability to understand
the procedures, tolerance of the required positioning,
and compliance with pretest preparation.

◯ Current health status: Consider conditions and
medications that can affect the client’s tolerance of
and recovery from the procedure.

◯ Cognitive status: Determine the client’s
understanding of the procedure and baseline
mental status.

◯ Support system: Determine whether a support person
will assist the client after the procedure.

◯ Recent food or fluid intake: Can affect the provider’s
ability to visualize key structures and increase the
risk for complications (aspiration). Notify the provider
if dietary restrictions were not followed.

Online Image: Endoscope

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◯ Medications: Some medications (NSAIDs, warfarin,
aspirin) place the client at risk for complications. Notify
the provider if medication restrictions were not followed.

◯ Previous radiographic examinations: Any recent
radiographic examinations using barium can affect
the provider’s ability to view key structures. Notify
the provider if contrast has been recently used.

◯ Electrolyte and fluid status: Imbalances secondary
to repeated enemas can affect bowel preparation
tolerance, especially in older adult clients.

◯ Ensure that the client followed proper bowel
preparation (laxatives, enemas). Inadequate bowel
preparation can result in cancellation and delays
the examination. This can also lead to the client
experiencing extended periods of being NPO or on a
liquid diet.

◯ Ensure that the client is NPO for the prescribed period
prior to the examination.

● CLIENT EDUCATION
◯ Understand the given instructions regarding
medication and food restrictions.

◯ Receive prescriptions for medications used for the
bowel prep.

◯ Remember the number and type of enemas,
if prescribed.

POSTPROCEDURE
● NURSING ACTIONS

◯ Monitor vital signs.
◯ Assess for complications.

● CLIENT EDUCATION: If a biopsy was performed, food
restrictions can be prescribed.

Colonoscopy

Use of a flexible fiber optic colonoscope, which enters
through the anus, to visualize the rectum and the sigmoid,
descending, transverse, and ascending colon

ANESTHESIA: Moderate sedation: Midazolam, an opiate
such as fentanyl, and/or propofol are commonly
used medications.

POSITIONING: Left side with knees to chest

PREPARATION
● Bowel prep
● Prep can include laxatives, such as bisacodyl and
polyethylene glycol.

● Polyethylene glycol is not recommended for older
adult clients because it can cause fluid and
electrolyte imbalances.

● Polyethylene glycol can inhibit the absorption
of some medications. Review the client’s
medications and consult with the provider.

● Clear liquid diet (avoid red, purple, orange fluids).
NPO after midnight.

● The client must avoid medications indicated by
the provider (aspirin, anticoagulants, antiplatelet).

POSTPROCEDURE
● Notify the provider of severe pain (possible perforation)

or indication of hemorrhage.
● Monitor for rectal bleeding.
● Monitor vital signs and respiratory status. Maintain an

open airway until the client is awake.
● Resume normal diet as prescribed.
● Encourage increased fluid intake.
● Instruct the client that there can be increased flatulence

due to air instillation during the procedure.
● Instruct the client not to drive or use equipment for
12 to 18 hr after the procedure.

EGD

Insertion of endoscope through the mouth into the
esophagus, stomach, and duodenum to identify or treat
areas of bleeding, dilate an esophageal stricture, and
diagnose gastric lesions or celiac disease

ANESTHESIA: Moderate sedation per IV access:
Topical anesthetic to depress the gag reflex, atropine to
decrease secretions

POSITIONING: Left side‑lying with head of bed elevated

PREPARATION: NPO 6 to 8 hr. Remove dentures prior
to procedure.

POSTPROCEDURE
● Monitor vital signs and respiratory status. Maintain an

open airway until the client is awake.
● Notify the provider of bleeding, abdominal or chest pain,

and any evidence of infection.
● Withhold fluids until return of gag reflex.
● Discontinue IV fluid therapy when the client tolerates

oral fluids without nausea and vomiting.
● Instruct the client not to drive or use equipment for
12 to 18 hr after the procedure.

● Teach the client to use throat lozenges if a sore throat or
hoarse voice persists following the procedure.

46.2 Endoscope

Endoscopy
● Endoscopic procedures allow direct visualization of body

cavities, tissues, and organs through the use of a
flexible, lighted tube (endoscope). They are performed
for diagnostic and therapeutic purposes.

● Endoscopic procedures are performed in a variety of
facilities. The provider can perform biopsies, remove
abnormal tissue, and perform minor surgery, such as
cauterizing a bleeding ulcer. A contrast medium can be
injected to allow visualization of structures beyond the
capabilities of the scope.

GASTROINTESTINAL SCOPE PROCEDURES
● Colonoscopy
● Esophagogastroduodenoscopy (EGD)
● Endoscopic retrograde cholangiopancreatography (ERCP)
● Small bowel capsule endoscopy (M2A)
● Sigmoidoscopy

INDICATIONS
POTENTIAL DIAGNOSES: GI bleeding, ulcerations,
inflammation, polyps, malignant tumors

CLIENT PRESENTATION
● Anemia (secondary to bleeding)
● Abdominal discomfort
● Abdominal distention or mass

CONSIDERATIONS

General endoscopic procedures

PREPROCEDURE
● NURSING ACTIONS

◯ Evaluate the client’s understanding of the procedure.
◯ Verify that a consent form has been signed.
◯ Assess vital signs, and verify the client’s allergies.
◯ Evaluate baseline laboratory tests and report
unexpected findings to the provider (CBC, electrolyte
panel, BUN, creatinine, PT, aPTT, and liver function
studies). Evaluate chest x‑ray, ECG, and ABGs,
as indicated.

◯ Evaluate the client’s medical history for increased risk
of complications.

◯ Age can influence the client’s ability to understand
the procedures, tolerance of the required positioning,
and compliance with pretest preparation.

◯ Current health status: Consider conditions and
medications that can affect the client’s tolerance of
and recovery from the procedure.

◯ Cognitive status: Determine the client’s
understanding of the procedure and baseline
mental status.

◯ Support system: Determine whether a support person
will assist the client after the procedure.

◯ Recent food or fluid intake: Can affect the provider’s
ability to visualize key structures and increase the
risk for complications (aspiration). Notify the provider
if dietary restrictions were not followed.

Online Image: Endoscope

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304 CHAPTER 46 gastrointestinal Diagnostic ProceDures CONTENT MASTERY SERIES

ERCP

Insertion of an endoscope through the mouth into the
biliary tree via the duodenum. Allows visualization of
the biliary ducts, gall bladder, liver, and pancreas. X‑rays
are taken after a contrast medium is injected into the
common duct.

ANESTHESIA: Moderate sedation per IV access:
Topical anesthetic to depress the gag reflex, atropine to
decrease secretions

POSITIONING: Initially semi‑prone with repositioning
throughout procedure

PREPARATION
● NPO 6 to 8 hr. Remove dentures prior to procedure.
● Explain the procedure and the need to change positions

during the procedure.

POSTPROCEDURE
● Monitor vital signs and respiratory status. Maintain an

open airway until the client is awake.
● Notify the provider of bleeding, abdominal or chest pain,

and any evidence of infection.
● Withhold fluids until return of gag reflex.
● Discontinue IV fluid therapy when the client tolerates

oral fluids without nausea and vomiting.
● Instruct the client not to drive or use equipment for
12 to 18 hr after the procedure.

● Teach the client to use throat lozenges if a sore throat or
hoarse voice persists following the procedure.

M2A

Swallow the capsule with a glass of water for a video
enteroscopy to visualize the entire small bowel over an
8‑hr period. The capsule is not used to view the colon.

ANESTHESIA: None

POSITIONING: Return to normal activity during the study

PREPARATION
● Fast (water only) for 8 to 10 hr before the test and NPO

for first 2 hr of the testing. Normal eating 4 hr after
swallowing the capsule.

● The abdomen is marked for the location of the sensor.
Eight‑lead sensors are placed and connected to a data
recorder, which captures images of the small
intestines.

POSTPROCEDURE
● After 8 hr, the client returns the recorder for

downloading of the images.
● The client will evacuate the capsule in the stool.

Sigmoidoscopy

Scope is shorter than colonoscope, allowing visualization
of the anus, rectum, and sigmoid colon to test for colon
cancer, investigate for a GI bleed, and diagnose or monitor
inflammatory bowel disease.

ANESTHESIA: None required

POSITIONING: On left side

PREPARATION
● Bowel prep, which can include laxatives (such

as bisacodyl), cleansing enema, or sodium
biphosphate enema

● Clear liquid diet at least 24 hr before the procedure
● NPO after midnight
● The client must avoid medications as indicated by

the provider

POSTPROCEDURE
● Monitor vital signs and respiratory status.
● Monitor for rectal bleeding.
● Resume normal diet as prescribed.
● Encourage increased fluid intake.
● Instruct the client that there can be increased flatulence

due to air instillation during the procedure.

INTERPRETATION OF FINDINGS
Can indicate a need for medication or surgical removal
of a lesion.

COMPLICATIONS

Oversedation

Use of moderate sedation places the client at risk for
oversedation.

MANIFESTATIONS: Difficult to arouse, poor respiratory
effort, evidence of hypoxemia, tachycardia, and elevated or
low blood pressure

NURSING ACTIONS
● Be prepared to administer antidotes for sedatives

administered prior to and during the procedure.
● Administer oxygen, and monitor vital signs. Maintain

an open airway until awake.
● Notify the provider immediately, and call for assistance.

CLIENT EDUCATION: Driving and major decision‑making
are restricted until the effects of the sedation have worn
off. This varies with the type of agent used.

Hemorrhage

MANIFESTATIONS: Bleeding, cool and clammy skin,
hypotension, tachycardia, dizziness, and tachypnea

NURSING ACTIONS
● Assess for hemorrhage from the site. Monitor vital signs.
● Monitor diagnostic test results (particularly Hgb and Hct).
● Notify the provider immediately.

CLIENT EDUCATION: Report fever, pain, and bleeding to
the provider.

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Aspiration

Using moderate sedation or topical anesthesia can affect
the gag reflex.

MANIFESTATIONS: Dyspnea, tachypnea, adventitious
breath sounds, tachycardia, and fever

NURSING ACTIONS
● Keep the client NPO until the gag reflex returns. Ensure

that the client is awake and alert prior to consuming
food or fluid. Encourage the client to deep breathe and
cough to promote removal of secretions.

● Notify the provider if there is a delay in gag reflex return.

CLIENT EDUCATION: Report any respiratory congestion or
compromise to the provider.

Perforation of the gastrointestinal tract

Manifestations include chest or abdominal pain, fever,
nausea, vomiting, and abdominal distention.

NURSING ACTIONS: Monitor diagnostic tests for evidence
of infection, including elevated WBC, and notify the
provider of unexpected findings.

CLIENT EDUCATION: Report fever, pain, and bleeding to
the provider.

Gastrointestinal series
GI studies are done with or without contrast and help
define anatomic or functional abnormalities.

● These include radiographic imaging of the esophagus,
stomach, and entire intestinal tract.

● Upper GI imaging is done by having the client
drink a radiopaque liquid (barium). For small bowel
follow‑through, barium is traced through the small
intestine to the ileocecal junction.

● A barium enema is done by instilling a radiopaque liquid
into the rectum and colon.

INDICATIONS
POTENTIAL DIAGNOSES: Gastric ulcers, peristaltic
disorders, tumors, varices, and intestinal enlargements
or constrictions

CLIENT PRESENTATION: Abdominal pain, altered
elimination habits (constipation, diarrhea), or GI bleeding

CONSIDERATIONS

PreProceDure
NURSING CONSIDERATIONS

● Inform the client about medications, food and fluid
restrictions (clear liquid and/or low residue diet, NPO
after midnight), and avoiding smoking or chewing gum
(increases peristalsis).

● Assess the client’s understanding of bowel preparation
(laxatives, enemas) so the image will not be
distorted by feces.

● Barium enema studies must be scheduled prior to upper
GI studies.

● Assess for contraindications to bowel preparation
(possible bowel perforation or obstruction,
inflammatory disease).

CLIENT EDUCATION
● Restrict food and fluids for bowel preparation.
● If the small intestine is to be visualized, additional

radiographs will be done over the next 24 hr.

PostProceDure
NURSING ACTIONS

● Monitor elimination of contrast material, and
administer a laxative if prescribed.

● Increase fluid intake to promote elimination of
contrast material.

CLIENT EDUCATION
● Monitor elimination of contrast material and report

retention of contrast material (constipation) or diarrhea
accompanied by weakness.

● An over‑the‑counter medication can be needed to
prevent constipation resulting from the barium.

● Stools will be white for 24 to 72 hr until barium clears.
Report abdominal fullness, pain, or delay in return to
brown stool.

INTERPRETATION OF FINDINGS
Include altered bowel shape and size, increased motility,
or obstruction.

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306 CHAPTER 46 gastrointestinal Diagnostic ProceDures CONTENT MASTERY SERIES

Application Exercises

1. a nurse is reviewing bowel prep using polyethylene
glycol with a client scheduled for a colonoscopy. Which
of the following instructions should the nurse include?

a. check with the provider about taking current
medications when consuming bowel prep.

B. consume a normal diet until
starting the bowel prep.

c. expect the bowel prep to not begin acting
until the day after all the prep is consumed.

D. Discontinue the bowel prep once
feces start to be expelled.

2. a nurse is having difficulty arousing a client following
an esophagogastroduodenoscopy (egD). Which of
the following is the priority action by the nurse?

a. assess the client’s airway.

B. allow the client to sleep.

c. Prepare to administer an antidote to the sedative.

D. evaluate preprocedure laboratory findings.

3. a nurse in a clinic is instructing a client about a
fecal occult blood test, which requires mailing three
specimens. Which of the following statements
by the client indicates understanding?

a. “i will continue taking my warfarin
while i complete these tests.”

B. “i’m glad i don’t have to follow any
special diet at this time.”

c. “this test determines if i have
parasites in my bowel.”

D. “this is an easy way to screen for colon cancer.”

4. a nurse is teaching a client who will undergo
a sigmoidoscopy. Which of the following
information about the procedure should the
nurse include? (select all that apply.)

a. increased flatulence can occur
following the procedure.

B. nPo status should be maintained preprocedure.

c. conscious sedation is used.

D. repositioning will occur throughout the procedure.

e. Fluid intake is limited the day after the procedure.

5. a nurse is reviewing the health record of a client
who has a suspected tumor of the jejunum. the
nurse should expect a prescription for which of
the following tests? (select all that apply.)

a. Blood alpha‑fetoprotein

B. endoscopic retrograde
cholangiopancreatography (ercP)

c. gastrointestinal x‑ray with contrast

D. small bowel capsule endoscopy (m2a)

e. colonoscopy

Active Learning Scenario

a nurse in a clinic is reviewing teaching with a client who will
undergo a gastrointestinal series of x‑rays. What should the
nurse include in the teaching? use the ati active learning
template: Diagnostic Procedure to complete this item.

DESCRIPTION OF PROCEDURE: Describe
the procedure and technique involved.

INDICATIONS: identify at least three potential
diagnoses and two manifestations.

CLIENT EDUCATION: Describe three teaching points.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 46 gastrointestinal Diagnostic ProceDures 307

Application Exercises Key

1. a. CORRECT: instruct the client to check with the provider
about taking current medication, because some
medications can be withheld when taking polyethylene
glycol due to their lack of absorption.

B. instruct the client to consume a clear liquid
diet prior to starting the bowel prep.

c. instruct the client that the actions of polyethylene
glycol begin within 2 to 3 hr after consumption.

D. instruct the client to consume the full amount prescribed.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

2. a. CORRECT: When using the airway, breathing, and circulation
priority‑setting framework, assessing and maintaining an
open airway is the priority action the nurse should take.

B. continue to allow the client to rest. However,
another action is the priority.

c. Prepare to administer an antidote to the sedative used during
the procedure. However, another action is the priority.

D. evaluate the preprocedure laboratory findings.
However, another action is the priority.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. clients are instructed to stop taking anticoagulants prior
to obtaining stool specimens for fecal occult blood testing
because they can interfere with the results.

B. clients are instructed to avoid consuming red meat, chicken,
and fish prior to obtaining stool specimens for fecal occult
blood testing because this can interfere with the results.

c. Fecal occult blood testing does not identify
parasites present in stool.

D. CORRECT: Fecal occult blood testing is a
screening procedure for colon cancer.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. a. CORRECT: teach the client that increased flatulence can
occur due to the instillation of air during the procedure.

B. CORRECT: instruct the client to remain nPo after
midnight the night before the procedure.

c. inform the client that sedation is not
indicated for a sigmoidoscopy.

D. inform the client that the position to lie for
the procedure is on the left side.

e. instruct the client to increase, not limit fluid
intake following the procedure.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. a. Blood alpha‑fetoprotein is a laboratory test used
in cases of suspected liver cancer.

B. an ercP is used to visualize the duodenum, biliary
ducts, gall bladder, liver, and pancreas.

c. CORRECT: a gastrointestinal x‑ray with contrast
involves the client drinking barium, which is then traced
through the small intestine to the junction with the
colon. this would identify a tumor in the jejunum.

D. CORRECT: m2a is a procedure in which the client swallows
a capsule with a glass of water for a video enteroscopy to
visualize the entire small bowel over an 8‑hr period.

e. a colonoscopy is the use of a flexible fiberoptic colonoscope,
which enters through the anus, to visualize the rectum and
the sigmoid, descending, transverse, and ascending colon.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

DESCRIPTION OF PROCEDURE: radiographic images are used
to define anatomic or functional abnormalities of the esophagus,
stomach, and intestinal tract. these can include an upper gi image,
which includes the client drinking radiopaque barium liquid that
is traced through the small intestine. the client can have a barium
enema, in which liquid barium is instilled into the rectum and colon.

INDICATIONS
● Diagnoses: gastric ulcers, peristaltic disorders, tumors,
varices, intestinal enlargements or constrictions

● manifestations: abdominal pain, altered elimination habits
(constipation, diarrhea), gastrointestinal bleeding

CLIENT EDUCATION
● Follow fluid and food restrictions for bowel preparation.
● additional radiographs can be done over a 24‑hr period.
● monitor elimination of contrast media, and report retention of
contrast media (constipation) or diarrhea accompanied by weakness.
over‑the‑counter medication can be used to prevent constipation.

● stool can be white for 24 to 72 hr until barium clears the system.
report abdominal fullness, pain, or a delay in a return to brown stool.

NCLEX® Connection: Reduction of Risk Potential, Therapeutic
Procedures

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308 CHAPTER 46 gastrointestinal Diagnostic ProceDures CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 47 gastrointestinal tHeraPeutic ProceDures 309

UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 47 Gastrointestinal
Therapeutic
Procedures

gastrointestinal therapeutic procedures are
performed for maintenance of nutritional intake,
and treatment of gastrointestinal obstructions,
obesity, and other disorders.

gastrointestinal therapeutic procedures nurses
should be knowledgeable about include
enteral feedings, total parenteral nutrition
(tPn), abdominal paracentesis, nasogastric
decompression, bariatric surgeries, and ostomies.

Enteral feedings
Enteral feedings are instituted for a client who has a
functioning GI tract but is unable to swallow or take in
adequate calories and protein orally. It can be in addition
to an oral diet, or it can be the only source of nutrition.

INDICATIONS

Potential Diagnoses
● Inability to eat due to a medical condition

(comatose, intubated)
● Pathologies that cause difficulty swallowing or increase

risk of aspiration (stroke, advanced Parkinson’s disease,
multiple sclerosis)

● Inability to maintain adequate oral nutritional intake
and need for supplementation due to increased
metabolic demands (cancer therapy, burns, sepsis)

client Presentation
● Malnutrition (decreased prealbumin, decreased

transferrin or total iron‑binding capacity)
● Aspiration pneumonia

COMPLICATIONS

Overfeeding

Overfeeding results from infusion of a greater quantity
of feeding than can be readily digested, resulting in
abdominal distention, nausea, and vomiting.

NURSING ACTIONS
● Check facility policy regarding residual check, which

is usually every 4 to 6 hr, and take corrective actions
as prescribed. Some facilities no longer require
residual checks.

● Follow protocol for slowing or withholding feedings
for excess residual volumes. Many facilities hold for
residual volumes of 100 to 200 mL and then restart at a
lower rate after a period of rest.

● Check pump for proper operation and ensure feeding
infused at correct rate.

Diarrhea

Diarrhea occurs secondary to concentration of feeding or
its constituents.

NURSING ACTIONS
● Slow the rate of feeding and notify the provider.
● Confer with a dietitian.
● Provide skin care and protection.
● Evaluate for Clostridium difficile if diarrhea continues,

especially if it has a very foul odor.

Aspiration pneumonia

Pneumonia can occur secondary to aspiration of feeding,
and can be a life‑threatening complication. Tube
displacement is the primary cause of aspiration of feeding.

NURSING ACTIONS
● For prevention, confirm tube placement before feedings,

and elevate the head of the bed at least 30° during
feedings, and for at least 1 hr after.

● Stop the feeding.
● Turn the client to one side and suction the airway.
Administer oxygen if indicated.

● Monitor vital signs for an elevated temperature.
● Auscultate breath sounds for increased congestion and

diminishing breath sounds.
● Notify the provider and obtain a chest x‑ray if prescribed.

Refeeding syndrome

Refeeding syndrome is a potentially life‑threatening
condition that occurs when enteral feeding is started in
a client who is in a starvation state and whose body has
begun to catabolize protein and fat for energy.

NURSING ACTIONS
● Monitor for new onset of confusion or seizures.
● Assess for shallow respirations.
● Monitor for increased muscular weakness.
● Notify the provider and obtain blood electrolytes if needed.

CHAPTER 47

310 CHAPTER 47 gastrointestinal tHeraPeutic ProceDures CONTENT MASTERY SERIES

Total parenteral nutrition
TPN is a hypertonic IV bolus solution. The purpose of
TPN administration is to prevent or correct nutritional
deficiencies and minimize the adverse effects
of malnourishment.

● TPN administration is usually through a central
line (a tunneled triple lumen catheter or a single‑ or
double‑lumen peripherally inserted central [PICC] line).

● TPN contains complete nutrition, including calories in
a high concentration (10% to 50%) of dextrose, lipids/
essential fatty acids, protein, electrolytes, vitamins, and
trace elements. Standard IV bolus therapy is typically no
more than 700 calories/day.

● Partial parenteral nutrition or peripheral parenteral
nutrition (PPN) is less hypertonic, intended for
short‑term use, and administered in a large peripheral
vein. Usual dextrose concentration is 10% or less. Risks
include phlebitis.

INDICATIONS
Any condition that

● Affects the ability to absorb nutrition
● Has a prolonged recovery
● Creates a hypermetabolic state
● Creates a chronic malnutrition

Potential Diagnoses
● Chronic pancreatitis
● Diffuse peritonitis
● Short bowel syndrome
● Gastric paresis from diabetes mellitus
● Severe burns

client Presentation
● Weight loss greater than 10% of body weight and NPO or

unable to eat or drink for more than 5 days
● Muscle wasting, poor tissue healing, burns, bowel

disease disorders, acute kidney failure

CONSIDERATIONS

PreParation oF tHe client
● Determine the client’s readiness for TPN.
● Obtain daily laboratory values, including electrolytes.

Solutions are customized for each client according to
daily laboratory results.

ongoing care
● The flow rate is gradually increased and gradually

decreased to allow body adjustment (usually no more
than a 10% hourly increase in rate).

! never abruptly stop tPn. speeding up/slowing
down the rate is contraindicated. an abrupt rate
change can alter blood glucose levels significantly.

● Assess vital signs every 4 to 8 hr and weights daily.
● Follow sterile procedures to minimize the risk of sepsis.

◯ TPN solution is prepared by the pharmacy using
aseptic technique with a laminar flow hood.

◯ Change tubing and solution bag (even if not empty)
every 24 hr.

◯ Ensure tubing has a filter to collect particles from
the solution.

◯ Do not use the line for other IV bolus solutions (prevents
contamination and interruption of the flow rate).

◯ Do not add anything to the solution due to risks of
contamination and incompatibility.

◯ Use sterile technique, including a mask, when changing
the central line dressing (per facility procedure).

interVentions
● Check capillary glucose every 4 to 6 hr for at least the

first 24 hr.
● Clients receiving TPN frequently need supplemental

regular insulin until the pancreas can increase its
endogenous production of insulin.

● Keep dextrose 10% in water at the bedside in case the
solution is unexpectedly ruined or the next bag is not
available. This will minimize the risk of hypoglycemia
with abrupt changes in dextrose concentrations.

● If a bag is unavailable and administered late, do not
attempt to catch up by increasing the infusion rate
because the client can develop hyperglycemia.

● OLDER ADULT CLIENTS have an increased incidence of
glucose intolerance.

COMPLICATIONS

Metabolic complications

Metabolic complications include hyperglycemia,
hypoglycemia, and vitamin deficiencies.

NURSING ACTIONS
● Review results of daily laboratory monitoring to ensure

that the components prescribed in the client’s TPN
match the client’s needs.

● Fluid needs are typically replaced with a separate IV
bolus to prevent fluid volume excess.

● Monitor for hyperglycemia.

Air embolism

A pressure change during tubing changes can lead to an
air embolism.

NURSING ACTIONS
● Monitor for manifestations of an air embolism (sudden

onset of dyspnea, chest pain, anxiety, hypoxia).
● Clamp the catheter immediately and place the client

on their left side in Trendelenburg position to trap air.
Administer oxygen and notify the provider so trapped
air can be aspirated.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 47 gastrointestinal tHeraPeutic ProceDures 311

Infection

Concentrated glucose is a medium for bacteria.

NURSING ACTIONS
● Observe the central line insertion site for local infection

(erythema, tenderness, exudate).
● Change the sterile dressing on a central line per

protocol (typically every 48 to 72 hr).
● Change IV tubing per protocol (typically every 24 hr).
● Observe the client for manifestations of systemic

infection (fever, increased WBC, chills, malaise).

! Do not use tPn line for other iV bolus
fluids and medications (repeated access
increases the risk for infection).

Fluid imbalance

TPN is a hyperosmotic solution (three to six times the
osmolarity of blood), which poses a risk for fluid shifts,
placing client at increased risk of fluid volume excess.

OLDER ADULT CLIENTS are more vulnerable to fluid and
electrolyte imbalances.

NURSING ACTIONS
● Assess lungs for crackles and monitor for

respiratory distress.
● Monitor daily weight and I&O.
● Use a controlled infusion pump to administer TPN at the

prescribed rate.
● Do not speed up the infusion to catch up.
● Gradually increase the flow rate until the prescribed

infusion rate is achieved.

Paracentesis
A paracentesis is performed by inserting a needle or trocar
through the abdominal wall into the peritoneal cavity. The
therapeutic goal is relief of abdominal ascites pressure.

● A paracentesis can be performed in a provider’s office,
outpatient center, radiology department, or acute care
setting at the bed side.

● Usually performed with ultrasound as a
safety precaution.

● Once drained, ascitic fluid can be sent for
laboratory culture.

INDICATIONS

Potential Diagnoses

Abdominal ascites
● Ascites is an abnormal accumulation of protein‑rich

fluid in the abdominal cavity most often caused by
cirrhosis of the liver. The result is increased abdominal
girth and distention.

● Respiratory distress is the determining factor in the use
of a paracentesis to treat ascites, and in the evaluation
of treatment effectiveness.

client Presentation
Compromised lung expansion, increased abdominal girth,
rapid weight gain

CONSIDERATIONS

PreProceDure
NURSING ACTIONS

● Determine the client’s readiness for the procedure.
Variables (the age of the client and chronic and acute
diseases) can influence ability to tolerate and recover
from this procedure.

● Assess pertinent blood testing results (albumin, protein,
glucose, amylase, BUN, and creatinine).

● Verify that the client has signed the informed
consent form.

● Gather equipment for the procedure.
● Have the client void, or insert an indwelling

urinary catheter.
● Position the client in an upright position, either on the

edge of the bed with feet supported or a high‑Fowler’s
position in the bed. Clients who have ascites are
typically more comfortable sitting up.

● Review baseline vital signs, record weight, and measure
abdominal girth.

● Administer sedation as prescribed.
● Administer IV bolus fluids or albumin, prior to or after a

paracentesis, to restore fluid balance.

CLIENT EDUCATION
● Local anesthetics will be used at the insertion site.
● There can be pressure or pain with needle insertion.

intraProceDure
NURSING ACTIONS

● Monitor vital signs.
● Adhere to standard precautions.
● Label laboratory specimens and send to the laboratory.
● Between 4 and 6 L of fluid is slowly drained from the

abdomen by gravity. Monitor the amount of drainage
and notify the provider of any evidence of complications.

PostProceDure
NURSING ACTIONS

● Maintain pressure at the insertion site for several
minutes. Apply a dressing to the site.

● If the insertion site continues to leak after holding
pressure for several minutes, dry sterile gauze dressings
should be applied and changed as often as necessary.

● Check vital signs, record weight, and measure
abdominal girth. Document and compare to
preprocedure measurements.

● Continue to monitor vital signs and insertion site per
facility protocol.

● Monitor temperature every 4 hr for a minimum of 48 hr.
Fever can indicate a bowel perforation.

● Assess I&O every 4 hr.

312 CHAPTER 47 gastrointestinal tHeraPeutic ProceDures CONTENT MASTERY SERIES

● Administer medication.
◯ Diuretics (spironolactone and furosemide) can be

prescribed to control fluid volume.
◯ Potassium supplements can be necessary when a loop
diuretic (furosemide) has been administrated.

● Administer IV bolus fluids or albumin as prescribed.
● Assist the client into a position of comfort with the head

of the bed elevated to promote lung expansion.
● Document color, odor, consistency, and amount of fluid

removed; location of insertion site; evidence of leakage
at the insertion site; manifestations of hypovolemia;
and changes in mental status.

● Continue monitoring of blood albumin, protein, glucose,
amylase, electrolytes, BUN, and creatinine levels.

CLIENT EDUCATION
● Avoid alcohol, maintain a low‑sodium diet, and monitor

the puncture site for bleeding or leakage of fluid.
● Report changes in mental and cognitive status due to

change in fluid and electrolyte balance.
● Change positions slowly to decrease the risk of falls,

which can be related to hypovolemia from the removal
of ascites fluid.

COMPLICATIONS

Hypovolemia

Albumin levels can drop dangerously low because the
peritoneal fluid removed contains a large amount of
protein. The removal of this protein‑rich fluid can cause
shifting of intravascular volume, resulting in hypovolemia.

NURSING ACTIONS
● Preventive measures include slow drainage of fluid

and administration of plasma expanders (albumin) to
counter albumin losses.

● Monitor for evidence of hypovolemia (tachycardia,
hypotension, pallor, diaphoresis, dizziness).

Bariatric surgeries
Bariatric surgeries are a treatment for obesity when other
weight control methods have failed. The client can try
using pharmacological medication for weight loss before
choosing bariatric surgery, including:

● Orlistat prevents digestion of fats. Adverse effects are
oily discharge, reduced food and vitamin absorption,
and decreased bile flow.

● Lorcaserin stimulates serotonin receptors in the
hypothalamus in the brain to curb appetite. Adverse
effects can be headache, dry mouth, fatigue, and nausea.

● Phentermine‑topiramate suppresses the appetite and
induces a feeling of satiety. Adverse effects include dry
mouth, constipation, nausea, change in taste, dizziness,
insomnia, and numbness and tingling of extremities.
Contraindicated if the client has hyperthyroidism,
glaucoma, or is taking an MAO inhibitor.

Bariatric surgeries include gastric restrictive
and malabsorption.

● Restrictive surgeries (laparoscopic adjustable gastric
band [LAGB] or laparoscopic sleeve gastrectomy [LSG])
reduce the stomach volume capacity, which limits the
amount of food the client can eat at one time. Weight
loss is often regained after a period of time unless the
client adheres to stringent weight loss protocols and
lifestyle modifications. (47.1)

◯ LAGB involves the placement of an adjustable band
at the proximal portion of the stomach to restrict
stomach volume to 10 to 15 mL.

◯ LSG involves removal of the portion of the stomach that
secretes ghrelin, a hormone that stimulates feelings of
hunger. Up to 85% of the stomach is removed.

● Vertical‑banded gastroplasty involves the creation of a
new, smaller stomach pouch using staples to decrease
its functional size. (47.2)

● Malabsorption surgeries (Roux‑en‑Y gastric bypass
[RNYGB] or simply gastric bypass) interfere with the
absorption of food and nutrients from the GI tract.
Most clients maintain 60% to 70% of weight loss even
20 years postprocedure.

◯ RNYGB involves restricting the volume of the stomach
to 20 to 30 mL. A section of the jejunum is anastomosed
to the smaller section of the stomach, bypassing the
majority of the stomach and the duodenum. (47.3)

● Some procedures combine more than one of
these approaches.

Many clients undergo plastic surgery to remove excess
skin following weight loss.

INDICATIONS

Diagnosis
History of obesity with unsuccessful attempts at
nonsurgical weight loss

client Presentation
BMI greater than 40, or BMI greater than
35 with comorbidities

CONSIDERATIONS

PreProceDure
NURSING ACTIONS

● Encourage the client to express emotions about
eating behaviors, weight, and weight loss to identify
psychosocial factors related to obesity.

● Ensure that the client understands needed diet and
lifestyle changes.

● Arrange for availability of a bariatric bed and mechanical
lifting devices to prevent client/staff injury.

● Assess pertinent lab results (CBC, electrolytes, BUN,
creatinine, HbA1C, iron, vitamin B12, thiamine, and folate).

● Apply sequential compression stockings to help prevent
deep vein thrombosis.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 47 gastrointestinal tHeraPeutic ProceDures 313

PostProceDure
NURSING ACTIONS

● Monitor for leak of anastomosis (increasing back,
shoulder, abdominal pain; restlessness; tachycardia;
oliguria) and notify the provider immediately. This is a
life‑threatening emergency.

● If the client has an NG tube, do not reposition it.
Repositioning can disrupt the sutures.

● Monitor for the development of postoperative
complications that are at increased risk due to obesity
(atelectasis, thromboemboli, skin fold breakdown,
incisional hernia, peritonitis).

● Assess the airway and oxygen saturation per facility
protocol. Maintain the client in a semi‑Fowler’s position
for lung expansion.

● Monitor bowel sounds and measure the abdominal girth
daily or as prescribed.

● Apply an abdominal binder as prescribed to prevent
dehiscence if there is an abdominal incision.

● Ambulate the client as soon as possible.
● Resume fluids as prescribed. The first fluids can be

restricted to 30 mL at a time for up to 120 mL/day
for the first few days, and increased in frequency
and volume.

● Provide six small meals a day when the client can
resume oral nutrients. Observe for indications of
dumping syndrome (cramps, diarrhea, tachycardia,
dizziness, fatigue).

● Collaborate with case management and mental health
resources to assist with long‑term
behavior modification.

CLIENT EDUCATION
● Adhere to the limited diet of liquids or pureed foods

for the first 6 weeks, as well as the volume that can be
consumed (often not to exceed 1 cup).

● Walk daily for at least 30 min.
● Overeating can dilate the surgically created pouch

causing weight to be regained.
● Take vitamin and mineral supplements.

COMPLICATIONS

Dehydration
● Warn the client that excessive thirst or concentrated

urine can be an indication of dehydration and the
surgeon should be notified.

● Work with the client to establish goals and schedule for
adequate daily fluid intake.

Malabsorption/malnutrition

Because bariatric surgeries reduce the size of the stomach
or bypass portions of the intestinal tract, fewer nutrients
are ingested and absorbed.

NURSING ACTIONS
● Monitor the client’s tolerance of increasing amounts of

food and fluids.
● Refer the client for dietary management.
● Encourage the client to consume meals in a

low‑Fowler’s position and to remain in this position
for 30 min after eating to delay stomach emptying and
minimize dumping syndrome.

CLIENT EDUCATION
● Eat two servings of protein a day.
● Eat only nutrition‑dense foods. Avoid empty calories

(colas and fruit juice drinks).

Nasogastric decompression
Clients who have an intestinal obstruction require NG
decompression. An NG tube is inserted, then suction
is applied to relieve abdominal distention. Treatment
continues until the obstruction resolves or is removed.
The obstruction can be mechanical or functional.

47.1 Adjustable band
gastroplasty

47.2 Vertical banded
gastroplasty

47.3 Roux-en-Y
gastric bypass

314 CHAPTER 47 gastrointestinal tHeraPeutic ProceDures CONTENT MASTERY SERIES

INDICATIONS

Potential Diagnoses
Any disorder that causes a mechanical (tumors, adhesions,
impaction) or functional (surgery, trauma, GI tract
infections, conditions in which peristalsis is absent)
intestinal obstruction

client Presentation
● Vomiting (begins with stomach contents and continues

until fecal material is also being regurgitated)
● Bowel sounds absent (paralytic ileus) or hyperactive and

high‑pitched (obstruction)
● Intermittent, colicky abdominal pain and distention
● Hiccups
● Abdominal distention

CONSIDERATIONS

PreProceDure
NURSING ACTIONS: Inform the client of the purpose of
the NG tube and the client’s role in its placement.

PostProceDure
NURSING ACTIONS

● Assess and maintain proper function of the NG tube and
suction equipment.

● Incorporate NG tube flushes and drainage into
I&O calculations.

● Assess bowel sounds and abdominal girth; return
of flatus.

● Monitor tube for displacement (decrease in drainage,
increased nausea, vomiting, distention).

● Assess pertinent lab results (electrolytes, hematocrit).
● Provide frequent oral and nares care.

CLIENT EDUCATION
● Maintain NPO status.
● Reposition frequently when in bed, and get out of the

bed as able to promote movement of the intestines.

COMPLICATIONS

Fluid/electrolyte imbalance

NURSING ACTIONS
● Monitor for fluid and electrolyte imbalance (metabolic

acidosis: low obstruction; alkalosis: high obstruction).
● Monitor I&O, observing for discrepancies.

Skin breakdown

NURSING ACTIONS: Assess nasal skin for irritation.

Ostomies
An ostomy is a surgical opening from the inside of the
body to the outside and can be located in various areas of
the body. Ostomies can be permanent or temporary.

● A stoma is the artificial opening created during the
ostomy surgery. (47.4)

● Main types of ostomies performed in the abdominal area
◯ Ileostomy: A surgical opening into the ileum to drain
stool, which is typically frequent and liquid because
large intestine is bypassed

◯ Colostomy: A surgical opening into the large intestine
to drain stool, with the ascending colon producing
more liquid stools, the transverse colon producing
more formed stools, and the sigmoid colon producing
near‑normal stool

INDICATIONS

Potential Diagnoses
Ileostomy: when the entire colon must be removed due to
disease (Crohn’s disease, ulcerative colitis).

Colostomy: when a portion of the bowel must be removed
(cancer, ischemic injury) or requires rest for healing
(diverticulitis, trauma).

CONSIDERATIONS

PreProceDure
NURSING ACTIONS

● Determine the client’s readiness for the procedure.
Assess visual acuity, manual dexterity, cognitive status,
cultural influences, and support systems.

● Initiate a referral to the wound ostomy care nurse (WOCN)
for ostomy placement marking and client teaching.

● Work collaboratively with the WOCN to begin teaching
the client and support person about ostomy care
and management.

CLIENT EDUCATION: Perform care and management of
an ostomy.

47.4 Healthy stoma

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 47 gastrointestinal tHeraPeutic ProceDures 315

PostProceDure
NURSING ACTIONS

● Assess the type and fit of the ostomy appliance. Monitor
for leakage (risk to skin integrity). Fit the ostomy
appliance based on the following.

◯ Type and location of the ostomy
◯ Visual acuity and manual dexterity of the client

● Assess peristomal skin integrity and appearance of the
stoma. The stoma should appear pink and moist.

● Apply skin barriers and creams (adhesive paste) to
peristomal skin and allow to dry before applying a
new appliance.

● Evaluate stoma output. Output should be more liquid
and more acidic the closer the ostomy is to the proximal
small intestine.

● Empty the ostomy bag when it is one‑third to one‑half
full of drainage.

● Assess for fluid and electrolyte imbalances, particularly
with a new ileostomy.

● Evaluate ability of the client or support person to
perform ostomy care.

CLIENT EDUCATION
● Follow instructions regarding dietary changes, and use

ostomy appliances that can help manage flatus and odor.
◯ Foods that can cause odor include fish, eggs,
asparagus, garlic, beans, and dark green leafy
vegetables. Buttermilk, cranberry juice, parsley, and
yogurt help to decrease odor.

◯ Foods that can cause gas include dark green leafy
vegetables, beer, carbonated beverages, dairy products,
and corn. Chewing gum, skipping meals, and smoking
can also cause gas. Yogurt, crackers, and toast can be
ingested to decrease gas.

◯ After an ostomy involving the small intestine is
placed, avoid high‑fiber foods for the first 2 months
after surgery, chew food well, increase fluid intake,
and evaluate for evidence of blockage when slowly
adding high‑fiber foods to the diet.

◯ Proper appliance fit and maintenance prevent odor
when pouch is not open. Filters, deodorizers, or a
breath mint can be placed in the pouch to minimize
odor while the pouch is open.

● Discuss feelings about the ostomy and concerns about
its effect on life. Look at and touch the stoma.

● Consider joining a local ostomy support group.

COMPLICATIONS

Stomal ischemia/necrosis

Stomal appearance should normally be pink or red and moist.
● Manifestations of stomal ischemia are a pale pink or

bluish purple color and dry appearance.
● If the stoma appears black or purple in color, this

indicates a serious impairment of blood flow and
requires immediate intervention.

NURSING ACTIONS: Obtain vital signs, oxygen saturation,
and current laboratory results.

CLIENT EDUCATION: Watch for indications of stomal
ischemia/necrosis.

Intestinal obstruction

Intestinal obstruction can occur for a variety of reasons.

NURSING ACTIONS
● Monitor and record output from the stoma.
● Assess for manifestations of obstruction, including

abdominal pain, hypoactive or absent bowel sounds,
distention, nausea, and vomiting.

CLIENT EDUCATION: Note indications of an intestinal
obstruction following discharge.

316 CHAPTER 47 gastrointestinal tHeraPeutic ProceDures CONTENT MASTERY SERIES

47.5 Changing an ostomy device

47.6 Expected output for ostomies

ILEOSTOMY TRANSVERSE COLOSTOMY SIGMOID COLOSTOMY

Normal postoperative output
more than 1,000 ml/day
can be bile‑colored and liquid

small semi‑liquid with some mucus
2 to 3 days after surgery
Blood can be present in the
first few days after surgery

small to moderate amount of mucus with
semi‑formed stool 4 to 5 days after surgery

Postoperative changes in output
after several days to weeks, the
output decreases to approximately
500 to 1,000 ml/day
Becomes more paste‑like as the small
intestine assumes the absorptive
function of the large intestine

after several days to weeks,
output becomes more stool‑like,
semi‑formed, or formed

after several days to weeks, output
resembles semi‑formed stool

Pattern of output
continuous output resumes a pattern similar to

the preoperative pattern
resumes a pattern similar to
the preoperative pattern

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 47 gastrointestinal tHeraPeutic ProceDures 317

Application Exercises

1. a nurse is caring for a client following a paracentesis.
Which of the following findings indicate the
bowel was perforated during the procedure?

a. client report of upper chest pain

B. Decreased urine output

c. Pallor

D. temperature elevation

2. a nurse is planning care for a client who has a new
prescription for total parenteral nutrition (tPn).
Which of the following interventions should be
included in the plan of care? (select all that apply.)

a. obtain a capillary blood glucose four times daily.

B. administer prescribed medications through
a secondary port on the tPn iV tubing.

c. monitor vital signs three times
during the 12‑hr shift.

D. change the tPn iV tubing every 24 hr.

e. ensure a daily aPtt is obtained.

3. a nurse is providing care to a client who is 1 day
postoperative following a paracentesis. the
nurse observes clear, pale‑yellow fluid leaking
from the operative site. Which of the following
is an appropriate nursing intervention?

a. Place a clean towel near the drainage site.

B. apply a dry, sterile dressing.

c. apply direct pressure to the site.

D. Place the client in a supine position.

4. a nurse is completing discharge teaching with
a client who is 3 days postoperative following
a transverse colostomy. Which of the following
should the nurse include in the teaching?

a. mucus will be present in stool for
5 to 7 days after surgery.

B. expect 500 to 1,000 ml of semi‑
liquid stool after 2 weeks.

c. stoma should be moist and pink.

D. change the ostomy bag when it is ¾ full.

5. a nurse is caring for a client who is receiving tPn
solution. the current bag of solution was hung 24 hr
ago, and 400 ml remains to infuse. Which of the
following is the appropriate action for the nurse to take?

a. remove the current bag and hang a new bag.

B. infuse the remaining solution at the
current rate and then hang a new bag.

c. increase the infusion rate so the
remaining solution is administered within
the hour and hang a new bag.

D. remove the current bag and hang
a bag of lactated ringer’s.

Active Learning Scenario

a nurse educator is reviewing care of a client who
will have bariatric surgery with a group of newly
hired nurses. What should the nurse include in this
discussion? use the ati active learning template:
therapeutic Procedure to complete this item.

DESCRIPTION OF PROCEDURE: Describe
three types of bariatric surgery.

NURSING INTERVENTIONS: Describe at least five, to
include equipment needed to promote client/staff safety.

CLIENT EDUCATION: Describe postoperative
pattern of food and fluid consumption.

318 CHAPTER 47 gastrointestinal tHeraPeutic ProceDures CONTENT MASTERY SERIES

Application Exercises Key

1. a. a report of sharp, constant abdominal pain is
associated with bowel perforation.

B. Decreased urine output is associated with bladder
perforation during a paracentesis.

c. Pallor may indicate hypovolemia related to fluid
removal of ascites fluid during the procedure.

D. CORRECT: Fever is an indication of bowel
perforation during a paracentesis.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

2. a. CORRECT: the client is at risk for hyperglycemia
during the administration of tPn and can
require supplemental insulin.

B. no other medications or fluids should be administered
through the iV tubing being used to administer
tPn due to the increased risk of infection and
disruption of the rate of tPn infusion.

c. CORRECT: Vital signs are recommended every 4 to 8 hr
to assess for fluid volume excess and infection.

D. CORRECT: it is recommended to change the iV tubing
that is used to administer tPn every 24 hr.

e. aPtt measures the coagulability of the blood, which
is unnecessary during the administration of tPn.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Total Parenteral Nutrition (TPN)

3. a. cover the operative site to prevent infection and
allow for assessment of drainage.

B. CORRECT: application of a sterile dressing
will contain the drainage and allow continuous
assessment of color and quantity.

c. application of direct pressure can cause discomfort
and potential harm to the client.

D. Place the client with the head of the bed
elevated to promote lung expansion.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. a. mucus and blood can be present for 2
to 3 days after surgery.

B. output should become stool‑like, semi‑formed,
or formed within days to weeks.

c. CORRECT: a pink, moist stoma is an
expected finding for a colostomy.

D. the ostomy bag should be changed when it is ¼ to ½ full.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

5. a. CORRECT: the current bag of tPn should not hang
more than 24 hr due to the risk of infection.

B. a bag of tPn should not infuse for more than
24 hr due to the risk of infection.

c. the rate of tPn infusion should never be increased
abruptly due to the risk of hyperglycemia.

D. administration of tPn should never be discontinued
abruptly. if the solution needs replacing and
another bag is not available, use dextrose 10% in
water to maintain blood glucose levels.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Total Parenteral Nutrition (TPN)

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

DESCRIPTION OF PROCEDURE
● Vertical banded gastroplasty involves stapling a portion
of the stomach to decrease its functional size.

● adjustable banded gastroplasty involves constricting
the functional size of the stomach.

● intestinal bypass involves bypassing the stomach and part of the
small intestine to decrease the absorption of nutrients and calories.

NURSING INTERVENTIONS
● encourage client to express emotions related to weight, weight loss,
and eating behaviors to identify related psychosocial concerns.

● ensure the client understands required dietary and lifestyle changes.
● arrange for availability of a bariatric bed and mechanical
lifting device to prevent client/staff injury.

● monitor for leak of anastomosis and notify
provider immediately if this occurs.

● assess airway and oxygen saturation. maintain client
in semi‑Fowler’s position for lung expansion.

● monitor bowel sounds.
● apply abdominal binder if prescribed.
● ambulate client as soon as possible.
● monitor intake and output.
● monitor ng tube placement and function, as well as function
of suction equipment. Do not reposition the ng tube.

CLIENT EDUCATION
● Fluids will be allowed beginning with 30 ml at a time with a
daily limit, and gradually increase in volume and frequency.

● Food will be allowed beginning with six small meals.
● Volume might be limited to 1 cup of liquid or pureed foods.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 48 esoPHageal DisorDers 319

UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: UPPER GASTROINTESTINAL DISORDERS

CHAPTER 48 Esophageal
Disorders

the esophagus is a muscular tube that leads
from the throat to the stomach. the esophagus
is about 25 cm (10 in) long. it extends from
the base of the pharynx to the stomach, about
4 cm (1.6 in) below the diaphragm. esophageal
disorders can affect any part of the esophagus.

there are two sphincters: upper esophageal
(ues) also referred to as the oropharyngeal
sphincter, and the lower esophageal (les) also
referred to as gastroesophageal sphincter. they
prevent the reflux of food and fluids into the
mouth or esophagus. (48.1)

Disorders of the esophagus, such as structural
defects, inflammation, obstruction, and cancer,
can interfere with nutritional intake.

contractions of the esophagus propel food and
fluids toward the stomach, while relaxation of
the lower esophageal sphincter allows passage
into the stomach. Following this, the les
contracts, preventing reflux of food back up into
the esophagus.

esophageal disorders include gastroesophageal
reflux disease (gerD), hiatal hernia, and
esophageal varices.

Gastroesophageal
reflux disease

GERD is a common condition characterized by gastric
content and enzyme backflow into the esophagus. Some
backflow of stomach contents into the esophagus is
normal. When the reflux is excessive due to any of the
following conditions—an incompetent LES, pyloric
stenosis, hiatal hernia, excessive intra‑abdominal or
intragastric pressure, or motility problems—the corrosive
fluids irritate the esophageal tissue, causing delay in their
clearance. This further exposes esophageal tissue to the
acidic fluids, causing more irritation.

● The primary treatment of GERD is diet and lifestyle
changes, advancing to medication use (antacids,
H2‑receptor antagonists, proton pump inhibitors)
and surgery.

● Untreated GERD leads to inflammation, breakdown, and
long‑term complications, such as Barrett’s esophagus or
adenocarcinoma of the esophagus.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Maintain a weight below BMI of 30.
● Stop smoking.
● Limit or avoid alcohol and tobacco use.
● Eat a low‑fat diet.
● Avoid foods that lower the LES pressure.
● Avoid eating or drinking 2 hr before bed.
● Avoid tight‑fitting clothes.
● Elevate the head of the bed 6 to 8 inches.

ASSESSMENT

risK Factors
● Obesity
● Older age (delayed gastric emptying and weakened

LES tone)
● Sleep apnea
● Nasogastric tube

CHAPTER 48

48.1 Esophageal sphincters

View Image: Esophageal Sphincters

320 CHAPTER 48 esoPHageal DisorDers CONTENT MASTERY SERIES

CONTRIBUTING FACTORS
● Excessive ingestion of foods that relax the LES include

fatty and fried foods, chocolate, caffeinated beverages
(coffee), peppermint, spicy foods, tomatoes, citrus fruits,
and alcohol

● Prolonged or frequent abdominal distention (from
overeating or delayed emptying)

● Increased abdominal pressure from obesity, pregnancy,
bending at the waist, ascites, or tight clothing at the waist

● Medications that relax the LES (theophylline, nitrates,
calcium channel blockers, anticholinergics, and diazepam)

● Increased gastric acid caused by medications (NSAIDs)
or stress (environmental)

● Debilitation resulting in weakened LES tone
● Hiatal hernia (LES displacement into the thorax with

delayed esophageal clearance)
● Gastritis due to helicobacter pylori can increase reflux.
● Lying flat

eXPecteD FinDings
● Report of dyspepsia (indigestion) after eating an

offending food or fluid, and regurgitation
● Radiating pain (neck, jaw, or back)
● Report of a feeling of having a heart attack.
● Pyrosis (burning sensation in the esophagus)
● Odynophagia (pain on swallowing)
● Pain that worsens with position (bending, straining,

laying down)
● Pain that occurs after eating and lasts 20 min to 2 hr
● Throat irritation (chronic cough, laryngitis),

hypersalivation, bitter taste in mouth (caused by
regurgitation). Chronic GERD can lead to dysphagia.

● Increased flatus and eructation (burping).
● Pain is relieved (almost immediately) by drinking water,

sitting upright, or taking antacids.
● Manifestations occurring four to five times per week on

a consistent basis are considered diagnostic.
● Dental caries
● Chest congestion and wheezing due to reflux material

entering the tracheobronchial tree

Diagnostic ProceDures

Esophagogastroduodenoscopy (EGD)
● EGD is done under moderate sedation to observe for

tissue damage and to dilate strictures in the esophagus.
The esophageal lining should be pink but is often red
with persistent GERD. Biopsies can be done to determine
if high‑grade dysplasia (HGD) is present.

● HGD is evidenced by squamous mucosa of the esophagus
replaced by columnar epithelium (cells seen in the
stomach or intestines). When HGD is found, there is a
30% increase in chance of developing cancer.

● EGD allows visualization of the esophagus, revealing
esophagitis or Barrett’s epithelium (premalignant cells).

NURSING ACTIONS: Verify gag response has returned
prior to providing oral fluids or food following the
procedure to reduce the risk for aspiration. Monitor client
for manifestations of esophageal perforation (fever, pain,
dyspnea, bleeding).

Esophageal pH monitoring

A small catheter is placed through the nose and into the
distal esophagus, or a small capsule is attached to the
esophageal wall during endoscopy. pH readings are taken
in relation to food, position, and activity for 24 to 48 hr.

● Most accurate method of diagnosing GERD
● Especially helpful in diagnosis for clients who have

atypical manifestations

NURSING ACTIONS: Instruct the client to keep a journal
of foods and beverages consumed, manifestations, and
activity during the 24‑hr test period.

Esophageal manometry

Esophageal manometry records lower esophageal
sphincter pressure and peristaltic activity of the
esophagus. The client swallows three small tubes, and
pressure readings and pH levels are tested.

Barium swallow

Barium swallow identifies a hiatal hernia, strictures, or
structural abnormalities, which would contribute to or
cause GERD.

NURSING ACTIONS: Instruct the client to use cathartics
to evacuate the barium from the GI tract following the
procedure. Failure to eliminate the barium places the
client at risk for fecal impaction.

PATIENT‑CENTERED CARE

meDications

Proton pump inhibitors (PPIs)

Pantoprazole, omeprazole, esomeprazole, rabeprazole, and
lansoprazole reduce gastric acid by inhibiting the cellular
pump of the gastric parietal cells necessary for gastric
acid secretion.

NURSING ACTIONS
● Monitor for electrolyte imbalances and hypoglycemia in

clients who have diabetes mellitus.
● Long‑term use has been related to the development

of community‑acquired pneumonia and Clostridium
difficile infections.

CLIENT EDUCATION: Long‑term use of PPIs increases the
risk for fractures, especially in older adults.

Antacids

Aluminum hydroxide, magnesium hydroxide, calcium
carbonate, and sodium bicarbonate neutralize excess acid
and increase LES pressure.

NURSING ACTIONS: Ensure there are no contraindications
with other prescribed medications (levothyroxine). Evaluate
kidney function in clients taking magnesium hydroxide.

CLIENT EDUCATION: Take antacids when acid secretion
is the highest (1 to 3 hr after eating and at bedtime), and
separate from other medications by at least 1 hr.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 48 esoPHageal DisorDers 321

Histamine2 receptor antagonists

Ranitidine, famotidine, cimetidine, and nizatidine reduce
the secretion of acid. The onset is longer than antacids,
but the effect has a longer duration.

NURSING ACTIONS: Use cautiously in clients who have
kidney disease.

CLIENT EDUCATION
● Take with meals and at bedtime.
● Separate dosages from antacids (1 hr before or after

taking antacid).

Prokinetics

Metoclopramide increases the motility of the esophagus
and stomach.

NURSING ACTIONS: Monitor the client taking
metoclopramide for extrapyramidal adverse effects.

CLIENT EDUCATION: Report abnormal,
involuntary movement.

tHeraPeutic ProceDures
Stretta procedure uses radiofrequency energy, applied
by an endoscope, to decrease vagus nerve activity. This
causes the LES muscle tissue to contract and tighten.

POSTOPERATIVE CLIENT EDUCATION
● Intake clear liquids for the first 24 hr following the

procedure, then advance to a soft diet.
● Do not take NSAIDs for 10 days following the procedure.
● Report chest or abdominal pain, bleeding, difficulty

swallowing, dyspnea, nausea, and/or vomiting immediately.

Fundoplication

Fundoplication might be indicated for clients who fail to
respond to other treatments. The fundus of the stomach
is wrapped around and behind the esophagus through a
laparoscope to create a physical barrier.

NURSING ACTIONS
● Complications following fundoplication include

temporary dysphagia (monitor for aspiration), gas bloat
syndrome (difficulty belching to relieve distention), and
atelectasis/pneumonia (monitor respiratory function).

● Monitor for bowel sounds.

client eDucation
● Diet

◯ Maintain a soft diet for 1 week following procedure.
◯ Avoid offending foods.
◯ Avoid large meals.
◯ Avoid carbonated beverages.
◯ Remain upright after eating.
◯ Avoid eating before bedtime.
◯ Consume four to six small meals throughout the day.

● Lifestyle
◯ Avoid clothing that is tight‑fitting around the abdomen.
◯ Lose weight, if applicable.
◯ Elevate the head of the bed 15.2 to 20.3 cm (6 to 8 in)
with blocks.

◯ Avoid lifting heavy objects.
◯ Walk daily.

● Report fever, nausea, vomiting, severe pain, dysphagia,
or persistent bloating to the surgeon.

COMPLICATIONS

Aspiration of gastric secretion

CAUSES: Reflux of gastric fluids into the esophagus can be
aspirated into the trachea.

RISKS ASSOCIATED WITH ASPIRATION
● Asthma exacerbations from inhaled aerosolized acid
● Frequent upper respiratory, sinus, or ear infections
● Aspiration pneumonia

Barrett’s epithelium (premalignant)
and esophageal adenocarcinoma

CAUSE: Reflux of gastric fluids leads to esophagitis. In
chronic esophagitis, the body continuously heals inflamed
tissue, eventually replacing normal esophageal epithelium
with premalignant tissue (Barrett’s epithelium) or
malignant adenocarcinoma.

NURSING ACTIONS: Determine the cause of GERD with
the client and review lifestyle changes that can decrease
gastric reflux. Monitor nutritional status.

Hiatal hernia
Hiatal hernia (diaphragmatic hernia) is a protrusion of
the stomach (in part or in total) above the diaphragm into
the thoracic cavity through the hiatus (the opening in the
diaphragm). There are two types of hiatal hernia.

Sliding (more common): A portion of the stomach and
gastroesophageal junction move above the diaphragm.
This generally occurs with increases in intra‑abdominal
pressure or while the client is in a supine position.

Paraesophageal (rolling): Part of the fundus of the
stomach moves above the diaphragm, although the
gastroesophageal junction remains below the diaphragm.

322 CHAPTER 48 esoPHageal DisorDers CONTENT MASTERY SERIES

HEALTH PROMOTION AND
DISEASE PREVENTION

● Avoid eating immediately prior to going to bed.
● Avoid foods and beverages that decrease LES pressure

(fatty and fried foods, chocolate, coffee, peppermint,
spicy foods, tomatoes, citrus fruits, and alcohol).

● Exercise regularly.
● Maintain a healthy weight.
● Elevate the head of the bed on 6‑inch blocks.
● Avoid straining or excessive vigorous exercise.
● Avoid wearing clothing that is tight around the abdomen.

ASSESSMENT

eXPecteD FinDings
Presenting manifestations depend on the type of hiatal
hernia and are typically worse following a meal.

Sliding: heartburn, reflux, chest pain, dysphagia, belching

Paraesophageal: fullness after eating, sense of
breathlessness/suffocation, chest pain, worsening of
manifestations when reclining

PHYSICAL ASSESSMENT FINDINGS
● Pharyngitis
● Inspiratory/expiratory wheeze

Diagnostic ProceDures

Barium swallow with fluoroscopy

Allows visualization of the esophagus

NURSING ACTIONS: Instruct the client to use cathartics
to evacuate the barium from the GI tract following the
procedure. Failure to eliminate the barium places the
client at risk for fecal impaction.

Esophagogastroduodenoscopy (EGD)

Allows visualization of the esophagus and the gastric lining

NURSING ACTIONS: Verify gag response has returned prior
to providing oral fluids or food following the procedure

CT scan of the chest with contrast

Allows visualization of the esophagus and stomach

NURSING ACTIONS: Assess for iodine allergies if IV
contrast is to be used. Encourage fluids following
procedure to promote dye excretion and minimize risk of
renal injury. Monitor BUN/creatinine.

PATIENT‑CENTERED CARE

meDications

Proton pump inhibitors

Pantoprazole, omeprazole, esomeprazole, rabeprazole, and
lansoprazole reduce gastric acid by inhibiting the cellular
pump of the gastric parietal cells necessary for gastric
acid secretion.

NURSING ACTIONS
● Monitor for electrolyte imbalances and hypoglycemia in

clients who have diabetes mellitus.
● Long‑term use has been related to the development

of community‑acquired pneumonia and Clostridium
difficile infections.

CLIENT EDUCATION: Long‑term use of PPIs increases the
risk for fractures, especially in older adults.

Antacids

Aluminum hydroxide, magnesium hydroxide, calcium
carbonate, and sodium bicarbonate neutralize excess acid
and increase LES pressure.

NURSING ACTIONS: Ensure there are no contraindications
with other prescribed medications (levothyroxine). Evaluate
kidney function in clients taking magnesium hydroxide.

CLIENT EDUCATION: Take antacids when acid secretion
is the highest (1 to 3 hr after eating and at bedtime), and
separate from other medications by at least 1 hr.

tHeraPeutic ProceDures
Fundoplication: reinforcement of the LES by wrapping
a portion of the fundus of the stomach around the
distal esophagus

Laparoscopic Nissen fundoplication: minimally invasive
with fewer complications

NURSING ACTIONS: Elevate the head of the bed to
promote lung expansion. Instruct the client to support
the incision during movement and coughing to minimize
strain on the suture lines.

CLIENT EDUCATION: Consume a soft diet for the first week
postoperatively. Avoid carbonated beverages. Ambulate,
but avoid heavy lifting.

COMPLICATIONS: Temporary dysphagia, gas bloat syndrome
(difficulty burping and distention), atelectasis/pneumonia

COMPLICATIONS
Volvulus: twisting of the esophagus and/or stomach

Obstruction (paraesophageal hernia): blockage of food in
the herniated portion of the stomach

Strangulation (paraesophageal hernia): compression of
the blood vessels to the herniated portion of the stomach

Iron‑deficiency anemia (paraesophageal hernia): resulting
from bleeding into the gastric mucosa due to obstruction

View Image: Varices

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 48 esoPHageal DisorDers 323

Esophageal varices
● Esophageal varices are swollen, fragile blood vessels

that are generally found in the submucosa of the
lower esophagus, but varices can develop higher in the
esophagus or extend into the stomach. (48.2)

● Esophageal varices occur as a result of portal
hypertension, usually due to cirrhosis of the liver.

● When esophageal varices hemorrhage, it is often a
medical emergency associated with a high mortality
rate. Recurrence of esophageal bleeding is common.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Avoid alcohol consumption.
● Avoid heavy lifting.
● Avoid straining with bowel movements.
● Chew food completely, as poorly‑chewed foods can

irritate the area.
● Avoid salicylates and other medications that can irritate

the esophagus.

ASSESSMENT

risK Factors
● Portal hypertension (elevated blood pressure in veins

that carry blood from the intestines to the liver)
◯ Caused by impaired circulation of blood through the
liver. Collateral circulation subsequently develops,
creating varices in the upper stomach and esophagus.
Varices are fragile and can bleed easily.

◯ The primary risk factor for development of
esophageal varices.

● Alcoholic cirrhosis
● Viral hepatitis
● OLDER ADULT CLIENTS frequently have depressed

immune function, decreased liver function, and cardiac
disorders that make them especially vulnerable
to bleeding.

eXPecteD FinDings
● The client can experience no manifestations until the

varices begin to bleed. Hematemesis (vomiting blood),
melena (black, tarry stools), and a general deterioration
of the client’s physical and mental status.

● Activities that precipitate bleeding are the Valsalva
maneuver, lifting heavy objects, coughing, sneezing,
and alcohol consumption.

PHYSICAL ASSESSMENT FINDINGS
(BLEEDING ESOPHAGEAL VARICES)

● Shock
● Hypotension
● Tachycardia
● Cool, clammy skin

laBoratorY tests
Liver function tests indicate a liver disorder.

Hemoglobin and hematocrit tests can indicate anemia
secondary to occult bleeding or overt bleeding.

Elevated blood ammonia level indicates an increased
nitrogen load from the bleeding varices.

Diagnostic ProceDures

Endoscopy

Therapeutic interventions can be performed during
the endoscopy.

NURSING ACTIONS: Administer preprocedure sedation.
After the procedure, monitor vital signs and take measures
to prevent aspiration, such as confirming the gag reflex
before offering oral fluids.

PATIENT‑CENTERED CARE

nursing care
If bleeding is suspected, establish IV access with a large
bore needle, monitor vital signs and hematocrit, type and
cross‑match for possible blood transfusions, and monitor
for overt and occult bleeding.

meDications

Nonselective beta-blockers
● Propranolol is prescribed to decrease heart rate and

consequently reduce hepatic venous pressure.
● Used prophylactically (not for emergency hemorrhage).

48.2 Esophageal varices

324 CHAPTER 48 esoPHageal DisorDers CONTENT MASTERY SERIES

Vasoconstrictors
● Octreotide is a synthetic form of the hormone

somatostatin, which decreases the bleeding from
the esophageal varices but does not affect the
blood pressure.

● Vasopressin causes constriction of the esophageal and
proximal gastric veins and reduces portal pressure.

NURSING ACTIONS
● Vasopressin should not be given to clients who have

coronary artery disease due to resultant coronary
constriction. Potent vasoconstriction can also cause
problems with peripheral and cerebral circulation. If
Vasopressin is used in combination with nitroglycerin IV
in this client population, it can decrease or prevent the
vasoconstriction of the coronary arteries.

● Monitor for fluid retention and hyponatremia, as
vasopressin has an antidiuretic effect.

tHeraPeutic ProceDures

Endoscopic variceal ligation (EVL)

Endoscopic variceal ligation (esophageal banding therapy)
can be used for acute bleeding.

● During endoscopy, the varices are rubber‑banded to cut
off the circulation to the varices. Necrosis of the tissue
occurs with eventual sloughing of the varix.

● There is a significant decrease in rebleeding as well as
decreased mortality postprocedure.

COMPLICATIONS
● Superficial ulceration
● Dysphagia
● Temporary chest discomfort
● Esophageal strictures (rare)

NURSING ACTIONS: Administer preprocedure sedation.
After the procedure, monitor vital signs and take measures
to prevent aspiration.

Endoscopic sclerotherapy

During endoscopy, a sclerosing agent is injected into the
varices, resulting in thrombosis of the varicosity.

COMPLICATIONS
● Bleeding
● Perforation of the esophagus
● Aspiration pneumonia
● Esophageal stricture

NURSING ACTIONS
● Administer preprocedure sedation. After the

procedure, monitor vital signs and take measures to
prevent aspiration.

● Antacids, H2‑receptor blockers, or PPIs can be
administered after the procedure to protect the
esophagus and prevent acid reflux which is often caused
by sclerotherapy.

Transjugular intrahepatic
portal-systemic shunt (TIPS)

● TIPS is used to treat an acute episode of bleeding when
EVL and pharmacological measures are not controlling
the variceal bleeding. It rapidly lowers the portal
pressure. The procedure is costly, and therefore is only
used when other measures do not work.

● While the client is under sedation or general anesthesia,
a catheter is passed into the liver via the jugular vein in
the neck. A stent is then placed between the portal and
hepatic veins bypassing the liver. Portal hypertension is
subsequently relieved.

COMPLICATIONS
● Bleeding
● Sepsis
● Heart failure
● Organ perforation
● Liver failure

NURSING ACTIONS: Monitor vital signs. Keep the head of
the bed elevated.

Esophagogastric balloon tamponade
● Rarely used but can be used to temporarily control

bleeding until another measure can be implemented.
● Risks: Tube migration, which can lead to airway

obstruction; aspiration of gastric contents into lungs.
● Clients are often intubated to protect the airway.
● Can cause necrosis of tissue if left in place for an

extended period of time. Balloon should be in place no
longer than 12 hr.

NURSING ACTIONS
● Check balloons for leaks prior to insertion.
● Monitor placement of the tube and observe for possible

obstruction of airway.
● Monitor for aspiration into the lungs and secretions or

blood from the esophagus.
● Provide oral suction as needed.
● Maintain balloon pressure at prescribed pressure for

prescribed time to decrease risk of esophageal or gastric
necrosis from ischemia.

● Monitor the client who has decreased mentation or
confusion and who might pull on the tube.

Surgical interventions
● Considered as a last resort. TIPS has replaced many

surgical measures. High morbidity and mortality rates
continue to be seen with surgical intervention.

● Bypass procedures establish a venous shunt that
bypasses the liver, decreasing portal hypertension.

◯ Common shunts include splenorenal (splenic, left
renal veins), mesocaval (mesenteric vein, vena cava),
and portacaval (portal vein, inferior vena cava).

◯ Clients commonly have a nasogastric tube inserted
during surgery to monitor for hemorrhage.

NURSING ACTIONS (PRE-, POSTPROCEDURE)
● Monitor for an increase in liver dysfunction

or encephalopathy.
● Monitor nasogastric tube secretions for bleeding.
● Monitor PT, aPTT, platelets, and INR.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 48 esoPHageal DisorDers 325

interProFessional care
Alcohol recovery program (varices secondary to alcohol
use disorder)

COMPLICATIONS

Hypovolemic shock

Due to hemorrhage from varices

NURSING ACTIONS
● Observe for manifestations of hemorrhage and shock

(tachycardia, hypotension).
● Monitor vital signs, Hgb, Hct, and coagulation studies.
● Replace losses and support therapeutic procedures to

stop and control bleeding.

Active Learning Scenario

a nurse is preparing a poster on gerD to be
displayed at a community health fair. What should be
included in the poster? use the ati active learning
template: system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)

RISK FACTORS: Describe at least seven.

EXPECTED FINDINGS: Describe at least seven.

Application Exercises

1. a nurse is caring for a client who has a new diagnosis
of gastroesophageal reflux disease (gerD). the
nurse should expect prescriptions for which of the
following medications? (select all that apply.)

a. antacids

B. Histamine2 receptor antagonists

c. opioid analgesics

D. Fiber laxatives

e. Proton pump inhibitors

2. a nurse is admitting a client who has bleeding
esophageal varices. the nurse should expect a
prescription for which of the following medications?

a. Propranolol

B. metoclopramide

c. ranitidine

D. Vasopressin

3. a nurse is completing an assessment of a client who has
gerD. Which of the following is an expected finding?

a. absence of saliva

B. Painful swallowing

c. sweet taste in mouth

D. absence of eructation

4. a nurse is teaching a client who has a hiatal
hernia. Which of the following client statements
indicates an understanding of the teaching?

a. “i can take my medications with soda.”

B. “Peppermint tea will increase my indigestion.”

c. “Wearing an abdominal binder will
limit my manifestations.”

D. “i will drink hot chocolate at
bedtime to help me sleep.”

e. “i can lift weights as a way to exercise.”

5. a nurse is completing discharge teaching with a
client who is postoperative following fundoplication.
Which of the following statements by the client
indicates understanding of the teaching?

a. “When sitting in my lounge chair after
a meal, i will lower the back of it.”

B. “i will try to eat three large meals a day.”

c. “i will elevate the head of my bed on blocks.”

D. “i will avoid eating within 1 hour before bedtime.”

326 CHAPTER 48 esoPHageal DisorDers CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: antacids neutralize gastric acid which
irritates the esophagus during reflux.

B. CORRECT: Histamine2 receptor antagonists decrease
acid secretion, which contributes to reflux.

c. opioid analgesics are not effective in treating gerD.
D. Fiber laxatives are not effective in treating gerD.
e. CORRECT: Proton pump inhibitors decrease gastric

acid production, which contributes to reflux.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

2. a. Propranolol is not used for clients who are
actively bleeding. it can be given prophylactically
to decrease portal hypertension.

B. metoclopramide decreases motility of
the esophagus and stomach.

c. Histamine2‑receptor antagonists are administered following
surgical procedures for bleeding esophageal varices.

D. CORRECT: Vasopressin constricts blood vessels and
is used to treat bleeding esophageal varices.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

3. a. Hypersalivation is an expected finding
in a client who has gerD.

B. CORRECT: Painful swallowing is a manifestation of
gerD due to esophageal stricture or inflammation.

c. a client who has gerD would report a
bitter taste in the mouth.

D. increased burping is an expected finding
in a client who has gerD.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. a. carbonated beverages decrease les pressure and should
be avoided by the client who has a hiatal hernia.

B. CORRECT: Peppermint decreases les pressure and should
be avoided by the client who has a hiatal hernia.

c. tight restrictive clothing or abdominal binders should
be avoided by the client who has a hiatal hernia, as
this increases intra‑abdominal pressure and causes the
protrusion of the stomach into the thoracic cavity.

D. the client should avoid consuming anything
immediately prior to bedtime. additionally, chocolate
relaxes the lower esophageal sphincter and should
be avoided by a client who has a hiatal hernia.

e. Heavy lifting and vigorous activities are to be
avoided in the client who has a hiatal hernia.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

5. a. the client is instructed to remain upright after
eating following a fundoplication.

B. the client is instructed to avoid large
meals after a fundoplication.

c. CORRECT: after a fundoplication, the client is instructed
to elevate the head of the bed to limit reflux.

D the client should avoid eating 2 hr before
bedtime to reduce the risk for reflux.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): gastroesophageal
reflux disease (gerD) is a common condition characterized
by gastric content and enzyme backflow into the esophagus.
these fluids are corrosive to esophageal tissue, causing a
delay in their clearance. this further exposes esophageal
tissue to the acidic fluids, increasing tissue irritation.

RISK FACTORS
● obesity
● older age
● sleep apnea
● excessive ingestion of foods that relax the lower esophageal
sphincter (fatty and fried foods, chocolate, caffeinated beverages,
peppermint, spicy foods, tomatoes, citrus fruits, and alcohol)

● Pregnancy
● Bending at the waist, wearing tight clothing at the waist
● medications (theophylline, nitrates, calcium
channel blockers, anticholinergics, nsaiDs)

● stress
● Hiatal hernia
● lying flat

EXPECTED FINDINGS
● Dyspepsia after eating and regurgitation (classic)
● throat irritation (chronic cough, laryngitis)
● Hypersalivation
● Bitter taste in mouth
● chest pain due to esophageal spasm
● increased flatus and eructation (burping)
● Pain relieved by drinking water, sitting upright or taking antacids

NCLEX® Connection: Health Promotion and Maintenance, Health
Promotion/Disease Prevention

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 49 PePtic ulcer Disease 327

UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: UPPER GASTROINTESTINAL DISORDERS

CHAPTER 49 Peptic Ulcer Disease
a peptic ulcer is an erosion of the mucosal
lining of the stomach, esophagus, or duodenum.
the most common area for a peptic ulcer is
the duodenum. the mucous membranes can
become eroded to the point that the epithelium
is exposed to gastric acid and pepsin, which can
precipitate bleeding and perforation. Perforation
that extends through all the layers of the stomach
or duodenum can cause peritonitis. an individual
who has a peptic ulcer has peptic ulcer disease.

most peptic ulcers are caused by an infection
from gram‑negative bacteria Helicobacter pylori
(H. pylori). contact with the bacteria occurs from
food, water, or exposure to body fluids such as
saliva. some people infected with the H. pylori
bacteria do not develop ulcers. stress ulcer
occurs from an acute period of physiological
stressful events, such as burns, shock, severe
sepsis, or multiple organ trauma. these ulcers
are different clinically from a peptic ulcer and
can be present in a ventilated client in the
intensive care unit. curling’s ulcer is seen in
clients who have burns. cushing’s ulcer can be
seen in clients who have head/brain trauma.
Bleeding is the primary manifestation of the
stress ulcer. clients experiencing trauma often
receive proton‑pump inhibitor prophylaxis to
prevent the development of stress ulcers.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Drink alcohol in moderation.
● Stop smoking and use of tobacco products.
● Use stress management techniques.
● Avoid NSAIDs as indicated.
● Limit caffeine‑containing beverages.
● Consume a balanced diet.
● Engage regularly in exercise.

ASSESSMENT

risK Factors
Causes of peptic ulcers

● Helicobacter pylori (H. pylori) infection
● NSAID and corticosteroid use
● Severe stress
● Familial tendency
● Hypersecretory states
● Gastrin‑secreting benign or malignant tumors of

the pancreas
● Type O blood
● Excess alcohol consumption
● Chronic pulmonary or kidney disease
● Zollinger‑Ellison syndrome (combination of

peptic ulcers, hypersecretion of gastric acid, and
gastrin‑secreting tumors)

● Pernicious anemia

eXPecteD FinDings
● Dyspepsia: heartburn, bloating, nausea, and vomiting

(vomiting is rare but can be caused by a gastric outlet
obstruction). Can be perceived as uncomfortable fullness
or hunger.

● Dull, gnawing pain or burning sensation at the
midepigastrium or the back

49.1 Ulcer pain
GASTRIC ULCER DUODENAL ULCER

● Pain most commonly occurs
30 to 60 min after a meal

● less often pain at night
(30% to 40% of clients)

● Pain exacerbated by
ingestion of food

● malnourishment
● Hematemesis

● Pain occurs 1.5 to
3 hr after a meal

● awakening with pain
during the night

● Pain relieved by ingestion
of food or antacid

● Well‑nourished
● melena

PHYSICAL ASSESSMENT FINDINGS
● Pain or epigastric tenderness or abdominal distension
● Bloody emesis (hematemesis) or stools (melena)
● Weight loss

CHAPTER 49

328 CHAPTER 49 PePtic ulcer Disease CONTENT MASTERY SERIES

laBoratorY tests
H. pylori testing: Gastric samples are collected via an
endoscopy to test for H. pylori.

Urea breath testing: The client exhales into a collection
container (baseline), drinks carbon‑enriched urea solution,
and is asked to exhale into a collection container. The client
should take nothing by mouth (NPO) prior to the test. If
H. pylori is present, the solution will break down and carbon
dioxide will be released. Serologic testing documents the
presence of H. pylori based on antibody assays.

Stool sample tests for the presence of the H. pylori antigen

Hemoglobin and hematocrit (unexpected findings
secondary to bleeding)

Stool sample for occult blood

Diagnostic ProceDures

Esophagogastroduodenoscopy (EGD)

Refer to CHAPTER 46: GASTROINTESTINAL DIAGNOSTIC

PROCEDURES. An EGD provides a definitive diagnosis
of peptic ulcers and can be repeated to evaluate the
effectiveness of treatment. Gastric samples are obtained to
test for H. pylori.

NURSING ACTIONS: Monitor vital signs until sedation
wears off. Keep client NPO until return of gag reflex.
Monitor for manifestations of perforation: pain,
bleeding, fever.

CLIENT EDUCATION: NPO 6 to 8 hr prior to the exam.

PATIENT‑CENTERED CARE

nursing care
● Instruct clients to avoid foods that cause distress (coffee,

tea, carbonated beverages).
● Monitor for orthostatic changes in vital signs and

tachycardia, as these findings are suggestive of
gastrointestinal bleeding or perforation.

● Administer saline lavage via nasogastric tube.
● Administer medication as prescribed.
● Decrease environmental stress.
● Encourage rest periods.
● Encourage smoking cessation and avoiding

alcohol consumption.
● Monitor laboratory results (hemoglobin, hematocrit,

coagulation studies).

meDications

Antibiotics

Metronidazole, amoxicillin, clarithromycin, and
tetracycline eliminate H. pylori infection.

NURSING ACTIONS: A combination of two or three
different antibiotics can be administered.

CLIENT EDUCATION: Complete a full course of medication.

Histamine2-receptor antagonists

Ranitidine, famotidine, cimetidine, and nizatidine
suppress the secretion of gastric acid by selectively
blocking H2 receptors in parietal cells lining the stomach.

● Used in conjunction with antibiotics to treat ulcers
caused by H. pylori.

● Used to prevent stress ulcers in clients who are NPO
after major surgery, have large areas of burns, are septic,
or have increased intracranial pressure.

NURSING ACTIONS
● Ranitidine and famotidine can be administered IV in

acute situations.
● Ranitidine can be taken with or without food.
● Treatment of peptic ulcer disease is usually started as an

oral dose twice a day until the ulcer is healed, followed by
a maintenance dose usually taken once a day at bedtime.

CLIENT EDUCATION
● Notify the provider of obvious or occult GI bleeding

(coffee‑ground emesis).
● Complete the prescribed regimen, even when

manifestations subside.

Proton-pump inhibitors

Pantoprazole, esomeprazole, omeprazole, lansoprazole,
and rabeprazole suppress gastric acid secretion by
irreversibly inhibiting the enzyme that produces gastric
acid, and inhibit basal and stimulated acid production.

NURSING ACTIONS
● Insignificant adverse effects with short‑term treatment.
● Long‑term use can increase the risk of fractures,

pneumonia, acid rebound, and the possibility of
developing Clostridium difficile.

● Rabeprazole and pantoprazole are enteric‑coated tablets
and should not be crushed.

CLIENT EDUCATION
● Do not to crush, chew, or break

sustained‑release capsules.
● Take omeprazole and lansoprazole once a day prior to

eating the main meal of the day.
● Take rabeprazole after the morning meal.
● Avoid alcohol and irritating medications (NSAIDs).
● Complete the prescribed regimen, even when

manifestations subside.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 49 PePtic ulcer Disease 329

Antacids
● Aluminum hydroxide and magnesium hydroxide

neutralize acid in the gut. The medication provides
manifestation relief but generally does not
accelerate healing.

● Antacids can be given 7 times per day, 1 to 2 hr after
meals and at bedtime, to neutralize gastric acid, which
occurs with food ingestion.

NURSING ACTIONS
● Give 1 to 2 hr apart from other medications to avoid

reducing the absorption of other medications.
● Monitor kidney function of clients prescribed aluminum

hydroxide and magnesium hydroxide.
● Encourage compliance by reinforcing the intended effect

of the antacid (relief of pain, promote healing of ulcer).

CLIENT EDUCATION
● Take all medications at least 1 to 2 hr before or after

taking an antacid.
● Avoid the use of flavored antacids, which delay emptying

of the stomach.

Mucosal protectants
● Sucralfate coats the ulcer and protects it from the

actions of pepsin and acid.
● Bismuth subsalicylate prevents H. pylori from binding to

the mucosal wall.

NURSING ACTIONS
● Administer on an empty stomach 1 hr before meals and

at bedtime.
● Oral suspension is easier for the older adult clients to

ingest because the tablet form is large and difficult
to swallow.

● Monitor for adverse effect of constipation.

CLIENT EDUCATION
● If taking bismuth subsalicylate, avoid aspirin products

to avoid salicylate toxicity.
● If taking bismuth subsalicylate, stools can be black. This

is temporary and harmless.

tHeraPeutic ProceDures

Esophagogastroduodenoscopy (EGD)

Areas of bleeding can be treated with epinephrine or
laser coagulation.

NURSING ACTIONS
● PREPROCEDURE: Initiate two large‑bore IV catheters.
● POSTPROCEDURE: Monitor vital signs. Keep client NPO

until gag reflex returns.

Surgical interventions

Can be used in clients when ulcers do not heal following
12 to 16 weeks of medical treatment, hemorrhage,
perforation, or obstruction.

Gastrectomy: All or part of the stomach is removed with
laparoscopic or open approach.

● Antrectomy: The antrum portion (lower portion of
stomach) of the stomach is removed.

● Gastrojejunostomy (Billroth II procedure): The lower
portion of the stomach is excised, the remaining
stomach is anastomosed to the jejunum, and the
remaining duodenum is surgically closed.

Vagotomy: The vagus nerve is cut to decrease gastric acid
production in the stomach. Often done laparoscopically to
reduce postoperative complications.

Pyloroplasty: The opening between the stomach and
small intestine is enlarged to increase the rate of
gastric emptying.

NURSING ACTIONS
● Monitor the incision for evidence of infection.
● Place the client in a semi‑Fowler’s position to facilitate

lung expansion.
● Monitor nasogastric tube drainage. Scant blood can be

seen in the first 12 to 24 hr.
● Notify the provider before repositioning or irrigating the

nasogastric tube (disruption of sutures).
● Monitor bowel sounds.
● Advance diet as tolerated to avoid undesired effects

(abdominal distention, diarrhea).
● Administer medication as prescribed (analgesics,

stool softeners).

CLIENT EDUCATION
● Take vitamin and mineral supplements due to decreased

absorption after a gastrectomy, including vitamin B12,
vitamin D, calcium, iron, and folate.

● Consume small, frequent meals while avoiding large
quantities of carbohydrates as directed.

interProFessional care
Nutrition consult: Diet that restricts acid‑producing foods:
milk products, caffeine, decaffeinated coffee, spicy foods,
medications (NSAIDs)

330 CHAPTER 49 PePtic ulcer Disease CONTENT MASTERY SERIES

COMPLICATIONS

Perforation/hemorrhage

When peptic ulcers perforate or bleed, it is an
emergency situation.

● Perforation presents as severe epigastric pain spreading
across the abdomen. The pain can radiate into the
shoulders, especially the right shoulder due to irritation
of the phrenic nerve. The abdomen can become tender
and rigid (boardlike). Hyperactive to diminished
bowel sounds can be auscultated, and there is rebound
tenderness. The client will display manifestations of
shock, hypotension, and tachycardia. Perforation is a
surgical emergency.

● Gastrointestinal bleeding in the form of hematemesis
or melena can cause manifestations of shock
(hypotension, tachycardia, dizziness, confusion), and
decreased hemoglobin.

NURSING ACTIONS
● Perform frequent assessments of pain and vital signs to

detect subtle changes that can indicate perforation
or bleeding.

● Provide oxygen and ventilator support as needed.
● Start two large‑bore IV lines for replacement of blood

and fluids.
● Report findings, prepare the client for endoscopic or

surgical intervention, replace fluid and blood losses to
maintain blood pressure, insert nasogastric tube, and
provide saline lavages.

Pernicious anemia
● Occurs due to a deficiency of the intrinsic factor

normally secreted by the gastric mucosa.
● Manifestations include pallor, glossitis, fatigue,

and paresthesias.

CLIENT EDUCATION: Lifelong monthly vitamin B12
injections will be necessary.

Dumping syndrome

This can occur following gastrectomy surgery, and is a
group of manifestations that occur following eating. A
shift of fluid to the abdomen is triggered by rapid gastric
emptying or high‑carbohydrate ingestion. The rapid
release of metabolic peptides following ingestion of a food
bolus causes dumping syndrome.

● The client can report a full sensation, weakness,
diaphoresis, palpitations, dizziness, and diarrhea.
Vasomotor manifestations that can occur 10 to 90 min
following a meal are pallor, perspiration, palpitations,
headache, feeling of warmth, dizziness, and drowsiness.

● Late manifestations of dumping syndrome can be related
to the rapid release of blood glucose, followed by an
increase in insulin production resulting in hypoglycemia.

NURSING ACTIONS
● Monitor for vasomotor manifestations.
● Assist/instruct the client to lie down when vasomotor

manifestations occur.
● Administer medications.

◯ Octreotide subcutaneously can be prescribed if
manifestations are severe and not effectively
controlled with dietary measures. Octreotide blocks
gastric and pancreatic hormones, which can lead to
findings of dumping syndrome.

◯ Acarbose slows the absorption of carbohydrates.
● Malnutrition and fluid electrolyte imbalances can occur

due to altered absorption. Monitor I&O, laboratory
values, and weight.

49.2 Vasomotor manifestations
EARLY
MANIFESTATIONS

LATE
MANIFESTATIONS

ONSET Within 30 min
after eating 1.5 to 3 hr after eating

CAUSE rapid emptying excessive insulin release

FINDINGS

nausea, vomiting,
sweating, and
dizziness
tachycardia
Palpitations

Dizziness and sweating
tachycardia and palpitations
shakiness and
feelings of anxiety
confusion

CLIENT EDUCATION
● Lying down after a meal slows the movement of food

within the intestines.
● Limit the amount of fluid ingested at one time.
● Eliminate liquids with meals, for 1 hr prior to and

following a meal.
● Consume a high‑protein, high‑fat, low‑fiber, and

low‑ to moderate‑carbohydrate diet.
● Avoid milk and sugars (sweets, fruit juice, sweetened

fruit, milk shakes, honey, syrup, jelly).
● Consume small, frequent meals rather than large meals.

Pyloric obstruction
● Pyloric obstruction occurs due to scarring, edema, or

spasm of the area distal to the pyloric sphincter and
prevents emptying of the stomach.

● Manifestations include feeling of fullness, distention,
nausea after eating, and emesis consisting of
undigested food.

NURSING ACTIONS
● Insert an NG tube for gastric decompression.
● Monitor fluid and electrolyte status.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 49 PePtic ulcer Disease 331

Active Learning Scenario

a nurse is preparing a poster about peptic ulcer disease
to be displayed at a community health fair. What should
be included in the poster? use the ati active learning
template: system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS):
include the types of ulcers.

HEALTH PROMOTION AND DISEASE PREVENTION:
Describe at least three prevention activities.

RISK FACTORS: Describe four risk factors for peptic ulcers.

Application Exercises

1. a nurse in the emergency department is
completing an assessment of a client who has
suspected stomach perforation due to a peptic
ulcer. Which of the following findings should
the nurse expect? (select all that apply.)

a. rigid abdomen

B. tachycardia

c. elevated blood pressure

D. circumoral cyanosis

e. rebound tenderness

2. a nurse is teaching a client who has a new
diagnosis of dumping syndrome following gastric
surgery. Which of the following information
should the nurse include in the teaching?

a. eat three moderate‑sized meals a day.

B. Drink at least one glass of water with each meal.

c. eat a bedtime snack that contains a milk product.

D. increase protein in the diet.

3. a nurse is completing discharge teaching for a client
who has an infection due to Helicobacter pylori
(H. pylori). Which of the following statements by the
client indicates understanding of the teaching?

a. “i will continue my prescription for corticosteroids.”

B. “i will schedule a ct scan to
monitor improvement.”

c. “i will take a combination of
medications for treatment.”

D. “i will have my throat swabbed to
recheck for this bacteria.”

4. a nurse is completing an assessment of a client who
has a gastric ulcer. Which of the following findings
should the nurse expect? (select all that apply.)

a. client reports pain relieved by eating.

B. client states that pain often occurs at night.

c. client reports a sensation of bloating.

D. client states that pain occurs 30
min to 1 hr after a meal.

e. client experiences pain upon palpation
of the epigastric region.

5. a nurse is teaching a client who has a duodenal
ulcer and a new prescription for esomeprazole.
Which of the following information should the nurse
include in the teaching? (select all that apply.)

a. take the medication 1 hr before a meal.

B. limit nsaiDs when taking this medication.

c. expect skin flushing when taking this medication.

D. increase fiber intake when taking this medication.

e. chew the medication thoroughly
before swallowing.

332 CHAPTER 49 PePtic ulcer Disease CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: manifestations of perforation include
a rigid, board‑like abdomen.

B. CORRECT: tachycardia occurs due to gastrointestinal
bleeding that accompanies a perforation.

c. Hypotension is an expected finding in a client
who has a perforation and bleeding.

D. circumoral cyanosis is not a manifestation of perforation.
e. CORRECT: rebound tenderness is an expected

finding in a client who has a perforation.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

2. a. consume small, frequent meals rather
than moderate‑sized meals.

B. eliminate liquids with meals and for 1 hr
prior to and following meals.

c. avoid milk products.
D. CORRECT: eat a high‑protein, high‑fat, low‑fiber,

and moderate‑ to low‑carbohydrate diet.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

3. a. corticosteroid use is a contributing factor to
an infection caused by H. pylori.

B. an esophagogastroduodenoscopy is done to
evaluate for the presence of H. pylori and to
evaluate effectiveness of treatment.

c. CORRECT: a combination of antibiotics and
a histamine2 receptor antagonist is used to
treat an infection caused by H. pylori.

D. H. pylori is evaluated by obtaining gastric
samples, not a throat swab.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. a. a client who has a duodenal ulcer will report
that pain is relieved by eating.

B. Pain that rarely occurs at night is an expected finding.
c. CORRECT: a client report of a bloating

sensation is an expected finding.
D. CORRECT: a client who has a gastric ulcer will

often report pain 30 to 60 min after a meal.
e. CORRECT: Pain in the epigastric region upon

palpation is an expected finding.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

5. a. CORRECT: take the medication 1 hr before meals.
B. CORRECT: limit taking nsaiDs when on this medication.
c. skin flushing is not an adverse effect of this medication.
D. Fiber intake does not need to be increased

when taking this medication.
e. swallow the capsule whole. it should

not be crushed or chewed.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): an erosion of the mucosal
lining of the stomach or duodenum. mucous membranes can
become eroded to the point that the epithelium is exposed to gastric
acid and pepsin, which can precipitate bleeding and perforation.
types of ulcers include gastric, duodenal, and stress ulcers.

HEALTH PROMOTION AND DISEASE PREVENTION
● Drink alcohol in moderation.
● stop smoking and use of tobacco products.
● use stress management strategies.
● avoid nsaiDs.
● limit caffeine‑containing beverages.

RISK FACTORS
● Helicobacter pylori (H. pylori)
● nsaiD and corticosteroid use
● severe stress
● Hypersecretory conditions
● Blood type o
● excess alcohol ingestion
● chronic pulmonary or kidney disease
● Zollinger‑ellison syndrome

NCLEX® Connection: Health Promotion and Maintenance, Health
Promotion/Disease Prevention

07/24/15 April 12, 2019 11:39 AM rm_rn_2019_ams_chp50

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 50 acute anD cHronic gastritis 333

UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: UPPER GASTROINTESTINAL DISORDERS

CHAPTER 50 Acute and
Chronic Gastritis

cyclooxygenase (coX) is an enzyme that
produces mucosal prostaglandins, decreases
gastric acid, increases secretion of bicarbonate
and cytoprotective mucus, and provides
maintenance of submucosal blood flow to
protect the gastric mucosa.

gastritis is an inflammation in the lining of the
stomach, either erosive or nonerosive, and can
be acute or chronic.

tYPes oF gastritis
Nonerosive gastritis (acute or chronic) is most often
caused by an infection, Helicobacter pylori.

Erosive gastritis is likely caused by NSAIDs, alcohol use
disorder, or recent radiation treatment.

Acute gastritis has sudden onset, is of short duration, and
can result in gastric bleeding if severe. A severe form of
acute gastritis is caused by the ingestion of an irritant,
(such as a strong acid or alkali) and can result in the
development of gangrenous tissue or perforation. Scarring
can result leading to pyloric stenosis.

Chronic gastritis can be related to autoimmune disease,
such as pernicious anemia, and H. pylori.

Extensive gastric mucosal wall damage can cause erosive
gastritis (ulcers) and increase the risk of stomach cancer.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Assist in the reduction of anxiety related to gastritis.
● Follow a prescribed diet.
● Decrease or eliminate alcohol use.
● The client who has pernicious anemia will need vitamin

B12 injections due to a decrease of the intrinsic factor by
the stomach parietal cells.

● Watch for indications of GI bleeding.
● Follow the prescribed medication regimen.
● Eat small, frequent meals, avoiding foods and beverages

that cause irritation.
● Report constipation, nausea, vomiting, or bloody stools.
● Stop smoking.

ASSESSMENT

risK Factors
● Family member who has H. pylori infection
● Family history of gastritis
● Prolonged use of NSAIDs, corticosteroids (stops

prostaglandin synthesis)
● Excessive alcohol use
● Bile reflux disease
● Advanced age
● Radiation therapy
● Smoking
● Caffeine
● Excessive stress
● Exposure to contaminated food or water

BACTERIAL INFECTION: Helicobacter pylori, Salmonella,
Streptococci, Staphylococci, or Escherichia coli

AUTOIMMUNE DISEASES: Systemic lupus, rheumatoid
arthritis, and pernicious anemia

eXPecteD FinDings
PHYSICAL ASSESSMENT FINDINGS

● Dyspepsia, general abdominal discomfort, indigestion
● Headache
● Hiccuping that can last for a few hours to several days
● Upper abdominal pain or burning which can increase or

decrease after eating
● Nausea and vomiting
● Reduced appetite and weight loss
● Abdominal bloating or distention
● Hematemesis (bloody emesis) and stools that test

positive for occult blood
● Gastric hemorrhage
● Anorexia
● Pernicious anemia
● Intolerance of spicy and fatty foods

manifestations can have rapid
onset with acute gastritis.

Erosive gastritis
● Black, tarry stools; coffee‑ground emesis
● Acute abdominal pain

laBoratorY tests

Noninvasive tests

CBC to check for anemia
● Females, Hgb less than 12 g/dL and RBC less than
4.2 cells/mcL

● Males, Hgb less than 14 g/dL and RBC less than
4.7 cells/mcL

Blood and stool antibody/antigen test for presence of H. pylori

C13 urea breath test: Used to measure H. pylori

CHAPTER 50

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334 CHAPTER 50 acute anD cHronic gastritis CONTENT MASTERY SERIES

Diagnostic ProceDures

Upper endoscopy

A small flexible scope is inserted through the mouth into
the esophagus, stomach, and duodenum to visualize the
upper digestive tract. This procedure allows for a biopsy,
cauterization, removal of polyps, dilation, or diagnosis.
(See CHAPTER 46: GASTROINTESTINAL DIAGNOSTIC PROCEDURES.)

CLIENT EDUCATION
● Maintain NPO status 6 to 8 hr prior to procedure.
● Have a ride home available after the procedure.
● A local anesthetic will be sprayed onto the back of the

throat, but the throat can be sore following the
procedure.

● Monitor for indications of perforation (chest or abdominal
pain, fever, nausea, vomiting, and abdominal distention)
and have emergency contact numbers available.

PATIENT‑CENTERED CARE

nursing care
● Monitor fluid intake and urine output.
● Administer IV fluids as prescribed.
● Monitor electrolytes. (Diarrhea and vomiting can

deplete electrolytes and cause dehydration.)
● Assist the client in identifying foods that are triggers.
● Provide small, frequent meals and encourage the client

to eat slowly.
● Advise the client to avoid alcohol, caffeine, and foods

that can cause gastric irritation.
● Assist the client in identifying ways to reduce stress.
● Monitor for indications of gastric bleeding

(coffee‑ground emesis; black, tarry stools).
● Monitor for findings of anemia (tachycardia,

hypotension, fatigue, shortness of breath, pallor, feeling
lightheaded or dizzy, chest pain).

meDications

Histamine2 antagonists

ACTION: Decreases gastric acid output by blocking gastric
histamine2 receptors

MEDICATIONS
● Nizatidine
● Famotidine
● Ranitidine
● Cimetidine

NURSING INTERVENTIONS
● Allow 1 hr before or after to administer antacid.
Antacids can decrease the effectiveness of H2 receptor
antagonists.

● Monitor for neutropenia and hypotension.
● Dilute and administer slowly when given IV; rapid

administration can cause bradycardia and hypotension.

CLIENT EDUCATION
● Do not to smoke or drink alcohol.
● Take oral dose with meals. Take famotidine 1 hr before

meals to decrease heartburn, acid indigestion, and
sour stomach.

● Wait 1 hr prior to or following H2 receptor antagonist to
take an antacid.

● Monitor for indications of GI bleeding (black stools,
coffee‑ground emesis).

Antacids

ACTION
● Increases gastric pH and neutralizes pepsin
● Improves mucosal protection

MEDICATIONS
● Aluminum hydroxide
● Magnesium hydroxide with aluminum hydroxide

NURSING INTERVENTIONS
● Do not give to clients who have acute kidney injury or

chronic kidney failure.
● Monitor aluminum antacids for aluminum toxicity and

constipation. Monitor magnesium antacids for diarrhea
or hypermagnesemia.

CLIENT EDUCATION
● Take antacids on an empty stomach.
● Wait 1 hr to take other medications.

Proton pump inhibitors

ACTION: Reduces gastric acid by stopping the hydrogen/
potassium ATPase enzyme system in parietal cells,
blocking acid production

MEDICATIONS
● Omeprazole
● Lansoprazole
● Rabeprazole sodium
● Pantoprazole
● Esomeprazole

50.1 H. pylori gastritis

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 50 acute anD cHronic gastritis 335

NURSING INTERVENTIONS
● Can cause nausea, vomiting, and abdominal pain.
● Use filter for IV administration for pantoprazole and

lansoprazole.

CLIENT EDUCATION
● Allow 60 min before eating when taking esomeprazole.
● Do not to crush or chew if any of the medications are

enteric‑coated or sustained‑release.
● It can take up to 4 days to see the effects.
● Take medication with or without food according to

the instructions.

Prostaglandins

ACTION: Replacement for endogenous prostaglandins that
stimulates mucosal protection. Reduces gastric acid secretion.

MEDICATIONS: Misoprostol

NURSING INTERVENTIONS
● Can be given with NSAIDs to prevent gastric

mucosal damage.
● Can cause abdominal pain and diarrhea.

CLIENT EDUCATION
● Use contraceptives.
● Do not take if there is a chance of becoming

pregnant.
● Take with food to reduce gastric effects.

Anti-ulcer/mucosal barriers

ACTION: Inhibits acid and forms a protective coating
over mucosa

MEDICATIONS: Sucralfate

NURSING INTERVENTIONS: Allow 30 min before or after to
give antacid.

CLIENT EDUCATION
● Take on an empty stomach.
● Do not smoke or drink alcohol.
● Continue to take medication even if

manifestations subside.

Antibiotics

ACTION: Eliminates H. pylori infection

MEDICATIONS
● Clarithromycin
● Amoxicillin
● Tetracycline
● Metronidazole

NURSING INTERVENTIONS
● Monitor for increased abdominal pain and diarrhea.
● Monitor electrolytes and hydration if fluid is depleted.
● Should be administered with meals to decrease GI upset.
● Use cautiously in clients who have kidney or hepatic

impairment.

CLIENT EDUCATION
● Complete prescribed dosage.
● Notify the provider of persistent diarrhea, which can

indicate superinfection of the bowel.

tHeraPeutic ProceDures
Upper endoscopy: Surgery is prescribed for clients
who have ulcerations or significant bleeding, or
when nonsurgical interventions are ineffective.
(See CHAPTER 49: PEPTIC ULCER DISEASE.)

Vagotomy or highly selective vagotomy: A highly selective
vagotomy severs only the nerve fibers that control gastric
acid secretion, and often is done laparoscopically to reduce
postoperative complications. Pyloroplasty is usually done
at the same time as the vagotomy.

Partial gastrectomy: Removal of the involved portion of
the stomach.

interProFessional care
● A nutritionist can assist in alterations to diet.
● Supportive care might be needed to reduce stress,

increase exercise, and stop smoking.

COMPLICATIONS

Gastric bleeding

CAUSES
● Severe acute gastritis with deep tissue inflammation

extending into the stomach muscle.
● In chronic erosive gastritis, bleeding can be slow or

profuse as in a perforation of the stomach wall.

NURSING ACTIONS
● Monitor vital signs and airway.
● Provide fluid replacement and blood products.
● Monitor CBC and clotting factors.
● Insert a nasogastric (NG) tube for gastric lavage (irrigate

with normal saline or water to stop active gastric bleed)
as indicated. Obtain an x‑ray to confirm placement of NG
tube prior to fluid instillation to prevent aspiration.

● Monitor NG tube for absence or presence of blood, assess
the amount of bleeding, and prevent gastric dilation.

● Administer IV medications (proton‑pump inhibitors,
H2‑receptor antagonists) as prescribed.

CLIENT EDUCATION: Monitor for indications of slow
gastric bleeding (coffee‑ground emesis; black, tarry stools).
Seek immediate medical attention with severe abdominal
pain or vomiting blood. Take medications as directed.

Gastric outlet obstruction

CAUSE: Severe acute gastritis with deep tissue
inflammation extending into the stomach muscle

NURSING ACTIONS
● Monitor fluids and electrolytes because continuous

vomiting results in loss of chloride (metabolic alkalosis)
and severe fluid and electrolyte depletion.

● Provide fluid and electrolyte replacement. Monitor I&O.
● Prepare to insert an NG tube to empty stomach contents.
● Prepare for a diagnostic endoscopy.

CLIENT EDUCATION: Seek medical attention for
continuous vomiting, bloating, and nausea.

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336 CHAPTER 50 acute anD cHronic gastritis CONTENT MASTERY SERIES

Application Exercises

1. a nurse is teaching about pernicious anemia with a
client who has chronic gastritis. Which of the following
information should the nurse include in the teaching?

a. Pernicious anemia is caused when the cells
producing gastric acid are damaged.

B. expect a monthly injection of vitamin B12.

c. Plan to take vitamin K supplements.

D. Pernicious anemia is caused by an
increased production of intrinsic factor.

2. a nurse is providing discharge teaching to a
client who has a new prescription for aluminum
hydroxide. Which of the following information
should the nurse include in the teaching?

a. take the medication with food.

B. monitor for diarrhea.

c. Wait 1 hr before taking other oral medications.

D. maintain a low‑fiber diet.

3. a nurse is planning care for a client who has
acute gastritis. Which of the following nursing
interventions should the nurse include in
the plan of care? (select all that apply.)

a. evaluate intake and output.

B. monitor laboratory reports of electrolytes.

c. Provide three large meals a day.

D. administer ibuprofen for pain.

e. observe stool characteristics.

4. a nurse is teaching a client who has a new prescription
for famotidine. Which of the following statements by
the client indicates understanding of the teaching?

a. “the medicine coats the lining of my stomach.”

B. “the medication should stop the pain right away.”

c. “i will take my pill at bedtime.”

D. “i will monitor for bleeding from my nose.”

5. a charge nurse is teaching a group of nurses
about a client who has chronic gastritis and is
scheduled for a selective vagotomy. Which of the
following statements by a unit nurse indicates
understanding of the purpose of the procedure?

a. “the client will have increased
duodenal gastric emptying.”

B. “the client will have a reduction
of gastric acid secretions.”

c. “the client will have an increase of
gastric mucus secretion.”

D. “the client will have an increased secretion
of hydrogen/potassium atPase enzymes.”

Dehydration

CAUSE: Loss of fluid due to vomiting or diarrhea

NURSING ACTIONS
● Monitor fluid intake and urine output.
● Provide IV fluids if needed.
● Monitor electrolytes.

CLIENT EDUCATION: Contact a provider for vomiting
and diarrhea.

Pernicious anemia

CAUSES
● Chronic gastritis can damage the parietal cells. This can

lead to reduced production of intrinsic factor, which is
necessary for the absorption of vitamin B12.

● Insufficient vitamin B12 can lead to pernicious anemia.

NURSING ACTIONS: Instruct the client of the need for
monthly vitamin B12 injections.

Dumping syndrome

CAUSES: The rapid release of metabolic peptides following
the ingestion of a food bolus.

MANIFESTATIONS
● Early manifestations include a feeling of fullness,

weakness, dizziness, palpitations, sweating, abdominal
cramping, and diarrhea.

● Manifestations resolve after having a bowel movement.
However, late or residual vasomotor manifestations can
occur 10 min to 3 hr after eating.

NURSING ACTIONS
● Instruct the client to lay down following meals to slow

movement of food through the intestine and
prevent injury.

● Instruct the client to eat a high‑protein, high‑fat, low to
moderate carbohydrate diet .

● Instruct the client to eat small meals and limit taking
liquids with meals.

● Instruct the client on self‑administration of octreotide
subcutaneous injection two to three times daily before
meals, as prescribed.

Active Learning Scenario

a nurse is reviewing acute and chronic gastritis with
a group of clients. What should the nurse include
in this discussion? use the ati active learning
template: system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)
● Describe gastritis.
● compare/contrast acute vs. chronic gastritis.

PATHOPHYSIOLOGY RELATED TO CLIENT
PROBLEM: Describe as related to client problem.

RISK FACTORS: Describe six.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 50 acute anD cHronic gastritis 337

Application Exercises Key

1. a. Damage to parietal cells has occurred, which leads
to pernicious anemia and causes a decrease of the
intrinsic factor by the stomach parietal cells.

B. CORRECT: include in the information that the client
will receive a monthly injection of vitamin B12 to
treat pernicious anemia due to a decrease of the
intrinsic factor by the stomach parietal cells.

c. Vitamin K supplements are given to clients
who have a bleeding disorder.

D. Parietal cell damage results in insufficient production
of intrinsic factor by the stomach parietal cells.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

2. a. advise the client to take aluminum hydroxide
on an empty stomach.

B. include in the teaching that aluminum
hydroxide can cause constipation.

c. CORRECT: advise the client not to take oral
medications within 1 hr of an antacid.

D. include in the teaching for the client to increase dietary
fiber due to the constipating effect of the medication.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

3. a. CORRECT: evaluate the client’s intake and output to
prevent electrolyte loss and dehydration.

B. CORRECT: monitor the client’s electrolyte laboratory
values to prevent fluid loss and dehydration.

c. instruct the client to eat small, frequent meals.
D. instruct the client to avoid taking ibuprofen, an

nsaiD, because of its erosive capabilities.
e. CORRECT: instruct the client to report to the provider

any indication of the presence of blood in the stools,
which can indicate gastrointestinal bleeding.

NCLEX® Connection: Physiological Adaptation,
Illness Management

4. a. Famotidine decreases gastric acid output. it does
not have a protective coating action.

B. the client might need to take famotidine for several days
before pain relief occurs when starting this therapy.

c. CORRECT: the client should take famotidine at bedtime,
which suppresses nocturnal acid production.

D. instruct the client to monitor for gi bleeding
when taking famotidine.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

5. a. Pyloroplasty will increase gastric emptying,
which is performed to widen the opening from
the stomach to the duodenum.

B. CORRECT: selective vagotomy will
reduce gastric acid secretions.

c. Prostaglandin analog medication will stimulate mucosal
protection and decrease gastric acid secretions.

D. a histamine2 antagonist medication will inhibit gastric
secretion by inhibiting the hydrogen/potassium atPase
enzyme system in the gastric parietal cells.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): gastritis is an inflammation
of the lining of the stomach as a result of irritation to the mucosa.

● acute: sudden onset, short duration, can result in gastric bleeding
● chronic: slow onset; when profuse, it can damage
parietal cells, resulting in pernicious anemia

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM: gastric acid
overwhelms the production of coX 1 enzymes, which provide mucosal
prostaglandins that line the stomach. this results in an erosion of
the mucosa and increases the risk for ulcers and stomach cancer.

RISK FACTORS
● Bacterial infection (H. pylori, Salmonella,
Streptococci, Staphylococci, E. coli)

● Family history of H. pylori
● Prolonged use of nsaiDs or corticosteroids
● excessive alcohol use
● Bile reflux disease
● autoimmune diseases
● advanced age
● radiation therapy
● smoking
● caffeine
● excessive stress
● exposure to contaminated food or water

NCLEX® Connection: Physiological Adaptation, Alterations in
Body Systems

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338 CHAPTER 50 acute anD cHronic gastritis CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 51 noninFlammatorY BoWel DisorDers 339

UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: LOWER GASTROINTESTINAL DISORDERS

CHAPTER 51 Noninflammatory
Bowel Disorders

noninflammatory bowel disorders can cause
pain, changes in bowel pattern, bleeding, and
malabsorption. this group of disorders includes
hemorrhoids, cancer, hernia, irritable bowel
syndrome (iBs), and intestinal obstruction.

Hemorrhoids are distended or edematous
intestinal veins resulting from increased
intra‑abdominal pressure (straining, obesity,
prolonged sitting or standing, constipation,
weight lifting). Pregnancy increases the
risk of hemorrhoids.

cancer of the small or large intestine can be
caused by age‑related changes (clients who are
50 years or older have an increased risk), genetic
influence, or chronic bowel disease, such as
crohn’s disease or ulcerative colitis.

nurses should be knowledgeable about
noninflammatory bowel disorders and treatments.
topics to be reviewed include hernia, irritable
bowel syndrome, and intestinal obstruction.

Hernia
Bowel herniation is the displacement of the bowel
through a weakness of the abdominal muscle into other
areas of the abdominal cavity.

Incisional hernias can occur as a postsurgical
complication due to inadequate healing of the incisional
site from malnutrition, infection, or obesity.

A hernia that cannot be moved back into place with gentle
palpation is considered irreducible and requires immediate
surgical evaluation.

In a hernia that is strangulated, blood supply is cut off to
a portion of the bowel, increasing the risk for obstruction,
necrosis, and perforation. Findings include abdominal
distention, tachycardia, vomiting, abdominal pain, and
fever. Surgical intervention is necessary.

ASSESSMENT

risK Factors
● Male sex (indirect inguinal hernia can be large and

descend into the scrotum)
● Advanced age (direct hernia)
● Increased intra‑abdominal pressure due to pregnancy or

obesity (femoral, adult‑acquired umbilical hernia)
● Genetics (congenital umbilical hernia)

eXPecteD FinDings
Protrusion or lump at involved site (groin area, umbilicus,
healed incision)

CHAPTER 51

51.1 Hernia

340 CHAPTER 51 noninFlammatorY BoWel DisorDers CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE
NURSING ACTIONS: If the hernia does not require surgery,
instruct the client to wear a truss pad with hernia belt during
waking hours to prevent the abdominal contents from
bulging into the hernia sac. Inspect skin under the pad daily.

POSTOPERATIVE CLIENT EDUCATION
● Avoid increased intra‑abdominal pressure for 2 to
3 weeks (avoid coughing, straining, and lifting objects
greater than 10 lb).

● Apply ice as prescribed and inspect and report redness
or swelling at the incisional site.

● Prevent constipation by increasing dietary fiber and fluids.
● Rest for several days and return to work

when recommended by the surgeon, usually
1 to 2 weeks postoperatively.

Irritable bowel syndrome
IBS is a disorder of the gastrointestinal system that causes
changes in bowel function (chronic diarrhea, constipation,
bloating, and/or abdominal pain).

● The etiology of IBS is uncertain, but it is thought that
environmental, immunological, genetic, hormonal, and
stress influence the development and course of the
disease. Food intolerances worsen the manifestations.

◯ Environmental factors: Dairy products, caffeinated
beverages, infectious agents

◯ Immunological factors: Cytokine genes
(pro‑inflammatory interleukins), tumor necrosis
factor (TNF) alpha

◯ Stress‑related factors: Anxiety, depression
● IBS is diagnosed primarily based on the presence

of manifestations. Criteria can include recurrent
abdominal pain for 3 days during a month in the past
3 months, and two or more of the following.

◯ Improvement when the client moves their bowels
◯ Onset when there is a change in frequency of stools
◯ Onset when there is a change in appearance of stools

HEALTH PROMOTION AND
DISEASE PREVENTION

● Avoid foods that trigger exacerbation (dairy, wheat, corn,
fried foods, alcohol, spicy foods, aspartame).

● Avoid alcoholic and caffeinated beverages, and other
fluids containing fructose and sorbitol.

● Consume 2 to 3 L fluid per day from food and fluid sources.
● Increase fiber intake (approximately 30 to 40 g/day).

ASSESSMENT

risK Factors
● Female sex
● Stress
● Eating large meals containing a large amount of fat
● Caffeine intake
● Alcohol intake

eXPecteD FinDings
● Cramping pain in abdomen
● Abdominal pain (left lower quadrant) due to changes in

bowel pattern and consistency
● Nausea with meals or passing stool
● Anorexia
● Abdominal bloating
● Belching
● Diarrhea (diarrhea‑predominant IBS)
● Constipation (constipation‑predominant IBS)
● Hyperactive or hypoactive bowel sounds
● Sensation of incomplete defecation
● Mucous in stools

laBoratorY tests
CBC, blood albumin, erythrocyte sedimentation rate (ESR),
and occult stools are all typically within the expected
reference range.

Diagnostic tests

Hydrogen breath test

A hydrogen breath test might be performed to identify
malabsorption, impaired digestion, or an overgrowth of
bacteria. The client is asked to exhale into a hydrogen
analyzer before and after ingesting test sugar. Positive test
results indicate excess hydrogen in the bloodstream from
bacterial overgrowth or malabsorption.

CLIENT EDUCATION: Remain NPO at least 12 hr prior to
test, except for sips of water.

PATIENT‑CENTERED CARE

nursing care
● Review strategies to reduce stress.
● Instruct the client to limit the intake of irritating agents

(gas‑forming foods, caffeine, alcohol).
● Encourage a diet high in fiber and fluids.
● Instruct client to keep a food diary to record intake and

bowel patterns (to adjust diet to prevent exacerbations).

meDications

Diarrhea-predominant IBS (IBS-D)

Loperamide
● Decreases peristalsis and increases bulk.
● Can cause drowsiness.
● Discontinue if no response after 48 hr.

Psyllium
● Bulk‑forming laxative.
● Discontinue for abdominal cramping, rectal bleeding,

and vomiting.
● Monitor for electrolyte imbalance.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 51 noninFlammatorY BoWel DisorDers 341

Alosetron
● An IBS‑specific medication that selectively blocks 5‑HT3

receptors that innervate the viscera. The expected result
is increased firmness in stools and decreased urgency
and frequency of defecation.

● Indicated for IBS‑D in females that has lasted more than
6 months and is resistant to conventional management.
Use with caution in females and only as a last resort.

NURSING ACTIONS: Contraindicated for clients who have
a history of bowel obstruction, Crohn’s disease, ulcerative
colitis, impaired intestinal circulation, or thrombophlebitis.

CLIENT EDUCATION
● Manifestations should resolve within 1 to
4 weeks. Discontinue medication after 4 weeks if
manifestations persist.

● Avoid concurrent use of psychoactive drugs
and antihistamines.

● Report constipation, fever, increasing abdominal pain,
fatigue, dark urine, bloody diarrhea, or rectal bleeding
immediately because alosetron can cause ischemic colitis.
Discontinue medication if these manifestations occur.

Constipation-predominant IBS (IBS-C)

Lubiprostone: An IBS‑specific medication that increases
fluid secretion in the intestine to promote intestinal
motility. This is indicated for IBS‑C in females.

● Contraindicated for clients who have known or possible
bowel obstruction.

● CLIENT EDUCATION: Take with food and water.

Linaclotide
● Increases fluid and motility in the intestine
● Can relieve pain and cramps
● CLIENT EDUCATION: Take daily about 30 min

before breakfast.

Intestinal obstruction
Intestinal obstruction can result from mechanical
or nonmechanical causes. Manifestations vary
according to type.

● Mechanical obstruction occurs when the bowel is
blocked by something outside or inside the intestines
(adhesions, fecal impactions). Complete mechanical
obstructions should be addressed surgically.

● Nonmechanical obstructions are caused by diminished
peristalsis within the bowel (paralytic ileus). This
can occur postoperatively due to the handling of the
intestines during surgery.

● Treatment focuses on fluid and electrolyte balance,
decompressing the bowel, and relief/removal of
the obstruction.

ASSESSMENT

risK Factors

Mechanical obstructions

Result from the following.
● Encirclement or compression of intestine by adhesions,

tumors, fibrosis (endometriosis), or strictures (Crohn’s
disease, radiation)

◯ Postsurgical adhesions are often the cause of small
bowel obstructions.

◯ Carcinomas are often the cause of large
intestine obstructions.

◯ OLDER ADULT CLIENTS: Diverticulitis, fecal impaction,
and tumors are common causes of obstruction. Bowel
regimens can be effective in preventing impactions.

● Hernia (bowel becomes trapped in weakened area of
abdominal wall) (51.1)

● Volvulus (twisting) or intussusception (telescoping) of
bowel segments (51.3)

Nonmechanical obstructions
● Nonmechanical obstructions (paralytic ileus) result

from decreased peristalsis secondary to the following.
◯ Neurogenic disorders (manipulation of the bowel
during major surgery and spinal fracture)

◯ Vascular disorders (vascular insufficiency and
mesenteric emboli)

◯ Electrolyte imbalances (hypokalemia)
◯ Inflammatory responses (peritonitis or sepsis)

● Manifestations of nonmechanical obstructions include
diffuse, constant pain; significant abdominal distention;
and frequent vomiting.

eXPecteD FinDings
Manifestations vary depending on the location of
the obstruction.

Small bowel and large intestine obstructions
● Obstipation: the inability to pass a stool and/or flatus for

more than 8 hr despite feeling the urge to defecate
● Abdominal distention
● High‑pitched bowel sounds above site of obstruction

(borborygmi) with hypoactive bowel sounds below, or
overall hypoactive; absent bowel sounds later in process

Small bowel obstructions
● Severe fluid and electrolyte imbalance
● Metabolic alkalosis
● Visible peristaltic waves (possible)
● Epigastric or upper abdominal distention
● Abdominal pain, discomfort
● Profuse, sudden projectile vomiting with fecal odor

View Images: Bowel Intussusception, Volvulus, Hernia

342 CHAPTER 51 noninFlammatorY BoWel DisorDers CONTENT MASTERY SERIES

Large intestine obstructions
● Minor fluid and electrolyte imbalance
● Metabolic acidosis (possible)
● Significant lower abdominal distention
● Intermittent abdominal cramping
● Infrequent vomiting
● Diarrhea or ribbon‑like stools around an impaction

laBoratorY tests
● Increased hemoglobin, BUN, creatinine, and hematocrit

can indicate dehydration.
● Increased blood amylase and WBC count can occur with

strangulating obstructions.
● Arterial blood gases (ABGs) indicate metabolic

imbalance, depending on obstruction type.
● Chemistry profiles reveal decreased blood sodium,

chloride, and potassium.

Diagnostic ProceDures
X‑ray: Flat plate and upright abdominal x‑rays evaluate
the presence of free air and gas patterns.

Endoscopy determines the cause of obstruction.

CT scan determines the cause and exact location of
the obstruction.

PATIENT‑CENTERED CARE

nursing care

Nonmechanical cause of obstruction
● Nothing by mouth with bowel rest.
● Assess bowel sounds.
● Provide oral hygiene.
● Administer IV fluid and electrolyte replacement

(particularly potassium).
● Manage pain (once diagnosis identified).
● Encourage ambulation.
● Place in semi‑Fowler’s position.

Mechanical cause of obstruction
● Prepare for surgery and provide preoperative nursing care.
● Withhold intake until peristalsis resumes.

meDications
Opioid antagonist (alvimopan) is administered for
short‑term use, to reverse the action of opioids on bowel
motility in clients who have a postoperative paralytic
ileus. Monitor for myocardial infarction.

Broad‑spectrum antibiotics , especially with suspected
bowel strangulation.

tHeraPeutic ProceDures
Nasogastric (NG) tube with a vent (to prevent damage
to the stomach mucosa during continuous suctioning) is
inserted to decompress the bowel.

NURSING ACTIONS
● Maintain intermittent suction as prescribed.
● Assess NG tube patency and placement. Irrigate every
4 hr, or as prescribed.

● Monitor and assess gastric output.
● Monitor nasal area for skin breakdown.
● Provide oral hygiene every 2 hr.
● Monitor vital signs, skin integrity, weight, and I&O.

Surgical interventions

Procedure varies based on cause of obstruction. These
can include lysis of adhesions, colon resection, colostomy
creation (temporary or permanent), embolectomy,
thrombectomy, resection of gangrenous intestinal tissue,
or complete colectomy.

Exploratory laparotomy
To determine and correct the cause of obstruction if possible

NURSING ACTIONS
● Ensure the client understands the type of procedure

(open or laparoscopic).
● Monitor for hemodynamic instability.
● Administer IV fluid replacement and maintenance

as prescribed.
● Monitor bowel sounds.
● Maintain NG tube patency and measure output.
● Clamp NG tube as prescribed to assess the client’s

tolerance prior to removal.
● Advance diet as tolerated when prescribed, beginning

with clear liquids. Clamp tube after eating for 1 to 2 hr.
● Instruct client to report intolerance of intake following NG

tube removal (nausea, vomiting, increasing distention).

View Image: Radiograph of Abdominal Obstruction

51.2 Bowel intussusception

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 51 noninFlammatorY BoWel DisorDers 343

COMPLICATIONS

Dehydration (small bowel obstruction)

CAUSE: Persistent vomiting

NURSING ACTIONS
● Assess hydration through evaluation of hematocrit, BUN,

orthostatic vital signs, skin turgor/mucous membranes,
urine output, and specifi c gravity. Notify the provider of
a fl uid imbalance.

● Administer IV fl uids as prescribed.

Electrolyte imbalance (small bowel obstruction)

CAUSE: Persistent vomiting

NURSING ACTIONS
● Monitor electrolytes, especially potassium levels.
● Notify the provider of an electrolyte imbalance.
● Administer IV fl uids as prescribed to replace electrolytes.

Metabolic alkalosis (small intestinal obstruction)

CAUSE: Persistent vomiting, leading to a loss of gastric
hydrochloride

NURSING ACTIONS
● Monitor for hypoventilation (confusion, hypercarbia),

which is a compensatory action by the lungs.
● Obtain arterial blood gas.
● Notify the provider of unexpected laboratory fi ndings.
● Replace fl uid and electrolytes as prescribed.
● Provide oral hygiene to alleviate increased thirst

response. Thirst response is decreased in the older adult.
Provide oral hygiene routinely to ensure maintenance of
moist mucous membranes.

Metabolic acidosis (large bowel obstructions)

CAUSE: A lower level obstruction

NURSING ACTIONS
● Monitor for deep, rapid respirations (compensatory

action by the lungs), confusion, hypotension, and
fl ushed skin.

● Obtain arterial blood gas.
● Notify the provider of unexpected laboratory fi ndings.

51.4 Radiograph of
abdominal obstruction

51.3 Volvulus

344 CHAPTER 51 noninFlammatorY BoWel DisorDers CONTENT MASTERY SERIES

Application Exercises

1. a nurse is completing an admission assessment
for a client who has a small bowel obstruction.
Which of the following findings should the nurse
report to the provider? (select all that apply.)

a. emesis prior to insertion of the nasogastric tube

B. urine specific gravity 1.040

c. Hematocrit 60%

D. Blood potassium 3.0 meq/l

e. WBc 10,000/ul

2. a nurse is planning care for a client who has a
small bowel obstruction and a nasogastric (ng)
tube in place. Which of the following interventions
should the nurse include? (select all that apply.)

a. Document the ng drainage with the client’s output.

B. irrigate the ng tube every 8 hr.

c. assess bowel sounds.

D. Provide oral hygiene every 2 hr.

e. monitor ng tube for placement.

3. a nurse is caring for a client who has a small
bowel obstruction from adhesions. Which
of the following findings are consistent with
this diagnosis? (select all that apply.)

a. emesis greater than 500 ml with a fecal odor

B. report of spasmodic abdominal pain

c. High‑pitched bowel sounds

D. abdomen flat with rebound
tenderness to palpation

e. laboratory findings indicating metabolic acidosis

4. a nurse is assessing a client in an extended care
facility. the nurse should recognize which of the
following findings is a manifestation of an obstruction
of the large intestine due to a fecal impaction?

a. the client reports one bowel movement yesterday.

B. the client is having small, frequent liquid stools.

c. the client is flatulent.

D. the client indicates vomiting once this morning.

5. a nurse is completing discharge teaching with a client
who has irritable bowel syndrome (iBs). Which of the
following instructions should the nurse include?

a. Keep a food diary to identify
triggers to exacerbation.

B. consume 15 to 20 g of fiber daily.

c. Plan three moderate to large meals per day.

D. limit fluid intake to 1 l each day.

Active Learning Scenario

a nurse is preparing a poster on caring for a client who
has a bowel obstruction. What information should the
nurse include on the poster? use the ati active learning
template: system Disorder to complete this item.

RISK FACTORS: identify at least two
for each form of obstruction.

EXPECTED FINDINGS: compare and
contrast the types of obstructions.

DIAGNOSTIC PROCEDURES: identify at least two.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 51 noninFlammatorY BoWel DisorDers 345

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS
● mechanical

◯ encirclement or compression of intestines by
adhesions, tumors, fibrosis, or strictures

◯ Volvulus, intussusception
◯ Hernia, fecal impaction

● nonmechanical: decreased peristalsis due to neurogenic or vascular
disorders, electrolyte imbalances, and inflammatory responses

◯ small bowel: postsurgical adhesions
◯ large bowel: carcinoma

EXPECTED FINDINGS
● mechanical: mild, colicky, intermittent pain
● nonmechanical: vague, diffuse, constant pain;
significant abdominal distention

◯ small bowel obstruction
■ Visible peristaltic waves possible
■ Profuse, sudden projectile vomiting with fecal odor, which relieves pain
■ severe fluid and electrolyte imbalance, metabolic alkalosis

◯ large bowel obstruction
■ significant abdominal distention, infrequent vomiting, diarrhea
or “ribbon‑like” stools around an impaction, minor fluid and
electrolyte imbalance, metabolic acidosis (possible)

■ Bowel sounds: hyperactive above and hypoactive below
the obstruction, inability to pass a stool, and/or flatus
for more than 8 hr despite urge to defecate

DIAGNOSTIC PROCEDURES
● X‑rays (flat plate, upright abdominal)
● endoscopy
● ct scan

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

Application Exercises Key

1. a. Profuse emesis is an expected finding for a
client who has a small bowel obstruction. Do not
report this finding to the provider.

B. CORRECT: this urine specific gravity is greater than
the expected reference range of 1.005 to 1.030. an
increased urine specific gravity is an indication of
dehydration. report this finding to the provider.

c. CORRECT: the Hct is greater than the expected
reference range of 42% to 52% for males and 37%
to 47% for females. an elevated Hct indicates
hemoconcentration, which is due to dehydration.

D. CORRECT: this potassium is below the expected reference
range of 3.5 to 5.0 meq/l caused by potassium loss
from vomiting. Hypokalemia can cause dysrhythmias,
muscle weakness, and lethargy, and requires potassium
replacement. report this finding to the provider.

e. this WBc is within the expected reference range of 5,000 to
10,000/mm3. Do not report this finding to the provider.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. CORRECT: Document the ng drainage as output. this helps
determine the amount of fluid replacement needed.

B. the ng tube is irrigated every 4 hr to maintain patency.
c. CORRECT: Bowel sounds should be assessed to evaluate

treatment and resolution of the obstruction.
D. CORRECT: an ng tube promotes mouth breathing.

Provide frequent oral hygiene to provide comfort.
e. CORRECT: check the placement of the ng tube prior

to irrigation to prevent aspiration and periodically to
prevent an increase in abdominal distention.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. CORRECT: large emesis with a fecal odor is a finding
in a client who has a small bowel obstruction.

B. CORRECT: report of abdominal pain is a finding in
a client who has a small bowel obstruction.

c. CORRECT: High‑pitched bowel sounds are a
manifestation of a small‑ or large‑bowel obstruction.

D. abdominal distention is a finding in a client
who has a small bowel obstruction.

e. metabolic alkalosis due to the loss of gastric acid is a
finding in a client who has a small bowel obstruction.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. a. a report of a bowel movement yesterday does
not indicate a mechanical obstruction of the large
intestine due to a fecal impaction.

B. CORRECT: small, frequent liquid stools can be passed
around a fecal impaction. other manifestations
include constipation and rectal pain.

c. the presence of flatus does not indicate a mechanical
obstruction of the large intestine due to a fecal impaction.

D. a report of a single episode of vomiting does not
indicate a mechanical obstruction of the large intestine
due to a fecal impaction. Frequent vomiting is a
manifestation of a small‑bowel obstruction.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

5. a. CORRECT: the client should keep a food diary to identify
foods that trigger exacerbation of manifestations.

B. the client should increase daily fiber intake to 30 to 40 g.
c. the client should eat small frequent meals.
D. the client should drink 2 to 3 l fluids per day

to promote a consistent bowel pattern.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 52 inFlammatorY BoWel Disease 347

UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: LOWER GASTROINTESTINAL DISORDERS

CHAPTER 52 Inflammatory
Bowel Disease

inflammatory bowel disease (iBD) can
affect structures or segments along the
gastrointestinal tract. the term includes both
acute and chronic disorders.

acute and chronic iBD can result in nutritional
deficits, altered bowel elimination, infection,
pain, and fluid or electrolyte imbalances. the
nurse needs to be knowledgeable about acute
and chronic iBD in order to collaborate with the
client and the interprofessional team in treating
and managing these disorders.

acute inFlammatorY BoWel Disease

Appendicitis

Inflammation of the appendix
● Caused by an obstruction of the lumen or opening of

the appendix.
● Fecaliths, or hard pieces of stool, can be the initial cause

of the obstruction.
● Adolescents and young adults are at increased risk.
● Refer to the NURSING CARE OF CHILDREN REVIEW MODULE,

CHAPTER 23: GASTROINTESTINAL STRUCTURAL AND

INFLAMMATORY DISORDERS.

Peritonitis

Inflammation of the peritoneum results from infection
of the peritoneum due to puncture (surgery or trauma),
rupture of part of the gastrointestinal tract (diverticulitis,
peptic ulcer disease, appendicitis, bowel obstruction), or
infection from continuous ambulatory peritoneal dialysis.

Gastroenteritis

Inflammation of the stomach and small intestine
● Triggered by infection (either bacterial or viral).
● Vomiting and frequent, watery stools place the client at

increased risk for fluid and electrolyte imbalance and
impaired nutrition.

cHronic inFlammatorY
BoWel Disease
Ulcerative colitis and Crohn’s disease are characterized by
frequent stools, cramping abdominal pain, exacerbations,
and remissions.

Ulcerative colitis

Edema and inflammation primarily in the rectum and
rectosigmoid colon

● In severe cases, it can involve the entire length of the
colon. Mucosa and submucosa become hyperemic
(increase in blood flow), and the colon will become
edematous and reddened. It can lead to abscess formation.

● Edema and thickened bowel mucosa can cause partial
bowel obstruction. Intestinal mucosal cell changes
can lead to colon cancer or insufficient production of
intrinsic factor, resulting in insufficient absorption of
vitamin B12 (pernicious anemia).

● Classified as either mild, moderate, severe, and fulminant.

Crohn’s disease

Inflammation and ulceration of the gastrointestinal tract,
often at the distal ileum

● All bowel layers can become involved; lesions are
sporadic. Fistulas are common.

● Can involve the entire GI tract from the mouth to the anus.
● Malabsorption and malnutrition can develop when

the jejunum and ileum become involved. Requires
supplemental vitamins and minerals, possibly including
vitamin B12 injections.

Diverticulitis

Diverticulitis is inflammation and infection of the bowel
mucosa caused by bacteria, food, or fecal matter trapped
in one or more diverticula (pouch‑like herniations in
the intestinal wall). Diverticulitis is not to be confused
with diverticulosis, which is the presence of many small
diverticula in the colon without inflammation.

● Not all clients who have diverticulosis
develop diverticulitis.

● Diverticula can perforate and cause peritonitis, and/or
severe bleeding.

ASSESSMENT
Etiology of ulcerative colitis and Crohn’s disease is
unknown but possibly due to a combination of genetic,
environmental, and immunological causes.

risK Factors
Genetics: Ulcerative colitis and Crohn’s disease

Culture: Caucasians (ulcerative colitis), Jewish heritage
(ulcerative colitis and Crohn’s disease), and African
Americans (diverticular disease)

Sex and age: The incidence of ulcerative colitis peaks at
adolescence to young adulthood (more often in females)
and older adulthood (more often in males). Crohn’s disease
usually develops in adolescents and young adults, but can
occur at any age. Diverticulitis occurs more often in older
adults and affects males more frequently than females.

Tobacco use: Crohn’s disease

CHAPTER 52

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348 CHAPTER 52 inFlammatorY BoWel Disease CONTENT MASTERY SERIES

eXPecteD FinDings

Ulcerative colitis
● Abdominal pain/cramping: often left‑lower quadrant pain
● Anorexia and weight loss

PHYSICAL ASSESSMENT FINDINGS
● Fever
● Diarrhea: up to 15 to 20 liquid stools/day
● Stools containing mucus, blood, or pus
● Abdominal distention, tenderness, and/or firmness

upon palpation
● High‑pitched bowel sounds
● Rectal bleeding

Crohn’s disease
● Abdominal pain/cramping: often right‑lower quadrant pain
● Anorexia and weight loss

PHYSICAL ASSESSMENT FINDINGS
● Fever
● Diarrhea: five loose stools/day with mucus or pus
● Abdominal distention, tenderness and/or firmness

upon palpation
● High‑pitched bowel sounds
● Steatorrhea

Diverticulitis
● Acute onset of abdominal pain often in left‑lower quadrant
● Nausea and vomiting

PHYSICAL ASSESSMENT FINDINGS
● Fever
● Chills
● Tachycardia
● Abdominal distention

laBoratorY tests

Ulcerative colitis

Hematocrit and hemoglobin: Decreased

Erythrocyte sedimentation rate (ESR): Increased

WBC: Increased

C‑reactive protein: Increased

Albumin: Decreased

Stool for occult blood: Can be positive

K+, Na, Mg, Ca, and Cl: Decreased

Crohn’s disease

Hematocrit and hemoglobin: Decreased

ESR: Increased

WBC: Increased

C‑reactive protein: Increased

Albumin: Decreased

Folic acid and B12: Decreased

Anti‑glycan antibodies: Increased

Stool for occult blood: Can be positive

Urinalysis: WBC

K+, Mg, and Ca: Decreased

Diverticulitis

Hematocrit and hemoglobin: Decreased

ESR: Increased

WBC: Increased

Stool for occult blood: Can be positive

Diagnostic ProceDures
Magnetic resonance enterography: Used with all IBD

CLIENT EDUCATION: Maintain NPO for 4 to 6 hr prior to
the exam. You might be asked to drink a contrast medium
prior to the test.

Ulcerative colitis

Sigmoidoscopy or colonoscopy: Can diagnose
ulcerative colitis

Barium enema: Helpful to distinguish ulcerative colitis
from other disease processes

CT scan or MRI: Can identify the presence of abscesses

Stool examination: For the presence of parasites
or microbes

Crohn’s disease

Endoscopy
● Newer diagnostic tools used, such as video

capsule endoscopy
● Proctosigmoidoscopy: Performed to identify

inflamed tissue
● Colonoscopy and sigmoidoscopy: A lighted, flexible

scope inserted into the rectum to visualize the rectum
and large intestine

Abdominal ultrasound, x‑ray, and CT scan: CT scans can
show bowel thickening.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 52 inFlammatorY BoWel Disease 349

Barium enema: Barium is inserted into the rectum as a
contrast medium for x‑rays. This allows for the rectum
and large intestine to be visualized, and is used to
diagnose ulcerative colitis. A barium enema can show the
presence of diverticulosis and is contraindicated in the
presence of diverticulitis due to the risk of perforation.

NURSING ACTIONS: Monitor postprocedure for
manifestations of bowel perforations (rectal bleeding, firm
abdomen, tachycardia, hypotension).

FINDINGS
● Small intestine ulcerations and narrowing is consistent

with Crohn’s disease.
● Ulcerations and inflammation of the sigmoid colon and

rectum is significant for ulcerative colitis.

CLIENT EDUCATION
● Remain NPO as required, and perform bowel preparation.
● There can be possible abdominal discomfort and

cramping during the barium enema.

PATIENT‑CENTERED CARE

nursing care

Ulcerative colitis and Crohn’s disease
● The client should receive instructions regarding the

usual course of the disease process.
● The client should receive instructions regarding

medication therapy and vitamin supplements.
● Monitor by colonoscopy due to the increased risk of

colon cancer.
● Assist the client in identifying foods that

trigger manifestations.
● Monitor for electrolyte imbalance, especially potassium.

Diarrhea can cause a loss of fluids and electrolytes.
● Monitor I&O, and assess for dehydration.
● Educate the client to eat high‑protein, high‑calorie,

low‑fiber foods.

CLIENT EDUCATION
● Seek emergency care for indications of bowel obstruction

or perforation (fever, severe abdominal pain, vomiting).
● For extreme or long exacerbations, NPO status and

administration of total parenteral nutrition promotes
bowel rest while providing adequate nutrition.

● Avoid caffeine and alcohol.
● Take a multivitamin that contains iron.
● Small, frequent meals can reduce the occurrence

of manifestations.
● Dietary supplements that are high in protein and low in

fiber (elemental and semi‑elemental products, canned
nutrition beverages) can be used.

● Weigh 1 or 2 times weekly.
● Use of vitamin supplements and B12 injections, if needed.

Diverticulitis
● For severe manifestations (severe pain, high fever), the

client is hospitalized, NPO, and receives nasogastric
suctioning, IV fluids, IV antibiotics, and opioid
analgesics for pain.

● Instruct the client who has mild diverticulitis about
self‑care at home. The client should take medications as
prescribed (antibiotics, analgesics, antispasmodics) and
get adequate rest.

● Provide the client with instructions to promote normal
bowel function and consistency. (Avoid laxatives and the
use of enemas. Drink adequate fluids.)

CLIENT EDUCATION
● Consume a clear liquid diet until manifestations subside.
● Progress to a low‑fiber diet once solid foods are tolerated

without other manifestations. Slowly advance to a
high‑fiber diet as tolerated when inflammation resolves.

● Avoid seeds or indigestible material (nuts, popcorn,
seeds), which can block diverticulum.

● Avoid foods or drinks that can irritate the bowel. (Avoid
alcohol. Limit fat to 30% of daily calorie intake.)

meDications For ulceratiVe
colitis, croHn’s Disease

5‑aminosalicylic acid: Anti‑inflammatory

Reduces inflammation of the intestinal mucosa and
inhibits prostaglandins

Sulfonamides: Sulfasalazine
● These medications are contraindicated if the client has a

sulfa allergy.
● Sulfasalazine is given orally.
● Adverse effects include nausea, fever, and rash.
● Can take up to 2 to 4 weeks for therapeutic effects.

NURSING ACTIONS
◯ Monitor CBC, and kidney and hepatic function.
◯ Monitor for the development of agranulocytosis,

hemolytic anemia, and macrocytic anemia.

CLIENT EDUCATION
◯ Take the medication with a full glass of water
after meals.

◯ Avoid sun exposure.
◯ Increase fluid intake to 2 L/day.
◯ This medication can cause urine, skin, and
contact lenses to have a yellow‑orange color.

◯ Notify the provider if nausea, vomiting, anorexia,
sore throat, rash, bruising, or fever occur.

◯ Take medication as directed. The usual maintenance
dose of sulfasalazine is 2 to 4 g/day.

◯ Take a folic acid supplement.

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350 CHAPTER 52 inFlammatorY BoWel Disease CONTENT MASTERY SERIES

Nonsulfonamides
● Mesalamine
● Balsalazide
● Olsalazine (for clients intolerant to sulfasalazine,

rarely used)
● The adverse effects are not as serious as sulfasalazine.
● These medications can be contraindicated if the client

has a salicylate or sulfa allergy.

NURSING ACTIONS: Monitor for kidney toxicity.

CLIENT EDUCATION: Report headache or gastrointestinal
problems (abdominal discomfort, diarrhea).

Corticosteroids

Reduces inflammation and pain
● For rectal inflammation, topical steroids can be

administered by a retention enema.
● Used to induce remission.
● Not for long‑term use due to adverse effects.
● Prolonged use can lead to adrenal suppression,

osteoporosis, risk of infection, and cushingoid
syndrome. Use corticosteroids in low doses to minimize
adverse effects.

● Can slow healing.

MEDICATIONS
● Prednisone
● Prednisolone
● Hydrocortisone
● Budesonide

NURSING ACTIONS
● Monitor blood pressure.
● Reduce systemic dose slowly.
● Monitor electrolytes and glucose.

CLIENT EDUCATION
● Take the oral dose with food.
● Avoid discontinuing dose suddenly.
● Report unexpected increase in weight or other

indications of fluid retention.
● Avoid crowds and other exposures to infectious diseases.
● Report evidence of infection (Crohn’s disease can mask

infection).

Immunosuppressants

Mechanism of action in treatment of IBD is unknown.

MEDICATIONS
● Cyclosporine
● Methotrexate
● Azathioprine
● Mercaptopurine

NURSING ACTIONS
● Monitor for pancreatitis and neutropenia.
● Can take up to 6 months to see therapeutic effects.
● Not used as monotherapy.
● Reserved for refractory disease due to toxicity.

CLIENT EDUCATION
● Avoid crowds and other chances of exposures to

infectious diseases, and report evidence of infection.
● Monitor for indications of bleeding, bruising, or infection.

Immunomodulators
● Suppresses the immune response
● Inhibits tumor necrosis factor, an antibody found in

Crohn’s disease

MEDICATIONS
● Infliximab
● Adalimumab (self‑administered by subcutaneous injection)
● Natalizumab (can cause progressive multi‑focal

leukoencephalopathy, a deadly brain infection)
● Certolizumab

NURSING ACTIONS
● Follow directions for IV use with care and in accordance

with facility policy; can require pretreatment to reduce
infusion reactions.

● Many adverse effects are possible, including chills,
fever, hypotension/hypertension, dysrhythmias, and
blood dyscrasias.

● Monitor liver enzymes, coagulation studies, and CBC.

CLIENT EDUCATION
● Avoid crowds and other exposures to infectious diseases,

and report evidence of infection. There is a risk for
development or reactivation of tuberculosis.

● Monitor and report evidence of bleeding, bruising, or
infection, and transfusion or allergic reaction.

Antidiarrheals

Suppress the number of stools
● Used to decrease risk of fluid volume deficit and

electrolyte imbalance. They also reduce discomfort.
● Use of antidiarrheals can lead to toxic megacolon (massive

dilation of the colon with a risk of the development of
gangrene and peritonitis). Use cautiously.

MEDICATIONS
● Diphenoxylate and atropine
● Loperamide

NURSING ACTIONS
● Observe for manifestations of toxic megacolon that

can result in gangrene and peritonitis (hypotension,
fever, abdominal distention, decrease or absence of
bowel sounds).

● Observe for indications of respiratory depression,
especially in older adult clients.

CLIENT EDUCATION: Due to the central nervous system
effects, avoid hazardous activities until the response to
the medication is established.

meDication For DiVerticulitis

Antimicrobials

Treat infection (decrease inflammation in Crohn’s disease,
used to treat abscesses or fistulas)

● Discontinue ciprofloxacin for tendon pain. Can cause
tendon rupture.

● Decreased dose should be used for clients who have
impaired kidney function.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 52 inFlammatorY BoWel Disease 351

MEDICATIONS
● Ciprofloxacin
● Metronidazole
● Sulfamethoxazole‑trimethoprim

NURSING ACTIONS: Monitor kidney and hepatic studies.

CLIENT EDUCATION
● Can cause a superinfection; observe for manifestations

of thrush or vaginal yeast infection.
● Urine can darken (expected, harmless effect).
● Monitor for manifestations of CNS effects (numbness

of extremities, ataxia, and seizures), and notify the
provider immediately.

tHeraPeutic ProceDures
Clients who do not have success with medical treatment or
who have complications (bowel perforation, colon cancer)
are candidates for surgery.

Ulcerative colitis: Colectomy with or without ileostomy

Crohn’s disease
● Laparoscopic stricturoplasty to increase the diameter of

the bowel for bowel strictures
● Surgical repair of fistulas or in response to other

complications related to the disease (perforation)

Diverticulitis (dependent on problem)
● Required for rupture of the diverticulum that results in

peritonitis, bowel obstruction, uncontrolled bleeding,
or abscess

● Colon resection with or without colostomy

PREOPERATIVE CARE
● Preoperative care is similar to other abdominal surgeries.
● If the creation of a stoma is planned, collaborate with an

enterostomal therapy nurse regarding care related to
the stoma.

● Administer antibiotic bowel prep (neomycin), if prescribed.
● Administer cleansing enema or laxative, if prescribed.

POSTOPERATIVE CARE
● Postoperative care is similar to care for clients who have

other types of abdominal surgery.
● The client should be NPO and have a nasogastric tube to

suction, unless the surgery was performed laparoscopically.
● An ileostomy can drain as much as 1,000 mL/day.

Prevent fluid volume deficit. Replace fluid loss with IV
fluids if the client is NPO. Oral hydration is slowly
introduced in 1 to 2 days.

CARE AFTER DISCHARGE: Refer the client who has an ostomy
to an enterostomal therapist and an ostomy support group.

interProFessional care
● Refer the client for nutritional counseling.
● The client might benefit from complementary therapy

(biofeedback, massage, yoga).
● Recommend community support groups or a mental

health referral for assistance with coping.

COMPLICATIONS
Complications of ulcerative colitis, Crohn’s disease, and
diverticulitis include bleeding and fluid and electrolyte
imbalance. Peritonitis can occur due to perforation of the
bowel. Abscess formation can occur as a complication of
diverticular disease and Crohn’s disease.

Peritonitis
● A life‑threatening inflammation of the peritoneum and

lining of the abdominal cavity
● Often caused by bacteria in the peritoneal cavity

ASSESSMENT FINDINGS
● Rigid, board‑like abdomen (hallmark indication)
● Abdominal distention
● Nausea, vomiting
● Rebound tenderness
● Tachycardia
● Fever
● Early manifestation in older adult clients: decreased

mental status, confusion

NURSING ACTIONS
● Place the client in Fowler’s or semi‑Fowler’s position to

promote drainage of peritoneal fluid and improve lung
expansion.

● Monitor respiratory status and administer oxygen
as prescribed. Turn, cough, deep breathe. Provide
mechanical ventilation if needed.

● Maintain and monitor nasogastric suction.
● Keep the client NPO.
● Monitor fluid and electrolyte status.
● Monitor for hypovolemia.
● Administer hypertonic IV fluids and broad‑spectrum

antibiotics as prescribed.
● Collaborate with case management to determine home

care and wound management needs.
● If surgery is performed:

◯ Closely monitor postoperative vital signs.
◯ Monitor I&O every hour immediately after surgery.
◯ Monitor surgical dressing for bleeding.
◯ If the client requires wound irrigation postoperatively,
use sterile technique, and monitor irrigation intake
and output to prevent fluid retention.

CLIENT EDUCATION
● Maintain adequate rest and resume home activity slowly,

as tolerated. No heavy lifting for at least 6 weeks.
● Monitor for evidence of return infection. Notify the

provider immediately.

Bleeding due to deterioration of the bowel

NURSING ACTIONS
● Observe for indications of rectal bleeding (black, tarry

stools; bright red blood).
● Monitor vital signs.
● Check laboratory values, especially hematocrit,

hemoglobin, and coagulation factors.

CLIENT EDUCATION
● Report rectal bleeding.
● Understand the importance of bed rest.

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352 CHAPTER 52 inFlammatorY BoWel Disease CONTENT MASTERY SERIES

Fluid and electrolyte imbalance

Occurs due to loss of fluid through diarrhea, vomiting, and
nasogastric suctioning.

NURSING ACTIONS
● Monitor laboratory values, and provide

replacement therapy.
● Monitor weight.
● Assess for indications of fluid volume deficit (loss or

absence of skin turgor).

CLIENT EDUCATION
● Record and report the number of loose stools.
● Maintain adequate fluid intake.
● Follow the prescribed diet.

Abscess and fistula formation

Occurs due to the destruction of the bowel wall, leading to
an infection

NURSING ACTIONS
● Monitor fluid and electrolytes.
● Observe for manifestations of dehydration (decreased

urine output, fever, hypotension, tachycardia, dizziness).
● Provide a diet high in protein and calories (at least
3,000 calories/day), and low in fiber.

● Administer a vitamin supplement.
● Consult with an enterostomal therapist to develop a

plan to prevent skin breakdown and promote
wound healing.

● Monitor for evidence of infection, which can indicate
abdominal abscesses or sepsis.

● Ensure the function of drainage devices if used.

Toxic megacolon

Occurs due to inactivity of the colon. Massive dilation of
the colon occurs, and the client is at risk for perforation.

NURSING ACTIONS
● Maintain nasogastric suction.
● Administer IV fluids and electrolytes.
● Administer prescribed medications (antibiotics,

corticosteroids).
● Prepare the client for surgery (usually an ileostomy)

if the client does not begin to show improvement
within 72 hr.

Active Learning Scenario

a nurse is teaching a client who has diverticulitis. What
should the nurse include in the teaching? use the ati active
learning template: system Disorder to complete this item.

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM

RISK FACTORS: identify two.

EXPECTED FINDINGS: identify two expected findings.

DIAGNOSTIC PROCEDURES: identify three.

CLIENT EDUCATION: Describe dietary teaching.

Application Exercises

1. a nurse is reviewing the laboratory data of a client who
has an acute exacerbation of crohn’s disease. Which
of the following blood laboratory results should the
nurse expect to be elevated? (select all that apply.)

a. Hematocrit

B. erythrocyte sedimentation rate

c. WBc

D. Folic acid

e. albumin

2. a nurse is assessing a client who has been taking
prednisone following an exacerbation of inflammatory
bowel disease. the nurse should recognize which
of the following findings as the priority?

a. client reports difficulty sleeping.

B. the client’s urine is positive for glucose.

c. client reports having an elevated
body temperature.

D. client reports gaining 4 lb in the last 6 months.

3. a nurse is teaching a client who has a new prescription
for sulfasalazine. Which of the following instructions
should the nurse include in the teaching?

a. “take the medication 2 hours after eating.”

B. “Discontinue this medication if your
skin turns yellow‑orange.”

c. “notify the provider if you
experience a sore throat.”

D. “expect your stools to turn black.”

4. a nurse is completing discharge teaching with a client
who has crohn’s disease. Which of the following
instructions should the nurse include in the teaching?

a. Decrease intake of calorie‑dense foods.

B. Drink canned protein supplements.

c. increase intake of high fiber foods.

D. eat high‑residue foods.

5. a nurse in a clinic is teaching a client who has ulcerative
colitis. Which of the following statements by the
client indicates understanding of the teaching?

a. “i will plan to limit fiber in my diet.”

B. “i will restrict fluid intake during meals.”

c. “i will switch to black tea instead
of drinking coffee.”

D. “i will try to eat cold foods rather than
warm when my stomach feels upset.”

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 52 inFlammatorY BoWel Disease 353

Application Exercises Key

1. a. Hematocrit is decreased as a result of chronic blood loss.
B. CORRECT: increased erythrocyte sedimentation

rate is a finding in a client who has crohn’s
disease as a result of inflammation.

c. CORRECT: increased WBc is a finding in a
client who has crohn’s disease.

D. a decrease in folic acid level is indicative of
malabsorption due to crohn’s disease.

e. a decrease in albumin is indicative of
malabsorption due to crohn’s disease.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. the client is at risk for sleep deprivation because
prednisone can cause anxiety and insomnia.
However, another finding is the priority.

B. the client is at risk for hyperglycemia because
prednisone can cause glucose intolerance.
However, another finding is the priority.

c. CORRECT: the greatest risk to the client is infection
because prednisone can cause immunosuppression.
therefore, identify manifestations of an infection, such as
an elevated body temperature, as the priority finding.

D. the client is at risk for weight gain because
prednisone can cause fluid retention. However,
another finding is the priority.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

3. a. sulfasalazine should be taken right after meals
and with a full glass of water to reduce gastric
upset and prevent crystalluria.

B. Yellow‑orange coloring of the skin and urine
is a harmless effect of sulfasalazine.

c. CORRECT: sulfasalazine can cause blood
dyscrasias. the client should monitor and report any
manifestations of infection, such as a sore throat.

D. sulfasalazine can cause thrombocytopenia and bleeding.
Black stools are a manifestation of gastrointestinal bleeding,
and the client should report this to the provider.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. a. a high‑protein diet is recommended for the
client who has crohn’s disease.

B. CORRECT: a high‑protein diet is recommended
for the client who has crohn’s disease. canned
protein supplements are encouraged.

c. a low‑fiber diet is recommended for the client who
has crohn’s disease to reduce inflammation.

D. instruct the client to eat low‑residue
foods to reduce inflammation.

NCLEX® Connection: Physiological Adaptation,
Illness Management

5. a. CORRECT: a low‑fiber diet is recommended for the client
who has ulcerative colitis to reduce inflammation.

B. a client who has dumping syndrome
should avoid fluids with meals.

c. caffeine can increase diarrhea and cramping. the client
should avoid caffeinated beverages, such as black tea.

D. the client should avoid cold foods because these can increase
intestinal motility and cause exacerbation of manifestations.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM: inflammation
and infection of the bowel mucosa caused by bacteria or fecal matter
trapped in one or more diverticula (pouches in the intestine)

RISK FACTORS
● older adult clients
● male sex

EXPECTED FINDINGS
● Hemoglobin and hematocrit are decreased.
● stool can be positive for occult blood.

DIAGNOSTIC PROCEDURES
● abdominal x‑ray
● ct scan
● colonoscopy
● sigmoidoscopy

CLIENT EDUCATION
● consume clear liquid until manifestations subside.
Progress to a low‑fiber diet once solid foods are
tolerated. slowly advance to a high‑fiber diet.

● avoid seeds or indigestible material (nuts, popcorn, seeds).
● avoid alcohol. limit fat to 30% of daily caloric intake.

NCLEX® Connection: Physiological Adaptation, Illness
Management

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354 CHAPTER 52 inFlammatorY BoWel Disease CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 53 cHolecYstitis anD cHolelitHiasis 355

UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: GALLBLADDER AND PANCREAS DISORDERS

CHAPTER 53 Cholecystitis and
Cholelithiasis

cholecystitis is an inflammation of the
gallbladder wall. cholecystitis is most often
caused by gallstones (cholelithiasis) obstructing
the cystic and/or common bile ducts (bile
flows from the gallbladder to the duodenum)
causing bile to back up and the gall bladder to
become inflamed.

cholelithiasis is the presence of stones in the
gallbladder related to the precipitation of either
bile or cholesterol into stones. Bile is used for
the digestion of fats. it is produced in the liver
and stored in the gall bladder. cholecystitis
can be acute or chronic, and can obstruct the
pancreatic duct, causing pancreatitis. it can also
cause the gallbladder to rupture, resulting in
secondary peritonitis.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Consume a low‑fat diet rich in HDL sources
(seafood, nuts, olive oil).

● Participate in a regular exercise program.
● Do not smoke.

ASSESSMENT

risK Factors
● More common in females
● Estrogen therapy and use of some oral contraceptives
● Obesity (impaired fat metabolism, high cholesterol)
● Genetic predisposition
● Older adults (decreased gall bladder contractility, more

likely to develop gallstones)
● Type 2 diabetes mellitus (high triglycerides) or

Crohn’s disease
● Low‑calorie, liquid protein diets
● Rapid weight loss (increases cholesterol)
● Native American or Mexican American ethnicity

eXPecteD FinDings
● Sharp pain in the right upper quadrant, often radiating

to the right shoulder
● Pain with deep inspiration during right subcostal

palpation (Murphy’s sign)
● Intense pain (increased heart rate, pallor, diaphoresis)

with nausea and vomiting after ingestion of high‑fat
food caused by biliary colic

● Rebound tenderness (Blumberg’s sign performed by the
provider or advanced practice nurse)

● Dyspepsia, eructation (belching), and flatulence
● Fever

PHYSICAL ASSESSMENT FINDINGS
● Jaundice, icterus (yellow discoloration of the sclera),

clay‑colored stools, steatorrhea (fatty stools), dark urine,
and pruritus (accumulation of bile salts in the skin) can
manifest in clients who have chronic cholecystitis (due
to biliary obstruction).

● OLDER ADULT CLIENTS can have atypical presentation
of cholecystitis (absence of pain or fever). Delirium
might be the initial manifestation, or the client might
have localized tenderness.

laBoratorY tests
● Increased WBC indicates inflammation.
● Direct, indirect, and total blood bilirubin can be

increased if a bile duct is obstructed.
● Amylase and lipase can be increased with

pancreatic involvement.
● Aspartate aminotransferase (AST), lactate

dehydrogenase (LDH), and alkaline phosphatase (ALP)
(increased with liver dysfunction) can indicate the
common bile duct is obstructed.

Diagnostic ProceDures
Ultrasound visualizes gallstones and a dilated common
bile duct.

Abdominal x‑ray or CT scan can visualize calcified
gallstones and an enlarged gallbladder.

Hepatobiliary scan (HIDA) assesses the patency of the
biliary duct system after an IV injection of contrast.

Endoscopic retrograde cholangiopancreatography
allows for direct visualization using an endoscope that is
inserted through the esophagus and into the common bile
duct via the duodenum. A sphincterotomy with gallstone
removal can be done during this procedure. (Refer to
CHAPTER 46: GASTROINTESTINAL DIAGNOSTIC PROCEDURES.)

Magnetic resonance cholangiopancreatography combines
the use of oral/IV contrast with an MRI. This test assists
the provider in determining the cause of cholecystitis or
cholelithiasis.

CHAPTER 53

356 CHAPTER 53 cHolecYstitis anD cHolelitHiasis CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

nursing care
Administer analgesics as needed and prescribed.

meDications
Analgesics

● Opioid analgesics, such as morphine sulfate or
hydromorphone, are preferred for acute biliary pain.

● An NSAID, such as ketorolac, is used for mild to
moderate pain. Monitor for GI bleeding.

Bile acid

Bile acid (chenodiol, ursodiol) gradually dissolves
cholesterol‑based gall stones.

NURSING ACTIONS: Use caution in clients who have liver
conditions or disorders with varices.

CLIENT EDUCATION: Report abdominal pain, diarrhea,
or vomiting. The medication is limited to 2 years of
administration and requires a gallbladder ultrasound
every 6 months during the first year to determine
effectiveness.

tHeraPeutic ProceDures
Extracorporeal shock wave lithotripsy

Shock waves are used to break up stones. This can be used
more on nonsurgical candidates of normal weight who
have small, cholesterol‑based stones.

NURSING ACTIONS
● Instruct and assist the client to lay on a fluid‑filled pad

for delivery of shock waves.
● Administer analgesia.

CLIENT EDUCATION: Several procedures can be required to
break up all stones. There can be pain intraprocedure due
to gallbladder spasms or movement of the stones.

Cholecystectomy
● Removal of the gallbladder with a laparoscopic,

minimally invasive, or open approach
● The client usually is discharged within 24 hr if a

laparoscopic approach is used. An open approach can
require hospitalization for 1 to 2 days.

NURSING ACTIONS
● Laparoscopic approach: Provide immediate

postoperative care.
● Minimally invasive approach: Natural orifice

transluminal endoscopic surgery. Explain to the client
that this surgical procedure is performed through
entry of the mouth, vagina, or rectum. This approach
eliminates visible incisions and decreases the risk of
complications for the client.

● Open approach: The provider can place a Jackson‑Pratt
drain in the gallbladder bed or a T‑tube in the common
bile duct.

● Though used less commonly, clients can have a T‑tube
placed in the common bile duct to drain bile if there
were intraoperative complications involving the bile duct.

● Care of the drainage tube
◯ Clients can have a Jackson‑Pratt drain or other
drainage tube placed intraoperatively to prevent
accumulation of fluid in the gallbladder bed.

◯ Monitor and record drainage (initially
serosanguineous stained with green‑brown bile).

◯ Antibiotics are often prescribed to decrease the risk
for infection.

● Care of the T‑tube
◯ Instruct client to report an absence of drainage with
manifestations of nausea and pain (can indicate
obstruction in the T‑tube).

◯ Inspect the surrounding skin for evidence of infection
or bile leakage.

◯ If prescribed, elevate the T‑tube above the level of the
abdomen to prevent the total loss of bile.

◯ Monitor and record the color and amount of drainage.
◯ Clamp the tube 1 hr before and after meals to provide
the bile necessary for food digestion.

◯ Assess stools for color (stools clay‑colored until
biliary flow is reestablished).

◯ Monitor for bile peritonitis (pain, fever, jaundice).
◯ Monitor and document response to food.
◯ Expect removal of the tube in 1 to 3 weeks.

CLIENT EDUCATION
● Laparoscopic or NOTES approach

◯ Ambulate frequently to minimize free air pain,
common following laparoscopic surgery (under the
right clavicle, shoulder, scapula).

◯ Monitor the incision for evidence of infection or
wound dehiscence (laparoscopic approach).

◯ Perform pain control.
◯ Report indications of bile leak (pain, vomiting,
abdominal distention) to the provider.

◯ Resume activity gradually and as tolerated, and
resume the preoperative diet.

● Open approach
◯ Resume activity gradually. Avoid heavy lifting for 4
to 6 weeks.

◯ Begin with clear liquids and advance to solid foods as
peristalsis returns.

◯ Report sudden increase in drainage, foul odor, pain,
fever, or jaundice.

◯ Take showers instead of baths until drainage tube
is removed.

◯ The color of stools should return to brown in about a
week, and diarrhea is common.

● Dietary counseling
◯ Adhere to a low‑fat diet (reduce dairy products and
avoid fried foods, chocolate, nuts, gravies). The client
can have increased tolerance of small, frequent meals.

◯ Avoid gas‑forming foods (beans, cabbage, cauliflower,
broccoli).

◯ Consider weight reduction.
◯ Take fat‑soluble vitamins or bile salts as prescribed to
enhance absorption and aid with digestion.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 53 cHolecYstitis anD cHolelitHiasis 357

COMPLICATIONS

Obstruction of the bile duct

This can cause ischemia, gangrene, and a rupture
of the gallbladder wall. A rupture of the gallbladder
wall can cause a local abscess or peritonitis (rigid,
board‑like abdomen, guarding), which requires a
surgical intervention and administration of broad
spectrum antibiotics.

Bile peritonitis

This can occur if adequate amounts of bile are not drained
from the surgical site. This is a rare but potentially
fatal complication.

NURSING ACTIONS
● Monitor for pain, fever, and jaundice.
● Report findings to the provider immediately.

Postcholecystectomy syndrome

Manifestations of gallbladder disease can continue after
surgery. The client should report findings similar to those
experienced prior to surgery related to pain and nausea.
Manifestations can recur immediately or months later.

NURSING ACTIONS: Assess pain characteristics and other
reported findings.

CLIENT EDUCATION: Possible further diagnostic
evaluation can be needed.

Active Learning Scenario

a nurse is presenting a program on gallbladder disease to
a group of clients at a health fair. What information should
the nurse include in the program? use the ati active
learning template: system Disorder to complete this item.

RISK FACTORS: Describe at least four.

EXPECTED FINDINGS: Describe at least eight findings.

CLIENT EDUCATION: Describe three preventative activities.

Application Exercises

1. a nurse is providing discharge teaching to
a client who is postoperative following a
laparoscopic cholecystectomy. Which of the
following instructions should the nurse include
in the teaching? (select all that apply.)

a. take baths rather than showers.

B. resume a diet of choice.

c. cleanse the puncture site using
mild soap and water.

D. remove adhesive strips from the
puncture site in 24 hr.

e. report nausea and vomiting to the surgeon.

2. a nurse is reviewing risk factors with a client who has
cholecystitis. the nurse should identify that which
of the following as a risk factor for cholecystitis?

a. obesity

B. rapid weight gain

c. Decreased blood triglyceride level

D. male sex

3. a nurse is completing preoperative teaching
for a client who is scheduled for a laparoscopic
cholecystectomy. Which of the following
should be included in the teaching?

a. “the scope will be passed through your rectum.”

B. “You might have shoulder pain after surgery.”

c. “You will have a Jackson‑Pratt
drain in place after surgery.”

D. “You should limit how often you
walk for 1 to 2 weeks.”

4. a nurse is reviewing a new prescription for
chenodiol with a client who has cholelithiasis.
Which of the following information should
the nurse include in the teaching?

a. this medication is used to
decrease acute biliary pain.

B. this medication requires thyroid function
monitoring every 6 months.

c. this medication is not recommended for
clients who have diabetes mellitus.

D. this medication dissolves gallstones
gradually over a period of up to 2 years.

5. a nurse in a clinic is reviewing the laboratory
reports of a client who has suspected cholelithiasis.
Which of the following is an expected finding?

a. Blood amylase 80 units/l

B. WBc 9,000/mm3

c. Direct bilirubin 2.1 mg/dl

D. alkaline phosphatase 25 units/l

358 CHAPTER 53 cHolecYstitis anD cHolelitHiasis CONTENT MASTERY SERIES

Application Exercises Key

1. a. the client can take a bath or shower within
1 to 2 days following surgery.

B. CORRECT: the client is able to resume a
regular diet of choice upon discharge.

c. CORRECT: the client should cleanse the puncture site with
mild soap and water to decrease the risk of infection.

D. the adhesive strips covering the puncture site should
remain in place until they fall off naturally.

e. CORRECT: the client should report nausea,
vomiting, or abdominal pain to the surgeon.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

2. a. CORRECT: obesity is considered a risk factor
for the development of cholecystitis.

B. rapid weight loss is a risk factor for the
development of cholecystitis.

c. increased blood cholesterol levels are a risk
factor for developing cholecystitis.

D. Female sex is a risk factor for the
development of cholecystitis.

NCLEX® Connection: Reduction of Risk Potential

3. a. surgery is possibly performed through the
rectum during the natural orifice transluminal
endoscopic surgery (notes) approach.

B. CORRECT: shoulder pain is expected postoperatively
due to free air that is introduced into the
abdomen during laparoscopic surgery.

c. a Jackson‑Pratt can be placed during
the open surgery approach.

D. the client is instructed to ambulate frequently
following a laparoscopic surgical approach to
minimize the free air that has been introduced.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. a. opioid analgesics are preferred for the
treatment of acute biliary pain.

B. the client should have an ultrasound of the gallbladder
every 6 months during the first year of treatment to
determine effectiveness of the medication.

c. chenodiol is used cautiously in clients who have
hepatic conditions or disorders with varices.

D. CORRECT: chenodiol is a bile acid that gradually
dissolves cholesterol‑based gall stones. the
medication can be taken for up to 2 years.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

5. a. expect the client who has cholelithiasis to have
an elevated blood amylase level if pancreatic
involvement is present. a blood amylase of 80 units/l
is within the expected reference range.

B. expect the client who has cholelithiasis to have an
elevated WBc level due to inflammation. a WBc of
9,000/mm3 is within the expected reference range.

c. CORRECT: expect the client who has cholelithiasis to
have an elevated direct bilirubin level if the bile duct
is obstructed. a direct bilirubin level of 2.1 mg/dl
is above the expected reference range.

D. expect the client who has cholelithiasis to have an
elevated alkaline phosphatase (alP) level if the
common bile duct is obstructed. an alP of 25 units/l
is less than the expected reference range.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS
● Female sex
● estrogen therapy and some oral contraceptives
● High‑fat or low‑calorie, liquid protein diets
● obesity
● genetic predisposition
● age over 60 years
● type 2 diabetes mellitus
● rapid weight loss
● native american or mexican american ethnicity

EXPECTED FINDINGS
● sharp pain in the right upper quadrant that
often radiates to the right shoulder

● Pain upon deep inspiration during right subcostal palpation
● intense pain with nausea and vomiting after ingestion of high‑fat food
● Dyspepsia
● eructation (belching)
● Flatulence
● Fever
● Jaundice
● clay‑colored stools
● steatorrhea (fatty stools)
● Dark urine
● Pruritus

CLIENT EDUCATION
● get regular exercise.
● stop using tobacco products.
● consume a low‑fat diet rich in HDl sources (seafood, nuts, olive oil).

NCLEX® Connection: Physiological Adaptation, Pathophysiology

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 54 Pancreatitis 359

UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: GALLBLADDER AND PANCREAS DISORDERS

CHAPTER 54 Pancreatitis
the islets of langerhans in the pancreas secrete
insulin and glucagon. the pancreatic tissues
secrete digestive enzymes that break down
carbohydrates, proteins, and fats.

Pancreatitis is an autodigestion of the pancreas
by pancreatic digestive enzymes that activate
prematurely before reaching the intestines. the
mechanism of action is unclear. inflammation of
the pancreatic tissue causes duct obstruction,
which can lead to increased pressure and duct
rupture, causing the release of pancreatic
enzymes into the pancreatic tissue. Pancreatitis
can result in pancreatic inflammation, necrosis,
and hemorrhage. classic presentation of an
acute attack includes severe, constant, knifelike
pain (left upper quadrant, midepigastric, and/or
radiating to the back).

acute pancreatitis is an inflammatory process
due to activated pancreatic enzymes
autodigesting the pancreas ranging from
mild to necrotizing hemorrhagic pancreatitis
(widespread bleeding and necrosis).

chronic pancreatitis is a progressive, destructive
disease of inflammation and fibrosis of the
pancreas. chronic pancreatitis is classified as
chronic calcifying pancreatitis (often associated
with alcohol use disorder), chronic obstructive
pancreatitis (often associated with cholelithiasis),
autoimmune pancreatitis, and idiopathic and
hereditary pancreatitis.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Avoid excessive alcohol consumption.
● Eat a low‑fat diet.

ASSESSMENT

risK Factors
● Biliary tract disease: Gallstones can cause a blockage

where the common bile duct and pancreatic duct meet.
● Alcohol use: The primary cause of chronic pancreatitis

is alcohol use disorder. Times of increased alcohol
consumption, such as vacations or holidays, are
associated with acute pancreatitis.

● Increased age: Pancreatitis is more common in
older adults.

● Endoscopic retrograde cholangiopancreatography (ERCP)
(postprocedure complication)

● Gastrointestinal surgery
● Metabolic disturbances (hyperlipidemia,

hyperparathyroidism, hypercalcemia)
● Kidney failure or transplant
● Genetic predisposition
● Trauma
● Penetrating ulcer (gastric or duodenal)
● Medication toxicity
● Viral infections: coxsackievirus B and human

immunodeficiency virus
● Cigarette smoking

eXPecteD FinDings
● Sudden onset of severe, boring pain (goes

through the body)
◯ Epigastric, radiating to back, left flank, or left shoulder
◯ Worse when lying down

● Pain relieved somewhat by fetal position or sitting
upright, bending forward

● Nausea and vomiting
● Weight loss

PHYSICAL ASSESSMENT FINDINGS
● Seepage of blood‑stained exudates into tissue as a result

of pancreatic enzyme actions
◯ Ecchymoses on the flanks (54.1)
◯ Bluish‑gray periumbilical discoloration (54.2)

● Generalized jaundice
● Absent or decreased bowel sounds (possible

paralytic ileus)
● Warm, moist skin; fruity breath (evidence

of hyperglycemia)
● Ascites
● Tetany due to hypocalcemia

◯ Trousseau’s sign: hand spasm when blood pressure
cuff is inflated

◯ Chvostek’s sign: facial twitching when facial
nerve is tapped

CHAPTER 54

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360 CHAPTER 54 Pancreatitis CONTENT MASTERY SERIES

laBoratorY tests
● Blood amylase increases within 24 hr, and remains

increased for 2 to 3 days (continued elevation can
indicate pancreatic abscess or pseudocyst). Blood lipase
increases slowly and can remain increased for days
longer than amylase.

◯ Urine amylase remains increased for up to 1 week.
◯ Increases in enzymes indicate pancreatic cell injury.

MEMORY AID: in pancreatitis,
the “ases” (aces) are high.

● WBC count: Increased due to infection and
inflammation

● Platelets: Decreased
● Blood calcium and magnesium: Decreased due to fat

necrosis with pancreatitis
● Blood liver enzymes and bilirubin: Increased with

associated biliary dysfunction
● Serum glucose: Increased due to a decrease in insulin

production by the pancreas
● Erythrocyte sedimentation rate: Elevated

Diagnostic ProceDures
Computed tomography scan with contrast is reliably
diagnostic of acute pancreatitis.

PATIENT‑CENTERED CARE

nursing care
● Rest the pancreas.

◯ NPO: No food until pain‑free
◯ For severe pancreatitis: Enteral or parenteral nutrition
◯ When diet is resumed: Bland, high protein, low‑fat
diet with no stimulants (caffeine); small,
frequent meals

◯ Antiemetic administered as needed
◯ Nasogastric tube: Gastric decompression (for severe
vomiting or paralytic ileus)

◯ No alcohol consumption
◯ No smoking
◯ Limit stress
◯ Pain management

● Position the client for comfort (fetal, side‑lying, head of
the bed elevated, sitting up or leaning forward).

● Administer analgesics and other medications
as prescribed.

● Monitor blood glucose, and provide insulin as needed
(potential for hyperglycemia).

● Monitor hydration status (orthostatic blood pressure,
I&O, laboratory values).

● Administer IV fluids and electrolyte replacement
as prescribed.

54.1 Ecchymoses of the flank 54.2 Periumbilical discoloration

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 54 Pancreatitis 361

meDications

Opioid analgesics

Morphine or hydromorphone for acute pain

Ketorolac, an NSAID, used for mild to moderate pain

NURSING ACTIONS: Meperidine is discouraged due to the
risk of seizures, especially in older adult clients.

Antibiotics: Imipenem

Antibiotics can be used, but are generally indicated for
clients who have acute necrotizing pancreatitis.

NURSING ACTIONS
● Monitor for evidence of infection.
● Monitor for seizures.

Histamine receptor antagonists: Ranitidine

Decreases gastric acid secretion.

CLIENT EDUCATION: Take 1 hr before or 1 hr after antacid.

Proton pump inhibitors: Omeprazole

Decreases gastric acid secretion.

NURSING CONSIDERATIONS: Monitor for hypomagnesemia.

Pancreatic enzymes: Pancrelipase

Aid with digestion of fats and proteins when taken with
meals and snacks.

CLIENT EDUCATION
● Contents of capsules can be sprinkled on

nonprotein foods.
● Drink a full glass of water following pancrelipase.
● Wipe lips and rinse mouth after taking medication (to

prevent skin breakdown or irritation).
● Take pancrelipase after antacid or histamine

receptor antagonists.
● Take pancrelipase with every meal and snack.

tHeraPeutic ProceDures
● ERCP to create an opening in the sphincter of Oddi if

pancreatitis is caused by gallstones
● Cholecystectomy if pancreatitis is a result of

cholecystitis and gallstones
● Sphincterotomy to enlarge the pancreatic duct sphincter
● Endoscopic pancreatic necrosectomy and natural

orifice transluminal endoscopic surgery to remove
necrotic tissue

● Pancreaticojejunostomy (Roux‑en‑Y) reroutes drainage
of pancreatic secretions into jejunum

interProFessional care
● Dietary referral for postpancreatitis diet and nutritional

supplements can be indicated when oral intake
is resumed.

● Home health services can be indicated for clients
regarding nutritional needs, possible wound care, and
assistance with ADLs.

● Substance‑related support groups can be indicated
for a client or family member who has an alcohol
use disorder.

client eDucation
● For pancreatitis induced by alcohol use disorder, abstain

from further alcohol intake. Alcohol use support groups
can be helpful.

● Avoid high‑fat foods or heavy meals to prevent acute
pancreatitis.

COMPLICATIONS

Hypovolemia

Up to 6 L of fluid can be third‑spaced; caused by
retroperitoneal loss of protein‑rich fluid from proteolytic
digestion. The client can develop hypovolemic shock.

NURSING ACTIONS: Monitor electrolytes, and for
hypotension and tachycardia. Provide IV fluid and
electrolyte replacement.

Pancreatic infection

Pseudocyst (outside pancreas); abscess (inside pancreas)

CAUSE: Leakage of fluid out of damaged pancreatic duct

MANIFESTATIONS: Fever, epigastric mass, nausea,
vomiting, jaundice

NURSING ACTIONS
● Monitor for rupture and hemorrhage.
● Maintain sump tube if placed for drainage of cyst.
● Monitor skin around tube for breakdown secondary to

corrosive enzymes.

Type 1 diabetes mellitus

CAUSE: Lack or absence of insulin (due to destruction of
pancreatic beta cells)

NURSING ACTIONS
● Monitor blood glucose.
● Administer insulin as prescribed.

CLIENT EDUCATION: Adhere to long‑term diabetes
management.

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362 CHAPTER 54 Pancreatitis CONTENT MASTERY SERIES

Left lung effusion and atelectasis
● More common complication in older adults
● Can precipitate pneumonia

CAUSES
● Splinting of chest due to pain upon coughing and

deep breathing
● Pancreatic ascites

NURSING ACTIONS: Monitor for hypoxia, and provide
ventilatory support.

Coagulation defects

Disseminated intravascular coagulopathy

CAUSES: Release of thromboplastic endotoxins secondary
to necrotizing hemorrhagic pancreatitis

NURSING ACTIONS: Monitor coagulation studies and
for bleeding.

Multi-system organ failure

Inflammation of pancreas is believed to trigger systemic
inflammation.

CAUSE: Necrotizing hemorrhagic pancreatitis

NURSING ACTIONS
● Administer treatments.
● Monitor for evidence of organ failure (respiratory

distress, jaundice, oliguria).
● Report unexpected findings to provider.

Active Learning Scenario

a nurse is reviewing the plan of care for a client who
has pancreatitis. What should the nurse include in
the plan? use the ati active learning template:
system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS): Describe
the classic presentation of pancreatitis.

LABORATORY TESTS: Describe four
tests and expected findings.

NURSING CARE: Describe at least six nursing actions.

Application Exercises

1. a nurse is reviewing the admission laboratory results
of a client who has acute pancreatitis. Which of
the following findings should the nurse expect?

a. Decreased blood lipase level

B. Decreased blood amylase level

c. increased blood calcium level

D. increased blood glucose level

2. a nurse is preparing to administer pancrelipase
to a client who has pancreatitis. Which of the
following actions should the nurse take?

a. instruct the client to chew the
medication before swallowing.

B. offer a glass of water following
medication administration.

c. administer the medication 30 min before meals.

D. sprinkle the contents on peanut butter.

3. a nurse is completing an admission assessment
of a client who has pancreatitis. Which of the
following findings should the nurse expect?

a. Pain in right upper quadrant
radiating to right shoulder

B. report of pain being worse when sitting upright

c. Pain relieved with defecation

D. epigastric pain radiating to the left shoulder

4. a nurse is assessing a client who has pancreatitis.
Which of the following findings should the nurse
identify as a manifestation of pancreatitis?

a. generalized cyanosis

B. Hyperactive bowel sounds

c. gray‑blue discoloration of the
skin around the umbilicus

D. Wheezing in the lower lung fields

5. a nurse is completing nutrition teaching for a
client who has pancreatitis. Which of the following
statements by the client indicates an understanding
of the teaching? (select all that apply.)

a. “i plan to eat small, frequent meals.”

B. “i will eat easy‑to‑digest foods with limited spice.”

c. “i will use skim milk when cooking.”

D. “i plan to drink regular cola.”

e. “i will limit alcohol intake to two drinks per day.”

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 54 Pancreatitis 363

Application Exercises Key

1. a. the client will experience an elevated blood lipase
level due to pancreatic cell injury.

B. the client will experience an elevated blood
amylase level due to pancreatic cell injury.

c. the client will experience a decreased blood
calcium level due to fat necrosis.

D. CORRECT: the client will experience an increased
blood glucose level due to pancreatic cell injury, which
results in impaired metabolism of carbohydrates
due to a decrease in the release of insulin.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

2. a. Pancrelipase should be swallowed without chewing to reduce
irritation and slow the release of the medication.

B. CORRECT: Drink a full glass of water following
administration of pancrelipase.

c. Pancrelipase should be administered
with every meal and snack.

D. the contents of the pancrelipase capsule can be sprinkled
on nonprotein foods, and peanut butter is a protein food.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

3. a. a client who has cholecystitis will report pain in the right
upper quadrant radiating to the right shoulder.

B. a client who has pancreatitis will report pain
being worse when lying down.

c. a client who has pancreatitis will report that pain
is relieved by assuming the fetal position.

D. CORRECT: a client who has pancreatitis will
report severe, boring epigastric pain that radiates
to the back, left flank, or left shoulder.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. a. expect to find generalized jaundice.
B. expect to find absent or decreased bowel sounds.
c. CORRECT: a gray‑blue discoloration in the periumbilical

area is a manifestation of pancreatitis.
D. expect to find diminished breath sounds

as well as dyspnea or orthopnea.

NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments

5. a. CORRECT: small, frequent meals are recommended
for the client who has pancreatitis.

B. CORRECT: Bland, easy‑to‑digest foods are
recommended for the client who has pancreatitis.

c. CORRECT: low‑fat foods are recommended
for the client who has pancreatitis.

D. caffeine‑free beverages are recommended for the client
who has pancreatitis. regular cola contains caffeine.

e. the client who has pancreatitis should
avoid any alcohol intake.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): severe, constant, knifelike
pain (left upper quadrant, midepigastric, and/or radiating to the back)

LABORATORY TESTS
● Blood amylase (increases within 12 hr, remains increased for 4 days)
● Blood lipase value (increases slowly and
remains increased for up to 2 weeks)

● urine amylase remains increased for up to 2 weeks
● increased WBc count due to inflammation/infection
● Decreased blood calcium and magnesium
● Blood liver enzymes and bilirubin increased
with associated biliary dysfunction

● Blood glucose increased

NURSING CARE
● maintain nPo status until the client is pain‑free.
● administer total parenteral nutrition or jejunal feedings
(contraindicated if paralytic ileus develops).

● maintain ng tube (for severe vomiting or paralytic ileus).
● resume diet beginning with bland, high protein,
low‑fat foods, and no caffeine.

● Plan small, frequent meals.
● administer antiemetics as needed.
● limit stress.
● Provide pain management.
● remind the client to not consume alcohol or smoke.

NCLEX® Connection: Physiological Adaptation, Alterations in
Body Systems

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364 CHAPTER 54 Pancreatitis CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 55 HePatitis anD cirrHosis 365

UNIT 7 GASTROINTESTINAL DISORDERS
SECTION: LIVER DISORDERS

CHAPTER 55 Hepatitis and
Cirrhosis

Hepatitis is an inflammation of liver cells.
Hepatitis can be caused by a viral or toxic agent,
or as a secondary infection in conjunction with
another virus. it is classified as acute or chronic.

cirrhosis is permanent scarring of the liver that
is usually caused by chronic inflammation.

Hepatitis
● Viral hepatitis is the most common type of hepatitis.
● Toxic and drug‑induced hepatitis occurs secondary

to an exposure to a chemical or medication agent
(alcohol, industrial toxins, ephedra, acetaminophen).

● Hepatitis can occur in conjunction with other viruses
(varicella‑zoster, cytomegalovirus, herpes simplex).

● After exposure to a virus or toxin, the liver becomes
enlarged from the inflammatory process. As the disease
progresses, there is an increase in inflammation and
necrosis, interfering with blood flow to the liver.

● Individuals can be infected with a hepatitis virus
and remain free of manifestations, and therefore are
unaware that they could be contagious.

Major categories of viral hepatitis
● Hepatitis A virus (HAV)
● Hepatitis B virus (HBV)
● Hepatitis C virus (HCV)
● Hepatitis D virus (HDV)
● Hepatitis E virus (HEV)

HEALTH PROMOTION AND
DISEASE PREVENTION

● Follow vaccination recommendations according to the CDC.
● Follow infection control precautions according to the CDC.
● Reinforce and use safe injection practices.

◯ Aseptic technique for preparation and administration
of parenteral medications

◯ Sterile, single‑use, disposable needle and syringe for
each injection

◯ Single‑dose vials whenever possible
◯ Needleless systems or safety caps

● Use proper hand hygiene (before preparing and eating
food, after using the toilet or changing a diaper).

● When traveling to underdeveloped countries, drink
purified water, and avoid sharing eating utensils and
bed linens.

ASSESSMENT

risK Factors

Hepatitis A

ROUTE OF TRANSMISSION: Fecal‑oral

RISK FACTORS
● Ingestion of contaminated food or water,

especially shellfish
● Contact with infected stool (incontinent individuals,

anal sexual activity)

Hepatitis B

ROUTE OF TRANSMISSION: Blood

RISK FACTORS
● Unprotected sex with infected individual
● Infants born to infected mothers
● Contact with infected blood
● Substance use disorder (injectable substances)

Hepatitis C

ROUTE OF TRANSMISSION: Blood

RISK FACTORS
● Substance use disorder (injectable substances)
● Blood, blood products, or organ transplants
● Contaminated needle sticks, unsanitary tattoo equipment
● Sexual contact

Hepatitis D

ROUTE OF TRANSMISSION: Coinfection with HBV

RISK FACTORS
● Substance use disorder (injectable substances)
● Unprotected sex with infected individual

Hepatitis E

ROUTE OF TRANSMISSION: Fecal‑oral

RISK FACTORS: Ingestion of food or water contaminated
with fecal waste

Additional risk factors
● Unscreened blood transfusions (prior to 1992)
● Hemodialysis
● Percutaneous exposure (dirty needles, sharp

instruments, body piercing, tattooing, use of another
person’s substance use paraphernalia or personal
hygiene tools)

● Ingestion of food prepared by a hepatitis‑infected person
who does not practice proper sanitation precautions

● Travel/residence in underdeveloped country
(using tap water to clean food products, drinking
contaminated water)

● Eating or living in crowded environments (correctional
facilities, dormitories, universities, long‑term care
facilities, military base housing)

CHAPTER 55

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366 CHAPTER 55 HePatitis anD cirrHosis CONTENT MASTERY SERIES

eXPecteD FinDings
● History of exposure to infected blood, stool, or

body fluid
● Influenza‑like manifestations

◯ Fatigue
◯ Decreased appetite with nausea
◯ Abdominal pain
◯ Joint pain

PHYSICAL ASSESSMENT FINDINGS
● Fever
● Vomiting
● Dark‑colored urine
● Clay‑colored stool
● Jaundice

laBoratorY tests

Hepatitis A

Alanine aminotransferase (ALT): Elevated;
expected reference range is 4 to 36 units/L.

Aspartate aminotransferase (AST): Elevated;
expected reference range is 0 to 35 units/L.

Alkaline phosphatase (ALP): Normal or elevated;
expected reference range is 30 to 120 units/L.

Total bilirubin level: Elevated; expected reference range is
0.3 to 1.0 mg/dL.

Hepatitis A virus antibodies (anti‑HAV):
Presence indicates the presence of hepatitis A.

Hepatitis B

ALT: Elevated

AST: Elevated

ALP: Normal or elevated

Total bilirubin level: Elevated

Hepatitis B surface antigen (HBsAg): Presence indicates
that the individual is infectious. However, a client who
is vaccinated against HBV will have a positive HBsAg,
indicating immunity to the disease.

Hepatitis C

ALT: Elevated

AST: Elevated

ALP: Normal or elevated

Total bilirubin level: Elevated

Hepatitis C virus antibodies (anti‑HCV): Detects presence
of antibodies to hepatitis C infection

Enzyme immunoassay (EIA): Detects presence of antigens
or antibodies to hepatitis C infection

HCV RNA polymerase chain reaction (PCR):
Qualitative test to detect the presence and amount of HCV

Hepatitis D

Identification of intrahepatic delta antigen

Hepatitis D virus antibodies (anti‑HDV):
Presence indicates the presence of HDV.

Hepatitis E

Hepatitis E virus antibodies (anti‑HEV):
Presence indicates the presence of HEV.

Diagnostic ProceDures

Liver biopsy

This is the most definitive diagnostic approach, and it
is used to identify the intensity of the infection and the
degree of liver damage.

PREPROCEDURE NURSING ACTIONS
● Explain the procedure.
● Witness informed consent.
● Ensure the client fasts starting at midnight on the day

of the procedure in case surgery is needed due to a
complication.

● Administer medications as prescribed.

INTRAPROCEDURE NURSING ACTIONS
● Assist the client into the supine position with the upper

right quadrant of the abdomen exposed.
● Assist the client with relaxation techniques.
● Instruct the client to exhale and hold for at least
10 seconds while the needle is inserted.

● Instruct the client to resume breathing once the needle
is withdrawn.

● Apply pressure to the puncture site.

POSTPROCEDURE NURSING ACTIONS
● Assist the client to a right side‑lying position and

maintain for several hours.
● Monitor vital signs.
● Assess for abdominal pain.
● Assess for bleeding from the puncture site.
● Assess for manifestations of pneumothorax (dyspnea,

cyanosis, restlessness) due to accidental puncture of the
pleura or lung.

PATIENT‑CENTERED CARE

nursing care
● Most clients will be cared for in the home unless they

are acutely ill.
● Enforce contact precautions if indicated.
● Provide a high‑carbohydrate, high‑calorie, moderate‑

fat, and moderate‑protein diet after nausea and
anorexia subsides, and small, frequent meals to promote
nutrition and healing.

● Promote hepatic rest and the regeneration of tissue.
◯ Administer only necessary medications, including
over‑the‑counter medications or herbal supplements.

◯ Avoid alcohol.
◯ Limit physical activity.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 55 HePatitis anD cirrHosis 367

● Educate the client and family regarding measures to
prevent the transmission of the disease to
others at home.

◯ Avoid sexual intercourse until hepatitis antibody
testing is negative.

◯ Use proper hand hygiene.
● Provide culturally sensitive care.
● Discuss use of or interest in complementary and

integrative therapies with the client as a way to improve
quality of life.

meDications

Hepatitis A
● Hepatitis A immunization is recommended for

post‑exposure protection.
● Immunoglobulin is recommended for post‑exposure

protection for clients older than 40 years, younger than
12 months, who have chronic liver disease, who are
immunosuppressed, or who are allergic to the vaccine.

Hepatitis B

Acute infection: No medications; supportive care

Chronic infection: Antiviral medications: tenofovir,
adefovir dipivoxil, interferon alfa‑2b, peginterferon
alfa‑2a, lamivudine, entecavir, and telbivudine

Hepatitis C

Combination therapy with peginterferon alfa‑2a and
ribavirin is the preferred treatment.

Hepatitis E

No medications; supportive care

interProFessional care
Possible consults with infection control, social
worker, primary care provider; connect the client with
community resources.

COMPLICATIONS
Chronic hepatitis

● Ongoing inflammation of the liver cells
● Results from hepatitis B, C, or D
● Increases the client’s risk for liver cancer

Fulminant hepatitis
● Extremely severe and potentially fatal form of

viral hepatitis.
● Clients develop manifestations of viral hepatitis, then

within hours or days develop severe liver failure.
● No medications, supportive care.

Cirrhosis of the liver: Permanent scarring of the liver that
is usually caused by chronic inflammation

Liver cancer

Liver failure: Irreversible damage to liver cells, with
decreased ability to function adequately to meet the
body’s needs

Hepatic encephalopathy: A life‑threatening complication
of liver failure. Toxic substances, which are normally
detoxified by the liver, enter systemic circulation.
Ammonia levels rise and enter the brain, causing clients
to develop changes in neurologic status that can progress
to stupor, asterixis (hand flapping), fetor hepaticus (fruity,
musty breath odor), seizures, and coma.

Cirrhosis
● Cirrhosis is extensive scarring of the liver caused by

necrotic injury or a chronic reaction to inflammation
over a prolonged period of time. Normal liver tissue is
replaced with fibrotic tissue that lacks function.

● Portal and periportal areas of the liver are primarily
involved, affecting the liver’s ability to handle the flow
of bile by nodules blocking the bile ducts and normal
blood flow throughout the liver. The development of
new bile channels causes an overgrowth of tissue and
liver scarring/enlargement. Jaundice is often the result.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Prevent infection with viral hepatitis (B, C, D).
● Avoid excessive alcohol intake.

Types of cirrhosis

Postnecrotic: Caused by viral hepatitis, or some
medications or toxins

Laennec’s: Caused by chronic alcohol use disorder

Biliary: Caused by chronic biliary obstruction or
autoimmune disease

ASSESSMENT

risK Factors
● Alcohol use disorder
● Chronic viral hepatitis (hepatitis B, C, or D)
● Autoimmune hepatitis (destruction of the liver cells by

the immune system)
● Steatohepatitis (fatty liver disease causing

chronic inflammation)
● Damage to the liver caused by medications, substances,

toxins, infections
● Chronic biliary cirrhosis (bile duct obstruction, bile

stasis, hepatic fibrosis)
● Cardiac cirrhosis resulting from severe right heart

failure inducing necrosis and fibrosis due to lack of
blood flow

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368 CHAPTER 55 HePatitis anD cirrHosis CONTENT MASTERY SERIES

eXPecteD FinDings
● Fatigue
● Weight loss, abdominal pain, distention
● Pruritus (severe itching of skin)
● Confusion or difficulty thinking (due to the buildup of

waste products in the blood and brain that the liver is
unable to get rid of)

● Personality and mentation changes, emotional lability,
euphoria, depression

PHYSICAL ASSESSMENT FINDINGS
● Cognitive changes
● Altered sleep/wake pattern
● Gastroesophageal bleeding (enlarged esophageal veins

[varices] develop and burst, causing vomiting and passing
of blood in bowel movements) or portal hypertensive
gastropathy, which causes bleeding of gastric mucosa

● Splenomegaly caused from backup of blood into
the spleen, which can cause thrombocytopenia and
platelet destruction

● Ascites (bloating or swelling due to fluid buildup in
abdomen and legs)

● Jaundice (yellowing of skin) and icterus (yellowing
of the eyes) from decreased excretion of bilirubin,
resulting in an increase of circulating bilirubin levels

● Petechiae (round, pinpoint, red‑purple lesions),
ecchymoses (large yellow and purple‑blue bruises),
nosebleeds, hematemesis, melena (decreased synthesis
of prothrombin, deteriorating hepatic function)

● Palmar erythema (redness, warmth of the palms of
the hands)

● Spider angiomas (red lesions, vascular in nature
with branches radiating on the nose, cheeks, upper
thorax, shoulders)

● Dependent peripheral edema of extremities and sacrum
● Asterixis (liver flapping tremor): coarse tremor

characterized by rapid, nonrhythmic extension and
flexion of the wrists and fingers

● Fetor hepaticus (liver breath): fruity or musty odor

laBoratorY tests

Blood liver enzymes: Elevated initially

Lactate dehydrogenase (LDH), ALT and AST are elevated
due to hepatic inflammation. ALT and AST return to
normal when liver cells are no longer able to create an
inflammatory response. ALP increases in cirrhosis due to
intrahepatic biliary obstruction.

ALT: Expected reference range 4 to 36 units/L

AST: Expected reference range 0 to 35 units/L

ALP: Expected reference range 30 to 120 units/L

Blood bilirubin: Elevated

Bilirubin levels are elevated in cirrhosis due to the
inability of the liver to excrete bilirubin.

Bilirubin, indirect (unconjugated): Elevated; expected
reference range 0.2 to 0.8 mg/dL

Bilirubin, total: Elevated; expected reference range
0.3 to 1.0 mg/dL

Blood protein
● Decreased due to the lack of hepatic synthesis
● Expected reference range 6.4 to 8.3 g/dL

Blood albumin
● Decreased due to the lack of hepatic synthesis
● Expected reference range 3.5 to 5 g/dL

Hematological tests

RBC: Decreased

Hemoglobin: Decreased

Hematocrit: Decreased

Platelet count: Decreased

PT/INR

Prolonged due to decreased synthesis of prothrombin

Ammonia levels
● Increase when hepatocellular injury (cirrhosis) prevents

the conversion of ammonia to urea for excretion.
● Expected reference range 6 to 47 µmol/L (10 to 80 mcg/dL)

Blood creatinine levels

Can increase due to deteriorating kidney function, which
can occur as a result of advanced liver disease

Diagnostic ProceDures
Ultrasound: Used to detect ascites, hepatomegaly,
splenomegaly, biliary stones, or biliary obstruction

Abdominal x‑rays and CT scan: Used to visualize possible
hepatomegaly, ascites, and splenomegaly

MRI: Used to visualize mass lesions and determine
whether the liver is malignant or benign

Liver biopsy (most definitive)
● A liver biopsy identifies the progression and extent of

the cirrhosis.
● To minimize the risk of hemorrhage, a radiologist can

perform the biopsy through the jugular vein, which
is threaded to the hepatic vein to obtain tissue for a
microscopic evaluation.

● This is done under fluoroscopy for safety because this
procedure can be problematic for cirrhosis clients due to
an increased risk for bleeding complications.

Esophagogastroduodenoscopy: This is performed under
moderate (conscious) sedation to detect the presence
of esophageal varices, ulcerations in the stomach, or
duodenal ulcers and bleeding.

Endoscopic retrograde cholangiopancreatography: Used
to view the biliary tract to assist in removing stones, to
collect specimens for biopsy, and for stent placement

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 55 HePatitis anD cirrHosis 369

PATIENT‑CENTERED CARE

nursing care
Respiratory status: Monitor oxygen saturation levels
and distress. Provide comfort measures by positioning
the client to ease respiratory effort (can be compromised
by plasma volume excess and ascites). Have the client
sit in a chair or elevate the head of the bed to 30° with
feet elevated.

Skin integrity: Monitor closely for skin breakdown.
Implement measures to prevent pressure injuries. Pruritus,
which is associated with jaundice, will cause the client to
scratch. Encourage washing with cold water and applying
lotion to decrease the itching.

Fluid balance: Monitor for indications of fluid volume
excess. Keep strict I&O, obtain daily weights, and assess
ascites and peripheral edema. Restrict fluids and sodium
if prescribed.

Vital signs: Monitor vital signs and pain level.

Neurologic status: Monitor for deteriorating mental status
and dementia consistent with hepatic encephalopathy.
Monitor for asterixis (coarse tremor of wrists and fingers)
and fetor hepaticus. Lactulose can be given to aid in
excretion of ammonia.

Nutritional status: High‑carbohydrate, high‑protein,
moderate‑fat, and low‑sodium diet with vitamin
supplements (thiamine, folate, multivitamins)

Gastrointestinal status: In the presence of ascites,
measure abdominal girth daily over the largest part of
the abdomen. Mark the location of tape for consistency.
Observe for potential bleeding complications.

Pain status: Assess pain, and administer analgesics and
gastrointestinal antispasmodics as needed.

meDications
Because the metabolism of most medications is dependent
upon a functioning liver, general medications are
administered sparingly, especially opioids, sedatives,
and barbiturates.

Diuretics: Decrease excessive fluid in the body

Beta‑blocking agent: Used for clients who have varices to
prevent bleeding

Lactulose: Used to promote excretion of ammonia from
the body through the stool

Nonabsorbable antibiotic: Can be used in place of lactulose

tHeraPeutic ProceDures

Paracentesis

Used to relieve ascites

PREPROCEDURE NURSING CARE
● Explain the procedure.
● Witness informed consent.
● Obtain vital signs and weight.
● Assist the client to void to reduce the risk of injury to

the bladder.
● Weigh client.

INTRAPROCEDURE NURSING CARE
● Position the client supine with head of bed elevated.
● Assist the client with relaxation techniques.
● Apply dressing over puncture site.

POSTPROCEDURE NURSING CARE
● Monitor vital signs.
● Maintain bed rest.
● Measure the fluid, and document amount and color.
● Send specimen to the laboratory.
● Access puncture site dressing for drainage.
● Weigh client.

Endoscopic variceal ligation/
endoscopic sclerotherapy

● Varices are either sclerosed or banded endoscopically.
● There is a decreased risk of hemorrhage with banding.

Transjugular intrahepatic portosystemic shunt

This is performed in interventional radiology for
clients who require further intervention with ascites or
hemorrhage.

Surgical bypass shunting procedures

This is a last resort for clients who have portal
hypertension and esophageal varices. Ascites is shunted
from the abdominal cavity to the superior vena cava.

Liver transplantation
● Portions of healthy livers from deceased donors (most

commonly trauma victims) or living donors can be used
for transplant.

● The transplanted liver portion will regenerate and grow
in size based on the needs of the body.

● The client must meet the transplant criteria to
be eligible.

● Clients who have severe cardiac and respiratory disease,
metastatic malignant liver cancer, or alcohol/substance
use disorder are not candidates for liver transplantation.

PREPROCEDURE NURSING ACTIONS
● Use a multidisciplinary approach.
● Witness informed consent.

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370 CHAPTER 55 HePatitis anD cirrHosis CONTENT MASTERY SERIES

POSTPROCEDURE NURSING ACTIONS
● Provide close monitoring during the immediate

postoperative period in an intensive care unit.
● Monitor vital signs frequently.
● Monitor neurologic status.
● Monitor for acute graft rejection: tachycardia, fever,

right upper quadrant pain, change in bile color or
increased jaundice, increased ALT and AST levels.

● Monitor for infection: fever or excessive,
foul‑smelling drainage.

● Monitor for clotting problems: blood in drainage
tubes, petechiae.

● Monitor for hepatic complications: decreased bile
drainage, increased right upper quadrant pain with
distention, nausea and vomiting, increased jaundice.

● Monitor for acute kidney injury: change in urine
output, increased BUN and creatinine levels, and
electrolyte imbalance.

● Administer immunosuppressant agents.
● Administer antibiotic prophylaxis.
● Obtain blood cultures.
● Keep T‑tube in dependent position, and empty

frequently, documenting amount and description.

interProFessional care
● A dietary consult can assist with specific diet needs.
● Initiate appropriate referrals (social services, Alcoholics
Anonymous, Al‑Anon).

client eDucation
● Abstain from alcohol and engage in an alcohol recovery

program if needed.
◯ Helps prevent further scarring and fibrosis of liver
◯ Allows healing and regeneration of liver tissue
◯ Prevents irritation of the stomach and
esophagus lining

◯ Helps decrease the risk of bleeding
◯ Helps prevent other life‑threatening complications

● Consult with the provider prior to taking any
over‑the‑counter medications or herbal supplements.

● Follow diet guidelines.
◯ High‑calorie, moderate‑fat diet
◯ Low‑sodium diet (if there is excessive fluid in the

peritoneal cavity)
◯ Low‑protein (if encephalopathy, elevated ammonia)
◯ Small, frequent, well‑balanced nutritional meals
◯ Nutritional supplement drinks or shakes and a daily
multivitamin

◯ Replacement and administration of vitamins due to
the inability of the liver to store them

◯ Fluid intake restrictions if blood sodium is low

COMPLICATIONS
Hepatic encephalopathy/
Portal systemic encephalopathy

Clients who have a poorly functioning liver are unable
to convert ammonia and other waste products to a less
toxic form. These products are carried to the brain and
cause neurologic manifestations. Clients are treated with
medications such as lactulose to reduce the ammonia
levels in the body via intestinal excretion. Reductions in
dietary protein are indicated as ammonia is formed when
protein is broken down by intestinal flora.

NURSING ACTIONS
● Administer lactulose as prescribed.
● Monitor laboratory findings, including potassium,

because clients can become hypokalemic with increased
stools from the lactulose therapy.

● Assess for changes in the level of consciousness
and orientation.

● Report asterixis (flapping of the hands) and fetor
hepaticus immediately to the provider. These are
clinical indications that encephalopathy is worsening.

CLIENT EDUCATION: Adhere to the prescribed diet.

Esophageal varices

CAUSES: Portal hypertension (elevated blood pressure in
veins that carry blood from the intestines to the liver) is
caused by impaired circulation of blood through the liver.
Collateral circulation is subsequently developed, creating
varices in the upper stomach and esophagus. Varices are
fragile and can bleed easily.

NURSING ACTIONS
● Assist with saline lavage (vasoconstriction),

esophagogastric balloon tamponade, blood transfusions,
ligation and sclerotherapy, and shunts to stop bleeding
and reduce the risk for hypovolemic shock.

● Monitor hemoglobin level and vital signs.
● Monitor for any bleeding.

Acute graft rejection post liver transplantation

This typically occurs between 4 and 10 days after surgery.

INDICATIONS OF REJECTION
● Tachycardia
● Upper right flank pain
● Jaundice
● Laboratory findings indicative of liver failure

CAUSES: Graft vs. host disease (recipient’s bone marrow
creates T‑cells to attack the new organ).

NURSING ACTIONS
● Early diagnosis of graft rejection is necessary to

successfully prevent total rejection of the liver.
● Administer immunosuppressants as prescribed.
● Monitor laboratory findings.

CLIENT EDUCATION
● Understand the importance of taking immunosuppressants

and monitoring white blood cell count.
● Report indications of rejection to the provider immediately.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 55 HePatitis anD cirrHosis 371

Active Learning Scenario

a nurse is caring for a client who has hepatitis c and will
undergo liver biopsy. use the ati active learning template:
Diagnostic Procedure to complete the following.

DESCRIPTION OF PROCEDURE

NURSING INTERVENTIONS (PRE, INTRA, POST): one
preprocedure, one intraprocedure, and one postprocedure.

POTENTIAL COMPLICATIONS: identify one
potential complication of the procedure.

Application Exercises

1. a nurse on a medical‑surgical unit is admitting a client
who has hepatitis B with ascites. Which of the following
actions should the nurse include in the plan of care?

a. initiate contact precautions.

B. Weigh the client weekly.

c. measure abdominal girth at the
base of the ribcage.

D. Provide a high‑calorie, high‑carbohydrate diet.

2. a nurse is caring for a client who has a new
diagnosis of hepatitis c. Which of the following
laboratory findings should the nurse expect?

a. Presence of immunoglobulin g antibodies (igg)

B. Positive eia test

c. aspartate aminotransferase (ast) 35 units/l

D. alanine aminotransferase (alt) 15 iu/l

3. a nurse is assessing a client who has advanced
cirrhosis. the nurse should identify which of
the following findings as indicators of hepatic
encephalopathy? (select all that apply.)

a. anorexia

B. change in orientation

c. asterixis

D. ascites

e. Fetor hepaticus

4. a nurse is caring for a client who has cirrhosis. Which
of the following medications can the nurse expect
to administer to this client? (select all that apply.)

a. Diuretic

B. Beta‑blocking agent

c. opioid analgesic

D. lactulose

e. sedative

5. a nurse is teaching a client who has hepatitis B about
home care. Which of the following instructions should
the nurse include in the teaching? (select all that apply.)

a. limit physical activity.

B. avoid alcohol.

c. take acetaminophen for comfort.

D. Wear a mask when in public places.

e. eat small frequent meals.

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372 CHAPTER 55 HePatitis anD cirrHosis CONTENT MASTERY SERIES

Application Exercises Key

1. a. Hepatitis B is transmitted via blood. standard
precautions are adequate.

B. Daily weights are obtained to monitor fluid status.
c. the client’s abdominal girth is measured over the largest

part of the abdomen, which will vary by client.
D. CORRECT: the client who has hepatitis B should

have a diet high in calories and carbohydrates.

NCLEX® Connection: Physiological Adaptation,
Illness Management

2. a. the presence of igg is an expected laboratory finding
in a client who has hepatitis a infection.

B. CORRECT: a positive eia test is an expected laboratory
finding in a client who has a new diagnosis of hepatitis c.

c. ast is elevated in clients who have hepatitis c infection;
35 units/l is within the expected reference range.

D. alt is elevated in clients who have hepatitis c infection;
15 units/l is within the expected reference range.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

3. a. anorexia is present in a client who has liver dysfunction, but
it is not an indication of hepatic encephalopathy.

B. CORRECT: a change in orientation indicates hepatic
encephalopathy in a client who has advanced cirrhosis.

c. CORRECT: asterixis, a coarse tremor of the wrists and
fingers, is observed as a late complication in a client
who has cirrhosis and hepatic encephalopathy.

D. ascites can be present in a client who has liver dysfunction,
but it is not an indication of hepatic encephalopathy.

e. CORRECT: Fetor hepaticus (a fruity, musty breath
odor) is a finding of hepatic encephalopathy in
the client who has advanced cirrhosis.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. a. CORRECT: Diuretics facilitate excretion of excess fluid
from the body in a client who has cirrhosis.

B. CORRECT: Beta‑blocking agents are prescribed for a client
who has cirrhosis to prevent bleeding from varices.

c. opioid analgesics are metabolized in the liver. they should
not be administered to a client who has cirrhosis.

D. CORRECT: lactulose is prescribed for a client who has
cirrhosis to aid in the elimination of ammonia in the stool.

e. sedatives are metabolized in the liver. they should
not be administered to a client who has cirrhosis.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

5. a. CORRECT: limiting physical activity and taking frequent
rest breaks conserves energy and assists in the recovery
process for a client who has hepatitis B.

B. CORRECT: alcohol is metabolized in the liver and should
be avoided by the client who has hepatitis B.

c. acetaminophen is metabolized in the liver and should
be avoided by the client who has hepatitis B.

D. Hepatitis B is a blood‑borne disease. Wearing a mask
is not necessary to prevent transmission to others.

e. CORRECT: the client who has hepatitis B should
eat small, frequent meals to promote improved
nutrition due to the presence of anorexia.

NCLEX® Connection: Physiological Adaptation,
Illness Management

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

DESCRIPTION OF PROCEDURE: a liver biopsy is a procedure to
collect a sample of liver tissue for diagnostic testing. a needle is
inserted in the intercostal space between the two right lower ribs
and into the liver. an aspirate of liver tissue is then collected.

NURSING ACTIONS (PRE, INTRA, POST)

Preprocedure
● explain the procedure to the client/family.
● Witness informed consent.
● ensure the client has been fasting since midnight.
● administer medication.

intraprocedure
● assist the client into the supine position with the
upper right quadrant of the abdomen exposed.

● assist the client with relaxation techniques.
● instruct the client to exhale and hold for at least
10 seconds while the needle is inserted.

● instruct the client to resume breathing once the needle is withdrawn.
● apply pressure to the puncture site.

Postprocedure
● assist the client to a right side‑lying position
and maintain for several hours.

● monitor vital signs.
● assess for abdominal pain.
● assess for bleeding from puncture site.

POTENTIAL COMPLICATIONS
● Bleeding
● Bile peritonitis
● Pneumothorax

NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

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RN ADULT MEDICAL SURGICAL NURSING ncleX® connections 373

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Health Promotion and Maintenance
HEALTH PROMOTION/DISEASE PREVENTION: Educate the
client on actions to promote/maintain health and prevent disease.

Basic Care and Comfort
NUTRITION AND ORAL HYDRATION:
Provide/maintain special diets based on the client
diagnosis/nutritional needs and cultural considerations.

Pharmacological and Parenteral Therapies
PAIN MANAGEMENT: Administer and document pharmacological
pain management appropriate for client age and diagnoses.

ADVERSE EFFECTS/CONTRAINDICATIONS/SIDE EFFECTS/
INTERACTIONS: Assess the client for actual or potential
side effects and adverse effects of medications.

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374 ncleX® connections CONTENT MASTERY SERIES

Reduction of Risk Potential
LABORATORY VALUES
Educate client about the purpose and procedure
of prescribed laboratory tests.

Compare client laboratory values to normal laboratory values.

POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC
TESTS/TREATMENTS/PROCEDURES
Intervene to manage potential circulatory complications.

Insert, maintain, or remove a urinary catheter.

THERAPEUTIC PROCEDURES
Educate client about treatments and procedures.

Provide postoperative care.

POTENTIAL FOR COMPLICATIONS FROM SURGICAL
PROCEDURES AND HEALTH ALTERATIONS: Apply knowledge
of pathophysiology to monitoring for complications.

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS
Perform and manage care of client receiving peritoneal dialysis.

Educate client about managing health problems.

HEMODYNAMICS: Manage the care of a client receiving
hemodialysis or continuous renal replacement therapy.

ILLNESS MANAGEMENT: Educate client
regarding an acute or chronic condition.

PATHOPHYSIOLOGY: Identify pathophysiology
related to an acute or chronic condition.

FLUID AND ELECTROLYTE IMBALANCES: Manage the
care of the client with a fluid and electrolyte imbalance.

UNEXPECTED RESPONSE TO THERAPIES: Promote recovery
of the client from unexpected response to therapy.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 56 renal Diagnostic ProceDures 375

UNIT 8 RENAL DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 56 Renal Diagnostic
Procedures

renal diagnostic procedures and laboratory
assessments evaluate kidney function. By testing
kidney function, providers can diagnose disease
and evaluate the efficacy of treatment.

LABORATORY TESTS

Blood creatinine

Results from protein and muscle breakdown
● Kidney disease is the only condition that increases blood

creatinine levels.
● Kidney function loss of at least 50% causes an elevation

of blood creatinine values.
● Although muscle mass and amount of creatinine

decreases with age, the blood creatinine values remain
constant in older adults who do not have kidney disease.

Blood urea nitrogen (BUN)

Results from the breakdown of protein in the liver, creating
the byproduct urea nitrogen excreted by the kidneys

● Factors affecting BUN are dehydration, infection,
chemotherapy, steroid therapy, and reabsorption of
blood in the liver from damaged tissue.

● Elevated BUN suggests kidney disease.
● Because liver failure limits urea production, BUN is

decreased when liver and kidney failure occur.

Urinalysis

Evaluates waste products from the kidney and detects
urologic disorders.

● Collection of an early‑morning specimen provides a
more concentrated sample.

● Urinalysis identifies color; clarity; concentration or
dilution; specific gravity; acidity or alkalinity; and
presence of drug metabolites, glucose, ketone bodies, and
protein. Glucose, ketone bodies, and protein, including
leukocyte esterase and nitrites, are not usually present in
urine and can indicate diabetes mellitus; fat metabolism;
infection; or, after a cytology analysis, cancer.

● Urine for culture and sensitivity identifies bacteria and
determines the type of antibiotic to treat the infection.

● A 24‑hr urine collection measures creatinine, urea nitrogen,
sodium, chloride, calcium, catecholamines, and proteins.

● A 24‑hr collection for creatinine clearance measures the
glomerular filtration rate for clients who have impaired
kidney function.

CLIENT EDUCATION
● Discard first voided specimen and note the time as the
24‑hr collection start time.

● Refrigerate urine collection or store on ice.

RENAL DIAGNOSTIC PROCEDURES

Radiography (x-ray)
● An x‑ray of the kidneys, ureters, and bladder (KUB or a
“flat plate”)

● Allows for visualization of structures and detects renal
calculi, strictures, calcium deposits, or obstructions

NURSING ACTIONS
● Ask clients if they are pregnant.
● Tell clients to remove clothes over the area and all

jewelry and metal objects.

COMPLICATIONS: No known complications

CT scan
● Provides three‑dimensional imaging of the renal/

urinary system to assess for kidney size and obstruction,
cysts, or masses.

● IV contrast media (iodine‑based) enhances images.

NURSING ACTIONS
● Same as KUB without contrast media
● Same as excretory urography with contrast media

(exclude bowel preparation)

COMPLICATIONS
● Media can cause acute kidney injury.
● Risk of complications is greater for the following clients.

◯ Older adult clients
◯ Clients who are dehydrated
◯ Clients who have a history of previous renal
insufficiency

◯ Clients who are taking nephrotoxic drugs.

MRI

Useful for staging cancer, similar to CT.

NURSING ACTIONS
● Clients lie down and have to remain still for the test.
● Clients who have metal implants are not eligible for an

MRI, because the magnet can move the metal implant.

COMPLICATIONS: Poor imaging if a client is unable to lie still

Ultrasound
● Assesses the size of kidneys; images the ureters, bladder,

masses, cysts, calculi, and obstructions of the lower
urinary tract

● Good alternative to excretory urography

NURSING ACTIONS: Provide skin care by removing gel
after the procedure.

COMPLICATIONS: Minimal risk for the client.

CHAPTER 56

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376 CHAPTER 56 renal Diagnostic ProceDures CONTENT MASTERY SERIES

Cystography, cystourethrography,
voiding cystourethrogram (VCUG)

● VCUG detects urethral or bladder injury after instillation
of contrast media through a urinary catheter to provide
an image of the bladder (cystography) and the ureters
(cystourethrography).

● VCUG detects via an x‑ray during urination whether
urine refluxes into the ureters.

● Contrast media does not reach the bloodstream or the
kidneys and is not nephrotoxic.

NURSING ACTIONS
● Monitor for infection for the first 72 hr after

the procedure.
● Encourage increased fluid intake to dilute urine and

minimize burning on urination.
● Monitor urine output (report less than 30 mL/hr) if

suspected pelvic or urethral trauma.

COMPLICATIONS
● Urinary tract infection due to catheter placement
● Cloudy, foul‑smelling urine
● Urgency
● Urine positive for leukocyte esterase and nitrites,

sediment, and RBCs

Kidney biopsy

Removal of a sample of tissue by excision or needle
aspiration for cytological (histological) examination

NURSING ACTIONS
● Clients receive sedation and ongoing monitoring.
● PREPROCEDURE

◯ Review coagulation studies.
◯ Ensure client has been NPO for 4 to 6 hr.

● POSTPROCEDURE
◯ Monitor vital signs following sedation.
◯ Assess dressings and urinary output (hematuria).
◯ Review Hgb and Hct values.
◯ Administer analgesia as needed.

COMPLICATIONS
● Hemorrhage
● Infection
● Cloudy, foul‑smelling urine
● Urgency
● Urine positive for leukocyte esterase and nitrites,

sediment, and RBCs

Cystoscopy, cystourethroscopy

Used to discover abnormalities of bladder wall
(cystoscopy) and/or occlusions of ureter or urethra
(cystourethroscopy).

NURSING ACTIONS
● Clients receive anesthesia for the procedure.
● Check for findings of bleeding and infection. Monitor for

infection for the first 72 hr after the procedure.

● PREPROCEDURE
◯ NPO after midnight.
◯ Administer laxative or enemas for bowel preparation
the night before the procedure.

● INTRAPROCEDURE
◯ Monitor vital signs.
◯ General and local anesthesia are options.
◯ Place the client in lithotomy position.

● POSTPROCEDURE
◯ Monitor vital signs and urine output.
◯ Document the color of urine (can be pink‑tinged).
◯ Irrigate urinary catheter with 0.9% sodium chloride
irrigation if blood clots are present or the urine output
is decreased or absent.

◯ Encourage oral fluids to increase urine output and
reduce any burning sensation with urination.

COMPLICATIONS
● Possible urinary tract infection from instrumentation
● Cloudy, foul‑smelling urine
● Urgency
● Urine positive for leukocyte esterase, nitrites,

sediment, and RBCs

Retrograde pyelogram, cystogram, urethrogram
● Identifies obstruction or structural disorders of the

ureters and renal pelvis of the kidneys (pyelogram) by
instilling contrast media during a cystoscopy

● Identifies fistulas, diverticula, and tumors in the bladder
(cystogram) and urethra (urethrogram) by instilling
contrast media during a cystoscopy

NURSING ACTIONS: Same as a cystoscopy

COMPLICATIONS: Same as a cystoscopy

Renal scan

Assesses renal blood flow and estimates glomerular
filtration rate (GFR) after IV injection of radioactive
material to produce a scanned image of the kidneys.

POSTPROCEDURE NURSING ACTIONS
● Assess blood pressure frequently during and after the

procedure if the client receives captopril during the
procedure to change the blood flow to the kidneys.

● Alert clients about possible orthostatic hypotension
following the procedure if they received captopril.

● Increase fluid intake if hypotension occurs and also to
promote excretion of the radioisotope.

COMPLICATIONS
● Radioactive material does not cause nephrotoxicity.
● Clients are not at risk from radioactive material they

excrete in the urine.

Excretory urography

Detects obstruction and parenchymal masses, and
assesses the size of the kidneys. IV contrast media
(iodine‑based) enhances the images.

NURSING ACTIONS: Same as KUB

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 56 renal Diagnostic ProceDures 377

● PREPROCEDURE
◯ Encourage increased fluids the day before procedure.
◯ Bowel cleansing with a laxative or an enema to
remove fecal contents, fluid, and gas from the colon
for a clearer visualization.

◯ NPO after midnight.
◯ Determine allergies to iodine, seafood, eggs, milk, or
chocolate, or if the client has asthma.

◯ Check creatinine and BUN levels.
◯ Withhold metformin for 24 hr before the procedure
(risk for lactic acidosis from contrast media
with iodine).

● POSTPROCEDURE
◯ Administer parenteral fluid, or encourage oral
fluids to flush media through the renal system and
prevent complications.

◯ Diuretics can increase media excretion.
◯ Check creatinine and BUN blood levels before
resuming metformin.

COMPLICATIONS: Media can cause acute kidney injury.

GERONTOLOGICAL CONSIDERATIONS
● Kidney size and function decrease with aging.
● Blood flow adaptability decreases, especially during a

hypotensive or hypertensive crisis.
● GFR decreases by half the rate of a young adult.
● Diabetes mellitus, hypertension, and heart failure can

affect GFR.
● Kidney injury can occur more easily from contrast

media and medication due to decreased kidney size,
blood flow, and GFR.

● Tubular changes can cause urgency and
nocturnal polyuria.

● A weak urinary sphincter muscle and a shorter
urethra in women can cause incontinence and urinary
tract infections.

● An enlarged prostate in males can cause urinary
retention and infection.

Active Learning Scenario

a nurse is developing a plan of care for a client who
will undergo a cystoscopy with retrograde pyelogram.
What information should the nurse include in the
plan of care? use the ati active learning template:
Diagnostic Procedure to complete this item.

DESCRIPTION OF PROCEDURE: Define the procedure.

INDICATIONS: identify one indication for
cystoscopy and two for retrograde pyelogram.

NURSING INTERVENTIONS (PRE, INTRA, POST):
Describe two nursing actions for preprocedure
and two for postprocedure.

Application Exercises

1. a nurse is teaching a client who will have an x‑ray of the
kidneys, ureters, and bladder. Which of the following
statements should the nurse include in the teaching?

a. “You will receive contrast dye
during the procedure.”

B. “an enema is necessary before the procedure.”

c. “You will need to lie in a prone
position during the procedure.”

D. “the procedure determines whether
you have a kidney stone.”

2. a nurse is monitoring a client who had a kidney
biopsy for postoperative complications. Which
of the following complications should the nurse
identify as causing the greatest risk to the client?

a. infection

B. Hemorrhage

c. Hematuria

D. Pain

3. a nurse is caring for a client who has type 2 diabetes
mellitus and will have excretory urography. Prior
to the procedure, which of the following actions
should the nurse take? (select all that apply.)

a. identify an allergy to seafood.

B. Withhold metformin for 24 hr.

c. administer an enema.

D. obtain a blood coagulation profile.

e. assess for asthma.

4. a nurse administered captopril to a client
during a renal scan. Which of the following
actions should the nurse take?

a. assess for hypertension.

B. limit the client’s fluid intake.

c. monitor for orthostatic hypotension.

D. encourage early ambulation.

5. a nurse is reviewing the results of a client’s
urinalysis. the findings indicate the urine is positive
for leukocyte esterase and nitrites. Which of
the following actions should the nurse take?

a. repeat the test early the next morning.

B. start a 24‑hr urine collection for
creatinine clearance.

c. obtain a clean‑catch urine specimen
for culture and sensitivity.

D. insert an indwelling catheter urinary
catheter to collect a urine specimen.

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378 CHAPTER 56 renal Diagnostic ProceDures CONTENT MASTERY SERIES

Application Exercises Key

1. a. clients do not receive any contrast media for this
procedure, as they would for excretory urography.

B. clients do not receive an enema before this procedure,
because it does not affect the gastrointestinal system.

c. the client will lie supine, not prone.
D. CORRECT: explain to the client that a KuB can

identify renal calculi, strictures, calcium deposits,
and obstructions of the urinary system.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

2. a. the client is at risk for infection of the kidney
because a biopsy is an invasive procedure. However,
another complication is the priority.

B. CORRECT: the greatest risk to the client following a kidney
biopsy is hemorrhage due to a lack of clotting at the puncture
site. report this finding to the provider immediately.

c. the client is at risk for hematuria, which is a common
complication the first 48 to 72 hr after the biopsy.
However, another complication is the priority.

D. the client is at risk for pain after a kidney biopsy because
blood in and around the kidney causes pressure on the nerves
in the area; however, another complication is the priority.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

3. a. CORRECT: clients who have an allergy to seafood are
at higher risk for an allergic reaction to the contrast
media they will receive during the procedure.

B. CORRECT: clients who take metformin are at risk
for lactic acidosis from the contrast media with
iodine they will receive during the procedure.

c. CORRECT: clients should receive an enema to
remove fecal contents, fluid, and gas from the
colon for a more clear visualization.

D. a blood coagulation profile is essential for a
client prior to a kidney biopsy because of the
risk of hemorrhage from the procedure.

e. CORRECT: clients who have asthma have a higher risk of
an exacerbation as an allergic response to the contrast
media they will receive during the procedure.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

4. a. captopril is an antihypertensive medication. assess
the client for hypotensive effects.

B. increasing the client’s fluid intake can help resolve hypotensive
effects following the administration of captopril.

c. CORRECT: monitor for orthostatic hypotension because
this is an adverse effect of captopril. this results in a change
in blood flow to the kidneys after the initial dose.

D. the client is at risk for falls when ambulating
due to the hypotensive effects of captopril.
encourage the client to remain in bed.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

5. a. repeating the test early the next morning will
not change the urinalysis results.

B. a 24‑hr urine collection for creatinine helps
to determine kidney function.

c. CORRECT: obtain a clean‑catch urine specimen for culture
and sensitivity. this test will identify which antibiotic will be
most effective for treating the client’s urinary tract infection.

D. insert a urinary catheter to collect urine when
a client cannot empty their bladder.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

DESCRIPTION OF PROCEDURE
● cystoscopy is instrumentation into the urinary
tract to inspect the bladder wall.

● retrograde pyelogram is the injection of media into the
ureters to inspect the ureters and pelvis of the kidney.

INDICATIONS
● cystoscopy discovers abnormalities of the
bladder wall (cysts, tumors, stones).

● retrograde pyelogram discovers obstructions or structural disorders
of the ureters and kidney pelvis (strictures, stones, mass).

NURSING INTERVENTIONS (PRE, INTRA, POST)

Preprocedure
● clients must be nPo after midnight.
● administer a laxative the night before the procedure.

Postprocedure
● monitor vital signs.
● encourage an increase in oral fluid intake to reduce
the burning sensation when voiding.

● Document the color of urine.
● For clients who have a urinary catheter, irrigate it with
0.9% sodium chloride irrigation for active bleeding,
clots, or decreased or absent urine output.

NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 57 HemoDialYsis anD Peritoneal DialYsis 379

UNIT 8 RENAL DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 57 Hemodialysis and
Peritoneal Dialysis

For clients who are experiencing acute kidney
injury or chronic kidney disease, dialysis can
sustain life (although it does not replace the
hormonal function of the kidney). the two types
of dialysis are hemodialysis and peritoneal dialysis.

Functions oF DialYsis
● Rids the body of excess fluid and electrolytes
● Achieves acid‑base balance
● Eliminates waste products
● Restores internal homeostasis by osmosis, diffusion,

and ultrafiltration

Hemodialysis
Hemodialysis shunts blood from the body through a
dialyzer and back into circulation. Hemodialysis requires
vascular access. Hemodialysis is based on manifestations,
not the glomerular filtration rate.

INDICATIONS
POTENTIAL DIAGNOSES

● Renal insufficiency
● Acute kidney injury
● Chronic kidney disease
● Medication or illicit drug toxicity
● Persistent hyperkalemia
● Hypervolemia that does not respond to diuretics

CLIENT PRESENTATION
● Fluid volume changes, electrolyte and pH imbalances,

and nitrogenous wastes.
● Manifestations include fluid overload, neurologic

changes, bleeding, and uremia (cognitive impairment,
pruritus, nausea, vomiting).

CONSIDERATIONS

PreProceDure
NURSING ACTIONS

● Check for informed consent.
● Use a temporary hemodialysis dual‑lumen catheter

or subcutaneous device until the provider inserts a
long‑term device and it is available for access.

● Assess the patency of a long‑term device: arteriovenous
(AV) fistula or AV graft (presence of bruit, palpable thrill,
distal pulses, circulation).

● Avoid measuring blood pressure, administering
injections, performing venipunctures, or inserting IV
catheters on or into an arm with an access site. Elevate
the extremity following surgical creation of an AV
fistula to reduce swelling.

● Assess vital signs, laboratory values (BUN, blood
creatinine, electrolytes, Hct), and weight.

● Discuss with the provider medications to withhold until
after dialysis. Withhold any dialyzable medications and
medications that lower blood pressure.

CLIENT EDUCATION: Hemodialysis will be needed three
times per week, for 3‑ to 5‑hr sessions. It involves insertion
of two needles, one into an artery and the other into a vein.

intraProceDure
NURSING ACTIONS

● Monitor for complications during dialysis.
◯ Dialysis circuit clotting, air bubbles in blood tubing,
temperature of the dialysate (37.8° C [100° F]),
regulation of the ultrafiltration

◯ Hypotension, cramping, vomiting, bleeding at the
access site, contamination of equipment

● Monitor vital signs and coagulation studies during
dialysis. Monitor for bleeding, such as oozing from
insertion site. Administer anticoagulants, such as heparin.

● Have protamine sulfate ready to reverse heparin.
● Provide emotional support and offer activities (books,

magazines, music, cards, or television).

CLIENT EDUCATION
● Notify the nurse of headache, nausea, or dizziness

during dialysis.
● Do not eat during dialysis.

PostProceDure
NURSING ACTIONS

● Monitor vital signs and laboratory values (BUN, blood
creatinine, electrolytes, Hct). Decreases in blood
pressure and changes in laboratory values are common
following dialysis.

● Compare the client’s preprocedure weight with the
postprocedure weight as a way to estimate the amount
of fluid the procedure removed.

1 l fluid equals 1 kg (2.2 lb).

● Assess for the following.
◯ Complications (hypotension, clotting of vascular
access, headache, muscle cramps, bleeding)

◯ Indications of bleeding or infection at the access site
◯ Findings of disequilibrium syndrome
◯ Findings of hypovolemia (hypotension,
dizziness, tachycardia)

● Avoid invasive procedures for 4 to 6 hr after dialysis due
to the risk of bleeding as a result of anticoagulation.

● Reinforce AV fistula or AV graft precautions.

CLIENT EDUCATION
● Alert the nurse of early findings of disequilibrium

syndrome, such as nausea and headache.
● Check the access site at intervals following dialysis.
Apply light pressure if bleeding.

CHAPTER 57

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380 CHAPTER 57 HemoDialYsis anD Peritoneal DialYsis CONTENT MASTERY SERIES

● Contact the provider if bleeding from the insertion site
lasts longer than 30 min following dialysis, for no thrill/
bruit, or findings of infection.

● Take medications and supplements to replace folate loss.
● Eat well‑balanced meals to include foods high in folate

(beans, green vegetables), and take supplements. Each
exchange during dialysis depletes protein, requiring
the client to increase protein intake over predialysis
limitations, but it still might require some restriction.

● Avoid lifting heavy objects with the access‑site arm.
● Avoid carrying objects that compress or constrict

the extremity.
● Avoid sleeping on top of the extremity with the

access device.
● Perform hand exercises that promote fistula maturation.

COMPLICATIONS

Clotting/infection of the access site
● Anticoagulants prevent blood clots from forming.

Monitor for hemorrhage at the insertion site.
● Cannulation can introduce infections at the access site.

◯ Immunosuppressive disorders increase the risk
for infection.

◯ Advanced age is a risk factor for dialysis‑induced
hypotension and access site complications due to
chronic illnesses or fragile veins.

NURSING ACTIONS
● Use surgical aseptic technique during cannulation.
● Avoid compression of the access site.
● Avoid venipuncture or blood pressure measurements on

the extremity with the access site.
● Administer anticoagulants.
● Assess the graft site for a palpable thrill or audible bruit

indicating vascular flow.
● Assess the access site for redness, swelling, or drainage.
● Monitor for fever.

Disequilibrium syndrome

Disequilibrium syndrome results from too rapid a decrease
of BUN and circulating fluid volume. It can result in
cerebral edema and increased intracranial pressure.

● Early recognition of disequilibrium syndrome is essential.
Manifestations include nausea, vomiting, changes in
level of consciousness, seizures, and agitation.

● Advanced age is a risk factor for dialysis disequilibrium
and hypotension due to rapid changes in fluid and
electrolyte status.

NURSING ACTIONS
● Use a slow dialysis exchange rate, especially for older

adult clients and first‑time hemodialysis.
● Administer anticonvulsants or barbiturates if the client

requires them.

Hypotension

Antihypertensive therapy and rapid fluid depletion during
dialysis can cause hypotension.

NURSING ACTIONS
● Carefully replace fluid volume by infusing IV fluids or

colloid. Slow the dialysis exchange rate.
● Lower the head of the client’s bed.
● For severe hypotension that does not respond to fluid

replacement, discontinue the dialysis.

Anemia

Blood loss and removal of folate during dialysis can
contribute to the anemia that often accompanies chronic
kidney disease (from decreased RBC production due to
decreased erythropoietin secretion).

NURSING ACTIONS
● Administer erythropoietin to stimulate the

production of RBC.
● Monitor Hgb and RBC level.
● Monitor for hypotension and tachycardia.
● Transfuse blood products.

Infectious diseases

Blood transfusions and frequent blood access due to
hemodialysis pose a risk for transmission of bloodborne
infections such as HIV and hepatitis B and C.

NURSING ACTIONS
● Use sterile equipment and skin antisepsis.
● Use standard precautions.

Peritoneal dialysis
● Peritoneal dialysis involves instillation of hypertonic

dialysate solution into the peritoneal cavity and
subsequent dwell times. Drain the dialysate solution
that includes the waste products. The peritoneum serves
as the filtration membrane.

● The client should have an intact peritoneal membrane,
without adhesions from infection or multiple surgeries.

INDICATIONS
● Peritoneal dialysis is the treatment of choice for the

older adults who require dialysis.
● Peritoneal dialysis treats clients requiring dialysis who:

◯ Are unable to tolerate anticoagulation.
◯ Have difficulty with vascular access.
◯ Have chronic infections or are unstable.
◯ Have chronic diseases (diabetes mellitus, heart failure,
severe hypertension).

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 57 HemoDialYsis anD Peritoneal DialYsis 381

CONSIDERATIONS

PreProceDure
NURSING ACTIONS

● Assess dry weight (without dialysate instillation), vital
signs, blood electrolytes, blood creatinine, BUN, and
blood glucose.

● Determine the client’s ability to self‑perform peritoneal
dialysis and follow sterile technique.

◯ Level of alertness
◯ Past experience with dialysis
◯ Understanding of procedure

CLIENT EDUCATION
● Follow instructions regarding the procedure. Fullness

can be felt when the dialysate is dwelling. There can be
discomfort initially with dialysate infusion.

● Continuous ambulatory peritoneal dialysis (CAPD)
requires 7 days/week for 4 to 8 hr. Clients can continue
normal activities during CAPD.

● Continuous‑cycle peritoneal dialysis (CCPD) is a 24‑hr
dialysis. The exchange occurs at night while sleeping.
The final exchange is left in to dwell during the day.

● Automated peritoneal dialysis (APD) is a 30‑min
exchange repeated over 8 to 10 hr while sleeping.

intraProceDure
NURSING ACTIONS

● Monitor vital signs frequently during initial dialysis of
clients in a hospital setting.

● Monitor blood glucose level (dialysate is a hypertonic
solution that contains glucose).

● Record the amount of inflow compared to outflow
of dialysate.

● Monitor the color (should be clear, light yellow) and
amount (should equal or exceed the amount of dialysate
inflow) of outflow.

● Monitor for findings of infection (fever; bloody, cloudy,
or frothy dialysate return; drainage at access site) and
for complications (respiratory distress, abdominal pain,
insufficient outflow, discolored outflow).

● Check the access site dressing for wetness (risk of
dialysate leakage) and exit‑site infections.

● Warm the dialysate prior to instilling. Avoid the use of
microwave ovens, which cause uneven heating.

● Adhere to the times for infusion, dwell, and outflow.
● Maintain surgical asepsis of the catheter insertion site

and when accessing the catheter.
● Keep the outflow bag lower than the client’s abdomen

(drain by gravity, prevent reflux).
● Reposition the client if inflow or outflow is inadequate.
● Carefully milk the peritoneal dialysis catheter if a fibrin

clot has formed.
● Provide emotional support to the client and family.

PostProceDure
NURSING ACTIONS: Monitor weight and blood levels of
electrolytes, creatinine, glucose, and urea nitrogen (BUN).

CLIENT EDUCATION
● Perform home care of the access site.
● Perform peritoneal dialysis exchanges at home. Support

can be provided with home peritoneal dialysis with
home visits.

● Seek additional information from the National Kidney
Foundation for local support groups.

● Follow instructions carefully and take all medications.
● Take essential minerals and vitamins with supplements

of phosphorus, calcium, sodium, and potassium.
● Older adult clients can be unable to care for a peritoneal

access site due to cognitive or physical deficits.
● Body image changes from bloating can be a concern.

COMPLICATIONS
Peritonitis

Peritoneal dialysis can allow micro‑organisms into the
peritoneum and cause peritonitis. Cloudy or opaque
effluent is the earliest indication of peritonitis.

NURSING ACTIONS
● Maintain surgical asepsis during the procedure.
● Monitor for infection (fever, purulent drainage, redness,

swelling, cloudy or discolored drained dialysate).

CLIENT EDUCATION
● Use strict sterile technique during exchanges.
● Notify the provider about any indications of infection.

Infection at the access site
● Infection at the access site can result from leakage of

dialysate. Access‑site infections can cause peritonitis.
● Advanced age is a risk factor for access site complications

due to chronic illnesses and/or fragile veins.

NURSING ACTIONS
● Maintain surgical asepsis at the access site.
● Assess the site for wetness from a leaking catheter.
● Monitor for infection (fever, purulent drainage,

redness, swelling).

CLIENT EDUCATION
● Use strict sterile technique during exchanges.
● Notify the provider of any indications of infection.
● Assess the site for leaks, and prevent tugging or

twisting of the tubing.

Protein loss

Peritoneal dialysis can remove protein from the blood as
well as excess fluid, wastes, and electrolytes.

NURSING ACTIONS
● Increase the client’s dietary intake of protein over

predialysis restrictions.
● Monitor blood albumin levels.

CLIENT EDUCATION: Follow the renal diet with an
increase in dietary protein.

Online Video: Peritoneal Dialysis

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382 CHAPTER 57 HemoDialYsis anD Peritoneal DialYsis CONTENT MASTERY SERIES

Application Exercises

1. a nurse is teaching a client who has chronic
kidney disease and is to begin hemodialysis.
Which of the following information should
the nurse include in the teaching?

a. Hemodialysis restores kidney function.

B. Hemodialysis replaces hormonal
function of the renal system.

c. Hemodialysis allows an unrestricted diet.

D. Hemodialysis returns a balance
to blood electrolytes.

2. a nurse is preparing to initiate hemodialysis for a client
who has acute kidney injury. Which of the following
actions should the nurse take? (select all that apply.)

a. review the medications the client currently takes.

B. assess the aV fistula for a bruit.

c. calculate the client’s hourly urine output.

D. measure the client’s weight.

e. check blood electrolytes.

F. use the access site area for venipuncture.

3. a nurse is planning postprocedure care for a
client who received hemodialysis. Which of the
following interventions should the nurse include
in the plan of care? (select all that apply.)

a. check Bun and blood creatinine.

B. administer medications the nurse
withheld prior to dialysis.

c. observe for findings of hypovolemia.

D. assess the access site for bleeding.

e. evaluate blood pressure on the arm with aV access.

4. a nurse is caring for a client who develops
disequilibrium syndrome after receiving hemodialysis.
Which of the following actions should the nurse take?

a. administer an opioid medication.

B. monitor for hypertension.

c. assess level of consciousness.

D. increase the dialysis exchange rate.

5. a nurse is planning care for a client who will undergo
peritoneal dialysis. Which of the following actions
should the nurse take? (select all that apply.)

a. monitor blood glucose levels.

B. report cloudy dialysate return.

c. Warm the dialysate in a microwave oven.

D. assess for shortness of breath.

e. check the access site dressing for wetness.

F. maintain medical asepsis when accessing
the catheter insertion site.

Hyperglycemia and hyperlipidemia
● Hyperglycemia can result from the hyperosmolarity of

the dialysate.
● The blood can absorb glucose from the dialysate.
● Hyperlipidemia can also occur from long‑term therapy

and lead to hypertension.

NURSING ACTIONS
● Monitor blood glucose.
● Administer insulin for glycemic control.
● Administer antilipemic medication for

triglyceride control.

CLIENT EDUCATION
● Check blood glucose.
● Follow the diet the provider recommends.
● Take antihypertensive medication for elevated

blood pressure.

Poor dialysate inflow or outflow

Causes include:
● Obstruction or twisting of the tubing
● Constipation
● Client positioning
● Fibrin clot formation
● Catheter displacement

NURSING ACTIONS
● Reposition the client if inflow or outflow is inadequate.
● Milk the tubing to break up fibrin clots.
● Check the tubing for kinks or closed clamps.

CLIENT EDUCATION
● Check the tubing for kinks, and follow instructions for

how to remove a fibrin clot.
● Monitor the inflow and outflow, and change position or

lower or raise the dialysate bag to improve flow.
● Prevent constipation with diet and stool softeners.
● Lie supine with head slightly elevated during CCPD and
APD treatment.

Active Learning Scenario

a nurse is reviewing complications that a client can
develop when receiving peritoneal dialysis. What
complications and nursing actions should the nurse
include in the review? use the ati active learning
template: Diagnostic Procedure to complete this item.

DESCRIPTION OF PROCEDURE: Write out the
name, and define the diagnostic test.

POTENTIAL COMPLICATIONS: list three.

NURSING INTERVENTIONS: list two nursing
actions for each of the three complications.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 57 HemoDialYsis anD Peritoneal DialYsis 383

Application Exercises Key

1. a. Hemodialysis does not restore kidney function, but it
sustains the life of a client who has kidney disease.

B. Hemodialysis does not replace hormonal function of the
renal system due to tissue damage causing dysfunction
of the renin‑angiotensin‑aldosterone system.

c. Hemodialysis does not allow an unrestricted diet.
it requires a diet high in folate and more protein
than predialysis restrictions allowed, and low in
sodium, potassium, and phosphorus.

D. CORRECT: explain to the client that hemodialysis
restores electrolyte balance by removing excess
sodium, potassium, fluids, and waste products,
and also restores acid‑base balance.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

2. a. CORRECT: reviewing the medications the
client currently takes can help determine which
medications to withhold until after dialysis.

B. CORRECT: assessing the aV fistula for a bruit
determines the patency of the fistula for dialysis.

c. the client’s hourly urine output can vary with
the remaining kidney function and does not
determine the need for dialysis.

D. CORRECT: measuring the client’s weight
before dialysis is essential for comparing it
with the client’s weight after dialysis.

e. CORRECT: checking the blood electrolytes
determines the need for dialysis.

F. never use the access site area for venipuncture
because compression from the tourniquet
can cause loss of the vascular access.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

3. a. CORRECT: check the Bun and blood creatinine to
determine the presence and degree of uremia or
waste products that remain following dialysis.

B. CORRECT: Withhold medications the treatment can partially
dialyze. after the treatment, the nurse should administer the
medications. antihypertensive medications might need to
be withheld until the next day if the client is hypotensive.

c. CORRECT: a client who is post‑dialysis is at risk for
hypovolemia due to a rapid decease in fluid volume.

D. CORRECT: assess the access site for bleeding
because the client receives heparin during the
procedure to prevent clotting of blood.

e. never measure blood pressure on the extremity
that has the aV access site because it can cause
collapse of the aV fistula or graft.

NCLEX® Connection: Physiological Adaptation, Hemodynamics

4. a. Do not administer an opioid medication because it
could worsen the client’s condition. the provider can
prescribe medication to decrease seizure activity.

B. monitor for hypotension due to rapid change in fluids
and electrolytes causing disequilibrium syndrome.

c. CORRECT: assess the client’s level of consciousness.
a change in urea levels can cause increased
intracranial pressure. subsequently, the client’s
level of consciousness decreases.

D. Decrease the dialysis exchange rate to slow the
rapid changes in fluid and electrolyte status when
a client develops disequilibrium syndrome.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

5. a. CORRECT: monitor blood glucose levels because
the dialysate solution contains glucose.

B. CORRECT: monitor for cloudy dialysate return,
which indicates an infection. clear, light‑yellow
solution is typical during the outflow process.

c. avoid warming the dialysate in a microwave oven,
which causes uneven heating of the solution.

D. CORRECT: assess for shortness of breath, which can
indicate inability to tolerate a large volume of dialysate.

e. CORRECT: check the access site dressing for wetness and
look for kinking, pulling, clamping, or twisting of the tubing,
which can increase the risk for exit‑site infections.

F. maintain surgical, not medical, asepsis when
accessing the catheter insertion site to prevent
infection from contamination.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

DESCRIPTION OF PROCEDURE: Peritoneal dialysis: to instill
a hypertonic dialysate solution into the peritoneal cavity,
allow the solution to dwell for prescribed amount of time, and
drain the solution that includes the waste products.

POTENTIAL COMPLICATIONS
● Peritonitis
● Protein loss from protein wasting
● Hyperglycemia
● Poor dialysate inflow or outflow

NURSING INTERVENTIONS

Peritonitis
● maintain surgical asepsis.
● monitor color of outflow
solution, and for pain or fever.

Protein loss
● increase dietary intake of protein.
● monitor albumin level.

Hyperglycemia
● monitor blood glucose level.
● administer insulin.

Poor dialysate inflow or outflow
● reposition the client.
● milk the tubing to break
up fibrin clots.

● check the tubing for kinks
or closed clamps.

● encourage stool softeners
and high‑fiber diet to
prevent constipation.

NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems

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384 CHAPTER 57 HemoDialYsis anD Peritoneal DialYsis CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 58 KiDneY transPlant 385

UNIT 8 RENAL DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 58 Kidney Transplant
a kidney transplant can greatly improve the
quality of life for clients whose kidneys no longer
function adequately to sustain life (related to
end‑stage kidney disease) and are otherwise
dialysis‑dependent.

the recipient’s tissue must be matched with a
donor’s. Donors for kidney transplantation can
be living, non‑heart‑beating, or cadaver donors.
in‑depth tissue typing includes assessment
of blood type (aBo) compatibility and
histocompatibility, including human leukocytic
antigen and other minor antigens. clients
receiving a donor kidney from a living, related
donor with matching tissue type have the
greatest chance of graft survival. Kidneys used
from cadaver or non‑heart‑beating donors must
be sufficiently perfused to maintain viability
of the organ. the donated kidney is surgically
implanted in the client.

INDICATIONS

Potential Diagnoses
INDICATIONS OF END-STAGE KIDNEY DISEASE

● Anuria
● Proteinuria
● Marked azotemia (elevated blood urea nitrogen [BUN]

and blood creatinine)
● Severe electrolyte imbalance

(hyperkalemia, hypernatremia)
● Fluid volume excess conditions (heart failure,

pulmonary edema)
● Uremic lung

client Presentation
EXPECTED FINDINGS OF END-STAGE KIDNEY DISEASE

● Anorexia
● Fatigue
● Numbness and tingling of extremities
● Shortness of breath
● Dry, itchy skin
● Metallic taste in the mouth
● Muscle cramping
● Decreased attention span
● Seizures
● Tremor
● Heart failure
● Edema of hands and feet
● Dyspnea
● Distended jugular veins
● Anemia
● Vomiting
● Pulmonary edema
● Hypertension
● Cardiac dysrhythmias
● Pallor
● Bruising
● Halitosis
● Diminished or dark‑colored urine

LABORATORY DATA
● Proteinuria
● Hematuria
● Elevated BUN levels
● Elevated blood creatinine
● Decreased glomerular filtration rate, either estimated

from blood or urine creatinine 24‑hr values
● Decreased hemoglobin and hematocrit
● Elevated potassium and phosphorus levels
● Sodium within expected reference range, increased,

or decreased
● Metabolic acidosis

CONSIDERATIONS

risK Factors
Conditions that increase the risks involved in kidney
transplantation surgery, lifelong immunosuppression, and
organ rejection

● Age younger than 2 years
● Age older than 70 years (Older adult clients are at risk

for developing advanced heart disease and malignancies,
which increases the risk for complications with kidney
transplantation surgery.)

● Advanced, untreatable cardiac disease
● Active cancer
● Chemical dependency
● Chronic infections or systemic diseases

(HIV, hepatitis B or C)
● Coagulopathies and certain immune disorders
● Morbid obesity
● Diabetes mellitus
● Chronic pulmonary disease
● Untreated gastrointestinal diseases, such as

peptic ulcer disease

CHAPTER 58

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386 CHAPTER 58 KiDneY transPlant CONTENT MASTERY SERIES

PreProceDure
● To increase the chance of graft survival, blood from

the live kidney donor is often transfused into the client
receiving the transplant.

● The client usually receives dialysis within 24 hr of surgery.

NURSING ACTIONS
● Schedule preoperative laboratory assessments, including

blood chemistry studies, CBC and differential, bleeding
times, urine culture, blood type, and crossmatch.

● Administer preoperative medications as prescribed.
◯ Prophylactic antibiotics
◯ Immunosuppressant therapy

■ Corticosteroids decrease the immune system
response of inflammation and rejection of the
donor kidney.

■ Cyclosporine, azathioprine: Immunosuppressant
medications prevent rejection of the donor kidney.

■ Mammalian target of rapamycin (mTOR) inhibitors
interrupt the stimulation of T‑cell signals.

■ Everolimus prevents activation of B cells and T cells
to prevent rejection of the donor kidney.

◯ Monoclonal antibodies: Basiliximab or daclizumab
are antibodies that bind with T cells to reduce T‑cell
growth and activation at the receptor site to prevent
rejection of the donor kidney.

CLIENT EDUCATION
● Prepare mentally and emotionally for the procedure.
● The interprofessional transplant team is involved in the

procedure. This includes nurses, provider, transplant
surgeon, anesthesiologists, nephrologists, clinical nurse
specialist, and other interprofessional health
care workers.

● Adherence with the post‑transplant interventions
(lifelong immunosuppression) and risk factor reduction
(smoking cessation, blood pressure and blood glucose
control) are crucial to the success of the transplantation.

PostProceDure
NURSING ACTIONS

● Assess vital signs every 15 min initially and advance
to every hour (follow institutional protocol). Maintain
blood pressure within prescribed parameters.

● Assess intake and output at least hourly.
◯ Urine output should be greater than 30 mL/hr. Notify
the provider of oliguria evidenced by urine output less
than 30 mL/hr.

◯ Monitor for abrupt decrease in urine output,
indicating rejection, tissue injury, thrombosis of the
renal artery, or obstruction in the renal system.

◯ Assess urine appearance and odor hourly (initially
pink and bloody, gradually returning to clear in a few
days to several weeks).

◯ Monitor daily urinalysis to check for protein, WBCs,
RBCs, ketones, glucose, specific gravity, and pH.

● Daily weight assists in monitoring fluid status.
● Monitor for fluid and electrolyte imbalances

(hypervolemia, hypovolemia, hypokalemia,
hyponatremia).

● Monitor for manifestations of infection (dyspnea, fever,
incisional drainage, redness).

● Monitor for early manifestations of organ rejection
(fever, hypertension, pain at the transplant site).

● Assess surgical dressing for bloody drainage, which can
indicate hemorrhage or hematoma formation.

● Administer intravenous fluids as prescribed, usually
calculated to replace hourly urine output.

● Administer oral fluids and discontinue IV fluid once
bowel function returns and fluids are tolerated.

● Provide urinary catheter care.
◯ Attach the large indwelling urinary catheter to
dependent bedside drainage.

◯ Maintain continuous bladder irrigation as prescribed
to prevent obstruction from blood clot formation,
which can cause damage to the transplanted kidney.

◯ Remove the urinary catheter as soon as possible to
decrease the risk of infection.

● Intervene for oliguria as prescribed. Diuretics
and/or dialysis can be necessary until kidney function
is satisfactory.

◯ Mannitol, an osmotic diuretic, preserves urine flow
and reduces the risk of acute kidney injury. Filtered
mannitol draws water into the nephrons of the kidney
and promotes diuresis.

◯ Thiazides and loop diuretics are less effective when
filtration rate is lower, causing less diuresis.

● Monitor for excessive diuresis, which can result in
hypovolemia and hypotension, and cause reduced blood
flow to the graft. Notify the provider immediately.

● Administer immunosuppressive medications to prevent
rejection (corticosteroids, cyclosporines, or other
prescribed medication, and monoclonal antibodies
[basiliximab or daclizumab]).

● Monitor for complications (infection, hypovolemia,
fluid retention).

● Immediately notify the surgeon if any manifestations of
organ rejection appear.

● Administer stool softeners to prevent straining and
constipation (risk associated with bowel manipulation
during abdominal surgery and the effects of general
anesthetics and analgesics).

● Arrange for counseling for the client and family
if necessary.

● Arrange for post‑transplant follow‑up appointments
and interventions.

CLIENT EDUCATION
● Monitor and report manifestations of infection (fever,

incisional drainage, redness).
● Adhere to the pharmacological regimen (corticosteroids,

antilymphocyte preparations, cyclosporine, monoclonal
antibodies).

● Adhere to the prescribed diet and activity level.
● Turn, cough, and deep breathe to prevent atelectasis

and pneumonia.

DIET RECOMMENDATIONS
● Low‑fat to decrease cholesterol
● High‑fiber to avoid constipation
● Increased protein to promote healing, and rebuild and

maintain muscle mass
● Adequate intake of potassium, calcium, and phosphorus
● Restricted sodium intake to prevent fluid retention and

hypertension especially when taking prednisone

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 58 KiDneY transPlant 387

● Avoidance of concentrated sugars or carbohydrates to
control glycemic factors when on prednisone

● Magnesium supplements because cyclosporine can
reduce magnesium levels

! avoid grapefruit, which causes increased cyclosporine
blood levels, when taking cyclosporine.

ACTIVITY RECOMMENDATIONS
● Avoid contact sports that can cause an injury to the

transplanted kidney.
● Increase activity as tolerated.

COMPLICATIONS

Organ rejection

NURSING ACTIONS: Monitor for and report manifestations
of rejection immediately.

Hyperacute: Occurs within 48 hr after surgery
● ETIOLOGY: An antibody‑mediated response causing

small blood clots to form in the transplanted kidney
that occlude vessels and result in massive cellular
destruction. The process is not reversible.

● FINDINGS: Fever, hypertension, pain at the
transplant site

● TREATMENT: Immediate removal of the donor kidney

Acute: Occurs 1 week to 2 years after surgery
● ETIOLOGY: An antibody‑mediated response causing

vasculitis in the donor kidney, and cellular destruction
starts with inflammation that causes lysis of the
donor kidney

● FINDINGS: Oliguria, anuria, low‑grade fever,
hypertension, tenderness over the transplanted kidney,
lethargy, azotemia, and fluid retention

● TREATMENT: Involves increased doses of
immunosuppressive medications

Chronic: Occurs gradually over months to years
● ETIOLOGY: Blood vessel injury from overgrowth of

the smooth muscles of the blood vessels causing
fibrotic tissue to replace normal tissue, resulting in a
nonfunctioning donor kidney

● FINDINGS: Gradual return of azotemia, fluid retention,
electrolyte imbalance, and fatigue

● TREATMENT: Conservative (monitor kidney status,
continue immunosuppressive therapy) until dialysis
is required

CLIENT EDUCATION
● Monitor for manifestations of rejection and contact the

provider immediately.
● Rejection is diagnosed through a kidney scan and

kidney biopsies.
● Adhere to the pharmacological regimen.

Ischemia

A delay in transplanting the donor kidney after harvesting
can result in hypoxic injury of the donor kidney.

NURSING ACTIONS
● Monitor urine output, blood creatinine, and BUN levels

to detect failure of the transplanted kidney.
● Report hourly output volumes less than 30 mL/hr.
● Assist the client with dialysis as indicated.
● Prepare the client for a kidney biopsy to distinguish

ischemia from organ rejection.

CLIENT EDUCATION: Dialysis might be needed until the
donor kidney heals.

Renal artery stenosis

Renal artery stenosis is due to scarring of
surgical anastomosis.

NURSING ACTIONS
● Monitor for and report hypertension, bruit over artery

anastomosis site, and decreased kidney function, such
as oliguria and elevated BUN and creatinine.

● Prepare the client for a kidney scan to verify the status
of renal blood flow.

● Angioplasty and/or surgical intervention might
be necessary.

CLIENT EDUCATION: Monitor for peripheral edema and
have blood pressure checked often.

Thrombosis

A blood clot can form in a major vessel of the
transplanted kidney.

NURSING ACTIONS
● Monitor for and report a sudden decrease in urine output.
● Prepare the client for emergency surgery requiring an

emergency transplant nephrectomy (removal of the
transplant kidney).

CLIENT EDUCATION
● Understand the risk of a blood clot.
● Inform the provider of a sudden decrease in urine output.

Infection
● Infection is a common cause of first‑transplant‑year

morbidity and mortality.
● Detection of early manifestations of infection are

difficult when the client receives immunosuppressive
therapy. Vague manifestations include low‑grade fevers,
mild reports of discomfort, and mental status changes.

NURSING ACTIONS
● Give high priority to infection control measures, such as

frequent hand hygiene.
● Monitor for and report manifestations of a localized

(wound) or systemic infection (pneumonia, sepsis).

CLIENT EDUCATION
● Monitor for and report manifestations of infection

(fever, incisional drainage, redness). Later indications of
infection can include fatigue and discomfort.

● Due to increased risk for infection during
immunosuppressant therapy, perform infection control
measures (frequent hand hygiene, avoiding crowds and
people who have a communicable disease). Consider
wearing a face mask when out in public.

● Adhere to the pharmacological regimen.

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388 CHAPTER 58 KiDneY transPlant CONTENT MASTERY SERIES

Application Exercises

1. a nurse is assessing a client who has end‑stage
kidney disease. Which of the following findings
should the nurse expect? (select all that apply.)

a. anuria

B. marked azotemia

c. crackles in the lungs

D. increased calcium level

e. Proteinuria

2. a nurse is planning postoperative care for a client
following a kidney transplant. Which of the following
actions should the nurse include? (select all that apply.)

a. obtain daily weights.

B. assess dressings for bloody drainage.

c. replace hourly urine output with iV fluids.

D. expect oliguria in the first 4 hr.

e. monitor blood electrolytes.

3. a nurse is teaching a client who is postoperative
following a kidney transplant and is taking
cyclosporine. Which of the following
instructions should the nurse include?

a. “Decrease your intake of protein‑rich foods.”

B. “take this medication with grapefruit juice.”

c. “monitor for and report a sore
throat to your provider.”

D. “expect your skin to turn yellow.”

4. a client who is scheduled for kidney transplantation
surgery is assessed by the nurse for risk factors of
surgery. Which of the following findings increase
the client’s risk of surgery? (select all that apply.)

a. age older than 70 years

B. Bmi of 41

c. administering nPH insulin each morning

D. Past history of lymphoma

e. Blood pressure averaging 120/70 mm Hg

5. a nurse is teaching a client who is scheduled
for a kidney transplant about organ rejection.
Which of the following statements should
the nurse include? (select all that apply.)

a. “expect an immediate removal of the donor
kidney for a hyperacute rejection.”

B. “You might need to begin dialysis to monitor your
kidney function for a hyperacute rejection.”

c. “a fever is a manifestation of an acute rejection.”

D. “Fluid retention is a manifestation
of an acute rejection.”

e. “Your provider will increase your
immunosuppressive medications
for a chronic rejection.”

Active Learning Scenario

a nurse is planning catheter care for a client who is
postoperative following kidney transplantation surgery.
to maintain indwelling urinary catheter patency and avoid
complications, what actions should the nurse take?

USE THE ATI ACTIVE LEARNING TEMPLATE:
nursing skill to complete this item.

INDICATIONS: list two reasons for an
indwelling urinary catheter.

POTENTIAL COMPLICATIONS: indicate three risk factors.

NURSING INTERVENTIONS: list three postoperative actions.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 58 KiDneY transPlant 389

Application Exercises Key

1. a. CORRECT: anuria is a manifestation of
end‑stage kidney disease.

B. CORRECT: marked azotemia is elevated Bun
and blood creatinine, which is a manifestation
of end‑stage kidney disease.

c. CORRECT: crackles in the lungs can indicate
the client has pulmonary edema, caused from
hypervolemia due to end‑stage kidney disease.

D. calcium levels are decreased due to increase
in blood phosphate levels when the client
has end‑stage kidney disease.

e. CORRECT: Proteinuria is a manifestation
of end‑stage kidney disease.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. CORRECT: Daily weights are obtained
to assess fluid status.

B. CORRECT: Drainage on the dressing is assessed
to monitor for hemorrhage or hematoma.

c. CORRECT: Hourly urine output with iV fluid
replacement is monitored to detect abrupt decrease
in urine output, which can indicate rejection or other
serious conditions of the transplant kidney.

D. oliguria can indicate ischemia, acute kidney injury, rejection,
or hypovolemia. report oliguria immediately to the provider.

e. CORRECT: electrolytes are monitored because electrolytes
loss can occur with postoperative diuresis.

NCLEX® Connection: Physiological Adaptation,
Illness Management

3. a. the client should not decrease protein‑rich foods in the
diet, which promote healing and rebuilds muscle. there
are no restrictions of protein intake for a client taking
cyclosporine following a kidney transplant.

B. the client should not drink grapefruit juice,
which can reduce cyclosporine metabolism and
cause increased cyclosporine levels.

c. CORRECT: the client should report any
manifestations of an infection because this
medication causes immunosuppression.

D. the client should report manifestations of hepatotoxicity,
such as jaundice, and abdominal pain.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. a. CORRECT: a client older than 70 years has an
increased risk for complications from surgery, lifelong
immunosuppression, and organ rejection.

B. CORRECT: a client who has a Bmi of 41 is morbidly obese
and is at an increased risk for complications of surgery,
lifelong immunosuppression, and organ rejection.

c. CORRECT: a client who requires nPH insulin for type
1 diabetes mellitus is at an increased risk from complication of
surgery, lifelong immunosuppression, and organ rejection.

D. CORRECT: a client who has a history of cancer, such as
lymphoma, is at an increased risk for complications of surgery,
lifelong immunosuppression, and organ rejection.

e. Blood pressure averaging 120/70 mm Hg is within
the expected reference range and does not place
the client at a greater risk for complication of surgery,
lifelong immunosuppression, and organ rejection.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

5. a. CORRECT: immediate removal of the donor kidney
is treatment for hyperacute rejection.

B. Dialysis can be required as a conservative treatment to
monitor the client’s kidney function for the progression
of chronic kidney failure following kidney transplant.

c. CORRECT: Fever is a manifestation of an acute rejection.
D. CORRECT: Fluid retention is a manifestation

of an acute rejection.
e. immunosuppressants are increased to

treat an acute rejection.

NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments

Active Learning Scenario Key

Using the ATI Active Learning Template: Nursing Skill

INDICATIONS
● monitor hourly urinary output.
● monitor color of urine and clots.

POTENTIAL COMPLICATIONS
● oliguria
● infection from an indwelling urinary catheter
● Blood clot formation

NURSING INTERVENTIONS
● regulate iV fluids according to urinary output, as prescribed.
● connect the indwelling urinary catheter to the bed
lower than the client to promote gravity drainage.

● remove the indwelling urinary catheter within
a few days of postprocedure.

● implement continuous bladder irrigation as prescribed to
remove blood clots that can obstruct the indwelling urinary
catheter and cause damage to the donor kidney.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 59 PolYcYstic KiDneY Disease, acute KiDneY inJurY, anD cHronic KiDneY Disease 391

UNIT 8 RENAL DISORDERS
SECTION: RENAL SYSTEM DISORDERS

CHAPTER 59 Polycystic
Kidney Disease,
Acute Kidney Injury,
and Chronic
Kidney Disease

the kidneys regulate fluid, acid‑base, and
electrolyte balance, and eliminate wastes from the
body. several disorders affect the renal system
and its ability to function (acute kidney injury,
chronic kidney disease, polycystic kidney disease).

Kidney failure is diagnosed as acute kidney
injury or chronic kidney disease. Without
aggressive treatment, or when complicating
preexisting conditions exist, acute kidney injury
can result in chronic kidney disease.

Acute kidney injury
Acute kidney injury (AKI) is the sudden cessation of renal
function that occurs when blood flow to the kidneys is
significantly compromised. Manifestations occur abruptly.

PHases
● Onset: Begins with the onset of the event, ends when

oliguria develops, and lasts for hours to days.
● Oliguria: Begins with the kidney insult; urine output is
100 to 400 mL/24 hr with or without diuretics; and lasts
for 1 to 3 weeks.

● Diuresis: Begins when the kidneys start to recover;
diuresis of a large amount of fluid occurs; and can last
for 2 to 6 weeks.

● Recovery: Continues until kidney function is fully
restored and can take up to 12 months.

classes
AKI is classified as one of three classes.

● Stage 1 (risk stage): Blood creatinine 1.5 to 1.9 times
baseline and urine output less than 0.5 mL/kg/hr for
6 hr or more.

● Stage 2 (injury stage): Blood creatinine 2 to 2.9 times
baseline and urine output less than 0.5 mL/kg/hr for
12 hr or more.

● Stage 3 (failure stage): Blood creatinine 3 times
baseline and urine output less than 0.3 mL/kg/hr for
12 hr or more.

tYPes
● Prerenal: Occurs as a result of volume depletion and

prolonged reduction of blood flow to the kidneys,
which leads to ischemia of the nephrons. Occurs before
damage to the kidney. Early intervention restoring fluid
volume deficit can reverse AKI and prevent chronic
kidney disease (CKD).

● Intrarenal: Occurs as a result of direct damage to the
kidney from lack of oxygen, indicating damage to the
glomeruli, nephrons, or tubules.

● Postrenal: Occurs as a result of bilateral obstruction of
structures leaving the kidney.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Drink at least 2 L daily. Consult with the provider
regarding prescribed fluid restriction if needed.

● Stop smoking.
● Maintain a healthy weight.
● Use NSAIDs and other prescribed medications cautiously.
● Control diabetes and hypertension to

prevent complications.
● Take all antibiotics prescribed for infections.

ASSESSMENT

risK Factors

Prerenal acute kidney injury
● Renal vascular obstruction
● Shock
● Decreased cardiac output causing decreased

renal profusion
● Sepsis
● Hypovolemia
● Peripheral vascular resistance
● Use of aspirin, ibuprofen, or NSAIDs
● Liver failure

Intrarenal acute kidney injury
● Physical injury: trauma
● Hypoxic injury: renal artery or vein stenosis

or thrombosis
● Chemical injury: acute nephrotoxins (antibiotics,

contrast dye, heavy metals, blood transfusion reaction,
alcohol, cocaine)

● Immunologic injury: infection, vasculitis, acute
glomerulonephritis

Postrenal acute kidney injury
● Stone, tumor, bladder atony
● Prostate hyperplasia, urethral stricture
● Spinal cord disease or injury

CHAPTER 59

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392 CHAPTER 59 PolYcYstic KiDneY Disease, acute KiDneY inJurY, anD cHronic KiDneY Disease CONTENT MASTERY SERIES

eXPecteD FinDings
In most cases, the findings of AKI are related to waste
buildup and decreased urine output. However, almost
every body system can be affected.

● CARDIOVASCULAR: Hypertension, fluid overload
(dependent and generalized edema), dysrhythmia
(hyperkalemia)

● RESPIRATORY: Crackles, decreased oxygenation,
shortness of breath

● RENAL: Scant to normal or excessive urine output,
depending on the phase; possible hematuria

● NEUROLOGIC: Lethargy, muscle twitching, seizures
● INTEGUMENTARY: Dry skin and mucous membranes

The nurse should also assess for findings associated with
the underlying cause.

laBoratorY tests
● Blood creatinine gradually increases 1 to 2 mg/dL every
24 to 48 hr, or 1 to 6 mg/dL in 1 week or less.

● Blood urea nitrogen (BUN) can increase to 80 to
100 mg/dL within 1 week.

● Urine specific gravity varies in postrenal type; can be
elevated up to 1.030 in prerenal type or diluted as low as
1.000 in intrarenal type.

● Electrolytes: Sodium can be decreased (prerenal
azotemia) or increased (intrarenal azotemia);
hyperkalemia, hyperphosphatemia, hypocalcemia.

● Hematocrit: decreased
● Urinalysis: presence of sediment (RBC, casts)
● ABG: metabolic acidosis

Diagnostic ProceDures
Kidney biopsy is performed when the cause of AKI is
uncertain and manifestations continue. This can also be
performed to detect immunological disease or determine
kidney dysfunction reversibility and need for dialysis therapy.

Imaging procedures
● X‑ray of the pelvis, or kidneys, urethra, and bladder

(KUB) to detect calculi and hydronephrosis and to
determine size of kidneys

● Ultrasound to detect an obstruction in the urinary tract
● CT scan without contrast dye or MRI to detect

anatomical changes, tumors, or other obstruction;
patency of ureters; renal perfusion

● Nuclear medicine tests (cystography,
retrograde pyelography)

PATIENT‑CENTERED CARE

nursing care
● Identify and assist with correcting the underlying cause.
● Monitor central venous pressure (CVP) and for

hypotension and tachycardia.
● Monitor fluid intake and output strictly.
● Review laboratory values (BUN, creatinine,

electrolytes, hematocrit).

● Avoid using nephrotoxic medications. If necessary,
give these medications sparingly and decrease the
medication dosage.

● Assess for edema and manifestations of heart failure or
pulmonary edema.

● Restrict fluid intake as prescribed.
● Assess for flank pain, nausea, and vomiting

(nephrolithiasis).
● Monitor for ECG dysrhythmias and changes (tall T waves).
● Monitor daily weights.
● Assess for changes in urination stream or difficulty

starting the stream of urine.
● Assess the urine for blood or particles.
● Treat fever or infection promptly to prevent increase in

the client’s metabolic rate.
● Provide skin care to prevent injury (bathe with cool

water, reposition frequently, provide adequate moisture).
● Provide psychosocial support to the client and family.

Teach the client and family about prescribed treatments.
● Teach the client to perform coughing and deep

breathing exercises, if lethargic.

NUTRITION
● Implement potassium, phosphate, sodium, and

magnesium restrictions, if prescribed (depending on the
stage of injury).

● Restrict fluid intake, if prescribed.
● High‑protein diet to replace the high rate of protein

breakdown due to stress from the illness. Possible total
parenteral nutrition (TPN).

meDications
● Administer IV fluid therapy as a fluid challenge to

promote kidney perfusion, or as fluid replacement if the
client is in the diuretic phase.

● Administer diuretics (furosemide, mannitol, ethacrynic
acid) to promote increased filtration of blood by kidney.

● For AKI caused by medication nephrotoxicity, administer
calcium channel blocker to prevent the movement
of calcium into the kidney cells and to maintain cell
integrity and increase the glomerular filtration rate (GFR).

● Sodium polystyrene sulfonate replaces sodium
with potassium in the intestinal tract to promote
potassium excretion.

● Sorbitol induces a bowel movement to promote
excretion of excess potassium.

● In an emergency, IV medications (dextrose, insulin and
calcium) can be required to reduce potassium.

● Administer sodium bicarbonate if the client has severe
metabolic acidosis.

● For hyperphosphatemia, administer
phosphate‑binding agents.

tHeraPeutic ProceDures
Continuous renal replacement therapy, hemodialysis,
peritoneal dialysis

interProFessional care
● Dietitian to calculate protein, calorie, and fluid needs
● Nephrology services to monitor kidney function

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Chronic kidney disease
CKD is a progressive, irreversible kidney disease.

● A client who has CKD can be free of manifestations
except during periods of stress (infection, surgery,
and trauma). As kidney dysfunction progresses,
manifestations become apparent.

● Older adult clients are at an increased risk for chronic
kidney disease related to the aging process (decreased
number of functioning nephrons, decreased GFR).

● Older adult clients who are on bed rest, confused, have
a lack of thirst, and do not have easy access to water
are at a higher risk for dehydration leading to chronic
kidney disease.

stages
CKD is comprised of five stages.

● Stage 1: Minimal kidney damage when GFR within
expected reference range (greater than 90 mL/min)

● Stage 2: Mild kidney damage with mildly decreased GFR
(60 to 89 mL/min)

● Stage 3: Moderate kidney damage with moderate
decrease in GFR (30 to 59 mL/min)

● Stage 4: Severe kidney damage with severe decrease in
GFR (15 to 29 mL/min)

● Stage 5: Kidney failure and end‑stage renal disease with
little or no glomerular filtration (less than 15 mL/min)

HEALTH PROMOTION AND
DISEASE PREVENTION

● Drink at least 2 L water daily. Consult with the provider
regarding any restrictions.

● Stop smoking.
● Limit alcohol intake.
● Use diet and exercise to manage weight and prevent or

control diabetes and hypertension.
● Adhere to medication prescription guidelines to prevent

kidney damage.
● Test for albumin in the urine yearly (clients who have

diabetes or hypertension).
● Take all antibiotics until completed.
● Limit over‑the‑counter NSAIDs.

ASSESSMENT
● End‑stage kidney disease exists when 90% of

the functioning nephrons are destroyed and are
no longer able to maintain fluid, electrolyte, and
acid‑base homeostasis.

● Dialysis or kidney transplantation can maintain life, but
neither is a cure for CKD.

risK Factors
● Acute kidney injury
● Diabetes mellitus
● Chronic glomerulonephritis
● Nephrotoxic medications (gentamicin, NSAIDs)

or chemicals

● Hypertension, especially in African American clients
● Autoimmune disorders (systemic lupus erythematosus)
● Polycystic kidney disease
● Pyelonephrosis
● Renal artery stenosis
● Recurrent severe infections

eXPecteD FinDings
Nausea, fatigue, lethargy, involuntary movement of legs,
depression, intractable hiccups

In most cases, findings of chronic kidney disease are
related to fluid volume overload and include the following.

NEUROLOGIC: lethargy, decreased attention span, slurred
speech, tremors or jerky movements, ataxia, seizures, coma

CARDIOVASCULAR: fluid overload (jugular distention;
sacrum, ocular, or peripheral edema), hyperlipidemia,
hypertension, dysrhythmias, heart failure, orthostatic
hypotension, peaked T wave on ECG (hyperkalemia)

RESPIRATORY: uremic halitosis with deep sighing,
yawning, shortness of breath, tachypnea, hyperpnea,
Kussmaul respirations, crackles, pleural friction rub,
frothy pink sputum

HEMATOLOGIC: anemia (pallor, weakness, dizziness),
ecchymoses, petechiae, melena

GASTROINTESTINAL: ulcers in mouth and throat, foul
breath, blood in stools, vomiting

MUSCULOSKELETAL: osteodystrophy (thin fragile bones)

RENAL: urine contains protein, blood, particles; change in
the amount, color, concentration

SKIN: decreased skin turgor, yellow cast to skin, dry,
pruritus, urea crystal on skin (uremic frost)

REPRODUCTIVE: erectile dysfunction

laBoratorY tests
Urinalysis: Hematuria, proteinuria, and decrease in
specific gravity

Blood creatinine: Gradual increase over months to years
for CKD exceeding 4 mg/dL; can increase to 15 to 30 mg/dL

BUN: Gradual increase with elevated blood creatinine over
months to years for CKD; can increase 10 to 20 times the
creatinine finding

Blood electrolytes: Decreased sodium (dilutional) and
calcium; increased potassium, phosphorus, and magnesium

CBC: Decreased hemoglobin and hematocrit from anemia
secondary to the loss of erythropoietin in CKD

Diagnostic ProceDures
● Cystoscopy
● Retrograde pyelography
● Kidney biopsy

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394 CHAPTER 59 PolYcYstic KiDneY Disease, acute KiDneY inJurY, anD cHronic KiDneY Disease CONTENT MASTERY SERIES

Imaging procedures
Radiologic procedures to detect disease processes,
obstruction, and arterial defects

● Ultrasound
● Kidneys, ureter, and bladder (KUB)
● Computerized tomography (CT)
● Magnetic resonance imaging (MRI) without contrast dye
● Aortorenal angiography

PATIENT‑CENTERED CARE

nursing care
● Report and monitor irregular findings.

◯ URINARY ELIMINATION PATTERNS: amount, color,
odor, and consistency.

◯ VITAL SIGNS: blood pressure can be increased
or decreased.

◯ WEIGHT: 1 kg (2.2 lb) daily weight increase is
approximately 1 L of fluid retained.

● Assess and monitor vascular access or peritoneal
dialysis insertion site.

● Obtain a detailed medication and herb history to
determine the client’s risk for continued kidney injury.

● Control protein intake based on the client’s stage of
chronic kidney disease and type of dialysis prescribed.

● Restrict dietary sodium, potassium, phosphorous,
and magnesium.

● Provide a diet that is high in carbohydrates and
moderate in fat.

● Restrict intake of fluids (based on urinary output).
● Monitor for weight gain trends.
● Adhere to meticulous cleaning of areas on skin not

intact and access sites to control infections.
● Balance the client’s activity and rest.
● Prepare the client for hemodialysis, peritoneal dialysis,

and hemofiltration if indicated.
● Provide skin care in order to increase comfort and

prevent breakdown.
● Protect the client from injury.
● Provide emotional support to the client and family.
● Encourage the client to ask questions and discuss fears.
● Administer medications as prescribed.

meDications
See the RN PHARMACOLOGY REVIEW MODULE for detailed
information on these medications.

! avoid administering antimicrobial medications
(aminoglycosides and amphotericin B),
nsaiDs, angiotensin‑converting enzyme
inhibitors, angiotensin‑receptor blockers, and
iV contrast dye, which are nephrotoxic.

Digoxin: a cardiac glycoside that increases contractility of
the myocardium and promotes cardiac output

● Monitor digoxin laboratory levels and expect dosages to be
reduced due to slow excretion of the medication with CKD.

● Monitor carefully for manifestations of digoxin toxicity
(nausea, vomiting, anorexia, visual changes). Monitor
potassium level.

● Administer digoxin after dialysis.

Sodium polystyrene: increases elimination of potassium
● Restrict sodium intake. Sodium polystyrene contains

sodium and can cause fluid retention and hypertension,
a complication of CKD.

Epoetin alfa: stimulates production of red blood cells;
given for anemia

Ferrous sulfate: an iron supplement to prevent severe
iron deficiency

Calcium carbonate
● Taken with meals to bind phosphate in food and stop

phosphate absorption.
● Take 2 hr before or after other medications.
● Can cause constipation, so clients can require a

stool softener.

Furosemide or bumetanide: loop‑diuretics administered
to excrete excess fluids

● Avoid administering to a client who has end‑stage
kidney disease.

● Clients can also receive thiazide diuretics,
potassium‑sparing diuretics, and osmotic diuretics.

tHeraPeutic ProceDures
● Peritoneal dialysis
● Hemodialysis
● Kidney transplantation

interProFessional care
● Nephrology services to manage dialysis or kidney failure
● Nutritional services to manage the nutritional needs

client eDucation
● Monitor the daily intake of carbohydrates, proteins,

sodium, and potassium.
● Monitor fluid intake according to prescribed

fluid restriction.
● Avoid antacids containing magnesium.
● Take rest periods from activity.
● Follow instructions for home or outpatient peritoneal

dialysis or hemodialysis.
● Measure blood pressure and weight at home.
● Ask questions and discuss fears.
● Diet, exercise, and take medication as prescribed.
● Notify the provider of skin breakdown.

CARE AFTER DISCHARGE
● Nephrology services is indicated if receiving outpatient

dialysis.
● Consider joining a community support group relating to

the disease.
● Consult nutritional services for dietary needs.
● Take part in a smoking‑cessation support group and

counseling if needed.

COMPLICATIONS
Potential complications include electrolyte imbalance,
dysrhythmias, fluid overload, hypertension, metabolic
acidosis, secondary infection, and uremia.

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Polycystic kidney disease
● Polycystic kidney disease (PKD) is a congenital disorder

where clusters of fluid‑filled cysts develop in the
nephrons. Healthy kidney tissue is replaced by multiple
non‑functioning cysts.

● PKD is hereditary and is caused by a genetic mutation.
● PKD is more common in Caucasian clients.

FORMS: There are two forms of PKD.
● Autosomal dominant trait: Most common form. Cysts

begin to multiply when the client reaches age 30.
● Autosomal recessive trait: Multiple cysts are

present at birth.

ASSESSMENT

eXPecteD FinDings
● Familial history of PKD
● Anxiety, guilt
● Abdominal and/or flank pain

◯ Dull pain indicates increased kidney size or possible
cyst infection

◯ Sharp pain indicates ruptured cyst or possible renal
lithiasis (kidney stone)

● Headaches
● Hypertension caused by kidney ischemia from the

enlarging cysts
● Enlarged abdominal girth
● Constipation
● Bloody and/or cloudy urine
● Renal lithiasis
● Hyponatremia
● Nocturia (excessive urination at night)
● Progressive kidney failure

laBoratorY tests
● Urinalysis
● Hematuria, proteinuria, and bacteria

indicating infection
● Gradual increase of blood creatinine, BUN,

creatinine clearance

Diagnostic ProceDures
Imaging procedures: Radiologic procedures to detect
disease processes and cysts: ultrasound, CT, and MRI

PATIENT‑CENTERED CARE

nursing care
HYPERTENSION CONTROL

● Controlling blood pressure is the highest nursing
priority for clients who have PKD.

● Manage hypertension with prescribed medication.
● Teach the client and family how to measure and record

blood pressure readings and daily weights.

PAIN MANAGEMENT
● Provide prescribed pain medications and

nonpharmacological pain methods (relaxation,
deep breathing, guided imagery, distraction). Use
NSAIDs cautiously in clients who have kidney disease.

● Apply dry heat to abdomen or flank areas to
reduce discomfort.

INFECTION PREVENTION
● Administer antibiotics, such as ciprofloxacin and

trimethoprim‑sulfamethoxazole. Monitor for
antibiotic‑induced nephrotoxicity by evaluating blood
creatinine levels and urinary output.

● Monitor urine specific gravity to assess renal function
and hydration status.

CONSTIPATION PREVENTION
● Provide adequate oral fluid intake (as allowed per

prescribed fluid restrictions), increase dietary fiber, and
encourage client to ambulate.

● Assess bowel sounds and bowel movements.
● Administer stool softeners as prescribed.

tHeraPeutic ProceDure
Needle aspiration and drainage of cysts

client eDucation
● Monitor blood pressure and weight daily.
● Notify the provider of elevated temperature.
● Adhere to a low‑sodium diet.
● Inform the provider if there are any changes in urine or

bowel movements.

CARE AFTER DISCHARGE
● Consider joining a community support group related to

the disease.
● Consult nutritional services for dietary needs.

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Application Exercises

1. a nurse is planning care for a client who has prerenal
acute kidney injury (aKi) following abdominal aortic
aneurysm repair. urinary output is 60 ml in the past
2 hr, and blood pressure is 92/58 mm Hg. the nurse
should expect which of the following interventions?

a. Prepare the client for a ct scan with contrast dye.

B. Plan to administer nitroprusside.

c. Prepare to administer a fluid challenge.

D. Plan to position the client in trendelenburg.

2. a nurse is planning care for a client who has
postrenal aKi due to metastatic cancer. the
client has a blood creatinine of 5 mg/dl. Which
of the following interventions should the nurse
include in the plan? (select all that apply.)

a. Provide a high‑protein diet.

B. assess the urine for blood.

c. monitor for intermittent anuria.

D. Weight the client once per week.

e. Provide nsaiDs for pain.

3. a nurse is planning care for a client who has
stage 4 chronic kidney disease. Which of the
following actions should the nurse include in
the plan of care? (select all that apply.)

a. assess for jugular vein distention.

B. Provide frequent mouth rinses.

c. auscultate for a pleural friction rub.

D. Provide a high‑sodium diet.

e. monitor for dysrhythmias.

4. a nurse is reviewing client laboratory data. Which
of the following findings is expected for a client
who has stage 4 chronic kidney disease?

a. Blood urea nitrogen (Bun) 15 mg/dl

B. glomerular filtration rate (gFr) 20 ml/min

c. Blood creatinine 1.1 mg/dl

D. Blood potassium 5.0 meq/l

5. a nurse is assessing a client who has prerenal
aKi. Which of the following findings should
the nurse expect? (select all that apply.)

a. reduced Bun

B. elevated cardiac enzymes

c. reduced urine output

D. elevated blood creatinine

e. elevated blood calcium

Active Learning Scenario

a nurse is preparing to administer medication to a client who
has chronic kidney disease (cKD). What information should the
nurse consider when administering medication? use the ati
active learning template: medication to complete this item.

MEDICATION: identify three.

THERAPEUTIC USES: Describe how the
medication is used to treat cKD.

NURSING INTERVENTIONS: Describe
two for each medication.

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Application Exercises Key

1. a. Do not plan for a ct scan. contrast dye is contraindicated
for a client who has possible acute kidney injury.

B. nitroprusside is a rapid‑acting vasodilator used to rapidly
reduce blood pressure for clients who have hypertensive
crisis. it is contraindicated for clients who have hypotension.

c. CORRECT: Plan to administer a fluid challenge
for hypovolemia, which is indicated by the client’s
low urinary output and blood pressure.

D. Position the client in reverse trendelenburg, with the head
down and feet up,if a client becomes hypotensive.

NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances

2. a. CORRECT: Provide a high‑protein diet due to the high rate of
protein breakdown that occurs with acute kidney injury.

B. CORRECT: assess urine for blood, stones,
and particles indicating an obstruction of the
urinary structures that leave the kidney.

c. CORRECT: assess for intermittent anuria due to obstruction
or damage to kidneys or urinary structures.

D. Weigh the client daily to monitor for fluid
retention due to acute kidney injury.

e. Do not administer nsaiDs, which are toxic
to the nephrons in the kidney.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

3. a. CORRECT: assess for jugular vein distention, which
can indicate fluid overload and heart failure.

B. CORRECT: Provide frequent mouth rinses due to uremic
halitosis caused by urea waste in the blood.

c. CORRECT: auscultate for a pleural friction rub related
to respiratory failure and pulmonary edema caused
by acid base imbalances and fluid retention.

D. monitor blood sodium and reduce the
client’s dietary sodium intake.

e. CORRECT: monitor for dysrhythmias related to increased
blood potassium caused by stage 4 chronic kidney disease.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. a. expect the Bun to be above the expected reference
range, about 10 to 20 times the Bun finding.

B. CORRECT: the gFr is severely decreased to
approximately 20 ml/min, which is indicative
of stage 4 chronic kidney disease.

c. in stage 4 chronic kidney disease, a blood creatinine
level can be as high as 15 to 30 mg/dl.

D. a client in stage 4 chronic kidney disease would have
a blood potassium level greater than 5.0 meq/l.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

5. a. a manifestation of prerenal aKi is an elevated Bun caused
by the retention of nitrogenous wastes in the blood.

B. elevated cardiac enzymes is a manifestation
of cardiac tissue injury, not aKi.

c. CORRECT: a manifestation of prerenal
aKi is reduced urine output.

D. CORRECT: a manifestation of prerenal
aKi is elevated blood creatinine.

e. a manifestation of prerenal aKi is reduced calcium level.

NCLEX® Connection: Physiological Adaptation,
Illness Management

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

MEDICATION
● Digoxin
● sodium polystyrene
● Furosemide

THERAPEUTIC USES
● Digoxin: a cardiac glycoside: increases contractility of
the myocardium and promotes cardiac output.

● sodium polystyrene: increases elimination of potassium.
● calcium carbonate: Binds to phosphate in food
and stops phosphate absorption.

● Furosemide: a loop diuretic that causes diuresis of excess fluids.

NURSING INTERVENTIONS
● Digoxin

◯ monitor blood digoxin and potassium levels.
◯ monitor for manifestations of toxicity (nausea,
vomiting, anorexia, visual changes).

● sodium polystyrene
◯ monitor for hypokalemia.
◯ restrict sodium intake.

● Furosemide
◯ monitor intake and output and blood pressure.
◯ avoid administering to a client who has end‑stage kidney disease.

NCLEX® Connection: Physiological Adaptation, Illness
Management

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398 CHAPTER 59 PolYcYstic KiDneY Disease, acute KiDneY inJurY, anD cHronic KiDneY Disease CONTENT MASTERY SERIES

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UNIT 8 RENAL DISORDERS
SECTION: RENAL SYSTEM DISORDERS

CHAPTER 60 Infections of
the Renal and
Urinary System

the renal system includes the kidneys and the
urinary system. the function of the renal system
includes maintaining fluid volume, removing
waste, regulating blood pressure, maintaining
acid‑base balance, producing erythropoietin,
and activating vitamin D.

there are three components to the urinary
system: the ureter, bladder, and urethra. the
function of the urinary system is to store and
remove urine.

urinary tract infections are infections of the
urinary system, and pyelonephritis is an infection
of the kidney and renal pelvis. acute and
chronic glomerulonephritis can develop from a
systemic infection and involves the glomeruli of
the kidney or the area responsible for filtering
particles from the blood to make urine.

Urinary tract infection
● A urinary tract infection (UTI) refers to any portion

of the lower urinary tract (ureters, bladder, urethra,
prostate). UTIs include the following.

◯ Cystitis
◯ Urethritis
◯ Prostatitis

● An upper UTI refers to conditions such as pyelonephritis
(inflammation of the kidney pelvis).

● UTIs are often caused by Escherichia coli. Other organisms
include enterobacteriaceae micro‑organisms (klebsiella,
proteus), pseudomonas, and Staphylococcus saprophyticus.

● Untreated UTIs can lead to pyelonephritis and urosepsis,
which can result in septic shock and death.

ASSESSMENT

risK Factors
● Alkaline urine promotes bacterial growth.
● Indwelling urinary catheters (significant source of

infection in clients who are hospitalized)
● Stool incontinence
● Bladder distention
● Urinary conditions (anomalies, stasis, calculi,

residual urine)
● Possible genetic links
● Disease (diabetes mellitus)

Female sex
● Short urethra predisposes females to UTIs
● Close proximity of the urethra to the rectum
● Decreased estrogen in aging females promotes atrophy

of the urethral opening toward the rectum (increases
the risk of urosepsis in females)

● Sexual intercourse
● Frequent use of feminine hygiene sprays, tampons,

sanitary napkins, and spermicidal jellies
● Pregnancy
● Poorly‑fitted diaphragm
● Hormonal influences within the vaginal flora
● Synthetic underwear and pantyhose
● Wet bathing suits
● Frequent submersion into baths or hot tubs

Older adult clients
● Increased risk of bacteremia, sepsis, and shock
● Incomplete bladder emptying caused by an enlarged

prostate or prostatitis in males
● Bladder prolapse in females
● Inability to empty bladder (neurogenic bladder) as a

result of a stroke or Parkinson’s disease
● Fecal incontinence with poor perineal hygiene
● Hypoestrogenism in females affecting the mucosa of the

vagina and urethra, causing bacteria to adhere to the
mucosal surface

● Renal complications increase due to decreased number
of functioning nephrons and fluid intake

eXPecteD FinDings
● Lower back or lower abdominal discomfort and

tenderness over the bladder area
● Nausea
● Urinary frequency and urgency
● Dysuria, bladder cramping, spasms
● Feeling of incomplete bladder emptying or

retention of urine
● Perineal itching
● Hematuria (red‑tinged, smoky, coffee‑colored urine)
● Pyuria (WBCs in the urine sample)
● Fever
● Vomiting
● Voiding in small amounts
● Nocturia
● Urethral discharge
● Cloudy or foul‑smelling urine

CHAPTER 60

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400 CHAPTER 60 inFections oF tHe renal anD urinarY sYstem CONTENT MASTERY SERIES

OLDER ADULT MANIFESTATIONS
● Confusion
● Incontinence
● Loss of appetite
● Nocturia and dysuria
● Hypotension, tachycardia, tachypnea, and fever

(indications of urosepsis)

laBoratorY tests

Urinalysis and urine culture and sensitivity

EXPECTED FINDINGS
● Bacteria, sediment, white blood cells (WBC), and red

blood cells (RBC)
● Positive leukocyte esterase and nitrates (68% to 88%

positive results indicates UTI)

NURSING ACTIONS
● Instruct the client regarding proper technique for the

collection of a clean‑catch urine specimen.
● Collect catheterized urine specimens using

sterile technique.

WBC count and differential
● If urosepsis is suspected
● White blood cell count equal to or greater than 10,000/uL

with a shift to the left, indicating an increased number
of immature cells (neutrophils) in response to infection

Sexually transmitted infection testing
● STIs can cause manifestations of a UTI.
● Chlamydia trachomatis, Neisseria gonorrhoeae, and herpes

simplex can cause acute urethritis.
● Trichomoniasis or candida can cause acute

vaginal infections.

Diagnostic ProceDures
Imaging procedures

● Cystoscopy is used for complicated UTIs.
● Cystourethroscopy detects strictures, calculi, tumors,

and cystitis.
● Computed tomography (CT) scan is used to

detect pyelonephritis.
● Ultrasonography detects cysts, tumors, calculi,

and abscesses.
● Transrectal ultrasonography is used to detect prostate

and bladder conditions in males.

PATIENT‑CENTERED CARE

nursing care
● Consult with the provider regarding prescribed fluid

restrictions if needed.
● Administer antibiotic medications as prescribed.
● Recommend warm sitz bath two or three times a day to

provide comfort.
● Avoid the use of indwelling catheters if possible. This

reduces the risk for infection.
● Clients who are pregnant require immediate and

effective treatment to prevent pyelonephritis that can
result in preterm labor.

meDications

Fluoroquinolones, nitrofurantoin,
trimethoprim, or sulfonamides

Antibiotics used to treat urinary infections by directly
killing bacteria and inhibiting bacterial reproduction.

● Penicillins and cephalosporins are administered less
frequently because the medication is less effective
and tolerated.

● Nitrofurantoin is an antibacterial medication where
therapeutic levels are achieved in the urine only.

NURSING ACTIONS
● If a sulfonamide is prescribed, ask the client about

allergy to sulfa.
● Advise clients taking fluoroquinolones or sulfonamides

that sun‑sensitivity is increased and sunburn is a risk
for even dark‑skinned individuals. These medications
can precipitate in the renal tubules, so advise client to
take these medications with a full glass of water and to
increase fluid intake.

CLIENT EDUCATION
● Understand the need to take all of the prescribed

antibiotics even if manifestations subside.
● Take the medication with food.
● Monitor and report watery diarrhea that can indicate

pseudomembranous colitis.

Phenazopyridine

Bladder analgesic used to treat UTIs

CLIENT EDUCATION
● The medication will turn urine orange.
● Take the medication with food.
● The medication will not treat the infection, but it will

help relieve bladder discomfort.

interProFessional care
Consult with urology services for managing UTIs.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 60 inFections oF tHe renal anD urinarY sYstem 401

client eDucation
● Drink at least 3 L fluid daily.
● Bathe daily to promote good body hygiene.
● Empty bladder every 3 to 4 hr instead of waiting until

the bladder is completely full.
● Urinate before and after intercourse.
● Drink cranberry juice to decrease the risk of

infection.
◯ The compound in cranberries might stop certain bacteria

from adhering to the mucosa of the urinary tract.
◯ Clients who have chronic cystitis should avoid
cranberry juice, which irritates the bladder.

● Empty the bladder as soon as there is an urgency to void.

Instruct female clients
● Wipe the perineal area from front to back.
● Avoid using bubble baths, and feminine products and

toilet paper containing perfumes.
● Avoid sitting in wet bathing suits.
● Avoid wearing pantyhose with slacks or tight clothing.

CARE AFTER DISCHARGE: Urology services can be
consulted for management of long‑term antibiotic therapy
for chronic UTIs.

COMPLICATIONS
Urethral obstruction, pyelonephritis, chronic kidney
disease, urosepsis, septic shock, and death

Pyelonephritis
● Pyelonephritis is an infection and inflammation of

the kidney pelvis, calyces, and medulla. The infection
usually begins in the lower urinary tract with
organisms ascending into the kidney pelvis.

● Escherichia coli organisms are frequently the cause of
acute pyelonephritis.

● Repeated infections can create scarring that changes the
blood flow to the kidney, glomerulus, and tubular structure.

● Filtration, reabsorption, and secretion are impaired,
which results in a decrease in kidney function.

● Acute pyelonephritis is an active bacterial infection that
occurs most frequently in females 20 to 30 years of age
and can cause the following.

◯ Interstitial inflammation
◯ Tubular cell necrosis
◯ Abscess formation in the capsule, cortex, or medulla
◯ Temporarily altered kidney function (this rarely

progresses to chronic kidney disease)
● Chronic pyelonephritis is the result of repeated infections

that cause progressive inflammation and scarring.
◯ This can result in the thickening of the calyces and

postinflammatory fibrosis with permanent renal
tissue scarring.

◯ It is more common with obstructions, urinary
anomaly, and vesicoureteral urine reflux.

◯ Reflux of urine occurs at the junction where the ureter
connects to the bladder.

ASSESSMENT

risK Factors
● Males over age 65 years who have prostatitis and

hypertrophy of the prostate
● Chronic urinary stone disorders (stones harbor bacteria)
● Spinal cord injury (clients have a higher incidence of reflux)
● Pregnancy
● Congenital malformations
● Bladder tumors
● Chronic illness (diabetes mellitus, hypertension,

chronic cystitis)
● Alkaline urine which promotes bacterial growth
● Incomplete bladder emptying, which is more common

among older adult clients
● Older adult clients can exhibit gastrointestinal or

pulmonary manifestations instead of febrile responses
because their temperature can vary at a
lower‑than‑normal state. Causes are inadequate diet,
loss of adipose tissue, lack of exercise, and reduction in
the client’s thermoregulator.

eXPecteD FinDings
● Chills
● Colicky‑type abdominal pain
● Nausea
● Malaise, fatigue
● Burning, urgency, and frequency with urination
● Costovertebral angle tenderness
● Flank and back pain
● Nocturia
● Fever
● Tachycardia
● Tachypnea
● Hypertension
● Vomiting
● Inability to concentrate urine or conserve sodium

(chronic pyelonephritis)
● Bacteremia without other manifestations

laBoratorY tests
● Urinalysis and urine culture and sensitivity are the

same as for a UTI (positive leukocyte esterase and
nitrites, WBCs, and bacteria).

● WBC count and differential are the same as for a UTI.
● Blood cultures will be positive for the presence of

bacteria if a systemic infection is present.
● Serum creatinine and blood urea nitrogen (BUN) are

elevated during acute episodes and consistently elevated
with chronic infection.

● C‑reactive protein is elevated during exacerbating
inflammatory processes of the kidneys. Erythrocyte
sedimentation rate (ESR) is elevated during acute or
chronic inflammation.

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402 CHAPTER 60 inFections oF tHe renal anD urinarY sYstem CONTENT MASTERY SERIES

Diagnostic ProceDures
Imaging procedures

● An x‑ray of the kidneys, ureters, and bladder (KUB) can
demonstrate calculi or structural abnormalities.

● Ultrasonography is used to detect cysts, tumors, calculi,
and abscesses.

● Gallium scan is a nuclear medicine test that uses
injectable radioactive dye to visualize organs,
glands, bones, and blood vessels that have infection
and inflammation.

● Intravenous pyelogram can demonstrate calculi,
structural, or vascular abnormalities.

PATIENT‑CENTERED CARE

nursing care

Nonsurgical
● Assess/monitor the following.

◯ Nutritional status
◯ Intake and output
◯ Fluid and electrolyte balance
◯ Temperature
◯ Onset, quality, duration, and severity of pain

● Increase fluid intake to 2 L/day unless contraindicated.
● Administer antipyretic, such as acetaminophen, as

needed for fever and opioid analgesics for pain
associated with pyelonephritis.

● Provide emotional support.
● Assist with personal hygiene.

Surgical
● Includes all the above information.
● Assess the dressings and incision.
● Balance rest and activities.
● Instruct the client on monitoring for indications

of infection.
● Instruct the client on the role of nutritious meals and

adequate fluid intake.

meDications
See the RN PHARMACOLOGY REVIEW MODULE for more
detailed information.

Opioid analgesics (opioid agonists), morphine sulfate,
and morphine: for moderate to severe pain

Antibiotics
● Mild to moderate pyelonephritis treated at home for
14 days with the following

◯ Anti‑infective: trimethoprim, sulfamethoxazole/
trimethoprim

◯ Quinolone antibiotic: ciprofloxacin, levofloxacin
● Severe pyelonephritis treated in the hospital for 24 to
48 hr with IV medication

◯ Quinolone antibiotics: ciprofloxacin
◯ Cephalosporin antibiotics: ceftriaxone, ceftazidime
◯ Aminopenicillin antibiotics: ampicillin,
ampicillin/sulbactam

◯ Aminoglycoside antibiotics: gentamicin, tobramycin

tHeraPeutic ProceDures
Provide preoperative teaching.

Intravenous antibiotics and analgesics are usually
administered for each procedure.

Pyelolithotomy: The removal of a large stone from the
kidney that causes infections and blocks the flow of urine
from the kidney

Nephrectomy: The removal of the kidney when all
procedures to clear the client of infection were unsuccessful

Ureteroplasty: Done to repair or revise the ureter and can
involve reimplantation of the ureter in the bladder wall to
preserve the function of the kidney and eliminate infection

interProFessional care
● Urology services to manage pyelonephritis
● Nutritional services to promote adequate calories

client eDucation
● Maintain an adequate nutritional status.
● Drink at least 2 L fluids daily unless otherwise indicated

by the provider.
● Notify the provider if acute onset of pain occurs or a

fever is present.
● Express any fears and anxiety related to the disease.
● Take rest periods from activity as needed.

CARE AFTER DISCHARGE
● Home care services can be indicated if needing

assistance with medications or nutritional therapy.
● Follow up with the provider as directed.

COMPLICATIONS
● Septic shock (hypotension, tachycardia, fever) due to

bacterial organism entering the blood stream
● Chronic kidney disease (elevated BUN, creatinine,

electrolytes) from inflammation and infection that
causes fibrosis of the kidney pelvis and calyx, scarring,
and changes in the blood vessels and the glomerular
and tubular filtration system

● Hypertension (related to fluid and sodium retention)
indicating chronic kidney disease caused by destruction
of the filtration system of the kidney due to infection

Glomerulonephritis
Immunologic kidney disorder that can start in the kidneys
(genetic basis and immune‑inducing inflammation) or be
a result of other health disorders (lupus erythematosus,
diabetic nephropathy) and results in glomerular injury

● This can lead to end‑stage kidney disease (ESKD).
● Acute glomerulonephritis often occurs following

an infection.
● Chronic glomerulonephritis develops over a period of
20 to 30 years.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 60 inFections oF tHe renal anD urinarY sYstem 403

ASSESSMENT

risK Factors
● Recent infection particularly of the skin or upper

respiratory tract
● Recent travel or other possible exposure to bacteria,

viruses, fungi or parasites
● Presence of systemic diseases (systemic lupus

erythematosus, Goodpasture syndrome)
● Recent surgery or illness

eXPecteD FinDings
● Anorexia
● Nausea
● Dysuria
● Oliguria
● Fatigue
● Hypertension
● Difficulty breathing
● Crackles
● S3 heart sound
● Weight gain
● Reddish‑brown or cola‑colored urine
● Older adult clients likely to have the less common

manifestations related to circulatory overload, which
can be confused with congestive heart failure

laBoratorY tests
● Urinalysis shows red blood cells and protein.
● Glomerular filtration rate is decreased.
● Blood, skin or throat cultures (if indicated).
● 24‑hr urine collection for protein assay (increased in

acute glomerulonephritis and decreased in chronic
glomerulonephritis).

● Blood urea nitrogen and creatinine are increased.
● Antistreptolysin O titers are increased after group A beta

hemolytic streptococcus infection.
● C3 complement levels decreased.
● Cryoglobulins present.
● Anti‑nuclear antibody (ANA) presence.
● Altered electrolytes: Hyperkalemia, hyperphosphatemia,

hypocalcemia.

Diagnostic ProceDures
Kidney biopsy will diagnose the condition, determine
prognosis, and guide treatment.

PATIENT‑CENTERED CARE

nursing care
● Coordinate care to conserve client energy.
● Consult with provider to determine if fluid restriction

is needed.
● Administer antibiotics as prescribed.
● Teach relaxation exercises to decrease stress.
● Monitor blood pressure.
● Monitor respiratory status.
● Monitor fluid and electrolytes.

meDications
Antibiotics: Penicillin, erythromycin, or azithromycin is
prescribed for glomerulonephritis infection due to
streptococcal infection.

Antihypertensives: To control hypertension

interProFessional care
● Collaborate with provider and nutritional support

regarding any potassium or protein restriction in diet.
● Dialysis or plasmapheresis if necessary.

client eDucation
● Complete full course of antibiotics.
● Monitor weight daily and report increases to provider.
● Adhere to dietary and fluid restrictions.
● Perform basic infection control practices, such as

hand hygiene.

CARE AFTER DISCHARGE
● Consider home care services for continued dialysis or

plasmapheresis if needed.
● Follow up with the provider as directed.

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404 CHAPTER 60 inFections oF tHe renal anD urinarY sYstem CONTENT MASTERY SERIES

Active Learning Scenario

a nurse is educating a client who has chronic
pyelonephritis. What information should the nurse
include in the teaching? use the ati active learning
template: system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)

COMPLICATIONS: list three, and explain why these occur.

CLIENT EDUCATION: include three teaching points.

Application Exercises

1. a nurse is planning care for a client who has chronic
pyelonephritis. Which of the following actions should
the nurse plan to take? (select all that apply.)

a. Provide a referral for nutrition counseling.

B. encourage daily fluid intake of 1 l.

c. Palpate the costovertebral angle.

D. monitor urinary output.

e. administer antibiotics.

2. a nurse is caring for a client who has a urinary
tract infection (uti). Which of the following
is the priority intervention by the nurse?

a. offer a warm sitz bath.

B. recommend drinking cranberry juice.

c. encourage increased fluids.

D. administer an antibiotic.

3. a nurse is preparing educational material to present
to a female client who has frequent urinary tract
infections. Which of the following information
should the nurse include? (select all that apply.)

a. avoid sitting in a wet bathing suit.

B. Wipe the perineal area back to
front following elimination.

c. empty the bladder when there is an urge to void.

D. Wear synthetic fabric underwear.

e. take a shower daily.

4. a nurse is caring for several clients. Which of
the following clients are at risk for developing
pyelonephritis? (select all that apply.)

a. a client who is at 32 weeks of gestation

B. a client who has kidney calculi

c. a client who has a urine pH of 4.2

D. a client who has a neurogenic bladder

e. a client who has diabetes mellitus

5. a nurse is reviewing urinalysis results for
four clients. Which of the following urinalysis
results indicates a urinary tract infection?

a. Positive for hyaline casts

B. Positive for leukocyte esterase

c. Positive for ketones

D. Positive for crystals

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 60 inFections oF tHe renal anD urinarY sYstem 405

Application Exercises Key

1. a. CORRECT: the client requires adequate
nutrition to promote healing.

B. encourage fluid intake of 2 l daily to maintain dilute urine.
c. CORRECT: gently palpate the costovertebral angle for flank

tenderness, which can indicate inflammation and infection.
D. CORRECT: monitor urinary output to determine

that 1 to 3 l of urine is excreted daily.
e. CORRECT: administer antibiotics to treat the bacteriuria

and decrease progressive damage to the kidney.

NCLEX® Connection: Physiological Adaptation,
Illness Management

2. a. offer a warm sitz bath to provide temporary
relief of the manifestations of the uti. However,
another action is the priority.

B. recommend that the client drink cranberry juice to prevent
a uti in the future. However, another action is the priority.

c. encourage the client to increase fluid intake to dilute the
urine, and flush the kidneys to relieve the manifestations
of the uti. However, another action is the priority.

D. CORRECT: the greatest risk to the client is injury
to the renal system and sepsis from the uti. the
priority intervention is to administer antibiotics.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

3. a. CORRECT: the client should avoid sitting in a wet bathing
suit, which can increase the risk for a uti by colonization
of bacteria in a moist, warm environment.

B. the client should wipe the perineal area from
front to back after elimination to prevent
contaminating the urethra with bacteria.

c. CORRECT: the client should empty the bladder when there
is an urge to void rather than retain urine for an extended
period of time, which increases the risk for a uti.

D. the client should wear cotton underwear that absorbs
moisture and keeps the perineal area drier, thus decreasing
colonization of bacteria that can cause a uti.

e. CORRECT: the client should take a shower daily to
promote good body hygiene and decrease colonization
of bacteria in the perineal area that can cause a uti.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

4. a. CORRECT: a client who is at 32 weeks of gestation
is at risk for developing pyelonephritis because of
increased pressure on the urinary system during
pregnancy causing reflux or retention of urine.

B. CORRECT: a client who has kidney calculi is at risk for
pyelonephritis because stones harbor bacteria.

c. the expected reference range for urine pH is 4.6 to
8.0. alkaline urine promotes bacteria growth. the
client who has a urine pH of 4.2 has acidic urine.

D. CORRECT: the client who has a neurogenic
bladder can retain urine, promoting bacterial
growth and causing pyelonephritis.

e. CORRECT: the client who has diabetes mellitus is
at risk of pyelonephritis because glucose that can
be in the urine promotes bacterial growth.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

5. a. Hyaline casts in the urine can indicate proteinuria
and can occur following exercise.

B. CORRECT: a positive leukocyte esterase
indicates a urinary tract infection.

c. Ketones in the urine is a manifestation of poorly
controlled diabetes mellitus or starvation.

D. crystals in the urine can indicate a potential
for kidney stone formation.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): chronic pyelonephritis
is a repetitive infection and inflammation of the kidney
pelvis, calyces, and medulla, which generally begins from
bacteria that ascends from a lower urinary tract infection.

COMPLICATIONS
● septic shock caused by micro‑organisms entering
the bloodstream from the infected kidney

● chronic kidney disease caused by inflammation, fibrosis,
and scarring of the kidney filtration structure

● Hypertension (related to fluid and sodium retention)
indicating chronic kidney disease caused by destruction
of the filtration system of the kidney from infection

CLIENT EDUCATION
● intake at least 2 l of fluids daily.
● take all medications as prescribed.
● notify the provider of acute, rapid onset of pain.
● express any fears and anxiety.
● Balance between rest and activity.

NCLEX® Connection: Physiological Adaptation, Illness
Management

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406 CHAPTER 60 inFections oF tHe renal anD urinarY sYstem CONTENT MASTERY SERIES

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 61 renal calculi 407

UNIT 8 RENAL DISORDERS
SECTION: RENAL SYSTEM DISORDERS

CHAPTER 61 Renal Calculi
urolithiasis is the presence of calculi (stones)
in the urinary tract. the majority of calculi are
composed of calcium phosphate or calcium
oxalate, but they can contain other substances
(uric acid, struvite, cystine).

a diet high in calcium is not believed to increase
the risk of calculi formation unless there is a
preexisting metabolic disorder or renal tubular
defect. recurrence is increased in individuals who
have a family history or whose first occurrence of
renal calculi is prior to the age of 25.

most clients can expel calculi without invasive
procedures. Factors that influence whether
a calculus will pass spontaneously or not
include the composition, size, and location of
the calculus.

ASSESSMENT

risK Factors
● Cause is unknown
● Increased incidence in males
● Genetic predisposition
● Urinary tract lining that is damaged
● Urine flow that is decreased, concentrated, and contains

particles (calcium)
● Metabolic defects

◯ Increased intestinal absorption or decreased renal
excretion of calcium

◯ Increased oxalate production (genetic) or inability
to metabolize oxalate from foods (black tea, spinach,
beets, Swiss chard, chocolate, and peanuts)

◯ Increased production or decreased clearance of
purines (contributing to increased uric‑acid levels)

● High alkalinity or acidity of urine
● Urinary stasis, urinary retention, immobilization, and

dehydration
● Decreased fluid intake or increased incidence of

dehydration among older adult clients

eXPecteD FinDings
● Severe pain (renal colic)

◯ Pain intensifies as the calculus moves through the ureter.
◯ Flank pain suggests calculi are located in the kidney
or ureter.

◯ Flank pain that radiates to the abdomen, scrotum,
testes, or vulva suggests calculi in the ureter
or bladder.

● Urinary frequency or dysuria (calculi in the bladder)
● Fever
● Diaphoresis
● Pallor
● Nausea/vomiting
● Tachycardia, tachypnea, increased blood pressure (pain),

or decreased blood pressure (shock)
● Oliguria/anuria occurs with calculi that obstruct urinary

flow. Urinary tract obstruction is a medical emergency
and needs to be treated to preserve kidney function.

● Hematuria (rusty or smoky‑looking urine)

STONE LOCATIONS
● Nephrolithiasis: Formation of the stones in the kidney;

these stones are typically found in the kidney’s renal
pelvis; acute pain in the costovertebral region.

● Ureterolithiasis: Formation of stones in the ureter; pain
is often described as wave‑like and excruciating.

laBoratorY tests

Urinalysis

Urine is analyzed for pH (determines the type of calculi),
specific gravity, and osmolarity (hydration status).

● Altered odor of the urine and increased urine turbidity if
infection is present

● Increased RBCs, WBCs, and bacteria (presence
of infection)

● Crystals noted on microscopic exam
● Abnormal blood calcium, phosphate, and uric‑acid levels

in the presence of metabolic disorders/defects
● Decreased pH: uric acid, cystine stones
● Increased pH: calcium or struvite stones

Diagnostic ProceDures

Radiology examination

X‑ray of kidney, ureters, bladder (KUB), or intravenous
pyelogram (IVP) is used to confirm the presence and
location of calculi. IVP is contraindicated if there is a
urinary obstruction.

CT or MRI of the abdomen and pelvis

A CT (noncontrast helical scan) or MRI is used to identify
cystine or uric‑acid calculi, which cannot be seen on
standard x‑rays.

Renal ultrasound or cystoscopy

These can confirm the diagnosis.

CHAPTER 61

408 CHAPTER 61 renal calculi CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

nursing care
● Report laboratory and diagnostic findings to the provider.
● Provide preoperative and postoperative care as indicated.
● Administer prescribed medications.
● Strain all urine to check for passage of the calculus, and

save the calculus for laboratory analysis.
● Encourage increased oral intake to 3 L/day

unless contraindicated.
● Encourage the use of hot baths and moist heat to

promote comfort.
● Administer IV fluids as prescribed.
● Encourage ambulation to promote passage of the calculus.
● Some clients can pass stones less than 5 mm without

any interventions. Monitor the client closely during
this period.

ASSESS/MONITOR
● Pain status
● Intake and output
● Urinary pH

meDications

Analgesics

Opioids
● Morphine sulfate can be used in the first 24 to
36 hr with the acute onset of calculi. It can be
administered IV or IM.

● Opioid agents are used to treat moderate to severe
pain. Activation of these receptors produces analgesia,
respiratory depression, euphoria, sedation, and
decreased GI motility.

● Use cautiously with clients who have asthma or
emphysema due to the risk of respiratory depression.

● NURSING ACTIONS
◯ Assess the client frequently.
◯ Watch for evidence of respiratory depression,
especially in older adult clients. If respirations are
12/min or less, stop the medication and notify the
provider immediately.

◯ Monitor vital signs for hypotension and
decreased respirations.

◯ Assess level of sedation (drowsiness, level
of consciousness).

● CLIENT EDUCATION: Drink plenty of fluids to
prevent constipation.

NSAIDs
● Ketorolac is used to treat mild to moderate pain, fever,

and inflammation.
● There is a risk for decreased renal function

and perfusion.
● NURSING ACTIONS: Observe for indications of bleeding.
● CLIENT EDUCATION

◯ Watch for bleeding (dark stools, blood in stools).
◯ Notify the provider if abdominal pain occurs, which
can be due to gastric ulceration.

Spasmolytic medications

Oxybutynin alleviates pain by decreasing bladder spasms
that can result due to renal calculi.

NURSING ACTIONS
● Assess for history of glaucoma, as this medication

increases intraocular pressure.
● Monitor for dizziness and tachycardia.
● Monitor for urinary retention.

CLIENT EDUCATION
● Report palpitations and problems with voiding

or constipation.
● Dizziness and dry mouth are common with

the medication.
● Suck on hard candies to alleviate dry mouth.

Antibiotics

Gentamicin and cephalexin are used to treat UTIs.

NURSING ACTIONS
● Administer medication with food to decrease GI distress.
● Monitor for nephrotoxicity and ototoxicity for clients

taking gentamicin.

CLIENT EDUCATION
● Urine can have foul odor related to the antibiotic.
● Report loose stools related to the medication.

Miscellaneous medications

Thiazide diuretics and allopurinol can be used to increase
excretion of calculi and decrease the pH of the urine.

interProFessional care
Urology services can be consulted for management
of urolithiasis.

Nutritional services can be consulted for dietary
modifications concerning foods related to calculi formation.

tHeraPeutic ProceDures

Extracorporeal shock wave lithotripsy (ESWL)
● Uses sound, laser, or shock‑wave energies to break

calculi into fragments
● Requires moderate (conscious) sedation and ECG

monitoring during the procedure

NURSING ACTIONS
● Preprocedure

◯ Obtain consent for treatment.
◯ Position the client in a flat position.
◯ Assist with the application of a topical anesthetic over
stone site 45 min prior to procedure.

◯ Assess for gross hematuria and strain urine following
the procedure.

● Postprocedure
◯ Strain all urine.
◯ Monitor site.

CLIENT EDUCATION
● Bruising is normal at the site where waves are applied.
● There will be hematuria postprocedure.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 61 renal calculi 409

Nonsurgical chemolysis

Nonsurgical chemolysis is the use
of chemical agents to dissolve
the calculus.

Surgical interventions

Stenting is the placement of a
small tube in the ureter during a
ureteroscopy to dilate the ureter
and allow passage of a calculus. An
indwelling urinary catheter can
be used to facilitate the passage of
calculus.

Retrograde ureteroscopy uses a
basket, forceps, or loop on the end
of the ureteroscope to grasp and
remove the calculus. An indwelling
urinary catheter can be used after the
procedure to drain stone fragments.

Percutaneous ureterolithotomy/
nephrolithotomy is the insertion of an
ultrasonic or laser lithotripter into the
ureter or kidney to grasp and extract
the calculus using a basket and forceps.

Open surgery uses a surgical incision
to remove the calculus. This surgery
is used for large or impacted calculi
(staghorn calculi) or for calculi not
removed by other approaches.

● Ureterolithotomy: into the ureter
● Pyelolithotomy: into the kidney pelvis
● Nephrolithotomy: into the kidney
● NURSING ACTIONS

◯ Preprocedure
■ Explain the procedure.
■ Maintain NPO status.
■ Ensure that the bowels have been prepped if needed.

◯ Postprocedure
■ Monitor for bleeding.
■ Maintain adequate fluids.
■ Initiate infection control measures.
■ Monitor for the passage of stone fragments.

CARE AFTER DISCHARGE: Nutritional services can be
consulted for dietary modifications concerning foods
related to calculi formation.

client eDucation
Adhere to the diet and medications in the treatment for
prevention of renal calculi.

Calcium phosphate
● Limit intake of food high in animal protein (reduction of

protein intake decreases calcium precipitation).
● Limit sodium intake.
● Reduced calcium intake (dairy products)

is individualized.

Medications
● Thiazide diuretics (hydrochlorothiazide) are used to

increase calcium reabsorption.
● Orthophosphates are used to decrease urine saturation

of calcium oxalate.
● Sodium cellulose phosphate is used to reduce the

intestinal absorption of calcium.

Calcium oxalate
● Avoid oxalate sources: spinach, black tea, rhubarb, cocoa,

beets, pecans, strawberries, peanuts, okra, chocolate,
wheat germ, lime peel, and Swiss chard.

● Limit sodium intake.

Struvite (magnesium ammonium phosphate)

Avoid high‑phosphate foods: dairy products, red and organ
meats, and whole grains.

Uric acid (urate)
● Decrease intake of purine sources: organ meats, poultry,

fish, gravies, red wine, and sardines.
● Lemon or orange juice can be consumed to alkalinize

the urine

Medications
● Allopurinol is used to prevent the formation of uric acid.
● Potassium or sodium citrate or sodium bicarbonate is

used to alkalinize the urine.

61.1 Renal calculi

410 CHAPTER 61 renal calculi CONTENT MASTERY SERIES

Active Learning Scenario

a nurse is planning care for a client who has renal calculi
and prescriptions for morphine and oxybutynin for pain
control. What should the nurse take into consideration
when administering these medications? use the ati active
learning template: medication to complete this item.

THERAPEUTIC USES: identify the rationale for
administering morphine and oxybutynin.

COMPLICATIONS: identify adverse effects the nurse should
monitor for when administering each of these medications.

NURSING INTERVENTIONS: identify nursing considerations
and client education the nurse should plan to provide
when administering each of these medications.

Cystine

Limit animal protein intake.

Medications
● Alpha mercaptopropionylglycine (AMPG) is used to lower

urine cystine.
● Captopril is used to lower urine cystine.

COMPLICATIONS

Urosepsis

Occurs with struvite stones when a urinary tract infection
spreads to the client’s bloodstream. This complication
is potentially life‑threatening due to organ failure
and shock.

NURSING ACTIONS
● Administer antibiotics prophylactically (especially prior to

invasive treatment) or to treat an existing infection.
● Monitor culture and sensitivity results.
● Monitor for indications of a urinary tract infection

(fever, tachycardia, increased urine turbidity, urine
odor, elevated blood WBC count, client report of pain
with urination).

● Monitor for shock.
● Encourage adequate fluid intake.
● Encourage adequate nutrition.

Obstruction

A calculus can block the passage of urine into the kidney,
ureter, or bladder. Urinary output can be diminished
or absent. This can predispose the client to hydroureter
(enlargement of the ureter).

NURSING ACTIONS
● Notify the provider immediately.
● Prepare the client for removal of the calculus.

Hydronephrosis

Occurs when a calculus has blocked a portion of the
urinary tract. The urine backs up and causes distention of
the kidney. This can lead to permanent kidney damage.

NURSING ACTIONS
● Notify the provider immediately.
● Prepare the client for removal of the calculus.

Application Exercises

1. a nurse is completing the admission assessment
of a client who has renal calculi. Which of the
following findings should the nurse expect?

a. Bradycardia

B. Diaphoresis

c. nocturia

D. Bradypnea

2. a nurse is reviewing discharge instructions with
a client who had spontaneous passage of a
calcium phosphate renal calculus. Which of the
following instructions should the nurse include
in the teaching? (select all that apply.)

a. limit intake of food high in animal protein.

B. reduce sodium intake.

c. strain urine for 48 hr.

D. report burning with urination to the provider.

e. increase fluid intake to 3 l/day.

3. a nurse is teaching a client who is scheduled for
extracorporeal shock wave lithotripsy (esWl).
Which of the following statements by the client
indicates understanding of the teaching?

a. “i will be fully awake during the procedure.”

B. “lithotripsy will reduce my chances
of having stones in the future.”

c. “i will report any bruising that occurs to my doctor.”

D. “straining my urine following the
procedure is important.”

4. a nurse is caring for a client who has a left renal
calculus and an indwelling urinary catheter.
Which of the following assessment findings is the
priority for the nurse to report to the provider?

a. Flank pain that radiates to the lower abdomen

B. client report of nausea

c. absent urine output for 1 hr

D. Blood WBc count 15,000/mm3

5. a nurse is completing discharge instructions with
a client who has spontaneously passed a calcium
oxalate calculus. to decrease the chance of recurrence,
the nurse should instruct the client to avoid which
of the following foods? (select all that apply.)

a. red meat

B. Black tea

c. cheese

D. Whole grains

e. spinach

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 61 renal calculi 411

Application Exercises Key

1. a. tachycardia is a manifestation associated with
a client who has renal calculi.

B. CORRECT: Diaphoresis is a manifestation associated
with a client who has renal calculi.

c. oliguria is a manifestation associated with
a client who has renal calculi.

D. tachypnea is a manifestation associated
with a client who has renal calculi.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. CORRECT: the client should limit the intake of food high in
animal protein, which contains calcium phosphate.

B. CORRECT: the client should limit intake of sodium, which
affects the precipitation of calcium phosphate in the urine.

c. the client does not need to continue straining
urine once the calculus has passed.

D. CORRECT: the client should report burning
with urination to the provider because this
can indicate a urinary tract infection.

e. CORRECT: the client should increase fluid intake to 2 to
3 l/day. a decrease in fluid intake can cause dehydration,
which increases the risk of calculi formation.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. the client receives moderate (conscious) sedation for
this procedure. the client is not fully awake.

B. lithotripsy does not decrease the recurrence rate
of renal calculi. the procedure breaks the calculi
into fragments so they will pass into urine.

c. Bruising is an expected finding following lithotripsy and
does not need to be reported to the provider.

D. CORRECT: a client is instructed to strain urine following
lithotripsy to verify that the calculi have passed.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

4. a. Flank pain radiating to the lower abdomen is a finding
associated with renal calculi, but there is another
finding that is a greater risk to the client.

B. client report of nausea is a finding associated
with renal calculi, but there is another finding
that is a greater risk to the client.

c. CORRECT: the greatest risk to this client is damage
to the kidney resulting from obstruction of urine
flow by the renal calculus. therefore, the priority
finding to report to the provider is anuria.

D. an elevated serum WBc is a finding associated with renal
calculus and can indicate a urinary tract infection, but there
is another finding that is a greater risk to the client.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

5. a. a client who has renal calculi composed of
calcium phosphate, struvite, uric acid, or cysteine
should limit intake of animal protein.

B. CORRECT: a client who has renal calculi composed
of calcium oxalate should avoid intake of black
tea because it is a source of oxalate.

c. a client who has renal calculi composed of calcium phosphate
or struvite should limit intake of dairy products.

D. a client who has renal calculi composed of struvite
should limit intake of whole grains.

e. CORRECT: a client who has renal calculi composed
of calcium oxalate should avoid intake of spinach
because it is a source of oxalate.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

THERAPEUTIC USES
● morphine sulfate, an opioid, is administered during the first 24 hr to
treat moderate to severe pain associated with acute renal calculi.

● oxybutynin, a spasmolytic, is administered to provide pain relief
by decreasing bladder spasms resulting from renal calculi.

COMPLICATIONS
● morphine sulfate: respiratory depression,
euphoria, sedation, decreased gi motility

● oxybutynin: dizziness, tachycardia, urinary
retention, dry mouth, constipation, nausea

NURSING INTERVENTIONS
● morphine sulfate

◯ administer cautiously with clients who have asthma or
emphysema due to the risk of respiratory depression.

◯ monitor frequently for respiratory depression, especially
in older adults. if respirations are 12/min or less, stop the
medication and notify the provider immediately.

◯ monitor vital signs frequently for hypotension.
◯ encourage the client to drink plenty of
fluids to prevent constipation.

● oxybutynin
◯ Determine prior to administration if the client has a history of
glaucoma, as this medication increases intraocular pressure.

◯ monitor for dizziness and tachycardia.
◯ monitor for urinary retention.
◯ instruct the client to report palpitations and
problems with voiding or constipation.

◯ inform the client that dizziness and dry mouth
are common with the medication.

◯ encourage the client to such on hard candies to alleviate
dry mouth and practice good oral hygiene measures.

◯ increase fiber or bulk in diet.

NCLEX® Connection: Reduction of Risk Potential, Therapeutic
Procedures

412 CHAPTER 61 renal calculi CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING ncleX® connections 413

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Health Promotion and Maintenance
HEALTH SCREENING: Apply knowledge of
pathophysiology to health screening.

HEALTH PROMOTION/DISEASE PREVENTION: Educate
the client on actions to promote/maintain health and prevent
disease; Identify risk factors for disease/illness.

Reduction of Risk Potential
DIAGNOSTIC TESTS
Compare client diagnostic findings with pretest results.

Monitor the results of diagnostic testing and intervene as needed.

THERAPEUTIC PROCEDURES
Educate client about treatments and procedures.

Educate client about home management of care.

POTENTIAL FOR COMPLICATIONS FROM SURGICAL
PROCEDURES AND HEALTH ALTERATIONS: Apply knowledge
of pathophysiology to monitoring for complications.

Pharmacological and Parenteral Therapies
MEDICATION ADMINISTRATION: Educate client about medication.

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS: Apply knowledge of nursing
procedures, pathophysiology and psychomotor skills when caring
for a client with an alteration in body systems; Assess adaptation
of a client to health alteration, illness and/or disease.

ILLNESS MANAGEMENT: Apply knowledge of client
pathophysiology to illness management.

PATHOPHYSIOLOGY: Identify pathophysiology
related to an acute or chronic condition.

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414 ncleX® connections CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 62 Diagnostic anD therapeutic proceDures for female reproDuctive DisorDers 415

UNIT 9 REPRODUCTIVE DISORDERS
SECTION: FEMALE REPRODUCTIVE DISORDERS

CHAPTER 62 Diagnostic and
Therapeutic
Procedures for
Female Reproductive
Disorders

Diagnostic procedures are used to evaluate
the structure, condition, and function of
a female client’s reproductive tissues and
organs. Biopsies can also serve as therapeutic
purposes in removing abnormal tissue. another
therapeutic procedure that nurses should be
knowledgeable about is a hysterectomy.

Pelvic exam with
Papanicolaou and human

papilloma virus tests
Bimanual examination of the cervix,
uterus, fallopian tubes, and ovaries
is performed by the provider. The
provider inserts two gloved fingers into
the vagina and traps the reproductive
structures between the fingers of the
one hand and the fingers of the opposite
hand that is on the abdomen. Palpation
of the structures is done during this time.

Two tests are used for cervical cancer
screening, the Papanicolaou (Pap) test
and the test for human papilloma virus
(HPV). Both can be performed prior to
the pelvic examination.

● The Pap test is use to identify
precancerous and cancerous cells of
the cervix.

● The HPV test is used to identify
HPV infections that can lead to
cervical cancer.

CONSIDERATIONS

preproceDure
NURSING ACTIONS

● Have the client empty the bladder.
● Place the client in the lithotomy position and

drape appropriately.
● Explain to the client how the procedure will be carried out.
● Have all necessary equipment available (cervical

scraping tools, glass slides, fixative, perineal pad).

CLIENT EDUCATION
● Schedule the test when not menstruating.
● Use of vaginal medications, douching, or sexual

intercourse within the past 24 hr can alter test results.

intraproceDure
NURSING ACTIONS

● Remain with the client and provide support.
● Have ready the necessary equipment for the provider

during procedure.
● Transfer specimens to slides and apply fixative to slides.

postproceDure
NURSING ACTIONS: Provide perineal pads and tissues.

CLIENT EDUCATION
● Minimal bleeding can occur from the cervix.
● Follow up with the provider if results are abnormal.

CHAPTER 62

62.1 Pap and HPV screening guidelines

the american cancer society provides guidelines for the prevention and early
detection of cervical cancer. see ww w . cancer . org.

Testing recommendations by age
21 all female clients begin screening for cervical cancer.

21 TO 29
pap test every 3 years.
hpv unnecessary unless needed following an abnormal pap test.

30 TO 65 pap and hpv every 5 years (if pap only, every 3 years).

OLDER
THAN 65

may discontinue testing if regular screenings have been negative.
if diagnosed with cervical precancer, continue to screen.
screening is unnecessary for clients who have had a hysterectomy with
removal of the cervix and have a negative history of cervical cancer.
clients who are at high risk for cervical cancer need to be
screened more frequently based on the advice of the provider.

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416 CHAPTER 62 Diagnostic anD therapeutic proceDures for female reproDuctive DisorDers CONTENT MASTERY SERIES

Colposcopy and
cervical biopsy

A colposcopy is the examination of the tissues of the vagina
and cervix using an electric microscope. Typically, the
provider also performs a biopsy. Several options are available.

● The provider can perform an endocervical curettage if a
lesion is visible.

● A cone biopsy is an extensive surgical biopsy. The
provider excises a cone-shaped sample of tissue
to remove potentially harmful cells. In some cases,
anesthesia is used for the procedure. Margins of the
excised tissue are examined to ensure removal of all
harmful cells. The surgeon can destroy the cells using
a scalpel, cryosurgery (extreme cold, which freezes the
tissue), lasers, or loop electrosurgical excision (LEEP).
LEEP uses an electric current, and the laser procedure
uses a laser beam that vaporizes the abnormal tissue.

● The best time to perform the procedure is in the early
phase of the menstrual cycle because the cervix is
less vascular.

INDICATIONS
Pap tests that demonstrate atypical or abnormal cells
must be followed up with a colposcopy and cervical biopsy.

CONSIDERATIONS

preproceDure
NURSING ACTIONS

● Provide psychological support.
● Preprocedure care is the same as that for a Pap test,

except a sterile biopsy cup will be needed instead of the
other equipment.

CLIENT EDUCATION: When the specimen is obtained,
expect temporary discomfort and cramping.

postproceDure
NURSING ACTIONS

● Postprocedure care is the same as for a Pap test.
● Provide client with perineal pad and tissues.

CLIENT EDUCATION
● Rest for the first 24 hr after the procedure.
● Abstain from sexual intercourse and avoid using a

douche, vaginal creams, or tampons until all discharge
has stopped (usually about 2 weeks).

● Avoid lifting heavy objects for approximately 2 weeks to
allow time for the cervix to heal.

● Use analgesics as directed by the provider, but avoid the
use of aspirin because it can cause bleeding.

● Report excessive bleeding, fever, or foul-smelling
drainage to the provider.

COMPLICATIONS

Bleeding

Heavy bleeding can result from the excision of tissue.

NURSING ACTIONS: Assess for heavy bleeding.

CLIENT EDUCATION: Notify the provider for heavy
vaginal bleeding.

Infection

NURSING ACTIONS: Assess for fever, chills, severe pain,
foul odor, or purulent vaginal discharge.

CLIENT EDUCATION: Notify the provider regarding
manifestations of infection.

Endometrial biopsy
A thin, hollow tube is inserted through the cervix, and
a curette or suction equipment is used to obtain the
endometrial tissue sample.

INDICATIONS
POTENTIAL DIAGNOSES: Endometrial biopsies are done to
assess for uterine cancer as well as evaluate for menstrual
irregularities and potential causes of infertility.

CLIENT PRESENTATION: Abnormal or
postmenopausal bleeding

CONSIDERATIONS

preproceDure
NURSING ACTIONS

● Obtain the client’s menstrual history.
● Administer an analgesic prior to the procedure.
● Prepare the client using same procedure as

pelvic examination.
● Witness consent.

CLIENT EDUCATION
● Biopsies are done while awake.
● The feeling of some discomfort and cramping will occur.
● Perform relaxation techniques.
● Empty the bladder.

postproceDure
NURSING ACTIONS: Postprocedure care is the same as that
for a Pap test.

CLIENT EDUCATION
● Rest on the examination table until cramping

has diminished.
● Spotting can be present for 1 to 2 days.
● Results will be available in approximately 72 hr.
● Abstain from sexual intercourse and avoid using a douche,

vaginal creams, or tampons until all discharge has stopped
(usually about 1 to 2 days).

● Notify the provider of heavy vaginal bleeding, fever, severe
pain, or foul discharge.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 62 Diagnostic anD therapeutic proceDures for female reproDuctive DisorDers 417

COMPLICATIONS

Bleeding

CLIENT EDUCATION: Notify the provider of heavy
vaginal bleeding.

Infection

NURSING ACTIONS: Assess for fever, chills, severe pain,
foul odor, and purulent vaginal discharge.

CLIENT EDUCATION: Notify the provider of any
manifestations of infection.

Sexually transmitted
infections

Syphilis

There are two serologic (blood) studies used to screen
for syphilis.

● Venereal disease research laboratory (VDRL): the oldest
test for syphilis that is still performed

● Rapid plasma reagin (RPR): a newer test for syphilis and
has replaced the VDRL test in many institutions

INTERPRETATION OF FINDINGS
● Both tests are done using a sample of blood and

reported as nonreactive (negative for syphilis) or
reactive (positive for syphilis).

● False positives can occur secondary to infection,
pregnancy, malignancies, and autoimmune disorders.

● If either test is reactive, diagnosis should be confirmed
using one of the following tests:

◯ Fluorescent treponemal antibody absorbed (FTA-ABS)
◯ Microhemagglutination assays for antibody to

T. pallidum

Human immune deficiency virus (HIV)

The enzyme immunoassay (EIA) test and Western blot
assay are used to detect the presence of HIV.

INTERPRETATION OF FINDINGS
● The EIA test, formerly the enzyme-linked

immunosorbent assay (ELISA) is an antibody test
used to measure the client’s response to HIV. The test
is typically positive 3 weeks to 3 months after the
infection occurs, but it can be delayed for as long as
36 months. False positive results can occur, so further
testing is needed.

● If the EIA is positive, the Western blot assay is used to
confirm the diagnosis of HIV.

Genital herpes

Although a diagnosis of genital herpes can be based on
the client’s history and physical, it can be confirmed with
laboratory testing, which include the following.

● Herpes viral culture: Fluid from a lesion is obtained
using a swab and placed in a cup for culture.

● Polymerase chain reaction (PRC) test: Identifies genetic
material of the virus. Cells from a lesion, blood, or other
body fluids can be tested. Identifies type of virus (herpes
simplex 1 [HSV 1] or herpes simplex 2 [HSV 2]).

● Antibody test: Blood is tested for antibodies to the virus.
Some tests can identify the type of virus. An immunoblot
and ELISA test can be used to differentiate between HSV
1 and HSV 2.

Mammography
During a mammogram, a breast is mechanically
compressed both vertically and horizontally by the
machine while radiologic pictures are taken of each breast.

INDICATIONS
Screening mammograms detect breast cancer lesions in
clients who do not have manifestations. Screening
mammograms decrease cancer death rates because the
treatment options and outcomes are best when the cancer
is detected early.

a number of organizations provide guidelines for
screening mammograms, including the american
cancer society and the u.s. preventive services task
force. for current guidelines, see www . cancer . org
and www . uspreventiveservicestaskforce . org.

Diagnostic mammograms are used when a screening
mammogram reveals abnormal findings or when breast
cancer manifestations are present. The diagnostic
mammogram provides a more detailed picture and is more
accurate than the screening mammogram.

● Traditional mammography images are stored on film.
● Digital mammography takes an electronic image and

can be more useful in clients who have dense breast
tissue. It is also more costly.

CONSIDERATIONS

preproceDure
CLIENT EDUCATION

● Avoid the use of deodorant, lotion, or powders in the
axillary region or on the breasts prior to the exam.

● Do not have a mammogram if pregnant.

intraproceDure
● Radiologic technicians are often the members of the

health care team who perform mammograms.
● The client can feel slight, temporary discomfort when

the breast is compressed.

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postproceDure
CLIENT EDUCATION

● Examine and inspect the breasts regularly to
detect changes.

● Follow the advice of the provider regarding when to
return for a follow-up mammogram.

Ultrasound
Ultrasonography is used to evaluate tissue.

INDICATIONS
● Assessment and monitoring of masses, cysts,

and fibroids
● Monitoring the effects of tumor-reducing treatment
● Follow-up of lesions noted during mammography

CONSIDERATIONS

preproceDure
For transvaginal ultrasound, insert an indwelling urinary
catheter for clients who are incontinent.

CLIENT EDUCATION
● For transvaginal ultrasound, empty the bladder prior to

testing. A transducer will be inserted into the vagina.
● For breast ultrasound, the chest will be exposed.
● For internal (transvaginal or transrectal) ultrasound,

mild discomfort can be experienced.
● For abdominal ultrasound, a full bladder can be required

to promote better visualization of the internal organs.

Hysterosalpingography
● Visualization of the cervix, uterus, and fallopian tubes

by x-ray with injection of contrast dye
● Performed 2 to 5 days following menstrual period to

avoid harm to an existing pregnancy

INDICATIONS
● Evaluation of fibroids, tumors and fistulas
● Assessment of fertility

CONSIDERATIONS

preproceDure
NURSING ACTIONS

● Confirm date of client’s last menstrual cycle.
● Assess for allergy to iodine.
● Witness informed consent.
● Prepare client as for a pelvic exam.

intraproceDure
NURSING ACTIONS

● Remain with the client and provide support.
● Have ready the necessary equipment for the provider

during the procedure.

postproceDure
NURSING ACTIONS: Provide perineal pad and tissues.

CLIENT EDUCATION
● Minimal bleeding can occur from the cervix.
● Take analgesics as prescribed for pelvic cramping.

Referred pain to the shoulder can also occur.
● Notify the provider if bleeding continues for 4 or more

days and to report any manifestations of infection (fever,
severe pain, foul discharge).

Hysterectomy
● There are a number of options available for a client who

requires a hysterectomy or other reproductive procedure.
In some cases, the decision regarding which procedure
is based on the client’s preference in conjunction with
the surgeon’s recommendation.

◯ Total hysterectomy: Uterus and cervix are removed.
◯ Subtotal hysterectomy: Uterus is removed; cervix is not.
◯ Bilateral salpingo-oophorectomy: Ovaries and
fallopian tubes are removed.

◯ Panhysterectomy: Uterus, cervix, ovaries, and
fallopian tubes are removed.

◯ Radical hysterectomy: Uterus, cervix, upper part of
the vagina, and adjacent tissue (including lymph
nodes) are removed.

● To treat leiomyomas (benign fibroid tumors),
uterine-sparing procedures are available.

● There are three methods of performing a hysterectomy.
◯ Abdominal approach, also known as a total
abdominal hysterectomy

◯ Vaginal approach
◯ Laparoscopy-assisted vaginal hysterectomy

INDICATIONS
POTENTIAL DIAGNOSES

● Uterine cancer
● Noncancerous conditions: fibroids, endometriosis

(inflammation of the endometrium), and genital
prolapse: that cause pain, bleeding, or emotional stress

CLIENT PRESENTATION
● Painful intercourse
● Hypermenorrhea
● Pelvic pressure
● Urinary urgency or frequency
● Constipation

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 62 Diagnostic anD therapeutic proceDures for female reproDuctive DisorDers 419

CONSIDERATIONS

preproceDure
NURSING ACTIONS

● Ensure that clients who have been taking anticoagulant
medications, aspirin, nonsteroidal anti-inflammatory
drugs (NSAIDs), or vitamin E have discontinued their use.

● Rule out pregnancy.
● Administer preoperative antibiotics.
● Place anti-embolism stockings.
● Complete psychological assessment.
● Maintain NPO status.
● Ensure that informed consent has been obtained.

CLIENT EDUCATION
● Turn, cough, and deep breathe, and use the

incentive spirometer.
● Follow instructions for early postoperative ambulation

to prevent complications.
● Ask questions if you need help understanding

preoperative and postoperative medications.

postproceDure
An indwelling urinary catheter is generally inserted
intraoperatively and in place for the first 24 hr
postoperatively.

NURSING ACTIONS
● Monitor vaginal bleeding. Excess bleeding is more than

one saturated pad in 4 hr.
● Priority assessments and interventions following a total

abdominal hysterectomy:
◯ Monitor vital signs (fever, hypotension).
◯ Monitor breath sounds (risk of atelectasis).
◯ Monitor bowel sounds (risk of paralytic ileus).
◯ Monitor urine output. (Call the provider if less than
30 mL/hr.)

◯ Provide IV fluid and electrolyte replacement until
bowel sounds return.

◯ Monitor the incision (infection, integrity, risk
of dehiscence).

◯ Monitor for indications of thrombophlebitis (warmth,
tenderness, edema).

◯ Take thromboembolism precautions (sequential
compression devices, ambulation).

◯ Monitor blood loss (Hgb and Hct, vital signs).

CLIENT EDUCATION
● Adhere to a well-balanced diet that is high in protein and

vitamin C for wound healing, and high in iron if anemic.
● If ovaries have been removed, menopausal manifestations

can develop. Be aware of issues related to hormone therapy.
● Restrict activity (heavy lifting, strenuous activity,

driving, stairs, sexual activity) for as long as 6 weeks
depending on the procedure that was performed.

● Avoid the use of tampons.
● Notify the surgeon of temperatures greater than 37.8° C

(100° F), foul-smelling drainage from incision, pain,
redness, swelling in calf, or burning on urination.

● If vaginal repair was also completed, you might experience
discomfort with intercourse. Use of water-based lubricants
will help, and the discomfort should decrease over time.

COMPLICATIONS
Complications are similar to other abdominal surgeries.
Monitor the client for complications, including the
following.

Hypovolemic shock

Hypovolemic shock due to blood loss is a potential
complication following a hysterectomy.

NURSING ACTIONS
● Monitor vital signs, Hgb, and Hct.
● Check for excessive vaginal bleeding (more than one

saturated perineal pad in 4 hr).
● Provide fluid replacement therapy and/or blood

transfusions as indicated.

Infection

Can be indicated by foul-smelling vaginal drainage,
temperatures greater than 37.8° C (100° F), and redness,
swelling, or drainage at the site of the incision.

Psychological reactions
● Psychological reactions can occur months to years

after surgery.
● Occasional sadness in the client is normal, but

persistent sadness or depression indicates a need for
counseling assistance.

● Factors that decrease risk include having a career
or other interests, having completed childbearing,
understanding the changes that will occur after surgery,
and having support.

CLIENT EDUCATION
● Focus on the positive aspects of life.
● Support groups can be helpful in coping with

this surgery.

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420 CHAPTER 62 Diagnostic anD therapeutic proceDures for female reproDuctive DisorDers CONTENT MASTERY SERIES

Application Exercises

1. a nurse in a clinic is reviewing the facility’s testing
process and procedures for human immune deficiency
virus (hiv) with a new employee. Which of the
following information should the nurse include?

a. in the presence of hiv, the enzyme
immunoassay (eia) test is typically reactive
within 72 hr after the client is infected.

B. the Western blot assay is used to
confirm diagnosis of hiv.

c. the polymerase chain reaction (prc) test
is used to confirm diagnosis of hiv.

D. cD4+ cell counts will be elevated in a
client who is infected with hiv.

2. a nurse is providing instructions to a client prior to an
initial mammogram. Which of the following information
should the nurse provide prior to the procedure?

a. “You should not take any aspirin products
prior to the mammogram.”

B. “Do not use apply any deodorant
the day of the exam.”

c. “You will need to avoid sexual intercourse
the day before the mammogram.”

D. “You should avoid exercise prior to the exam.”

3. a nurse is providing education to a client prior
to an initial papanicolaou (pap) test. Which of the
following statements should the nurse make?

a. “You should urinate immediately
after the procedure is over.”

B. “You will not feel any discomfort.”
c. “You may experience some bleeding

after the procedure.”
D. “You will need to hold your breath

during the procedure.”

4. a nurse in a provider’s office is reviewing a client’s
laboratory results, which shows a positive rapid plasma
regain (rpr). Which of the following tests will be
administered to confirm the diagnosis of syphilis?

a. venereal Disease research laboratory (vDrl)
B. D-dimer
c. fluorescent treponemal antibody

absorbed (fta-aBs)
D. sickledex

5. a nurse is providing teaching for a client
who is to undergo a cervical biopsy. Which
of the following information should the
nurse include? (select all that apply.)

a. “the procedure is painless.”
B. “avoid heavy lifting for approximately

2 weeks after the procedure.”
c. “heavy bleeding is common during the

first 12 hours after the procedure.”
D. “plan to rest for the first 72 hours

after the procedure.”
e. “avoid the use of tampons for

2 weeks after the procedure.”

Active Learning Scenario

a nurse is planning care for a client who will have a total
abdominal hysterectomy. use the ati active learning
template: therapeutic procedure to complete this item.

NURSING INTERVENTIONS (PRE, INTRA, POST):
list at least two nursing actions the nurse should
include preprocedure and at least four actions
the nurse should include postprocedure.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 62 Diagnostic anD therapeutic proceDures for female reproDuctive DisorDers 421

Application Exercises Key

1. a. the eia test is typically reactive 3 weeks to
3 months after the infection occurs, but it can
be delayed for as long as 36 months.

B. CORRECT: confirming hiv is a two-step process. if the eia
is positive, a second test (the Western blot assay) is done.

c. the prc test is used to confirm the
diagnosis of genital herpes.

D. the eia test is typically reactive 3 weeks to
3 months after the infection occurs, but it can
be delayed for as long as 36 months.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. taking aspirin products does not alter the
accuracy of a mammogram.

B. CORRECT: applying deodorant or powder can alter the
accuracy of a mammogram by causing a shadow to appear.

c. having sexual intercourse does not alter
the accuracy of a mammogram.

D. exercising does not alter the accuracy of a mammogram.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. the client is instructed to urinate immediately
before the procedure.

B. the client can experience discomfort when the
provider obtains the cervical sample.

c. CORRECT: the client can experience a small amount
of vaginal bleeding due to scraping of the cervix.

D. the client should use relaxation techniques, such as
taking deep breaths during the procedure.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. a. the vDrl is another screening test for syphilis.
B. the D-dimer is a test used measure fibrin and is used to

diagnose disseminated intravascular coagulation.
c. CORRECT: the fluorescent treponemal antibody

absorbed is used to confirm the diagnosis of syphilis.
D. the sickledex is used to diagnose sickle cell anemia.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

5. a. typically the client will experience temporary discomfort
and cramping when the specimen is obtained.

B. CORRECT: the client should avoid heavy lifting until the
cervix has healed, which takes approximately 2 weeks.

c. some bleeding is common after a cervical biopsy,
but excessive bleeding is a complication and
should be reported to the provider.

D. the client should plan to rest for the first
24 hr after the procedure.

e. CORRECT: the client should not use tampons until the
cervix has healed, which takes approximately 2 weeks.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

NURSING ACTIONS (PRE, INTRA, POST)

preprocedure
● maintain npo status.
● ensure that informed consent has been obtained.
● teach the client to turn, cough, and deep breathe; to use the
incentive spirometer; and the importance of early ambulation

● teach the client about preoperative and postoperative medications.
● rule out pregnancy.
● ensure that clients who have been taking anticoagulant
medications, aspirin, nonsteroidal anti-inflammatory drugs
(nsaiDs), or vitamin e have discontinued their use.

● administer preoperative antibiotics.
● place antiembolism stockings.
● complete psychological assessment.

postprocedure
● monitor vaginal bleeding. the client should have no
more than one saturated perineal pad in 4 hr.

● maintain indwelling urinary catheter and monitor urine
output. the client should have at least 30 ml/hr.

● monitor vital signs.
● monitor breath sounds and use of incentive spirometer.
● assist with ambulation.
● monitor bowel sounds.
● provide iv fluid and electrolyte replacement.
● monitor the client’s incision.
● monitor the hgb and hct.
● monitor for indications of thrombosis and
take thromboembolism precautions.

● instruct the client about diets that promote wound
healing (high protein and vitamin c).

● instruct the client to restrict activity.
● if ovaries have been removed, discuss issues
related to hormone therapy.

● remind the client to avoid the use of tampons.
● tell the client to notify the surgeon of temperature over
37.8° c (100° f), foul-smelling drainage from incision, pain,
redness, swelling in calf, and burning on urination.

● assess psychological status.

NCLEX® Connection: Reduction of Risk Potential, Therapeutic
Procedures

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422 CHAPTER 62 Diagnostic anD therapeutic proceDures for female reproDuctive DisorDers CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 63 female phYsiologic processes 423

UNIT 9 REPRODUCTIVE DISORDERS
SECTION: FEMALE REPRODUCTIVE DISORDERS

CHAPTER 63 Female Physiologic
Processes

the average age of menarche (first menses)
is 12.4 years but can occur from 9 to 17 years.
assessment is indicated if an adolescent has not
begun menstruation by 16.5 years of age.

menstrual cycles are typically 28 days long,
with a range from 23 to 35 days. the first day
of menstruation is day 1 of a menstrual cycle.
ovulation typically occurs around day 14.
menstruation begins 14 days after ovulation and
typically lasts 4 to 6 days, but it can continue for
up to 9 days.

menstrual cycles continue until menopause or
surgical removal of the uterus. menopause is
when ovulation ceases and menstrual cycles
become irregular and eventually stop. the
median age of onset of menopause is 51 years.

Menstrual disorders
Painful menstruation, or dysmenorrhea, is common in
adolescents and young clients. In many clients, this pain
is significantly decreased after the birth of a child or as
the client becomes older.

Dysfunctional uterine bleeding (DUB) is believed to be
due to a hormonal imbalance of decreased estrogen and
can include menorrhagia and metrorrhagia.

● Menorrhagia is excessive menstrual bleeding
(in amount and duration), possibly with clots that
saturate more than one tampon or pad per hour.

● Metrorrhagia is bleeding between menstrual periods.
It is more common in clients who are entering
menopause and in adolescents.

Amenorrhea is the absence of menses. In a client who
has had menstrual cycles, this can be an indication of
pregnancy or a medical disorder, such as thyroid disorder
or structural disorders of the reproductive system.
A common cause is low percentage of body fat in clients
who are involved in sports or strenuous physical activity.
Anorexia nervosa also can result in amenorrhea due to a
decrease in body fat.

Premenstrual syndrome (PMS) is thought to be caused by
an imbalance between estrogen and progesterone.

● Manifestations can vary among client and can vary
for an individual from one cycle to the next. Common
manifestations include irritability, impaired memory,
depression, poor concentration, mood swings, binge
eating, breast tenderness, bloating, weight gain,
headache, and back pain.

● Premenstrual dystrophic disorder (PMDD) is a severe
form of PMS seen in only a small number of clients, and
it interferes with the ability to carry out daily activities.
With either condition, manifestations begin a few days
before the menstrual period and end a few days after
the onset of the menstrual period.

Endometriosis is characterized by an overgrowth of
endometrial tissue that extends outside the uterus into
the fallopian tubes, onto the ovaries, and into the pelvis.
Blockage of the fallopian tubes by endometrial tissue is a
common cause of infertility.

ASSESSMENT
When assessing a client who has a menstrual disorder, the
nurse should assess the client’s:

● Menstrual history (age of first menses, monthly cycle).
● Sexual history.
● Nutritional history.

eXpecteD finDings
● Report of premenstrual depression, irritability,

changes in appetite, abdominal bloating, fatigue,
emotional lability, or fluid retention

● Characteristics of flow
● Characteristics and location of pain during

menstrual cycle
● Pelvic tenderness during palpation of the lower

abdomen and the pelvic examination
● Metabolic disorders (thyroid disorders)

laBoratorY tests
Hemoglobin and hematocrit can be below the
expected reference range due to excessive blood loss.

CA‑125 is an immunodiagnostic test in which findings
are elevated in ovarian cancer. Endometriosis and other
conditions can also cause CA-125 to be elevated above the
expected reference range.

Diagnostic proceDures
Endometrial biopsy determines the relationship between
menstrual flow and the hormone cycle, as well as possible
pathologic reasons for bleeding, such as uterine cancer.

Transvaginal ultrasound can identify the presence
of uterine fibroids, endometrial abnormalities,
or leiomyomas.

CHAPTER 63

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424 CHAPTER 63 female phYsiologic processes CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

meDications

Hormonal contraceptives
● Can be used to decrease manifestations of PMS, PMDD,

dysmenorrhea, and DUB
● Might be the initial treatment for endometriosis

Diuretic

An aldosterone antagonist (spironolactone) can be
used to treat bloating and weight gain associated with
PMS and PMDD.

Leuprolide: synthetic luteinizing hormone
● Reduces the follicle-stimulating and luteinizing

hormone levels in DUB
● Suppresses estrogen and testosterone production

in the body, making it an effective treatment for
endometriosis (promotes atrophy of ectopic tissue)

● Can cause birth defects, so the client should use a
reliable form of contraception

● Can cause decreased libido and increased risk
of osteoporosis

NSAIDs: ibuprofen
● Prescribed for endometriosis to inhibit production

of prostaglandins
● Aids in treatment of pain and discomfort related to

PMS and PMDD

Oral iron supplements

Used to treat anemia associated with DUB

SSRIs: fluoxetine, sertraline

Used to treat the emotional and physical manifestations of
PMS and PMDD

therapeutic proceDures

DUB

Dilatation and curettage: Used to diagnose and treat DUB.
The cervix is dilated, and the wall of the uterus is scraped
with a curette. Endometrium scraped from the uterine
wall is sent to the laboratory for examination.

Endometrial ablation: Used to remove endometrial tissue
in the uterus. The tissue can be removed by laser, heat,
electricity, or cryotherapy.

Hysterectomy: If other treatments are unsuccessful

Endometriosis

Laparoscopic removal of ectopic tissue and adhesions:
A laser can be used to remove tissue.

Perimenopause
● Perimenopause is the time (approximately 4 years) that

precedes menopause.
● Ovarian function declines as ova slowly diminish. The

menstrual cycle can be anovulatory, which can lead to
irregular bleeding.

ASSESSMENT

eXpecteD finDings
Bleeding: Irregular menstrual flow; menstrual periods can
produce spotting for 2 to 3 days followed by 1 to 2 days of
heavy menstrual bleeding

Genitourinary: Vaginal and urethral atrophy, vaginal
dryness, vaginitis, dyspareunia (can result in postcoital
bleeding)

Vasomotor: Hot flashes and flushes, irregular menses,
night sweats, fluctuations of vasoconstriction or vascular
spasms that can lead to dizziness, numbness and tingling
in fingers and toes, headaches

Psychological: Clients who report hot flashes and night
sweats often report insomnia, fatigue from loss of sleep,
and feelings of depression. Some also report decreased
control of emotions.

Reproductive: Reduction in fertility

PATIENT‑CENTERED CARE

client eDucation
Although fertility is decreased, pregnancy can still occur
during perimenopause. Maintain some form of birth
control if pregnancy is not desired.

COMPLICATIONS

Osteoporosis

Metabolic disease in which there is a decrease in bone
mass, which can lead to an increased risk of fractures.

RISK FACTORS: Inadequate calcium intake, excessive
caffeine intake can increase calcium excretion, vitamin D
deficiency, tobacco use, steroid therapy, hyperthyroidism,
diabetes mellitus

Coronary heart disease

A client’s risk of developing and dying from cardiovascular
disease increases due to a decrease in estrogen

RISK FACTORS: Obesity, tobacco use, elevated cholesterol,
hypertension, diabetes, family history, alcohol
use disorder

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 63 female phYsiologic processes 425

Menopause
● Menopause is the cessation of menses. Menses will

appear on an infrequent cycle for a period of time
that does not exceed 2 years. Menopause is considered
complete when no menses have occurred for 12 months.

● The client can have natural or surgically
induced menopause.

ASSESSMENT

eXpecteD finDings
Vasomotor manifestations: Hot flashes and
irregular menses

Genitourinary: Atrophic vaginitis, shrinking of
labia, decreased vaginal secretions, dyspareunia,
increased vaginal pH, vaginal dryness, incontinence

Psychological: Mood swings, changes in sleep patterns,
decreased REM sleep

Skeletal: Decreased bone density

Cardiovascular: Decreased HDL, increased LDL

Dermatological: Decreased skin elasticity, loss of hair on
the head and pubic area

Reproductive: Breast tissue changes

laBoratorY tests
Follicle stimulating hormone (FSH):
Increased during menopause

Blood, urine, and saliva hormone levels:
Estrogens, progesterone, testosterone

Diagnostic proceDures
Pelvic examination with Papanicolaou (Pap) test to rule
out cancer in cases of abnormal bleeding

Breast examination with mammogram to rule out
cancer in cases of a palpable change from predominantly
glandular tissue to fatty tissue

Biopsy of uterine lining in cases of undiagnosed abnormal
uterine bleeding in a client older than 40 years of age,
or in a client whose menses has stopped for 1 year and
bleeding has begun again

Bone mineral density measurement using dual‑energy
x‑ray absorptiometry DXA) to determine the client’s risk
for osteoporosis

PATIENT‑CENTERED CARE

meDications

Menopausal hormone therapy (HT)
● Estrogen deficiency manifestations occur naturally

as part of the aging process during menopause.
Menopausal hormone therapy is prescribed to suppress
hot flashes associated with menopause, to prevent
atrophy of vaginal tissue, and to reduce the risk of
fractures due to osteoporosis. For a client who has a
uterus, HT includes estrogen and progestin. For a client
who no longer has a uterus (following a hysterectomy),
estrogen alone is prescribed.

● Many preparations of HT are available (oral, transdermal,
intravaginal, intramuscular). The provider can prescribe
HT as a continuous, combined estrogen-progesterone
therapy or a variety of cyclic patterns.

● Based on their individual risk factors and health care
needs, clients should discuss the risks and benefits of
using HT with their providers.

◯ The risk associated with the use of HT depends on
many factors (the age of the client, their personal/
family history, the regimen prescribed).

◯ HT places clients at risk for a number of adverse
conditions, including coronary heart disease,
myocardial infarction, deep-vein thrombosis, stroke,
and breast cancer.

● If HT is required for management of menopausal
manifestations, the best recommendation is to use HT
on a short-term basis.

CLIENT EDUCATION
● Understand the advantages and disadvantages of HT.

HT can be beneficial in the prevention of age-related
problems such as osteoporosis and fractures.

● Atrophic vaginitis, which is characterized by vaginal
burning and bleeding, pruritus, and painful intercourse,
can improve with HT. Vaginal instillations of estrogen
can be the best option because systemic absorption
is reduced.

● Learn self-administration of HT.
● Quit smoking immediately if applicable.
● Prevent and assess the development of venous

thrombosis.
◯ Avoid wearing knee-high stockings and clothing or
socks that are restrictive.

◯ Note and report manifestations of unilateral leg pain,
edema, warmth, and redness.

◯ Avoid sitting for long periods of time.
◯ Take short walks throughout the day to

promote circulation.
◯ Perform frequent ankle pumps, and move and
stretch legs.

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426 CHAPTER 63 female phYsiologic processes CONTENT MASTERY SERIES

Application Exercises

1. a school nurse is providing an education session
about menstruation with a group of adolescent
students. Which of the following statements
should the nurse include? (select all that apply.)

a. “the average age of onset of menstruation is 10.”

B. “the range for a typical menstrual
cycle is between 23 and 35 days.”

c. “the first day of the menstrual cycle begins
with the last day of the menstrual period.”

D. “ovulation typically occurs around the
14th day of the menstrual cycle.”

e. “a menstrual period can last as long as 9 days.”

2. a nurse is reviewing the medical record of a client
who has premenstrual syndrome (pms). the nurse
should identify that which of the following medications
are used to treat pms? (select all that apply.)

a. fluoxetine
B. spironolactone
c. ethinyl estradiol/drospirenone
D. ferrous sulfate
e. methylergonovine

3. a nurse in a provider’s office is providing information to
a client who has dysfunctional uterine bleeding (DuB).
Which of the following statements by the client indicate
understanding of the information? (select all that apply.)

a. “my heavy bleeding can be due
to a hormonal imbalance.”

B. “if i experience menstrual pain,
i should take aspirin.”

c. “oral contraceptives are contraindicated for clients
who have heavy uterine bleeding like mine.”

D. “my doctor can perform a D&c to find out
what’s causing my abnormal bleeding.”

e. “my condition is more common in
clients who are in their 30s.”

4. a nurse is providing support to a client who has a
new diagnosis of endometriosis. the nurse should
inform the client that which of the following conditions
is a possible complication of endometriosis?

a. insulin resistance
B. infertility
c. vaginitis
D. pelvic inflammatory disease

5. a nurse is reviewing the medical record of a client
who is menopausal. Which of the following findings
should the nurse expect? (select all that apply.)

a. increased vaginal secretions
B. Decreased bone density
c. increased hDl level
D. Decreased skin elasticity
e. increased pubic hair growth
f. Decreased follicle stimulating hormone level

● Manifestations of myocardial infarction (MI) in female
clients include dyspnea, jaw discomfort, indigestion,
and pain between the shoulders. If these manifestations
occur, seek assistance immediately.

● If oral therapy causes nausea, taking medication with
food can help.

● If using vaginal creams or suppositories of estrogen
compounds, be sure to refrain from inserting them
prior to intercourse, or the partner can absorb some of
the product.

Alternative therapies
● Ask the client about their use of complementary and

alternative therapies (black cohosh, ginseng, red clover)
to relieve the effects of menopause. Research regarding
their usefulness is inconsistent.

● Phytoestrogens interact with estrogen receptors in
the body, which can result in a decrease in the
manifestations of menopause. Vegetables such as
dandelion greens, alfalfa sprouts, black beans, and soy
beans contain phytoestrogens.

● Vitamins E and B6 are reported to decrease hot flashes
in some clients.

CLIENT EDUCATION: Older adult clients can decrease the
risk of osteoporosis by performing regular weight-bearing
exercises; increasing intake of high-protein and
high-calcium foods; avoiding alcohol, caffeine, and
tobacco; and taking calcium with vitamin D
supplements.

COMPLICATIONS

Embolic complications

Risk increased by concurrent tobacco use
● Myocardial infarction, especially during the first year

of therapy
● Stroke
● Venous thrombosis: Thrombophlebitis, especially during

the first year of therapy

Cancer
● In some studies, long-term use of HT has been found to

increase the risk for breast cancer.
● Some studies indicate that long-term use of

estrogen-only HT increases the risk for ovarian and
endometrial cancer.

Active Learning Scenario

a nurse is instructing a client who is being evaluated for
premenstrual syndrome (pms) to journal manifestations
to aid in diagnosis. use the ati active learning
template: system Disorder to complete this item.

EXPECTED FINDINGS: identify six manifestations of pms.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 63 female phYsiologic processes 427

Application Exercises Key

1. a. although some clients experience the onset of menstruation
as early as age 9, the average age is 12.4 years of age.

B. CORRECT: although a typical menstrual
cycle is 28 days, a range of 23 to 35 days is
considered a regular menstrual cycle.

c. the first day of the menstrual cycle begins with
the first day of the menstrual period.

D. CORRECT: the first half of the menstrual cycle is
the follicular phase, and the second half is the luteal
phase. ovulation typically occurs around the middle
of the cycle, or day 14 in a 28-day cycle.

e. CORRECT: a menstrual period typically lasts from
4 to 6 days but can continue for up to 9 days.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. CORRECT: fluoxetine, an ssri, is used to treat
the emotional manifestations of pms, such as
irritability and mood swings, and has an added
effect of treating physical manifestations.

B. CORRECT: spironolactone is a diuretic and can reduce
bloating and weight gain associated with pms.

c. CORRECT: oral contraceptives can be prescribed
to reduce the manifestations of pms.

D. oral iron supplements, such as ferrous sulfate, are used to
treat anemia associated with dysfunctional uterine bleeding.

e. methylergonovine is used to treat postpartum hemorrhage.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

3. a. CORRECT: the client should be aware that DuB can
be caused by a progesterone deficiency.

B. the client should avoid aspirin due to the increased
risk for bleeding. nsaiDs can be recommended as
needed for menstrual pain or discomfort.

c. the client should be aware that contraceptives
can be prescribed to treat DuB.

D. CORRECT: the client should be aware that when the provider
performs a dilatation and curettage, endometrium scraped
from the uterine wall is sent to the laboratory for evaluation.

e. the client should be aware that DuB is more common in
adolescents and in clients who are nearing menopause.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. a. insulin resistance is a complication of
polycystic ovary syndrome.

B. CORRECT: infertility is a complication of
endometriosis because endometrial tissue
overgrowth can block the fallopian tubes.

c. vaginitis is typically caused by an infection.
D. pelvic inflammatory disease is caused by

an infection of the pelvic organs.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications from Surgical Procedures and Health Alterations

5. a. clients who are menopausal are expected to
have decreased vaginal secretions.

B. CORRECT: clients who are menopausal are
expected to have decreased bone density.

c. clients who are menopausal are expected to have a
decreased hDl level and increased lDl level.

D. CORRECT: clients who are menopausal are
expected to have decreased skin elasticity.

e. clients who are menopausal are expected to have a
loss of hair on the head and in the pubic area.

f. clients who are menopausal are expected to have an
increased follicle stimulating hormone (fsh) level.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

EXPECTED FINDINGS
● irritability
● impaired memory
● Depression
● poor concentration
● mood swings
● Binge eating
● Breast tenderness
● Bloating
● Weight gain
● headache
● Back pain

NCLEX® Connection: Physiological Adaptation, Pathophysiology

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UNIT 9 REPRODUCTIVE DISORDERS
SECTION: FEMALE REPRODUCTIVE DISORDERS

CHAPTER 64 Disorders of Female
Reproductive Tissue

pelvic organ prolapse occurs when the female
client’s pelvic floor muscles and ligaments
become weakened or damaged, resulting
in a cystocele or rectocele. a cystocele is a
protrusion of the posterior bladder through the
anterior vaginal wall. it is caused by weakened
pelvic muscles and/or structures. a rectocele is a
protrusion of the anterior rectal wall through the
posterior vaginal wall. it is caused by a defect
of the pelvic structures, a difficult delivery, or
a forceps delivery. uterine prolapse is another
form of pelvic organ prolapse.

medical treatment is possible for clients who
have a cystocele or a rectocele causing mild
manifestations. if treatment is unsuccessful, the
provider can recommend surgical intervention.

fibrocystic breast condition is a noncancerous
breast condition. it is most common in
younger females. it occurs less frequently
in postmenopausal clients. the condition
is thought to occur due to cyclic hormonal
changes. fibrosis (of connective tissue) and
cysts (fluid-filled sacs) develop.

Cystocele and rectocele

HEALTH PROMOTION AND
DISEASE PREVENTION

● Lose weight if obese and at risk.
● Eat high-fiber diets and drink adequate fluids to

prevent constipation.

ASSESSMENT

risK factors
● Cystocele and rectocele can develop in older adult

females, usually following menopause.
● Older adult clients are more susceptible to constipation

and chronic bearing down during elimination, which
can displace weakened structures.

Cystocele
● Obesity
● Advanced age (loss of estrogen)
● Family history
● Multiparity
● Increased abdominal pressure during pregnancy
● Strain and injury during vaginal childbirth

Rectocele
● Pelvic structure defects
● Obesity
● Aging
● Constipation
● Family history
● Difficult vaginal childbirth necessitating repair of a tear

eXpecteD finDings

Cystocele
● Urinary frequency and/or urgency
● Stress incontinence
● History of frequent urinary tract infections
● Sense of vaginal fullness
● Dyspareunia
● Fatigue
● Back and pelvic pain

Rectocele
● Constipation and/or the need to place fingers in the vagina

to elevate the rectocele to complete evacuation of feces
● Sensation of a mass in the vagina
● Pelvic/rectal pressure or pain
● Dyspareunia
● Fecal incontinence
● Uncontrollable flatus
● Hemorrhoids

CHAPTER 64

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430 CHAPTER 64 DisorDers of female reproDuctive tissue CONTENT MASTERY SERIES

Diagnostic proceDures

Cystocele
● A pelvic examination reveals a bulging of the anterior

vaginal wall when the client is instructed to bear down.
● Bladder ultrasound measures residual urine.
● Urine culture and sensitivity is used to diagnose urinary

tract infection associated with urinary stasis.
● A cystography is performed to identify the degree of

bladder protrusion.
● An x-ray can help assess the degree of cystocele.

Rectocele
● A pelvic examination reveals a bulging of the posterior

wall when the client is instructed to bear down.
● A rectal examination reveals the presence of a rectocele.

PATIENT‑CENTERED CARE

therapeutic proceDures
Intravaginal estrogen: Intravaginal estrogen is used
to prevent atrophy of the pelvic muscles in clients who
are postmenopausal.

Bladder training: Contributes to urinary continence

Vaginal pessary (64.1)

A removable rubber, plastic, or silicone device inserted
into the vagina to provide support and block protrusion of
other organs into the vagina. The provider selects the type
of pessary and ensures that it fits correctly.

NURSING ACTIONS
◯ Teach the client how to insert, remove, and clean
the device.

◯ Ensure that the client does not have a latex allergy if
a rubber pessary is prescribed.

CLIENT EDUCTION
◯ Routine checks by the provider are necessary to
ensure proper fit, and to monitor for complications.

◯ Notify the provider of pain, discomfort, or
vaginal discharge.

Kegel exercises
Exercises the client performs to strengthen the pelvic
floor muscles, which results in reduction or prevention of
pelvic organ prolapse and stress urinary incontinence

CLIENT EDUCATION
◯ Perform the exercises.
◯ Contract the circumvaginal and perirectal muscles.
◯ Tighten pelvic muscles.
◯ Gradually increase the contraction period to 10 seconds.
◯ Follow each contraction period with a relaxation

period of 10 seconds.
◯ Perform while lying down, sitting, and standing.
◯ Perform the exercises 30 to 80 times daily.
◯ Keep abdominal muscles relaxed during contractions.

64.1 Pessary

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 64 DisorDers of female reproDuctive tissue 431

Transvaginal repair: A transvaginal repair is performed
to treat prolapse of pelvic organs. Vaginal mesh or tape is
used to create a sling that supports the pelvic floor.

Anterior‑posterior repair: Surgical repair of both a
cystocele and a rectocele.

Hysterectomy: Can be performed at the same time as
cystocele or rectocele repair.

Cystocele

Anterior colporrhaphy: Using a vaginal or laparoscopic
approach, the pelvic muscles are shortened and tightened,
resulting in increased bladder support.

Rectocele

Posterior colporrhaphy: Using a vaginal/perineal approach,
the pelvic muscles are shortened and tightened, resulting
in a reduction of rectal protrusion into the vaginal canal.

POSTOPERATIVE NURSING ACTIONS
● Provide routine postoperative care to prevent complications.
● Administer analgesics, antimicrobials, and stool

softeners/laxatives as prescribed.
● Apply a warm compress to the abdomen to

decrease discomfort.
● Suggest that the client take frequent sitz baths to

soothe the perineal area.
● Provide a low-residue diet until normal bowel

function returns.

client eDucation
● Notify the provider about indications of infection (elevated

temperature, pulse, or respirations; foul-smelling or
purulent vaginal discharge; or consistent pain).

● Avoid straining at defecation; sneezing; coughing;
lifting; and sitting, walking, or standing for prolonged
periods following surgery.

● Tighten and support pelvic muscles when coughing
or sneezing.

● Adhere to postoperative restrictions, including avoidance
of strenuous activity, lifting anything weighing greater
than 5 lb, and sexual intercourse, for 6 weeks.

● The sutures are absorbable and do not require removal.

COMPLICATIONS
Complications are similar to those associated with a
vaginal hysterectomy.

● Vaginal erosion and serious infection has led to the
recall of some surgical mesh or tape used to repair pelvic
organ prolapse. For more information, see www.fda.gov.

● Provide the client with written information from the
manufacturer regarding the specific product used.

● Dyspareunia (painful sexual intercourse) is a possible
surgical complication due to surgical alteration of the
vaginal orifice.

Fibrocystic breast condition
ASSESSMENT

risK factors
● Premenopausal status
● Postmenopausal hormone replacement therapy

eXpecteD finDings
● Breast pain
● Tender lumps, commonly in upper, outer quadrant

PHYSICAL ASSESSMENT FINDINGS: Palpable rubberlike
lumps, usually in the upper, outer quadrant

Diagnostic proceDures
Breast ultrasound is used to confirm the diagnosis.

Fine‑needle aspiration is used to confirm the diagnosis or
to reduce pain due to fluid build-up.

PATIENT‑CENTERED CARE

nursing care
● Suggest that the client reduce the intake of salt before

menses, wear a supportive bra, and apply either local
heat or cold to temporarily reduce pain.

● Discuss the risks (liver disease, stroke) of hormonal
medication therapy with clients considering this form
of treatment.

● Encourage the client to follow the provider’s
recommendations and to journal the effectiveness of the
treatment plan.

● Inform the client that having fibrocystic breast
condition does not increase the risk of breast cancer.

meDications
● Over-the-counter analgesics such as acetaminophen

or ibuprofen
● Oral contraceptives or hormonal medication therapy

if manifestations are severe to suppress estrogen/
progesterone secretion

● Diuretics to decrease breast engorgement

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432 CHAPTER 64 DisorDers of female reproDuctive tissue CONTENT MASTERY SERIES

Application Exercises

1. a nurse is instructing a client how to perform Kegel
exercises. Which of the following instructions
should the nurse include? (select all that apply.)

a. perform exercises about 50 times each day.

B. contract the circumvaginal and/or
perirectal muscles.

c. gradually increase the contraction
period to 10 seconds.

D. follow each contraction with at least
a 10-second relaxation period.

e. perform while sitting, lying, and standing.

f. tighten abdominal muscles during contractions.

2. a nurse is performing a preoperative assessment for a
client who is scheduled for an anterior colporrhaphy.
Which of the following client statements should the
nurse expect as an indication for this procedure?

a. “i have to push the feces out of a pouch
in my vagina with my fingers.”

B. “i have pain and bleeding when i
have a bowel movement.”

c. “i have had frequent urinary tract infections.”

D. “i am embarrassed by uncontrollable flatus.”

3. a nurse is reviewing the medical record of a
client who has a cystocele. Which of the following
findings should the nurse identify as a risk
factor for the development of this disorder?

a. Bmi of 18

B. nulliparity

c. chronic constipation

D. postmenopausal

4. a nurse is preparing to discharge a client following
an anterior and posterior colporrhaphy. Which of the
following instructions should the nurse provide?

a. “Do not bend over for at least 6 weeks.”

B. “You can lift objects as heavy as 10 pounds.”

c. “Do not engage in intercourse for at least 6 weeks.”

D. “You might have foul-smelling drainage
for the first week after surgery.”

5. a nurse in a provider’s office is reviewing the
medical record of a client who has fibrocystic
breast condition. Which of the following
findings should the nurse expect?

a. palpable rubberlike lump in the
upper outer quadrant

B. Brca1 gene mutation

c. elevated ca-125

D. Peau d’orange dimpling of the breast

Active Learning Scenario

a nurse is preparing an educational session for a group
of clients on medications used to treat fibrocystic
breast condition. use the ati active learning
template: medication to complete this item.

THERAPEUTIC USES: identify three types of
medications used to treat the condition, and provide
a brief description of the purpose of the medications
in treating fibrocystic breast condition.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 64 DisorDers of female reproDuctive tissue 433

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

THERAPEUTIC USES
● analgesics, such as acetaminophen or
ibuprofen, are used to relieve pain.

● oral contraceptives or hormonal medication therapy
suppress estrogen/progesterone secretion.

● Diuretics decrease breast engorgement.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

Application Exercises Key

1. a. CORRECT: the client should perform Kegel
exercises 30 to 80 times a day.

B. CORRECT: the client should contract the
circumvaginal and perirectal muscles as if trying
to stop the flow of urine or passing flatus.

c. CORRECT: the client should hold the contraction for
10 seconds. they might need to gradually increase
the contraction period to reach this goal.

D. CORRECT: the client should follow each contraction
with a relaxation period of 10 seconds.

e. CORRECT: the client can perform the exercises
while lying, sitting, or standing.

f. the client should relax their other muscles, such
as those in the abdomen and thighs.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

2. a. pouching of feces is an expected finding associated
with a rectocele. the surgical procedure for a
rectocele is posterior colporrhaphy.

B. pain and bleeding with a bowel movement is an
expected finding associated with a rectocele.

c. CORRECT: Due to urinary stasis associated with a cystocele,
this finding is an expected finding of a cystocele. the
surgery for a cystocele is an anterior colporrhaphy.

D. uncontrollable flatus is an expected finding
associated with a rectocele.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

3. a. identify obesity as a risk factor for the
development of a cystocele. a Bmi of 18
indicates the client is underweight.

B. identify multiparity as a risk factor for the
development of a cystocele.

c. identify constipation as a risk factor for
the development of a rectocele.

D. CORRECT: identify that the advancing age and loss of
estrogen that correlate with postmenopausal status are
risk factors for the development of a cystocele.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

4. a. the client does not have a restriction
regarding bending over.

B. the client should not lift an object that
weighs more than 5 lb.

c. CORRECT: the client should refrain from
intercourse to allow time for the surgical site to
heal, which is typically about 6 weeks.

D. foul-smelling drainage is an indication of infection,
which should be reported to the provider.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. a. CORRECT: clients who have fibrocystic breast condition
typically have breast pain and rubbery palpable lumps
in the upper outer quadrant of the breasts.

B. Brca1 gene mutation is a risk factor for breast cancer.
c. an elevated ca-125 is a finding associated

with ovarian cancer.
D. Peau d’orange dimpling of the breast is a

finding associated with breast cancer.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 65 Diagnostic proceDures for male reproDuctive DisorDers 435

UNIT 9 REPRODUCTIVE DISORDERS
SECTION: MALE REPRODUCTIVE DISORDERS

CHAPTER 65 Diagnostic
Procedures for
Male Reproductive
Disorders

changes to the prostate gland are common as
males age, and routine diagnostic procedures
are recommended to evaluate these changes.
enlargement of the prostate gland is usually
benign and is called benign prostatic
hyperplasia (Bph). prostate cancer is one of the
most common forms of cancer in males.

Diagnostic procedures for male reproductive
disorders include prostate-specific
antigen (psa), early prostate cancer antigen
(epca-2), digital rectal exam (Dre), Doppler
ultrasonography, urinalysis/urine culture, complete
blood count, and transrectal ultrasound (trus).

Prostate‑specific antigen,
early prostate cancer antigen,

and digital rectal exam
PSA measures the amount of a protein produced by the
prostate gland in the bloodstream. It is performed prior
to the DRE because a rise in PSA can occur due to the
irritation that occurs upon palpation of the gland. A
sample of blood is used to determine the PSA level.

EPCA‑2 measures the amount of protein in the blood that
is only produced by abnormal prostate cells.

DRE is done in an office or clinic.
● With the client leaning over the examination table, the

provider places a gloved, lubricated finger in the client’s
anus and palpates the posterior portion of the prostate
gland through the rectal wall. The client also can be
placed on one side or in the lithotomy position for
the exam.

● If the DRE reveals an abnormality, the location of the
potentially cancerous prostate lesion is determined by
ultrasonography and confirmed by a biopsy.

INDICATIONS
● Many providers recommend an annual PSA and DRE for

males older than 50 years to help ensure early detection
of prostate cancer. African American males and males
who have a family history of prostate cancer should
begin screening at an earlier age.

● Because the EPCA-2 is highly sensitive in detecting
prostate cancer, some providers are using this test in
place of a biopsy. The EPCA-2 is also used to monitor
the client’s response to treatment for prostate cancer.

● For additional information regarding screening for and
treatment of prostate cancer, see www.cdc.gov.

CLIENT PRESENTATION: As the prostate gland enlarges, it
encroaches on the urethra and causes diminished flow and
retention of urine. Blood can also be found in the urine.
These findings can indicate BPH or prostate cancer.

INTERPRETATION OF FINDINGS
PSA: An increase can indicate that a client has
prostatic cancer or prostatitis.

● PSA levels increase with age. For a male younger than
50 years of age, a PSA level of 2.5 ng/mL is within the
expected range.

● The client can have an elevated PSA level for up to
6 weeks following a urinary tract infection.

● A PSA value greater than 4 ng/mL requires further
evaluation. An elevated PSA is an indication of a number
of conditions, including prostate cancer, BPH, and
acute prostatitis.

EPCA‑2: A value of 30 ng/mL or greater is highly
suggestive of prostate cancer.

DRE: Abnormal findings during the DRE include an
abnormally large and hard prostate with an irregular
shape or lumps.

Transrectal ultrasound
● With the client in a left, side-lying position, a probe

is inserted into the client’s rectum, and sound waves
are bounced off the surface of the prostate gland to
provide an image.

● The provider can prescribe an enema prior to the procedure.
● The procedure is contraindicated for clients who have a

latex allergy. The rectal ultrasound probe is covered by a
latex sac. Therefore, it is important to check the client for
a latex allergy prior to the procedure.

INDICATIONS
A TRUS is done if a client’s PSA is elevated or the DRE
reveals a possible abnormality.

INTERPRETATION OF FINDINGS
If an irregularity is found, the image is used to guide a
needle biopsy.

CHAPTER 65

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436 CHAPTER 65 Diagnostic proceDures for male reproDuctive DisorDers CONTENT MASTERY SERIES

Penile Doppler
ultrasonography

● This diagnostic test is used to determine the normal
anatomy and blood flow of the penis.

● This test identifies many conditions of the penis,
including erectile dysfunction.

● An injection is given to increase blood flow to the penis,
causing an erection.

● The procedure measures penile arterial blood flow.

NURSING ACTIONS: Place the client in the supine position
with the penis in correct anatomical position against
the abdomen.

CLIENT EDUCATION: No erectile dysfunction medications
should be taken for 2 days prior to the test.

Culture and sensitivity of prostatic fluid

If infection is suspected, as with prostatitis, expressed
prostatic fluid can be tested for culture and sensitivity to
identify the causative organism (bacteria) and determine
the type of antibiotic to treat the infection.

Complete blood count (CBC): To evaluate any evidence of
systemic infection or anemia from hematuria

Active Learning Scenario

a nurse in a provider’s office is providing information
to an older adult client who is scheduled for a
prostate-specific antigen (psa) test and a digital rectal
exam (Dre). use the ati active learning template:
Diagnostic procedure to complete this item.

DESCRIPTION OF PROCEDURE: include the
order in which they are performed.

INDICATIONS: identify two factors that the
nurse should discuss with the client that place
the client at risk for prostate cancer.

Application Exercises

1. a nurse at a provider’s office is caring for an older
adult client who is having an annual physical
exam. Which of the following findings indicates
additional follow-up is needed in regard to
the prostate gland? (select all that apply.)

a. prostate-specific antigen (psa) is 7.1 ng/ml.

B. a digital rectal exam (Dre) reveals an
enlarged and nodular prostate.

c. the client reports a weak urine stream.

D. the client reports urinating once during the night.

e. smegma is present below the glans of the penis.

2. a nurse is providing information to a client who is
scheduled for a transrectal ultrasound (trus). Which
of the following information should the nurse include?

a. “this procedure will determine whether
you have prostate cancer.”

B. “the procedure is contraindicated if
you have an allergy to eggs.”

c. “sound waves will be used to create
a picture of your prostate.”

D. “You should avoid having a bowel movement
for 1 hr prior to the procedure.”

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 65 Diagnostic proceDures for male reproDuctive DisorDers 437

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

DESCRIPTION OF PROCEDURE

psa: a blood sample is taken to measure a specific protein
produced by the prostate gland that is present in the bloodstream.
the psa is performed first because examination of the prostate
irritates the prostate and can cause the psa to rise.

Dre: With the client either leaning over the exam table, placed on
one side, or in the lithotomy position, the examiner uses a gloved,
lubricated finger to palpate the prostate through the rectal wall
to identify any abnormalities in size, shape, and consistency.

INDICATIONS
● age greater than 50 years old
● african american descent
● family history of prostate cancer

NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

Application Exercises Key

1. a. CORRECT: although the psa level is typically
elevated in an older adult male, a psa level greater
than 4 ng/ml warrants additional follow-up.

B. CORRECT: an enlarged and nodular prostate is a possible
indication of prostate cancer and requires further evaluation.

c. CORRECT: a weak urine stream is a manifestation of
benign prostatic hyperplasia and warrants follow-up.

D. urinating once during the night is an expected
finding for an older adult male.

e. smegma is a normal secretion that can
accumulate beneath the glans penis.

NCLEX® Connection: Health Promotion and Maintenance,
Health Screening

2. a. a biopsy or epca-2 is used to make the
diagnosis of prostate cancer.

B. a trus is contraindicated if the client has an allergy to latex.
c. CORRECT: a transrectal ultrasound creates an

image of the prostate using sound waves.
D. the provider may prescribe an enema prior to

the procedure to decrease the interference of
feces with obtaining accurate test results.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 66 Benign prostatic hYperplasia, erectile DYsfunction, anD prostatitis 439

UNIT 9 REPRODUCTIVE DISORDERS
SECTION: MALE REPRODUCTIVE DISORDERS

CHAPTER 66 Benign Prostatic
Hyperplasia,
Erectile Dysfunction,
and Prostatitis

as an adult male ages, the prostate gland
enlarges. When the enlargement of the gland
begins to cause urinary dysfunction, it is called
benign prostatic hyperplasia (Bph). Bph is a very
common condition of the older adult male.

Bph can significantly impair the outflow of urine
from the bladder, making a client susceptible
to infection and retention. excessive amounts
of urine retained can cause reflux of urine into
the kidney, dilating the ureter and causing
kidney infections.

erectile dysfunction (eD) is the inability to
achieve or maintain an erection. the two major
types of eD are organic and functional.

prostatitis is inflammation with possible infection
of the prostate. it often occurs with Bph.

Benign prostatic hyperplasia

ASSESSMENT

risK factors
● Increased age
● Smoking, chronic alcohol use
● Sedentary lifestyle, obesity
● Western diet (high-fat, -protein, -carbohydrate;

low-fiber)
● Diabetes mellitus, heart disease

eXpecteD finDings
● The International Prostate Symptom Score (I-PSS) is

an assessment tool used to determine the severity
of manifestations and their effect on the client’s
quality of life. The client rates the severity of lower
urinary tract manifestations using a 0 to 5 scale and
also rates their quality of life as affected by urinary
tract manifestations.

● Clients who have BPH typically report urinary frequency,
urgency, hesitancy, or incontinence; incomplete
emptying of the bladder; dribbling post-voiding;
nocturia; diminished force of urinary stream;
straining with urination; and hematuria.

● Urinary stasis and persistent urinary retention leads to
frequent urinary tract infections.

● If BPH persists, back flow of urine into the ureters and
kidney can lead to kidney damage.

laBoratorY tests
Urinalysis and culture: WBCs elevated, hematuria, and
bacteria present with urinary tract infection

CBC: WBCs elevated if systemic infection present, RBCs
possibly decreased due to hematuria

BUN and creatinine: Elevated, indicating kidney damage

Prostate‑specific antigen: To rule out prostate cancer

Culture and sensitivity of prostatic fluid: Can be
performed if fluid is expressed during digital
rectal examination

Diagnostic proceDures
Digital rectal exam will reveal an enlarged,
smooth prostate.

Transrectal ultrasound with needle aspiration biopsy is
performed to rule out prostate cancer in the presence of
an enlarged prostate.

Early prostate cancer antigen blood test can be prescribed
instead of a biopsy to rule out prostate cancer.

PATIENT‑CENTERED CARE

meDications
The goal of medication for BPH is to re-establish
uninhibited urine flow out of the bladder.

Dihydrotestosterone (DHT)‑lowering medications

5-alpha reductase inhibitor (5-ARI), such as finasteride
● DHT-lowering medications decrease the production of

testosterone in the prostate gland.
● Decreasing DHT often causes a decrease in the size of

the prostate.

CLIENT EDUCATION
● It can take 6 months before effects of the medication

are evident.
● Impotence and a decrease in libido are possible

adverse effects.
● Report breast enlargement to the provider.
● Finasteride is teratogenic to a male fetus. The

medication is potentially absorbed through the skin.
Clients who are pregnant or who could become pregnant
should avoid contact with tablets that are crushed or
broken and with the semen of a client currently taking
this medication.

CHAPTER 66

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440 CHAPTER 66 Benign prostatic hYperplasia, erectile DYsfunction, anD prostatitis CONTENT MASTERY SERIES

Alpha‑blocking agents: tamsulosin
● Alpha-adrenergic receptor antagonists cause relaxation

of the bladder outlet and prostate gland.
● These agents decrease pressure on the urethra, thereby

re-establishing a stronger urine flow.

CLIENT EDUCATION
● Tachycardia, syncope, and postural hypotension can

occur. Change positions slowly.
● Concurrent use with cimetidine can potentiate the

hypotensive effect.

therapeutic proceDures

Transurethral needle ablation

Low-level radiation is used to shrink the prostate.

Transurethral microwave therapy

Heat is applied to the prostate to decease its size.

Prostatic stent

Placed to keep the urethra patent, especially if client is a
poor candidate for surgery

Interstitial laser coagulation
● This is also called contact laser prostatectomy.
● Laser energy is used to coagulate excess prostatic tissue.

Electrovaporization of the prostate

High-frequency electrical current is used to cut and
vaporize excess tissue.

Surgical resection

An option for clients who do not receive adequate relief
from conservative measures

Transurethral incision of the prostate

Involves incisions into the prostate to relieve constriction
of the urethra

● Tissue is not removed with this procedure.
● It is minimally invasive and typically performed in an

outpatient setting.

Holmium laser enucleation of the prostate

Uses a laser to remove excess prostatic tissue that is
obstructing the client’s urethra

● The tissue is then moved to the bladder where the client
eliminates it in the urine.

● The client often has an indwelling urinary catheter that
is left in place overnight.

Transurethral resection of the prostate (TURP)

The most common surgical procedure for BPH
● TURP is performed using a resectoscope (similar to

a cystoscope) that is inserted through the urethra
and trims away excess prostatic tissue, enlarging the
passageway of the urethra through the prostate gland.

● Typically, epidural and spinal anesthesia are used.

PREOPERATIVE NURSING ACTIONS
● Carefully assess cardiovascular, respiratory, and

renal systems.
● Ensure that the client fully understands the procedure

and what to expect postoperatively.

POSTOPERATIVE NURSING ACTIONS
● Postoperative treatment for a TURP usually includes

placement of an indwelling three-way catheter.
◯ The urinary catheter drains urine and allows for
instillation of a continuous bladder irrigation (CBI) of
normal saline (isotonic) or another prescribed
irrigating solution to keep the catheter free
from obstruction.

◯ The rate of the CBI is adjusted to keep the irrigation
return pink or lighter. For example, if bright-red or
ketchup-appearing (arterial) bleeding with clots is
observed, increase the CBI rate.

◯ If the catheter becomes obstructed (bladder spasms,
reduced irrigation outflow), turn off the CBI and
irrigate with 50 mL irrigation solution using a large
piston syringe or per facility or surgeon protocol.
Contact the surgeon if unable to dislodge the clot.

◯ Record the amount of irrigating solution instilled
(generally very large volumes) and the amount of
return. The difference equals urine output.

◯ The catheter has a large balloon (30 to 45 mL). The
catheter is taped tightly to the leg, creating traction
so that the balloon will apply firm pressure to the
prostatic fossa to prevent bleeding. This makes the
client feel a continuous need to urinate. Instruct the
client to not void around the catheter as this causes
bladder spasms. Avoid kinks in the tubing.

● Monitor vital signs and urinary output.
● Administer/provide increased fluids.
● Monitor for bleeding (persistent bright-red bleeding

unresponsive to increase in CBI and traction on the
catheter or reduced Hgb levels) and report to the provider.

● Assist the client to ambulate as soon as possible to
reduce the risk of deep-vein thrombosis and other
complications that occur due to immobility.

● Administer medications.
◯ Analgesics (surgical manipulation or
incisional discomfort)

◯ Antispasmodics (bladder spasms)
◯ Antibiotics (prophylaxis)
◯ Stool softeners (avoid straining)

● When the catheter is removed, monitor urinary
output. The initial voiding following removal can be
uncomfortable, red in color, and contain clots. The
color of the urine should progress toward amber in
2 to 3 days. Instruct the client that expected output is
150 to 200 mL every 3 to 4 hr. The client should contact
the provider if unable to void.

Online Video: Continuous Bladder Irrigation

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CLIENT EDUCATION
● Avoid heavy lifting, strenuous exercise, straining, and

sexual intercourse for the prescribed length of time
(usually 2 to 6 weeks).

● Drink 12 or more 8-oz glasses of water each day unless
contraindicated.

● Avoid nonsteroidal anti-inflammatory medications due
to increased risk for bleeding.

● Avoid bladder stimulants (caffeine, alcohol).
● If urine becomes bloody, then stop activity, rest, and

increase fluid intake.
● Contact the surgeon for persistent bleeding or

obstruction (less than expected output or distention).

client eDucation
● Frequent ejaculation releases retained prostatic fluids,

thereby decreasing the size of the prostate.
● Avoid drinking large amounts of fluids at one time, and

urinate when the urge is initially felt.
● Avoid bladder stimulants (caffeine, alcohol).
● Avoid medications that cause decreased bladder tone

(anticholinergics, decongestants, antihistamines).
● Medication is used for conservative treatment of BPH.

COMPLICATIONS
Complications of procedures to treat BPH include
regrowth of prostate tissue and recurrence of bladder
neck obstruction.

TURP complications

Urethral trauma, urinary retention, bleeding,
and infection

NURSING ACTIONS
● Monitor the client and intervene for bleeding.
● Provide antibiotic prophylaxis to the client.

Erectile dysfunction
Organic ED involves a gradual reduction in function
resulting from other sources (diabetes, medications,
vascular disease).

Functional ED is a result of a psychological cause such as
high stress.

ASSESSMENT

risK factors
● Inflammation of seminal vesicles, urethra, and prostate
● Prostatectomy
● Pelvic fractures
● Lumbosacral injuries
● Vascular disease, such as hypertension
● Chronic neurologic conditions (multiple sclerosis,

Parkinson’s)
● Endocrine disorders (diabetes, thyroid disorders)

● Smoking and alcohol consumption
● Medications such as antihypertensives
● Poor overall health that prevents sexual intercourse

eXpecteD finDings
Inability to achieve or maintain an erection for sexual
intercourse

Diagnostic proceDures

Penile Doppler ultrasonography
● Diagnostic test determines the normal anatomy and

blood flow of the penis.
● This is used to identify many conditions of the penis,

including erectile dysfunction.
● An injection is given to increase blood flow to the penis,

causing an erection.
● The procedure measures penile blood flow.

NURSING ACTIONS: Place the client in the supine position
with the penis in correct anatomical position against
the abdomen.

CLIENT EDUCATION: No erectile dysfunction medications
should be taken for2 days prior to the test.

PATIENT‑CENTERED CARE

meDications
Prior to medication therapy, a cardiovascular workup is
recommended.

Phosphodiesterace‑5 (PDE‑5) inhibitors

Relax the smooth muscles in the corpora cavernosa to
increase penile blood flow while compressing the veins to
prevent loss of blood.

CLIENT EDUCATION
● Take the medication 1 hour before sexual intercourse.
● With sildenafil and vardenafil, sexual stimulation is

needed within ½-1 hour to promote the erection.
● With tadalafil, sexual stimulation can occur over a

longer period of time.
● Avoid alcohol when taking PDE-5 inhibitors.
● Potential adverse effects of PDE-5 inhibitors include

dyspepsia, headaches, facial flushing, and stuffy nose.
● Taking more than one dose in a day can cause leg and

back cramps, nausea, and vomiting.
● If taking nitrates, avoid PDE-5 inhibitors due

to vasodilation effects that can cause profound
hypotension and reduction of blood flow to vital organs.

Vasodilators

Vasodilators (alprostadil, papaverine, phentolamine, or a
combination of these) are injected into the penis to cause
engorgement resulting in an erection.

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442 CHAPTER 66 Benign prostatic hYperplasia, erectile DYsfunction, anD prostatitis CONTENT MASTERY SERIES

therapeutic proceDures

Vacuum constriction device (VCD)
● A cylinder is placed around the penis while a vacuum is

created to draw blood into the penis.
● A rubber ring is then placed at the base of the penis to

maintain an erection and the cylinder is removed.

Penile implants
● This modality is used when other interventions fail.
● A three-piece inflatable device is implanted in the penis

with the reservoir planted in the scrotum.

CLIENT EDUCATION
● Squeeze the pump located in the scrotum to fill the

penis with fluid to achieve erection of the penis.
● Depress the release button to deflate the prosthesis

following sexual activity.
● Observe the surgical site for bleeding and infection

following insertion.

Penile suppository

Relaxes smooth muscle, increasing blood flow
into the penis

CLIENT EDUCATION
● A urethral suppository (alprostadil) is inserted 10 min

before intercourse.
● Erections can last up to 1 hr and can be used twice a day.
● Adverse effects include urethral and genital pain, risk of

hypertension, and syncope.
● This medication is not recommended with

pregnant partners.

Prostatitis
● Prostatitis is an inflammation of the prostate gland

often associated with lower urinary tract findings and
findings including sexual dysfunction.

● Organisms reach the prostate through the urethra
or bloodstream.

ASSESSMENT

eXpecteD finDings

Acute prostatitis
● Fever, chills
● Dysuria
● Urethral discharge
● Boggy, tender prostate
● Palpation of the prostate that can result in urethral

discharge containing white blood cells

Chronic prostatitis
● Urinary hesitancy and frequency
● Dysuria
● Difficulty initiating and stopping the flow of urine
● Decreased strength and volume of urine
● Pain in back and perineal area
● Irregularly enlarged prostate

Diagnostic proceDures

Prostate specific antigen

PSA value greater than 4 ng/mL requires further
evaluation. An elevated PSA is an indication of a number
of conditions, including prostate cancer, BPH, and acute
prostatitis.

Urinalysis
● Collection of an early morning specimen provides a

more concentrated sample.
● If infection is suspected, possibly in prostatitis, a

midstream, clean-catch sample should be obtained.
● Urine for culture and sensitivity identifies the causative

organism (bacteria) and determines the type of
antibiotic to treat the infection.

White blood cell count increased due to infection and
inflammation seen in prostatitis

PATIENT‑CENTERED CARE

meDications

Antimicrobials

Prescribed based on the results of the culture and
sensitivity testing of urine

CLIENT EDUCATION: Antimicrobial treatment can last
weeks or months and can require hospitalization inpatient
IV antibiotics.

Alpha‑blocking agents: tamsulosin
● Alpha-adrenergic receptor antagonists cause relaxation

of the bladder outlet and prostate gland.
● These agents decrease pressure on the urethra, thereby

re-establishing a stronger urine flow.

CLIENT EDUCATION
● Postural hypotension can occur. Change positions slowly.
● Concurrent use with cimetidine can potentiate the

hypotensive effect.

Stool softeners

Used for prevention of straining and rectal irritation of the
prostate during bowel movements.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 66 Benign prostatic hYperplasia, erectile DYsfunction, anD prostatitis 443

client eDucation
● Use sitz baths, NSAIDS, and muscle relaxants if

prescribed for promotion of comfort.
● Avoid alcohol, tea, coffee, and spicy foods that

increase findings.
● Avoid over-the-counter cold preparations that contain

decongestants or antihistamines that can cause
urinary retention.

● Take medications as directed and complete the entire
course of therapy.

● Sexual intercourse and masturbation helps to manage
chronic prostatitis.

● Prostatitis is not infectious or contagious.

COMPLICATIONS
● Epididymitis: inflammation of the epididymis
● Cystitis: inflammation of the bladder
● Urinary tract infections
● Difficulty with sexual function

Active Learning Scenario

a nurse is teaching a client who has a new prescription
for finasteride about the medication. use the ati active
learning template: medication to complete this item.

THERAPEUTIC USES: identify the therapeutic
use of this medication for this client.

CLIENT EDUCATION: identify four
instructions the nurse should include.

Application Exercises

1. a nurse in a provider’s office is obtaining a history
from a client who is undergoing an evaluation for
benign prostatic hyperplasia (Bph). the nurse should
identify that which of the following findings are
indicative of this condition? (select all that apply.)

a. Backache

B. frequent urinary tract infections

c. Weight loss

D. hematuria

e. urinary incontinence

2. a nurse is caring for a client who has a new
diagnosis of benign prostatic hyperplasia
(Bph). the nurse should expect a prescription
for which of the following medications?

a. oxybutynin

B. Diphenhydramine

c. ipratropium

D. tamsulosin

3. a nurse is instructing a client who is scheduled for
a transurethral resection of the prostate (turp)
about postoperative care. Which of the following
information should the nurse include in the teaching?

a. “You might have a continuous sensation of needing
to void even though you have a catheter.”

B. “You will be on bed rest for the first
2 days after the procedure.”

c. “You will be instructed to limit your
fluid intake after the procedure.”

D. “Your urine should be clear yellow
the evening after the surgery.”

4. a nurse is providing discharge instructions to
a client who is postoperative following a turp.
Which of the following instructions should
the nurse include? (select all that apply.)

a. avoid sexual intercourse for
3 months after the surgery.

B. if urine appears bloody, stop activity and rest.

c. avoid drinking caffeinated beverages.

D. take a stool softener once a day.

e. treat pain with ibuprofen.

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Application Exercises Key

1. a. Backache occurs in the presence of prostate cancer
that has spread to other areas of the body.

B. CORRECT: in the presence of Bph, pressure on urinary
structures leads to urinary stasis, which in turn promotes
the occurrence of urinary tract infections.

c. Weight loss occurs in the presence of prostate cancer.
D. CORRECT: hematuria occurs in the presence of Bph.
e. CORRECT: overflow incontinence occurs in the presence

of Bph due to an increased volume of residual urine.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. oxybutynin is an anticholinergic medication that
is used to treat overactive bladder. anticholinergic
medications are contraindicated for a client who has
Bph. oxybutynin causes urinary retention.

B. Diphenhydramine is an antihistamine and
is contraindicated for a client who has Bph.
Diphenhydramine causes urinary retention.

c. ipratropium is an anticholinergic medication used
to treat asthma and other respiratory conditions.
ipratropium causes urinary retention.

D. CORRECT: tamsulosin is an alpha-adrenergic receptor
antagonist that relaxes the bladder outlet and the
prostate gland, which improves urinary flow.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

3. a. CORRECT: to reduce the risk of postoperative
bleeding, the client will have a catheter with a large
balloon that places pressure on the internal sphincter
of the bladder. pressure on the sphincter causes a
continuous sensation of needing to void.

B. the client is ambulated early in the postoperative
period to reduce the risk of deep-vein thrombosis and
other complications that occur due to immobility.

c. the client is encouraged to increase their fluid intake unless
contraindicated by another condition. a liberal fluid intake
reduces the risks of urinary tract infection and dysuria.

D. the client’s urine is expected to be pink
the first 24 hr after surgery.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. a. the client should follow the provider’s instructions,
which typically includes avoidance of sexual intercourse
for 2 to 6 weeks after the surgery.

B. CORRECT: excessive activity can cause
recurrence of bleeding. the client should rest to
promote reclotting at the incisional site.

c. CORRECT: the client should avoid caffeine
and other bladder stimulants.

D. CORRECT: the client should take a stool softener to
keep the stool soft and thus prevent the complication
of bleeding at the time of a bowel movement.

e. the client should avoid taking nonsteroidal anti-inflammatory
drugs because they can cause bleeding.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

THERAPEUTIC USES: finasteride inhibits 5-alpha reductase and
enzyme, which converts testosterone to dihydrotestosterone.
production of testosterone in the prostate gland is reduced,
which in turn reduces the size of prostate tissue.

CLIENT EDUCATION
● the medication is prescribed on a long-term basis. it may take as
long as 1 year before the effects of the medication are evident.

● impotence and a decreased libido are possible adverse effects.
● report breast enlargement to the provider.
● finasteride is teratogenic to the male fetus. the medication
can be absorbed through the skin. clients who are
pregnant or who could become pregnant should avoid
contact with tablets that are crushed or broken and with
the semen of a client currently taking this medication.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

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RN ADULT MEDICAL SURGICAL NURSING ncleX® connections 445

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Basic Care and Comfort
MOBILITY/IMMOBILITY: Maintain/correct the
adjustment of client’s traction device.

NON-PHARMACOLOGICAL COMFORT INTERVENTIONS:
Provide non-pharmacological comfort measures.

NUTRITION AND ORAL HYDRATION: Provide/
maintain special diets based on the client diagnosis/
nutritional needs and cultural considerations.

Health Promotion and Maintenance
HEALTH PROMOTION/DISEASE PREVENTION
Assist the client in maintaining an optimum level of health.

Identify risk factors for disease/illness

Management of Care
CASE MANAGEMENT: Provide client with information on
discharge procedures to home, or community setting.

Reduction of Risk Potential
POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC
TESTS/TREATMENTS/PROCEDURES
Position the client to prevent complications
following tests/treatments/procedures.

Use precautions to prevent injury and/or complications
associated with a procedure or diagnosis.

POTENTIAL FOR COMPLICATIONS FROM SURGICAL
PROCEDURES AND HEALTH ALTERATIONS: Apply knowledge
of pathophysiology to monitoring for complications.

SYSTEM SPECIFIC ASSESSMENTS: Assess the
client for abnormal neurological status.

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446 ncleX® connections CONTENT MASTERY SERIES

Pharmacological and Parenteral Therapies
MEDICATION ADMINISTRATION: Educate client on medication
self-administration procedures; Educate client about medication.

PHARMACOLOGICAL PAIN MANAGEMENT: Administer
and document pharmacological pain management
appropriate for client age and diagnoses.

THERAPEUTIC PROCEDURES: Apply knowledge of related nursing
procedures and psychomotor skills when caring for clients undergoing
therapeutic procedures; Provide preoperative or postoperative
education; Educate client about treatments and procedures.

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS
Apply knowledge of nursing procedures, pathophysiology
and psychomotor skills when caring for a client
with an alteration in body systems

Educate client about managing health problems.

ILLNESS MANAGEMENT
Promote and provide continuity of care in illness management activities.

Provide postoperative care.

MEDICAL EMERGENCIES: Apply knowledge of pathophysiology
when caring for a client experiencing a medical emergency.

PATHOPHYSIOLOGY: Identify pathophysiology
related to an acute or chronic condition.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 67 musculosKeletal Diagnostic proceDures 447

UNIT 10 MUSCULOSKELETAL DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 67 Musculoskeletal
Diagnostic
Procedures

imaging studies are the primary diagnostic
procedures for musculoskeletal disorders.
muscle weakness is an indication for evaluating
the conduction of electrical impulses.
arthroscopy assesses the condition of a joint and
allows the repair of tears and other joint defects.

musculoskeletal diagnostic procedures
that nurses should be knowledgeable
about include arthroscopy, nuclear scans
(bone scan, gallium scan, thallium scan),
dual-energy x-ray absorptiometry scans (DXa),
electromyography (emg), and nerve conduction
studies. other diagnostic procedures that
help detect joint problems and identify
musculoskeletal structures are x-ray studies,
ultrasound (us), computed tomography (ct)
scans, and magnetic resonance imaging (mri).

Arthroscopy
● Arthroscopy allows visualization of the internal

structures of a joint through the use of an endoscope.
It is most commonly used to evaluate the knee and
shoulder joints and is performed in the operating room
under sterile conditions using local or general anesthesia.

● Number and placement of incisions depend on the area
of the joint undergoing visualization and the extent of
the repair.

● Infection in the joint and a lack of joint mobility are
contraindications for arthroscopy.

INDICATIONS
POTENTIAL DIAGNOSES: A client who has a joint
injury can undergo arthroscopy to ascertain the extent
of damage, during which the provider can use the
arthroscope to repair a torn ligament or meniscus or
perform a synovial biopsy.

CLIENT PRESENTATION
● Joint swelling, pain, and crepitus
● Joint instability

CONSIDERATIONS

preproceDure
NURSING ACTIONS: Ensure that the client signed the
informed consent form.

CLIENT EDUCATION: The provider might require
performing postoperative joint exercises (straight-leg
raises, quadriceps setting isometrics).

postproceDure
NURSING ACTIONS

● Provide postoperative care; specific actions and recovery
time depend on type of sedation used. The procedure is
usually done in an outpatient setting.

● Assess neurovascular status and dressings on the
client’s limb every hour or per the facility’s protocol.

● Administer mild analgesia for mild pain; opioids can be
required if the operation was corrective.

CLIENT EDUCATION
● Apply ice for the first 24 hr to control edema.
● Elevate the extremity for 12 to 24 hr.
● Maintain activity restrictions.
● Monitor the color and temperature of the extremity,

as well as pain and sensation.
● Notify the provider of any changes, such as swelling,

increased joint pain, thrombophlebitis, or infection
(redness, swelling, purulent drainage, fever).

complications

Infection

Complications are uncommon after this procedure, but
infection can occur as with any procedure that disrupts
the integrity of the skin.

CLIENT EDUCATION: Notify the provider immediately of
swelling, redness, or fever.

CHAPTER 67

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448 CHAPTER 67 musculosKeletal Diagnostic proceDures CONTENT MASTERY SERIES

Nuclear scans
Bone scans

Bone scans evaluate the entire skeletal system.
● A radionuclide test involves a radioactive isotope via

injection 2 to 3 hr before scanning. Areas of abnormal
bone formation will appear brighter when later scanned.

● Bone scans can detect hairline bone fractures, tumors,
fractures, and diseases of the bone (osteomyelitis,
osteoporosis, vertebral compression fractures).

● Bone scans are becoming less common due to the
increased availability of MRI equipment.

Gallium and thallium scans

Gallium and thallium scans are more sensitive for
detecting bone problems than a bone scan.

● The radioisotope migrates to tissues of the brain, liver,
and breast, and helps detect disease of these organs.

● The client receives the radionuclide injection 4 to 6 hr
before scanning.

● The scan takes 30 to 60 min and can require sedation
to help the client lie still during that time. Repeat
scanning occurs at 24, 48, and 72 hr.

INDICATIONS
POTENTIAL DIAGNOSES

● Degenerative bone diseases and their progression
● Osteomyelitis
● Stress or vertebral compression fractures, or

nonhealing fractures
● Osteoporosis
● Primary or metastatic bone cancer
● Bone pain of unknown origin
● Aseptic necrosis

CLIENT PRESENTATION: Bone pain

CONSIDERATIONS

preproceDure
NURSING ACTIONS

● Inform the client about the procedure.
● Assess for allergy to radioisotope or conditions that

would prevent performing the procedure (pregnancy,
lactation, kidney disease).

CLIENT EDUCATION
● Remain still during the entire procedure.
● Empty the bladder before the procedure to promote

visualization of pelvic bones.

postproceDure
CLIENT EDUCATION

● Following the procedure, radioactive precautions no
longer need to be taken.

● Drink fluids to increase excretion of radioisotope in the
urine and feces.

Dual‑energy x‑ray
absorptiometry

● DXA scans estimate the density of bone mass—
usually in the hip or spine—and the presence/extent
of osteoporosis.

● A DXA scan uses two beams of radiation. A computer
analyzes the findings and a radiologist interprets them.
Clients do not receive contrast material. Clients receive
a score that relates their amount of bone density to that
of other people with demographic similarities.

● Clients lie on an x-ray table during scanning of the
hip or spine.

note: these scores are not sex-specific.

INDICATIONS
POTENTIAL DIAGNOSES

● Osteoporosis
● Postmenopausal state
● Baseline testing: females in their 40s

CLIENT PRESENTATION
● Loss of height
● Bone pain
● Fractures

CONSIDERATIONS
PREPROCEDURE CLIENT EDUCATION

● The procedure is not recommended for clients who are
pregnant or lactating.

● Stay dressed but remove metallic objects.

POSTPROCEDURE CLIENT EDUCATION: Follow up with the
provider to discuss possible supplements and medications
if bone loss is present.

Electromyography and
nerve conduction studies

EMG and nerve conduction studies determine the presence
and cause of muscle weakness.

EMG
● Clients undergo EMG at the bedside or in an

EMG laboratory.
● The technician places thin needles in the muscle under

study. Electrodes attach the needles to an oscilloscope,
which records activity during a muscle contraction.

Nerve conduction study
● The technician attaches surface or needle electrodes

to the skin.
● Low electrical currents go through the electrodes,

producing a recording of the muscle response to
the stimulus.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 67 musculosKeletal Diagnostic proceDures 449

INDICATIONS
POTENTIAL DIAGNOSES

● Neuromuscular disorders
● Motor neuron disease
● Peripheral nerve disorders (carpal tunnel)

CONSIDERATIONS

preproceDure
NURSING ACTIONS

● Inform the client about what to expect.
● Determine whether the client takes an anticoagulant,

because anticoagulation is a contraindication for this
procedure due to the risk for bleeding within the muscle
with needle insertion.

● Check for any skin infections in the area of assessment.
Infection is a contraindication for this procedure due to the
risk for transmission of the infection to the muscle.

● Ask whether the client takes any muscle relaxants. The
provider might discontinue these prior to the procedure
to ensure accurate test results.

● Make sure the client signed the consent form.

CLIENT EDUCATION
● Avoid the application of cream or lotion to the area on

the day of the procedure.
● Discomfort is possible during needle insertion and when

the electrical current goes through the electrodes.
● You might be asked to flex certain muscles during

needle insertion.

postproceDure
CLIENT EDUCATION

● Bruising can occur at needle insertion sites.
● Report swelling or tenderness at any of the sites to

the provider.
● Apply ice to prevent hematoma formation at the

needle insertion sites and to reduce swelling or warm
compresses to relieve residual discomfort.

CT scan, resonance imaging,
radiography, ultrasonography

● Provides detailed images of the body structures, bone
density and texture as well as surgical hardware.

● MRI, US and CT provide visualization of soft tissues.

INDICATIONS
POTENTIAL DIAGNOSES

● Injuries to tendons and ligaments
● Fractures of bony structures of the chest and pelvis
● Skull and vertebral fracture or herniated disc

CLIENT PRESENTATION
● Bone pain
● Joint instability

NURSING ACTIONS
● CT scan: If contrast media is prescribed, assess for

allergy, and ensure client has adequate fluid intake
following testing.

● MRI: Determine whether the client has metal in the
body (pacemakers) and be sure to remove exterior metal
(jewelry, hair clips).

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450 CHAPTER 67 musculosKeletal Diagnostic proceDures CONTENT MASTERY SERIES

Active Learning Scenario

a nurse is teaching a client who is having a gallium
scan. What information should the nurse include in
the teaching? use the ati active learning template:
Diagnostic procedure to complete this item.

DESCRIPTION OF PROCEDURE

INDICATIONS: list three.

NURSING INTERVENTIONS (PRE, INTRA, POST):
list two preprocedure and one postprocedure.

Application Exercises

1. a nurse is completing preoperative teaching for a
client who is to undergo an arthroscopy to repair a
shoulder injury. Which of the following statements
should the nurse include? (select all that apply.)

a. “avoid damage or moisture to
the cast on your arm.”

B. “inspect your incision daily for
indications of infection.”

c. “apply ice packs to the area for the first 24 hours.”

D. “Keep your arm in a dependent position.”

e. “perform isometric exercises.”

2. a nurse is planning care for a client who is
postoperative following an arthroscopy of the
knee. Which of the following actions should
the nurse take? (select all that apply.)

a. assess color and temperature of the extremity.

B. apply warm compresses to incision sites.

c. place pillows under the extremity.

D. administer analgesic medication.

e. assess pulse and sensation in the foot.

3. a nurse is teaching a client who is going to
have a bone scan. Which of the following
statements should the nurse include?

a. “You will receive an injection of a radioactive
isotope when the scanning procedure begins.”

B. “You will be inside a tube-like structure
during the procedure.”

c. “You will need to take radioactive precautions
with your urine for 24 hours after the procedure.”

D. “You will have to urinate just before the procedure.”

4. a nurse is educating clients at a health fair
about dual-energy x-ray absorptiometry (DXa)
scans. Which of the following information should
the nurse include? (select all that apply.)

a. the test requires the use of contrast material.

B. the hip and spine are the usual
areas the device scans.

c. the scan detects osteoarthritis.

D. Bone pain can indicate a need for a scan.

e. females should have a baseline
scan during their 40s.

5. a nurse is planning care for a client who will undergo
an electromyography (emg). Which of the following
actions should the nurse include? (select all that apply.)

a. assess for bruising.

B. administer aspirin prior to the procedure.

c. Determine whether the client
takes a muscle relaxant.

D. instruct the client to flex muscles
during needle insertion.

e. expect swelling, redness, and
tenderness at the insertion sites.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 67 musculosKeletal Diagnostic proceDures 451

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

DESCRIPTION OF PROCEDURE: a gallium scan involves
a radioisotope called radionuclide that is injected into the
client 4 to 6 hr before the scan to view the client’s bones. the
radionuclide also migrates to the tissues of the brain, liver,
and breast and is used to detect disease of these organs.

INDICATIONS: Detect fractures, osteoporosis,
bone lesions, osteomyelitis, and arthritis

NURSING INTERVENTIONS (PRE, INTRA, POST)

preprocedure
● assess for allergy to radioisotopes.
● assess for existing conditions, such as pregnancy or kidney
disease, that are contraindications for the procedure.

● have the client empty their bladder before the procedure.

postprocedure: inform the client to increase fluid intake to promote
the excretion of the radioisotope in the urine and feces.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Application Exercises Key

1. a. a cast is not typically required following arthroscopy.
B. CORRECT: the client should inspect the incision for evidence

of infection (redness, swelling, purulent drainage).
c. CORRECT: the client should apply ice packs to the affected

area for the first 24 hr to reduce swelling and discomfort.
D. the client should elevate the affected extremity

for 12 to 24 hr to reduce swelling.
e. CORRECT: the client should perform the

isometric exercises as the provider prescribed
and as physical therapist directed.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

2. a. CORRECT: assessing color and temperature of the affected
extremity helps identify alterations in circulation.

B. cold compresses on the incisional site for the first
24 hr help decrease swelling and pain.

c. CORRECT: elevating the leg will help decrease
swelling and pain in the affected extremity.

D. CORRECT: administering analgesic medication helps
relieve joint pain in the affected extremity.

e. CORRECT: assessing pulse and sensation of the affected
extremity helps identify alterations in circulation.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

3. a. inform the client that the radioactive isotope is injected
through an iv 2 to 3 hr before the scanning.

B. inform the client that the procedure does not
use a tube-like structure as for an mri.

c. inform the client that radioactive precautions for his
urine are not necessary following the procedure.

D. CORRECT: inform the client that he will need to
urinate prior to the procedure. an empty bladder
promotes visualization of the pelvic bones.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. a. inform the client that a DXa scan does not
require contrast material.

B. CORRECT: inform the client that the most common
areas for a DXa scan are the hip and spine for more
clear visualization of a large area of bone.

c. inform the client that a DXa scan detects
osteoporosis, not osteoarthritis.

D. CORRECT: inform the client that bone pain,
loss of height, and fractures are findings that
can indicate the need for a DXa scan.

e. CORRECT: inform the client that a baseline scan for
females in their 40s is helpful for comparison with
a scan during the postmenopausal period.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. a. CORRECT: some bruising can occur at
the needle insertion sites.

B. the client should withhold any anticoagulant medication
prior to the procedure to reduce the risk of bleeding.

c. CORRECT: assess the client’s medications to
determine whether they take a muscle relaxant, which
can decrease the accuracy of the test results.

D. CORRECT: ask the client to flex their muscles for an
easier insertion of the needle into the muscle.

e. instruct the client to report swelling, redness, and
tenderness at the insertion sites to the provider
because this can indicate an infection.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

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452 CHAPTER 67 musculosKeletal Diagnostic proceDures CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 68 arthroplastY 453

UNIT 10 MUSCULOSKELETAL DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 68 Arthroplasty
most musculoskeletal surgical procedures are
performed to repair damaged joints, particularly
the knees and the hips.

Arthroplasty refers to the surgical removal
of a diseased joint due to osteoarthritis,
osteonecrosis, rheumatoid arthritis, trauma, or
congenital anomalies, and replacement with
prosthetics or artificial components made of
metal (stainless steel, titanium) and/or plastic.

Total joint arthroplasty, also called total
joint replacement, involves replacement of all
components of an articulating joint.

Total knee arthroplasty involves the
replacement of the distal femoral component,
the tibia plate, and the patellar button. total
knee arthroplasty is a surgical option when
conservative measures fail. (68.1)

Unicondylar knee replacement is done when a
client’s joint is diseased in one compartment of
the joint.

Total hip arthroplasty involves the replacement
of the acetabular cup, femoral head, and
femoral stem. (68.2)

Hemiarthroplasty refers to half of a joint
replacement. fractures of the femoral neck can
be treated only with the replacement of the
femoral component.

INDICATIONS
The goal of both hip and knee arthroplasty is to eliminate
pain, restore joint motions, and improve a client’s
functional status and quality of life.

POTENTIAL DIAGNOSES
● Knee and hip arthroplasty treats degenerative disease

(osteoarthritis, rheumatoid arthritis).
● Osteonecrosis is a necrosis of the bone secondary to lack

of blood flow with trauma or chronic steroid therapy as
the cause.

CLIENT PRESENTATION
● Pain when bearing weight on the joint

(walking, running)
● Joint crepitus and stiffness
● Joint swelling (primarily occurs in the knees)

CHAPTER 68

68.1 Artificial knee joint 68.2 Artificial hip joint

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454 CHAPTER 68 arthroplastY CONTENT MASTERY SERIES

CONSIDERATIONS

contrainDications
● Recent or active infection (urinary tract infection),

which can cause micro-organisms to migrate to the
surgical area and cause the prosthesis to fail

● Arterial impairment to the affected extremity
● Client inability to follow the postsurgical regimen
● A comorbid condition (uncontrolled diabetes mellitus

or hypertension, advanced osteoporosis, progressive
inflammatory condition, unstable cardiac or
respiratory conditions)

preproceDure

NURSING ACTIONS: Review diagnostic test results.
● CBC, urinalysis, electrolytes, BUN, creatinine: Assess

surgical readiness, and rule out anemia, infection, or
organ failure. Epoetin alfa can be prescribed several
weeks preoperatively to increase Hgb for a client who
has mild anemia.

● Chest x‑ray: Rule out pulmonary surgical
contraindications (infection, tumor).

● ECG: Gather baseline rhythm to identify cardiovascular
surgical contraindications (dysrhythmia).

CLIENT EDUCATION
● Postoperative care includes incentive spirometry,

transfusion, surgical drains, dressing, pain control,
transfer, exercises, and activity limits.

● Consider autologous blood donation. The client donates
blood prior to procedure to be used during or after
the procedure.

● Scrub the surgical site with a prescribed antiseptic soap
the night before and the morning of surgery to decrease
bacterial count on skin, which helps lower the chance of
infection.

● Wear clean clothes and sleep on clean linens the night
before surgery.

● Take antihypertensive and other medications the surgeon
allows with a sip of water the morning of surgery.

intraproceDure
● General or spinal anesthesia can be used.
● Joint components are removed and replaced with

artificial components.
● Components can be cemented in place. Components

that do not use cement allow the bone to grow into
the prosthesis to stabilize it. Weight bearing is delayed
several weeks until the femoral shaft has grown into
the prosthesis.

postproceDure

CLIENT EDUCATION
● Extensive physical therapy is required to regain

mobility. Discharge can be to home or to an acute
rehabilitation facility. If discharged home, outpatient or
in-home therapy must be provided. Home care should
be available for 4 to 6 weeks.

● Monitor for evidence of incisional infection (fever,
increased redness, swelling, purulent drainage).

● Care for the incision (clean daily with soap and water).
● Monitor for deep vein thrombosis (swelling, redness,

pain in calf), pulmonary embolism (shortness of breath,
chest pain), and bleeding if taking an anticoagulant.

Knee arthroplasty

NURSING ACTIONS
● Provide postoperative care, and prevent postoperative

complications (venous thromboembolism developing
into deep vein thrombosis [DVT], which can lead
to a pulmonary embolism, anemia, infection,
neurovascular compromise).

● Older adult clients are at a higher risk for medical
complications related to chronic conditions, including
hypertension, diabetes mellitus, coronary artery disease,
and obstructive pulmonary disease.

● A continuous passive motion (CPM) machine can be
prescribed to promote motion in the knee, promote
circulation, and prevent scar tissue formation. CPM
is usually placed and initiated immediately after
surgery. CPM provides passive range of motion from
full extension to the prescribed amount of flexion.
Follow the prescribed duration of use, but turn it off
during meals.

● Positions of flexion of the knee are limited to avoid
flexion contractures.

◯ Avoid knee gatch and pillows placed behind the knee.
◯ Place one pillow under the lower calf and foot to
cause a slight extension of the knee joint and to
prevent flexion contractures. The knee can also rest
flat on the bed.

● To prevent pressure injury on the heels, place a small
blanket or pillow slightly above the ankle area to keep
heels off the bed.

● Provide medications as prescribed. Focus needs to
be about pain medications. This promotes client
participation in early ambulation.

◯ Analgesics: Opioids (epidural, PCA, IV, oral), NSAIDs
◯ Peripheral nerve blockade: Inject the femoral or
sciatic nerve with a local anesthetic, or the client
can receive a continuous infusion of local anesthetic
directly into sciatic or femoral nerve.

■ A continuous peripheral nerve block provides
localized pain relief.

■ Monitor for systemic effects of local anesthetic
(metallic taste in the mouth, tinnitus, slurred
speech, decreased respiratory rate, hypotension,
bradycardia, restlessness, or seizure).

◯ Antibiotics: Prophylaxis is generally administered
30 min before the surgical incision is made
and continued for 24 hr postoperatively to
prevent infection.

◯ Anticoagulant: Warfarin, fondaparinux,
rivaroxaban, or low-molecular-weight heparin
(enoxaparin). The client can have a prescription
for sequential compression devices, foot pumps,
and/or anti-embolism stockings to prevent
venous thromboembolism formation that can
develop into DVT.

● Apply ice or cold therapy to the incisional area to reduce
postoperative swelling.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 68 arthroplastY 455

● Monitor neurovascular status of the surgical extremity
(movement, sensation, color, pulse, capillary refill)
every 2 to 4 hr, and compare with the other extremity.

● Assess frequently for overt bleeding and manifestations
of hypovolemia (hypotension, tachycardia)

● Monitor the compression bandage and wound suction
drain for excessive drainage.

● Monitor the autotransfusion drainage system, if used,
and re-infuse blood as prescribed.

INTERPROFESSIONAL CARE: Physical therapy, to assist
with mobility on the first postoperative day with a
knee immobilizer in place. Degree of weight-bearing is
determined by the provider.

CLIENT EDUCATION: Dislocation is not common following
total knee arthroplasty. However, kneeling and deep-knee
bends are limited indefinitely.

Hip arthroplasty

NURSING ACTIONS
● Provide postoperative care, and prevent complications.
● Check the dressing site frequently, noting any evidence

of bleeding. Monitor and record drainage from
surgical drains.

● Monitor daily laboratory values, including Hgb and Hct
levels. Hgb and Hct can continue to drop for 48 hr after
surgery. Autologous blood from presurgery donation or
blood salvaged intraoperatively or postoperatively using
collection devices can be used for postoperative blood
replacement. Blood transfusions are relatively common
for Hgb levels less than 9 g/dL.

● Monitor the neurovascular status of the surgical
extremity (movement, sensation, color, pulse, capillary
refill, and compare with contralateral extremity) every
2 to 4 hr.

● Provide medications as prescribed.
◯ Analgesics: Opioids (epidural, PCA, IV, oral), NSAIDs
◯ Antibiotics: Generally administered 30 min before

the surgical incision is made as a prophylaxis,
and continued for 24 hr postoperatively to
prevent infection

◯ Anticoagulant: Warfarin, dalteparin, fondaparinux,
rivaroxaban, or low-molecular-weight heparin
(enoxaparin)

● Provide early ambulation.
◯ Transfer the client out of bed from their unaffected
side into a chair or wheelchair.

◯ Weight-bearing status is determined by the
orthopedic surgeon and by choice of cemented
(usually partial/full weight-bearing as tolerated) vs.
non-cemented prostheses (usually only partial or
minimal weight-bearing [toe touch] until after a few
weeks of bone growth).

◯ Use assistive (walker) and adaptive (raised toilet seat,
grab bars, and shower chairs) devices when caring for
the client.

◯ Apply ice to the surgical site following ambulation
as a nonpharmacological measure to decrease pain
and discomfort.

● Place the client supine with the head slightly elevated
and the affected leg in a neutral position. Place a pillow
or abduction device between the legs when turning to
the unaffected side. The client should not be turned to
the operative side, which could cause hip dislocation.

● Use total hip precautions to prevent dislocation of the
new joint.

● Monitor for new joint dislocation: acute onset of
pain, reports hearing “a pop,” internal or external
rotation of the affected extremity, and shortened
affected extremity.

CLIENT EDUCATION
● Use raised toilet seats, and assistive items

(long-handled shoehorn, dressing sticks) to prevent
strain on the prosthesis.

● Follow position restrictions to avoid dislocation.
◯ Use elevated seating and a raised toilet seat.
◯ Use straight chairs with arms.
◯ Use an abduction pillow or regular pillow, if

prescribed, between the legs while in bed (and with
turning, if restless, or in an altered mental state).

◯ Externally rotate the toes.
◯ Use extended handles on shoehorns and dressing
sticks to prevent flexion greater than 90°.

◯ Avoid flexion of hip greater than 90°.
◯ Avoid low chairs.
◯ Do not cross the legs.
◯ Do not internally rotate the toes.
◯ Avoid turning to the operative side, unless prescribed.
◯ Anticoagulant medications (warfarin, aspirin) can be
required for several weeks after surgery.

COMPLICATIONS

Venous thromboembolism

Can develop into a DVT resulting in a pulmonary
embolism, a life-threatening complication after total
hip arthroplasty

● Older adult clients are at the greatest risk for a
potentially life-threatening complication (venous
thromboembolism formation that develops into DVT,
pulmonary emboli) due to age and compromised
circulation before surgery.

● Clients who are obese or who have a history of venous
thromboembolism formation are also at increased risk
for developing DVT or pulmonary emboli.

NURSING ACTIONS
● Monitor for manifestations of pulmonary embolism,

including acute dyspnea, tachycardia, and pleuritic
chest pain.

● Follow venous thromboembolism prophylaxis to include
pharmacological management, antiembolic stockings,
and sequential compression devices or foot pumps
while in bed.

● Encourage plantar flexion, dorsiflexion, and
circumduction exercises to prevent clot formation.

● Encourage early ambulation with physical and
occupational therapy.

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456 CHAPTER 68 arthroplastY CONTENT MASTERY SERIES

Joint dislocation, infection, anemia,
neurovascular compromise

Older adult clients are at an increased risk for medical
complications related to chronic conditions (hypertension,
diabetes mellitus, coronary artery disease, obstructive
pulmonary disease).

NURSING ACTIONS
● Monitor for bleeding.
● Maintain aseptic technique during dressing changes.
● Monitor incision site for manifestations of infection.
● Follow prescriptions regarding mobility and positioning

to protect the joint and prosthesis.
● Assess neurovascular status of operative extremity

(color, temperature, capillary refill, presence of edema,
quality of pulses, sensation).

Active Learning Scenario

a nurse is preparing to administer enoxaparin to a client
who had a total knee arthroplasty. What should the
nurse consider before administering the medication? use
the ati active learning template: medication and the
pharmacology review module to complete this item.

EXPECTED PHARMACOLOGICAL ACTION: Define.

NURSING INTERVENTIONS: list two nursing interventions.

CLIENT EDUCATION: list three client teaching points.

Application Exercises

1. a nurse is reviewing the health record of a client
who is to undergo total joint arthroplasty. the
nurse should recognize which of the following
findings as a contraindication to this procedure?

a. age 78 years

B. history of cancer

c. previous joint replacement

D. Bronchitis 2 weeks ago

2. a nurse is admitting a client to the orthopedic
unit following a total knee arthroplasty.
Which of the following actions by the nurse
are appropriate? (select all that apply.)

a. check continuous passive motion device settings.

B. palpate dorsal pedal pulses.

c. place a pillow behind the knee.

D. elevate heels off bed.

e. apply heat therapy to incision.

3. a nurse is planning discharge teaching for a
client who had a total hip arthroplasty. Which
of the following should the nurse include
in the teaching? (select all that apply.)

a. clean the incision daily with soap and water.

B. turn the toes inward when sitting or lying.

c. sit in a straight-backed armchair.

D. Bend at the waist when putting on socks.

e. use a raised toilet seat.

4. a nurse is assessing a client who is scheduled
to undergo a right knee arthroplasty. the
nurse should expect which of the following
findings? (select all that apply.)

a. skin reddened over the joint

B. pain when bearing weight

c. Joint crepitus

D. swelling of the affected joint

e. limited joint motion

5. a nurse is completing a preoperative teaching plan
for a client who is scheduled to have a total hip
arthroplasty. Which of the following should the nurse
include in the teaching plan? (select all that apply.)

a. encourage complete autologous blood donation.

B. sit in a low reclining chair.

c. instruct the client to roll onto the operative hip.

D. use an abductor pillow when turning the client.

e. perform isometric exercises.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 68 arthroplastY 457

Application Exercises Key

1. a. age greater than 70 is not a contraindication for a total joint
arthroplasty unless there are comorbidity factors.

B. history of cancer is not a contraindication for a total joint
arthroplasty unless there are comorbidity factors.

c. previous joint arthroplasty surgery is a contraindication for
total joint arthroplasty unless there are comorbidity factors.

D. CORRECT: the client who recently had bronchitis
or a recent infection can experience failure of the
prosthesis if micro-organisms are still present in
the body and migrate to the surgical site.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. CORRECT: check the continuous passive motion device
settings to determine if the settings are as prescribed.

B. CORRECT: assess the strength of the pulses of both lower
extremities to help determine adequate circulation.

c. place one pillow under the lower calf and foot to cause a
slight extension of the knee joint and to prevent flexion
contractures. the knee can also rest flat on the bed.

D. CORRECT: prevent pressure injuries on the client’s heels
by elevating the heels off the bed with a pillow.

e. apply cold therapy to reduce postoperative swelling.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. CORRECT: the client should wash the surgical incision daily
with soap and water to decrease the risk of infection.

B. the client should externally rotate toes to
prevent dislocation of the hip prosthesis.

c. CORRECT: using a straight-backed armchair decreases
the chance of bending at a greater than 90° angle,
which can cause dislocation of the hip prosthesis.

D. Bending at the waist places the hip in a position greater than a
90° angle, which can cause dislocation of the hip prosthesis.

e. CORRECT: using a toilet riser decreases the
chance of bending greater than 90°, which can
cause dislocation of the hip prosthesis.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

4. a. skin over the knee that is reddened can indicate
infection and is not an expected finding.

B. CORRECT: pain when bearing weight is an expected
finding due to degeneration of the joint.

c. CORRECT: Joint crepitus due to degeneration
of the joint tissue is an expected finding.

D. CORRECT: swelling of the affected joint due to
degeneration of the joint tissue is an expected finding.

e. CORRECT: limited joint motion is due to degeneration
of the joint tissue and is an expected finding.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

5. a. CORRECT: encourage the client to donate blood
that can be used postoperatively.

B. have the client sit in a hard back chair to keep the
hip at a 90° angle. this prevents dislocation.

c. avoid turning the client to the operative side to
prevent dislocation of the prosthesis.

D. CORRECT: place an abductor device or pillow
between the client’s legs when turning to
prevent dislocation of the affected hip.

e. CORRECT: instruct the client to perform isometric exercises
to prevent blood clots and maintain muscle tone.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

EXPECTED PHARMACOLOGICAL ACTION: enoxaparin is
an anticoagulant. use low molecular-weight heparin after
abdominal and orthopedic surgery to prevent deep vein
thrombosis that may lead to pulmonary embolism.

NURSING INTERVENTIONS
● Do not expel the air bubble from the syringe before
injection. it’s nitrous oxide and allows the client to
receive all the medication during the injection.

● rotate injection sites.
● monitor for manifestations of unexplained bleeding.

CLIENT EDUCATION
● encourage the use of a soft toothbrush and shaving
with an electric razor to prevent bleeding.

● avoid over-the-counter medication unless prescribed by a provider.
● Don’t take enoxaparin with garlic, ginger, ginkgo, or feverfew.
these supplements may increase the risk of bleeding.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Expected Actions/Outcomes

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458 CHAPTER 68 arthroplastY CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 69 amputations 459

UNIT 10 MUSCULOSKELETAL DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 69 Amputations
amputation is the removal of a body part, most
commonly an extremity. amputations can be
elective due to complications of peripheral
vascular disease and arteriosclerosis, congenital
deformities, chronic osteomyelitis, or malignant
tumor; or traumatic due to an accident.

amputations are described in regard to
the extremity and whether they are located
above or below the designated joint. the
term disarticulation describes an amputation
performed through a joint.

the higher the level of amputation, the greater
the amount of effort that will be required to
use a prosthesis. the level of the amputation is
determined by the presence of adequate blood
flow needed for healing.

many older adult clients do not have the energy
required for ambulation training with a prosthetic
and might not be candidates for the device.

significant changes to body image occur after
an amputation and should be addressed during
the perioperative and rehabilitative phases.

upper eXtremitY amputations
● Upper extremity amputations include above- and

below-the-elbow amputations, wrist and shoulder
disarticulations, and finger amputations.

● Traumatic amputation caused by crashes, war,
or other injury is the primary cause of upper
extremity amputations.

loWer eXtremitY amputations
● Lower extremity amputations include above-

and below-the-knee amputations, hip and knee
disarticulations, Syme’s amputation (removal of foot
with ankle saved), and mid-foot and toe amputations.

● Peripheral vascular disease is the cause of most lower
extremity amputations.

● Every effort is made to save as much of the extremity as
possible. Even loss of the big toe can significantly affect
balance, gait, and push-off ability during ambulation.
Salvage of the knee with a below-the-knee amputation
also improves function vs. an above-the-knee amputation.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Clients who have diabetes mellitus should monitor
blood glucose and maintain it within the expected
reference range.

● Use safety measures when working with heavy
machinery or in areas where there is a risk of
electrocution or burns.

● Encourage clients to quit or not start smoking, maintain
a healthy weight, and exercise regularly.

● Tell clients to maintain good foot care and to seek early
medical attention for non-healing wounds.

ASSESSMENT

risK factors
● Traumatic injury: motor vehicle crashes,

industrial equipment, and war-related injuries
● Thermal injury: frostbite, electrocution, burns
● Malignancy

CHRONIC DISEASE PROCESSES
● Older adult clients have a higher risk of peripheral

vascular disease and diabetes mellitus resulting in
decreased tissue perfusion and peripheral neuropathy.
Both conditions place older adult clients at risk for lower
extremity amputation.

● Peripheral vascular disease resulting in
ischemia/gangrene

● Diabetes mellitus resulting in peripheral neuropathy
and peripheral vascular disease

● Infection (osteomyelitis)

eXpecteD finDings
Decreased tissue perfusion

● Clients might report pain
● History of injury or disease process

precipitating amputation
● Altered peripheral pulses compared to the client’s

expected skin tone (can need to use Doppler)
● Differences in temperature of extremities (note the level

of leg at which temperature becomes cool)
● Altered color of extremities (pallor, cyanosis, or

gangrenous skin)
● Presence of infection and open wounds
● Lack of sensation in the affected extremity

NURSING ACTIONS
● Monitor capillary refill by comparing the extremities.

In older adult clients, capillary refill can be difficult to
monitor due to thickened and opaque nails.

● Observe for edema, necrosis, and lack of hair
distribution of the extremity due to inadequate
peripheral circulation.

CHAPTER 69 Online Video: Doppler Assessment of Pulses

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460 CHAPTER 69 amputations CONTENT MASTERY SERIES

Diagnostic proceDures
To determine blood flow at various levels of an extremity

Angiography: Allows visualization of peripheral
vasculature and areas of impaired circulation

Doppler laser and ultrasonography studies:
Measures speed of blood flow in an extremity

Transcutaneous oxygen pressure (TcPO2): Measures
oxygen pressures in an extremity to indicate blood flow in
the extremity, which is a reliable indicator for healing

Ankle‑brachial index: Measures difference between ankle
and brachial systolic pressures

PATIENT‑CENTERED CARE

management of traumatic
amputation

● Implement a medical emergency system (EMS).
● Apply direct pressure using gauze, if available, or clean

cloth to prevent life-threatening hemorrhage.
● Elevate the extremity above the heart to decrease

blood loss.
● Wrap the severed extremity in dry sterile gauze (if

available) or in a clean cloth, and place in a sealed
plastic bag. Submerge the bag in ice water (one part ice
and three parts water), and send with the client.

nursing care
● Prevent postoperative complications (hypovolemia,

pain, infection).
● Assess surgical site for bleeding. Monitor vital

signs frequently.
● Monitor tissue perfusion of end of residual limb.

◯ Palpate residual limb for warmth. Heat can
indicate infection.

◯ Compare pulse most proximal to incision with pulse
in other extremity.

● Monitor for manifestations of infection and non-healing
of incision. Infection can lead to osteomyelitis.

◯ Amputation might not heal if performed below the
level of adequate tissue perfusion.

◯ Position the affected extremity in dependent position
to promote blood flow/oxygenation.

◯ Administer antibiotics and change dressings as
prescribed if open amputation was performed.

◯ Record characteristics of drainage (amount, color,
and odor).

Pain
● Monitor and treat pain.
● Differentiate between phantom limb and incisional pain.

Incisional pain is treated with analgesics.

Phantom limb pain
● The sensation of pain in the location of the extremity

following the amputation
● Related to severed nerve pathways and is a frequent

complication in clients who experienced chronic limb
pain before the amputation

● Can be experienced immediately after surgery, up to
several weeks, or indefinitely

● Occurs less frequently following traumatic amputation
● Often described as deep and burning, cramping,

shooting, or aching
● Treated much differently from incisional pain

◯ Administration of calcitonin during the first week of
after having an amputation can decrease phantom
limb pain.

◯ Administering beta blockers (propranolol) can relieve
the continual dull, burning sensation associated with
the amputated limb.

◯ Administering antiepileptics (gabapentin or
pregabalin) can relieve sharp, stabbing, and burning
phantom limb pain.

◯ Some clients can have relief from antispasmodics
(baclofen) and antidepressant medication.

◯ The nurse should recognize the pain is real and
manage it accordingly.

◯ Alternative treatment for phantom limb pain can
include nonpharmacological methods (massage,
heat, transcutaneous electrical nerve stimulation
[TENS], ultrasound therapy, biofeedback, acupuncture,
relaxation therapy).

◯ Teach the client how to push the residual limb down
toward the bed while supported on a soft pillow. This
helps reduce phantom limb pain and prepare the limb
for a prosthesis.

Client perception and feelings regarding amputation
● Allow for the client and family to grieve for the loss of

the body part and change in body image.
● Feelings can include depression, anger, withdrawal,

and grief.
● The nurse should assess the psychosocial well-being

of the client. Assess for feelings of altered self-concept
and self-esteem, and willingness and motivation
for rehabilitation.

● The nurse should facilitate a supportive environment for
the client and family so grief can be processed. Refer the
client to religious/spiritual adviser, social worker,
or counselor.

● Rehabilitation should include adaptation to a new body
image and integration of prosthetic and adaptive devices
into self-image.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 69 amputations 461

Residual limb preparation and prosthesis fitting

Residual limb must be shaped and shrunk in preparation
for prosthetic training.

SHRINKAGE INTERVENTIONS
● Wrap the residual limb, using elastic bandages

(figure-eight wrap) to prevent restriction of blood flow
and decrease edema.

● Use a residual limb shrinker sock (easier for the client
to apply).

● Use an air splint (plastic inflatable device) inflated to
protect and shape the residual limb and for easy access
to inspect the wound.

CLIENT EDUCATION
● Care for and wrap the residual limb, and perform

limb-strengthening exercises.
● Properly apply and care for the prosthesis.
● Safely transfer and use mobility devices and

adaptive aids.
● Manage phantom limb pain.

therapeutic proceDures
Closed amputation: This is the most common technique
used. A skin flap is sutured over the end of the residual
limb, closing the site.

Open amputation: This technique is used when an active
infection is present. A skin flap is not sutured over the end
of the residual limb, allowing for drainage of infection.
The skin flap is closed at a later date.

interprofessional care
Intensive efforts by the interprofessional team are
necessary to facilitate successful rehabilitation.

● A certified prosthetic orthotist will fit client with
prosthesis after the wound is healed and the residual
limb has shrunk.

● A physical therapist will train the client in the
application and care of the prosthesis and mobility aids.

● A psychologist can be needed to help with adjustment to
loss of the extremity.

● A social worker will assist the client who has financial
issues and can refer the client to resources and a
support group or organization for people who have
had amputations.

COMPLICATIONS

Flexion contractures

Flexion contractures are more likely with the hip or knee
joint following amputation due to improper positioning.

● Prevention includes range-of-motion (ROM) exercises
and proper positioning immediately after surgery.

● To prevent hip or knee flexion contracture, some
providers do not advocate elevating the residual limb on
a pillow. However, other providers allow elevation for
the first 24 to 48 hr to reduce swelling and
discomfort.

NURSING ACTIONS
● Have the client lie prone for 20 to 30 min several times a

day to help prevent hip flexion contractures.
● Discourage prolonged sitting.

CLIENT EDUCATION
● Practice exercises that will prevent contractures.
● Stand using good posture with residual limb in

extension. This also will aid in balance.

Online Video: Amputation Stump Wrapping

Active Learning Scenario

a nurse is completing discharge planning for a
client who had an amputation. What members of an
interprofessional team should the nurse include in the
discharge planning process? use the ati active learning
template: Basic concept to complete this item.

RELATED CONTENT: list three members of
the interprofessional team and describe the
principal purpose of each member.

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT
● certified prosthetic orthotist fits the client with the
prosthesis following healing and shrinking of the stump.

● physical therapist provides training for applying the prosthesis,
assists in mobility training, and reviews mobility aids.

● psychologist assists the client and family in
adjusting to the loss of an extremity.

● social worker provides referral information for financial
assistance, resources and support groups, or organizations
to help adjust to life-changing physical conditions.

NCLEX® Connection: Health Promotion and Maintenance,
Aging Process

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462 CHAPTER 69 amputations CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: provide information about smoking cessation,
which can decrease the development of arteriosclerosis
and possible amputation of a lower extremity.

B. CORRECT: provide information about regulating
blood glucose levels within a normal reference range
to prevent the development of arteriosclerosis and
possible amputation of a lower extremity.

c. CORRECT: provide information about unplugging electrical
equipment when performing repairs to prevent electrocution
and injury to an extremity, which can lead to amputation.

D. CORRECT: provide information about maintaining good foot
care to prevent infection, which can result in amputation.

e. Driving under the influence of pain medication
can lead the client to an accident or injury to
an extremity requiring amputation.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

2. a. CORRECT: the client can have coolness of the affected
extremity where decreased vascularization starts.

B. the nurse should expect the client to have decreased
sensation of the affected extremity.

c. the client will have a lack of or diminished pedal pulse of
the affected extremity due to decreased vascularization.

D. CORRECT: the client can have decreased hair growth on areas
of the affected extremity due to decreased vascularization.

e. CORRECT: the client can have blackened areas on
several toes suggestive of gangrene due to decreased
vascularization to the affected extremity.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. a. CORRECT: place the residual limb in a dependent
position to improve circulation to the end of
the stump and promote healing.

B. CORRECT: inspect the residual limb for the
presence and amount of drainage to determine
early manifestations of infection.

c. CORRECT: prepare the residual limb to include shrinkage
interventions before fitting of the prosthesis.

D. Wrap the residual limb with an elastic bandage
in a figure-eight manner to prevent restriction of
blood flow before fitting for the prosthesis.

e. CORRECT: assess for feelings of depression, anger,
withdrawal, and grief due to body image changes.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. a. the nurse should not remove the initial pressure dressing.
the surgeon should remove the dressing in 36 to 48 hr.
however, this action will not reduce phantom pain.

B. heat therapy, not cold therapy, to the residual
limb is an alternative therapy that the nurse can
implement to relieve phantom pain.

c. phantom pain is related to the severed nerve
pathways following the amputation. Do not
question whether the pain is real.

D. CORRECT: an antiepileptic medication can relieve
a sharp, stabbing type of phantom pain.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

5. a. to avoid flexion contractures, encourage the client
to perform range-of-motion exercise to the residual
limb to prevent flexion contractures.

B. CORRECT: have the client lie prone several times each
day for 20 to 30 min to prevent flexion contractures.

c. the client can have the residual limb wrapped in a
figure eight to prepare for the prosthesis, but this
action does not prevent flexion contractures.

D. the client can develop flexion contractures by allowing
the residual stump to hang in a bent position when sitting
for an extended period following the amputation.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

Application Exercises

1. a nurse is presenting information to a group of
clients at a health fair about measures to reduce the
risk of amputation. Which of the follow information
should the nurse provide? (select all that apply.)

a. encourage clients who smoke to consider
smoking cessation programs.

B. encourage clients who have diabetes
mellitus to maintain blood glucose within
the expected reference range.

c. instruct clients to unplug electrical
equipment when performing repairs.

D. encourage clients who have vascular
disease to maintain good foot care.

e. advise clients to wait 2 hr after taking
pain medication before driving.

2. a nurse is assessing a client who has
arteriosclerosis and is scheduled for a possible
right lower extremity amputation. Which of
the following are expected findings in the
affected extremity? (select all that apply.)

a. skin cool to touch from mid-calf to the toes

B. increased sensitivity to fine touch.

c. palpable pounding pedal pulse

D. lack of hair on lower leg

e. Blackened areas on several toes

3. a nurse is caring for a client following a
below-the-elbow amputation. Which of the following
actions should the nurse take? (select all that apply.)

a. encourage dependent positioning
of the residual limb.

B. inspect for presence and amount of drainage.

c. implement shrinkage intervention
of the residual limb.

D. Wrap the residual limb in a circular
manner using gauze.

e. assess for feelings of body image changes.

4. a nurse is caring for a client who had an
above-the-knee amputation. the client reports a
sharp, stabbing type of phantom pain. Which of
the following actions should the nurse take?

a. remove the initial pressure dressing.

B. encourage use of cold therapy.

c. Question whether the pain is real.

D. administer an antiepileptic medication.

5. a nurse is preparing a plan of care to prevent a client
from developing flexion contractions following a
below-the-knee amputation 24 hr ago. Which of
the following actions should the nurse include?

a. limit any type of exercise to the residual
limb for the first 48 hr after surgery.

B. position the client prone several times each day.

c. Wrap the residual limb in a figure-eight pattern.

D. encourage sitting in a chair during the day.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 70 osteoporosis 463

UNIT 10 MUSCULOSKELETAL DISORDERS
SECTION: MUSCULOSKELETAL DISORDERS

CHAPTER 70 Osteoporosis
osteoporosis is a common chronic metabolic
bone disorder resulting in low bone density.
osteoporosis occurs when the rate of bone
resorption (osteoclast cells) exceeds the rate
of bone formation (osteoblast cells) resulting in
fragile bone tissue and can lead to fractures.
common sites of osteoporotic fractures include
the wrists, hips, and the spine, although any
bone can sustain a fracture.

osteopenia, the precursor to osteoporosis,
refers to low bone mineral density relative to
the client’s age and sex. Bone mineral density
peaks between the ages of 18 to 30. after peak
years, bone density decreases, with a significant
increase in the rate of loss in postmenopausal
clients due to estrogen loss.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Consume adequate amounts of calcium and vitamin
D, from food or supplements, especially during
young adulthood.

◯ Foods rich in vitamin D are most fish, egg yolks,
fortified milk, and cereal.

◯ Foods rich in calcium are milk products, green leafy
vegetables, fortified orange juice and cereals, red and
white beans, and figs. Some soy and rice products are
fortified with vitamin D and calcium.

● Spend time outdoors to increase the body’s production
of vitamin D. Exposure to the sun for any length of
time should include wearing sunscreen to avoid getting
a sunburn.

● Engage in weight-bearing exercises (walking, lifting
weights). These activities promote bone rebuilding
and maintenance.

ASSESSMENT

risK factors
● Family history, and thin, lean body build are precursors

to low bone density.
● Females have a higher risk for primary osteoporosis.

The decline in estrogen levels following menopause or
ovary removal increases the rate of bone resorption.

● Males have a higher risk for secondary osteoporosis;
a decrease in testosterone can lead to decreased
bone mass.

● History of low calcium intake with suboptimal levels of
vitamin D decreases bone formation (causes calcium to
be removed from bones).

● Clients who limit protein have a reduced ability
to use calcium because up to 50% of calcium is
bound to protein. Clients who follow a high-protein,
low-carbohydrate diet can eliminate important
nutrients (calcium-rich foods).

● Tobacco smoke exposure (active or passive) and
high alcohol intake (three or more drinks per day)
causes decreased bone formation and increased
bone absorption.

● Excess caffeine consumption causes excretion of
calcium in the urine.

● History of malabsorption disorders (anorexia nervosa,
celiac disease, bariatric surgery) limits the amount of
calcium available.

● Lack of physical activity or prolonged immobility
increases risk.

● Secondary osteoporosis results from medical conditions.
◯ Co-morbidities (hyperparathyroidism,

hyperthyroidism, diabetes mellitus, Cushing’s
syndrome, rheumatoid arthritis, bone cancer, female
hypogonadism, growth hormone deficiency, chronic
airway disorders that affect calcium absorption and
bone development [COPD, asthma])

◯ Medication use over a prolonged period (loop
diuretics, corticosteroids, thyroid medications,
anticonvulsants) affects calcium absorption and
bone metabolism.

◯ Long-term lack of weight-bearing (spinal cord injury,
sedentary lifestyle)

● Older adult clients have an increased risk of falls related
to impaired balance, generalized weakness, gait
changes, and impaired vision and hearing. Adverse
medication effects can cause orthostatic hypotension,
urinary frequency, or confusion, which can also raise
the risk for falls. The body also does not absorb and use
calcium as efficiently, but it does excrete calcium more
readily than occurs in the younger adult.

● High phosphorus intake increases the rate of calcium
loss. Drinking more than 40 oz/day of carbonated
beverages increases osteoporosis risk due to the amount
of phosphorus consumed.

CHAPTER 70

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464 CHAPTER 70 osteoporosis CONTENT MASTERY SERIES

eXpecteD finDings
● Reduced height of 5 to 7.5 cm (2 to 3 in)
● Acute back pain after lifting or bending (worse with

activity, relieved by rest)
● Restriction in movement and spinal deformity
● History of fractures (wrist, femur, thoracic spine)
● Thoracic (kyphosis) of the dorsal spine (70.1)
● Pain upon palpation over affected area

laBoratorY tests
● Blood calcium, vitamin D, phosphorus, hematocrit,

ESR, and alkaline phosphatase levels are drawn to rule
out other metabolic bone diseases (Paget’s disease or
osteomalacia). Blood calcium and vitamin D should be
checked yearly for females at high risk and yearly after
age 50 for males at high risk.

● 24-hr urine can evaluate the rate of calcium excretion.
● Bone turnover markers measure bone formation and

resorption activity.

Diagnostic proceDures

Radiography

Radiographs of the spine and long bones reveal low bone
density and fractures.

Dual‑energy x‑ray absorptiometry (DXA)
● A DXA scan is used to screen for early changes in bone

density and is usually done on the hip or spine.
● A peripheral DXA scan is used to assess the bone density

of the heel, forearm, or finger.
● DXA uses two beams of radiation. Findings are analyzed

by a computer and interpreted by a radiologist. Clients
receive a score that relates their amount of bone density
that of young, healthy adults (T score). Another reading,
a Z score, compares the client’s readings with those of a
group of age-matched clients who serve as a control.

● The client will lie on an x-ray table while a scan of a
selected area is done. Although clothing is not removed
for the test, metallic objects that might interfere with
the scanning procedure should be removed.

Peripheral quantitative ultrasound (pQUS)
● An ultrasound, usually of the heel, tibia, and patella,

is performed.
● pQUS is an inexpensive, portable, and low-risk method

to determine osteoporosis and assessing for risk of
fracture, especially in men over age 70 years.

Quantitative computed tomography

Quantitative computer tomography, as well as CT-
based absorptiometry, is used to measure bone density,
especially in the vertebral column.

● Used to predict spinal or hip fractures
● Require more radiation than DXA scanning

Magnetic resonance imaging (MRI) and
magnetic resonance spectroscopy (MRS)

● These provide information about bone density without
exposing the client to radiation.

● Areas of osteoporosis show decreased perfusion.
● Fat marrow content is higher if the client has reduced

bone mineral density.
● MRS provides a graph to quantify bone marrow

adipose tissue.

PATIENT‑CENTERED CARE

nursing care
● Instruct the client and family regarding dietary calcium

food sources.
● Provide information regarding calcium and vitamin D

supplementation. (Take with food.)
● Reinforce the need for exposure to vitamin D (moderate

sun exposure using sunscreen, fortified milk).
● Encourage weight-bearing exercises (at least 30 min,

three to five times a week) to improve strength and
reduce bone loss.

● Assess the home environment for safety (remove throw
rugs, provide adequate lighting, clear walkways) to
prevent falls, which can result in fractures.

◯ Reinforce the use of safety equipment and
assistive devices.

◯ Clearly mark thresholds, doorways, and steps.

client eDucation
● Limit excess caffeine, alcohol, and carbonated

beverages, which increase bone loss.
● Consume adequate amounts of protein, magnesium,

vitamin K, and other trace minerals needed for
bone formation.

● Avoid slippery surfaces and wear
rubber-bottomed shoes.

● Exercise, under guidance from the provider, to reduce
the risk for vertebral fractures.

◯ Isometric exercises can help with
strengthening the core.

◯ Avoid activities that would increase body stress
(jarring activities, strenuous lifting).

meDications
Medications (calcium and vitamin D) can slow or
prevent osteoporosis. A combination of several of these
medications can be used.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 70 osteoporosis 465

Thyroid hormone

Calcitonin (salmon)

THERAPEUTIC USES: Decreases bone resorption
by inhibiting osteoclast activity for treatment of
osteoporosis, hypercalcemia, and Paget’s disease
of the bone

NURSING ACTIONS
● Calcitonin human can only be

administered subcutaneously.
● Calcitonin salmon can be administered subcutaneously,

intramuscularly, and intranasally.

Teriparatide
● Medication is contraindicated for hypercalcemia,

history of bone cancer, radiation, or Paget’s disease.
● Adverse effects include nausea, back pain and

arthralgia, and leg cramps.
● Orthostatic hypotension can occur up to 4 hr after

receiving the medication.

THERAPEUTIC USES
● A parathyroid hormone that stimulates osteoblasts to

increase new bone formation to increase bone mass
● Stimulates calcium absorption
● Limited use in clients who are at high risk for fractures

and those who have prolonged corticosteroid use

NURSING ACTIONS: Administer only subcutaneously.

CLIENT EDUCATION: Teriparatide can only be used
2 years, and then bisphosphonates are started.

Estrogen hormone supplements

Estrogen, estrogen, medroxyprogesterone

Estrogen should be given along with progesterone in
clients who still have their uterus.

THERAPEUTIC USES: Replaces estrogen lost due to
menopause or surgical removal of ovaries

CLIENT EDUCATION
● Potential complications include breast and endometrial

cancers and deep-vein thrombosis (DVT).
● Perform monthly breast self-examinations.

Selective estrogen receptor modulators
(estrogen agonist/antagonist)

Raloxifene

THERAPEUTIC USES
● Decreases osteoclast activity, subsequently decreasing

bone resorption and increasing bone mineral density
● Prevents and treats postmenopausal osteoporosis and

breast cancer

NURSING ACTIONS
● Avoid for clients who have a history of DVT.
● Monitor liver function tests.
● Discontinue use 72 hr before prolonged bed rest.

CLIENT EDUCATION
● Report unusual calf pain or tenderness, acute migraine,

insomnia, urinary tract infection, or vaginal burning/
itching to the provider.

● Take calcium and vitamin D supplements.

Calcium supplement

Calcium carbonate, calcium citrate

THERAPEUTIC USES: Supplements calcium consumed
in food products to promote healthy bones (not to
slow osteoporosis)

NURSING ACTIONS
● Give with food in divided doses with 6 to 8 oz of water.
● Calcium supplements can cause GI upset.
● Monitor for constipation and of hypercalcemia.

Vitamin D supplement

Vitamin D is a fat-soluble vitamin, so toxicity can occur.
Findings of toxicity include weakness, fatigue, nausea,
constipation, and kidney stones.

THERAPEUTIC USES
● Increases absorption of calcium from the intestinal

tract and availability of calcium in the blood needed for
remineralization of bone

● Needed by individuals who are not exposed to adequate
amounts of sunlight or who do not meet its daily
requirements

70.1 Kyphosis

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466 CHAPTER 70 osteoporosis CONTENT MASTERY SERIES

Bisphosphonates

Alendronate, ibandronate, risedronate,
zoledronic acid, pamidronate

THERAPEUTIC USES: Decreases number and actions of
osteoclasts, subsequently inhibiting bone resorption for
prevention and treatment of osteoporosis, hypercalcemia,
and Paget’s disease of the bone

NURSING ACTIONS: Monitor calcium levels in clients
receiving IV preparations.

NURSING ACTIONS
● There is a risk for esophagitis and esophageal ulcers

with oral preparations. Report early manifestations of
indigestion, chest pain, difficulty swallowing, or bloody
emesis to the provider immediately.

● Take with 8 oz water in the early morning before eating.
● Remain upright for 30 min after taking oral medication.
● Clients using IV preparations should have dental

examinations and preventative treatment prior to
starting therapy to minimize the risk of osteonecrosis
of the jaw.

Monoclonal antibody

Denosumab
● Contraindicated for clients who have hypocalcemia.
● Clients should have dental examinations and

preventative treatment prior to starting therapy to
minimize the risk of osteonecrosis of the jaw.

THERAPEUTIC USES
● Reduces bone resorption and increases bone density
● Limited use in clients who are at high risk for fractures

NURSING ACTIONS
● Monitor calcium levels.
● Administer subcutaneously into the upper arm, upper

thigh, or abdomen.

CLIENT EDUCATION: Notify the provider if manifestations
of infection develop.

therapeutic proceDures

Orthotic devices

Orthotic devices are available for immobilization of
the spine immediately after a compression fracture of
the spine (a trunk orthosis or lumbosacral corset).

● The device provides support and decreases pain.
● A physical therapist fits the device for the client and

teaches them how to apply it.

CLIENT EDUCATION
● Check for skin breakdown under the orthotic device.
● Use good posture and body mechanics.
● Log roll when getting out of bed.
● Use heat and back rubs to promote muscle relaxation.

Joint repair or joint arthroplasty

Can be necessary to repair or replace a joint weakened by
osteoporosis. This is most often the hip joint.

Vertebroplasty or kyphoplasty

Minimally invasive procedures performed by a surgeon
or radiologist. Used after other conservative measures to
treat the fractures have proven ineffective.

● Bone cement is injected into the fractured space of the
vertebral column with or without balloon inflation.

● Balloon inflation of the fracture is to contain the cement
and add height to the fractured vertebra.

● Mild sedation is used.
● Client lies in a supine position for 1 to 2 hr following

procedure. The client might be discharged within 4 hr.

NURSING ACTIONS
● Monitor vital findings for shortness of breath and the

puncture site for bleeding.
● Complete a neurologic assessment.
● Apply cold therapy to the injection site.

CLIENT EDUCATION
● Avoid driving for 24 hr following the procedure
● Keep the dressing dry. Remove it the day following

the procedure.
● Monitor the site for findings of infection.
● Resume activities (walking) the day following the

procedure and gradually increase activity level
as tolerated.

interprofessional care
● Physical therapy can be used to establish an

exercise regimen: 20 to 30 min of aerobic exercise
(such as walking) at least three times per week in
addition to weightlifting.

● Clients can need rehabilitation if fractures cause
immobilization or disability.

● Most hip fractures are due to osteoporosis. Joint repair
or joint arthroplasty requires physical therapy for a
full recovery.

COMPLICATIONS

Fractures

Fractures are the leading complication of osteoporosis.
Early recognition and treatment is essential.

NURSING ACTIONS: Support the client’s knees in a flexed
position to relieve back pain.

CLIENT EDUCATION: Move the trunk as a unit and avoid
twisting to relieve pain from vertebral fractures.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 70 osteoporosis 467

Active Learning Scenario

a nurse is administering raloxifene to a client who has
osteoporosis. What should the nurse consider before
administering the medication? use the ati active
learning template: medication to complete this item.

THERAPEUTIC USES: list two.

NURSING INTERVENTIONS: Describe two.

EVALUATION OF MEDICATION
EFFECTIVENESS: Describe one.

Application Exercises

1. a nurse is admitting an adult client who has suspected
osteoporosis. Which of following findings are risk
factors for osteoporosis? (select all that apply.)

a. history of consuming one glass of wine daily

B. loss in height of 2 in (5.1 cm)

c. Body mass index (Bmi) of 18

D. Kyphotic curve at upper thoracic spine

e. history of lactose intolerance

2. a nurse is providing care for a client who had a
vertebroplasty of the thoracic spine. Which of
the following actions should the nurse take?

a. apply heat to the puncture site.

B. place the client in a supine position.

c. turn the client every 1 hr.

D. ambulate the client within the
first hour postprocedure.

3. a nurse is providing dietary teaching about
calcium-rich foods to a client who has
osteoporosis. Which of the following foods
should the nurse include in the instructions?

a. White bread

B. Kale

c. apples

D. Brown rice

4. a nurse is performing health screenings at a health
fair. Which of the following clients have a risk
factor for osteoporosis? (select all that apply.)

a. a 40-year-old client who has been
taking prednisone for 4 months

B. a 30-year-old client who jogs 3 miles daily

c. a 45-year-old client who takes
phenytoin for seizures

D. a 65-year-old client who has a sedentary lifestyle

e. a 70-year-old client who has smoked for 50 years

5. a nurse is planning discharge teaching on home
safety for an adult client who has osteoporosis.
Which of the following information should the nurse
include in the teaching? (select all that apply.)

a. remove throw rugs in walkways.

B. use prescribed assistive devices.

c. remove clutter from the environment.

D. Wear soft-bottomed shoes.

e. maintain lighting of doorway areas.

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468 CHAPTER 70 osteoporosis CONTENT MASTERY SERIES

Application Exercises Key

1. a. a client who consumes more than three glasses of
alcohol each day is at risk for developing osteoporosis
because alcohol can increase bone loss.

B. CORRECT: the loss of 2 inches of height is suggestive of
osteoporosis due to fractures of the vertebral column.

c. CORRECT: a client who has a Bmi of 18 is at risk of
developing osteoporosis due to low body weight and
thin body build, suggesting decreased bone mass.

D. CORRECT: Kyphosis curve is highly suggestive of osteoporosis
due to fractures of the vertebrae causing the curve.

e. CORRECT: lactose intolerance is highly suggestive of
osteoporosis due to possible lack of calcium intake.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. the client should have cold therapy applied
to the puncture site to decrease bleeding and
swelling following the procedure.

B. CORRECT: the client should remain in a supine position
with the bed flat for the first 1 to 2 hr following the
procedure to allow for hardening of the cement.

c. the client should remain in a supine position with the
bed flat for 1 to 2 hr following the procedure.

D. the client should remain in a supine position with the
bed flat for 1 to 2 hr following the procedure.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. White bread is not a calcium-rich food, but it is
a good source of carbohydrates.

B. CORRECT: green leafy vegetables (broccoli, kale,
mustard greens) are good sources of calcium.

c. apples are not a calcium-rich food, but
are a good source of fiber.

D. Brown rice is not a calcium-rich food, but it
is a good source of carbohydrates.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

4. a. CORRECT: prednisone affects the absorption and metabolism
of calcium and places the client at risk for osteoporosis
when taken for an extended time (at least 3 months).

B. Weight-bearing activities decrease the risk for
osteoporosis due to placing stress on bones, which
promotes bone rebuilding and maintenance.

c. CORRECT: phenytoin affects the absorption and metabolism
of calcium and places the client at risk for osteoporosis.

D. CORRECT: a sedentary lifestyle places the client at risk
for osteoporosis because bones need the stress of weight
bearing activity for bone rebuilding and maintenance.

e. CORRECT: smoking increases the risk for osteoporosis
because it decreases osteogenesis.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

5. a. CORRECT: removing throw rugs in walkways can
help to prevent a fall and bone fracture.

B. CORRECT: using prescribed assistive devices can
help to prevent a fall and bone fracture.

c. CORRECT: removing clutter from the environment can
help to prevent tripping, falling, and a bone fracture.

D. the client should wear rubber-bottomed
shoes to prevent slipping.

e. CORRECT: good lighting in doorway areas
can prevent a fall and bone fracture.

NCLEX® Connection: Safety and Infection Control, Home Safety

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

THERAPEUTIC USES

selective estrogen receptor modulator (estrogen agonist/antagonist)
● Decreases bone resorption and increases bone density
● treatment of postmenopausal osteoporosis
● treatment of breast cancer by reducing the risk of cancer metastasis

NURSING INTERVENTIONS
● avoid administering to a client who has a
history of deep vein thrombosis (Dvt).

● instruct the client to report unusual calf pain
or tenderness, manifestations of Dvt.

● assess liver function tests periodically.
● review need for calcium and vitamin D
supplements when taking the medication.

EVALUATION OF MEDICATION EFFECTIVENESS
● improved bone mineral density
● no further loss in height
● no metastasis of the cancer

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 71 musculosKeletal trauma 469

UNIT 10 MUSCULOSKELETAL DISORDERS
SECTION: MUSCULOSKELETAL DISORDERS

CHAPTER 71 Musculoskeletal
Trauma

a fracture is a break in a bone secondary to
trauma or a pathological condition. fractures
caused by trauma are the most common type
of bone fracture. pathological fractures can be
caused by metastatic cancer, osteoporosis, or
paget’s disease.

Bone is continually going through a process of
remodeling as osteoclasts release calcium from
the bone and osteoblasts build up the bone.
remodeling of bone occurs at equal rates until
an individual reaches their thirties. from this
age on, the activity of the osteoclasts outpace
the osteoblasts, increasing an individual’s risk
of osteoporosis. this process significantly
increases following menopause. subsequently,
these clients experience fractures secondary to
osteoporosis about a decade earlier than clients
who do not enter menopause.

Fractures
● A closed (simple) fracture does not break through the

skin surface.
● An open (compound) fracture disrupts the skin

integrity, causing an open wound and tissue injury with
a risk of infection.

● Open fractures are graded based upon the extent of
tissue injury.

◯ Grade I: minimal skin damage
◯ Grade II: damage includes skin and muscle contusions

but without extensive soft tissue injury
◯ Grade III: damage is excessive to skin, muscles,

nerves, and blood vessels
● A complete fracture goes through the entire bone,

dividing it into two distinct parts. An incomplete
fracture goes through part of the bone.

● A simple fracture has one fracture line, while a
comminuted fracture has multiple fracture lines
splitting the bone into multiple pieces.

● A displaced fracture has bone fragments that are not
in alignment, and a non‑displaced fracture has bone
fragments that remain in alignment.

● A fatigue (stress) fracture results when excess strain
occurs from recreational and athletic activities.

● A pathological (spontaneous) fracture occurs to bone
that is weak from a disease process (bone cancer or
osteoporosis).

● Compression fracture occurs from a loading force
pressing on cancellous bone. This condition is common
among older adult clients who have osteoporosis.

common tYpes of fractures
Comminuted: Bone is fragmented.

Oblique: Fracture occurs at oblique angle and across bone.

Spiral: Fracture occurs from twisting motion (common
with physical abuse).

Impacted: Fractured bone is wedged inside opposite
fractured fragment.

Greenstick: Fracture occurs on one side (cortex) but does
not extend completely through the bone (most often
in children).

hip fractures are the most common injury in older
adults and are usually associated with falls.

CHAPTER 71

71.1 X-ray of leg fracture

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470 CHAPTER 71 musculosKeletal trauma CONTENT MASTERY SERIES

HEALTH PROMOTION AND
DISEASE PREVENTION

● Ensure recommended intake of calcium for
developmental stage in life.

● Ensure adequate intake of vitamin D and/or exposure
to sunlight.

● Monitor for development of osteoporosis, especially
in postmenopausal clients and clients who have a
thyroid disorder.

● Engage in weight-bearing exercise on a regular basis.
● Take a bisphosphonate if prescribed to slow bone

resorption and treat osteoporosis.
● Use caution to prevent falls or accidents.
● Prevent injury with the use of seat belts and helmets.

ASSESSMENT

risK factors
● Osteoporosis
● Falls
● Motor vehicle crashes
● Substance use disorder
● Diseases (bone cancer, Paget’s disease)
● Contact sports and hazardous recreational activities

(football, skiing)
● Physical abuse
● Lactose intolerance
● Age, as bone becomes less dense with advancing age

eXpecteD finDings
● History of trauma, metabolic bone disorders, chronic

conditions, and possible use of corticosteroid therapy
● Pain and reduced movement manifest at the area of

fracture or the area distal to the fracture.

PHYSICAL ASSESSMENT FINDINGS
● Position the client standing or sitting to examine upper

extremities; have the client lie down to examine the
legs and pelvis.

● Crepitus (a grating sound created by the rubbing of
bone fragments)

● Deformity: Internal or external rotation of extremity,
shortened extremity, visible bone with open fracture,
asymmetrical appearance of the affected limb
(compared to the other side of the body)

● Muscle spasms due to the pulling forces of the bone
when not aligned

● Edema (swelling) from trauma
● Ecchymosis (bleeding into underlying soft tissues)

from trauma
● Subcutaneous emphysema (air bubbles under the skin):

late finding

laBoratorY tests
● CBC can help detect bleeding (decreased hemoglobin,

hematocrit) or infection (increased WBC).
● ESR can be increased if inflammation is present.

Diagnostic proceDures
● Standard radiographs, computed tomography (CT)

imaging scan used to detect fractures of the hip and
pelvis, and/or magnetic resonance imagery (MRI)

◯ Identify the type of fracture and location.
◯ Indicate pathological fracture resulting from

tumor or mass.
◯ Determine soft tissue damage around fracture (MRI).

● Bone scan using radioactive material determines
hairline fractures and complications/delayed healing.

PATIENT‑CENTERED CARE

initial nursing care
● Provide emergency care at time of injury.
● Maintain ABCs.
● Monitor vital signs and neurologic status because

injury to vital organs can occur due to bone fragments
(fractures of pelvis, ribs).

● Stabilize the injured area, including the joints above and
below the fracture, by using a splint and avoiding
unnecessary movement.

● Ask the client about the cause of the injury, to
determine if other internal injuries are possible.

● Maintain proper alignment of the affected extremity.
● Elevate the limb above the heart and apply ice.
● Assess for bleeding and apply pressure, if needed.
● Cover open wounds with a sterile dressing.
● Remove clothing and jewelry near the injury or on the

affected extremity.
● Keep the client warm.
● Assess pain frequently and follow pain

management protocols, both pharmacological
and nonpharmacological.

● Initiate and continue neurovascular checks at least
every hour. Immediately report any change in status to
the provider.

● Prepare the client for any immobilization procedure
appropriate for the fracture.

● Provide nonpharmacological pain control (ice or heat
packs, electrical stimulation, iontophoresis [delivery of
dexamethasone through electrodes on the skin]).

PATIENT‑CENTERED CARE

nursing care

Neurovascular assessment

Neurovascular assessment is essential throughout
immobilization. Assessments are performed every hour
for the first 24 hr and every 1 to 4 hr thereafter following
initial trauma to monitor neurovascular compromise
related to edema and/or the immobilization device.
Neurovascular assessment includes the following.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 71 musculosKeletal trauma 471

Pain: Assess pain level, location, and frequency. Assess
pain using a 0 to 10 pain rating scale, and have the client
describe the pain. Immobilization, ice, and elevation of
the extremity with the use of analgesics should relieve
most of the pain.

Sensation: Assess for numbness or tingling of the
extremity. Loss of sensation can indicate nerve damage.

Skin temperature: Check the temperature of the affected
extremity. The extremity should be warm, not cool, to
touch. Cool skin can indicate decreased arterial perfusion.

Capillary refill: Press nail beds of affected extremity until
blanching occurs. Blood return should be within 3 seconds.
Prolonged refill indicates decreased arterial perfusion. Nail
beds that are cyanotic can indicate venous congestion.

Pulses: Pulses should be palpable and strong. Pulses
should be equal to the unaffected extremity. Edema
can make it difficult to palpate pulses, so Doppler
ultrasonography might be required.

Movement: Client should be able to move affected
extremity in active motion.

Nutrition
● Provide diet high in protein and calcium to facilitate

bone healing.
● If the client experienced blood loss, encourage foods

high in iron.

CLIENT EDUCATION: Vitamin and mineral supplements
promote healing.

meDications
Analgesics

● Opioid and non-opioid analgesics as needed to
control pain.

● NSAIDs decrease associated tissue inflammation and
can delay bone healing.

Muscle relaxants: Relieve muscle spasms

Stool softener: To prevent constipation

Antibiotic: Prophylactic antibiotics to decrease the risk of
infection for open fractures

therapeutic proceDures
Immobilizing interventions

Immobilization secures the injured extremity in order to
● Prevent further injury.
● Promote healing/circulation.
● Reduce pain.
● Correct a deformity.

TYPES OF IMMOBILIZATION DEVICES
● Braces
● Casts
● Splints/immobilizers
● Traction
● External fixation
● Internal fixation
● Orthopedic shoes and boots

Closed reduction

A pulling force (traction) is applied manually to realign the
displaced fractured bone fragments. Once the fracture is
reduced, immobilization is used to allow the bone to heal.

Splint and immobilizer use

Splints and immobilizers provide support, control
movement, reduce pain, correct a deformity, and prevent
additional injury.

● Splints are removable and allow for monitoring of skin
swelling or integrity.

● Splints can support fractured/injured areas until casting
occurs and swelling is decreased. Casting is then used
for post-paralysis injuries to avoid joint contracture.

● Immobilizers are prefabricated and typically fasten with
hook-and-loop fastener straps.

CLIENT EDUCATION
● Adhere to application protocol regarding full-time or

part-time use.
● Observe for skin breakdown at pressure points.

Cast application

Casts are more effective than splints or immobilizers
because the client is unable to remove.

● Casts, as circumferential immobilizers, are applied
once the swelling has subsided (to avoid compartment
syndrome). If the swelling continues after cast
application and causes unrelieved pain, the cast can be
split on one side (univalve) or on both sides (bivalved).

● A window can be placed in an area of the cast to allow
for skin inspection (such as a client who has a wound
under the cast), wound drainage, or checking the pulse.

● Moleskin is used over any rough area of the cast that
can rub against the client’s skin.

● A fitted stockinette is placed under the plaster cast.

TYPES OF CASTS
● Short and long arm and leg casts
● Walking cast (a rubber walking pad on the sole of

the cast assists the client in ambulating when weight
bearing is allowed)

● Spica casts (a portion of the trunk and one or two
extremities; typically used on children who have
congenital hip dysplasia)

● Body casts (encircle the trunk of the body)

CASTING MATERIALS
● Plaster of Paris casts are heavy, not water-resistant, and

can take 24 to 72 hr to dry.
● Synthetic fiberglass casts are light, stronger,

water-resistant, dry very quickly (in 30 min), and are
most commonly used.

NURSING ACTIONS
● Monitor neurovascular status every hour for first 24 hr

and assess pain.
● Apply ice for 24 to 48 hr.
● Handle a plaster cast with the palms, not fingertips,

until the cast is dry to prevent denting the cast.
● Avoid setting the cast on hard surfaces or sharp edges.

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472 CHAPTER 71 musculosKeletal trauma CONTENT MASTERY SERIES

● Prior to casting, the area is cleaned and dried. Tubular
cotton web roll is placed over the affected area to
maintain skin integrity. The casting material is
then applied.

● After cast application, position the client so that warm,
dry air circulates around and under the cast (support
the casted area without pressure under or directly on
the cast) for faster drying and to prevent pressure from
changing the shape of the cast. Use gloves to touch the
cast until it is completely dry.

● Elevate the cast during the first 24 to 48 hr to prevent
edema of the affected extremity. Use a cloth-covered
pillow instead of plastic while cast is drying. Elevate
arm casts above heart level; elevate leg cast on several
pillows when resting.

● Ensure that cast is not too tight; there should be room
for one finger between the skin and cast.

● Document presence of drainage and report sudden
increase in drainage. Circling drainage on cast is
an unreliable indicator of drainage amount and can
increase client anxiety.

● Older adult clients have an increased risk for impaired
skin integrity due to the loss of elasticity of the skin
and decreased sensation (comorbidities).

● Provide assistive devices (sling to support the weight of
an arm cast, cast shoes/boots to facilitate walking).

● Inspect the cast every 8 to 12 hr.
● Monitor for drainage, and report increased drainage to

the provider.

CLIENT EDUCATION
● Never place any foreign objects inside the cast to avoid

trauma to the skin. Itching under the cast is relieved by
blowing cool air from a hair dryer into the cast.

● Cover the cast with plastic if needed to avoid soiling
from urine or feces.

● Cover the cast with a plastic bag before baths and
showers to keep the cast dry.

● Report any areas under the cast that are painful, have
a “hot spot,” have increased drainage, are warm to the
touch, or have an odor, which can indicate infection.

● Report change in mobility and complications (shortness
of breath, skin breakdown, constipation).

● Casts often become too loose after swelling subsides
and need to be replaced.

Traction
● Traction uses a pulling force to promote and maintain

alignment of the injured area.
● Traction prescriptions should include the type of

traction, amount of weight, and whether traction can be
removed for nursing care.

GOALS OF TRACTION
● Prevent soft tissue injury
● Realign of bone fragments
● Decrease muscle spasms and pain
● Correct or prevent further deformities

TYPES OF TRACTION
● Manual: A pulling force is applied by the hands of

the provider for temporary immobilization, usually
with sedation or anesthesia, in conjunction with the
application of an immobilizing device.

● Straight or running: The counter traction is provided
by the client’s body by applying a pulling force in a
straight line. Movement of the client’s body can alter
the traction provided.

◯ Skin: Primary purpose is to decrease muscle spasms
and immobilize the extremity prior to surgery. The
pulling force is applied by weights that are attached
by rope to the client’s skin with tape, straps, boots,
or cuffs. Examples include Bryant’s traction (used
for congenital hip dislocation in children) and Buck’s
traction (used preoperatively for hip fractures for
immobilization in adult clients). (71.2)

● Balanced suspension: The counter traction is produced
by devices (slings or splints) to support the fractured
extremity off the bed while pulling with ropes and
weights. The client’s body can move without altering
the traction. (71.3)

◯ Skeletal: Screws are inserted into the bone (such as
halo traction). Can use heavier weights (15 to 30 lb)
and longer traction time to realign the bone. Provide
frequent pin site care to prevent infection. (71.4)

71.3 Balanced suspension skeletal traction

71.2 Buck’s traction

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 71 musculosKeletal trauma 473

NURSING ACTIONS
● Assess neurovascular status of the affected body part

every hour for 24 hr and every 4 hr after that.
● Maintain body alignment and realign if the client

seems uncomfortable or reports pain.
● Avoid lifting or removing weights.
● Ensure that weights hang freely and are not resting on

the floor.
● If the weights are accidentally displaced, replace

the weights. If the problem is not corrected, notify
the provider.

● Ensure that pulley ropes are free of knots, fraying,
loosening, and improper positioning at least every
8 to 12 hr.

● Notify the provider if the client experiences severe
pain from muscle spasms unrelieved with medications
or repositioning.

● Move the client in halo traction as a unit, without
applying pressure to the rods. This will prevent
loosening of the pins and pain.

● Routinely monitor skin integrity and document.
● Use heat/massage as prescribed to treat muscle spasms.
● Use therapeutic touch and relaxation techniques.

PIN SITE CARE
● Pin care is done frequently throughout immobilization

(skeletal traction and external fixation methods) to
prevent and to monitor for manifestations of infection.

◯ Drainage and redness (color, amount, odor)
◯ Loosening of pins
◯ Tenting of skin at pin site (skin rising up pin)

● Pin care protocols (chlorhexidine) are based on provider
preference and facility policy. A primary concept of pin
care is that one cotton swab is designated for each pin
to avoid cross-contamination.

● Pin care is provided usually once a shift, 1 to 2 times
a day, or per facility protocol. Increase the frequency
of care if an increased amount of drainage is noted or
infection is suspected.

External fixation

External fixation involves fracture immobilization using
percutaneous pins and wires that are attached to a rigid
external frame.

USED TO TREAT
● Comminuted fracture or nonunion fractures with

extensive soft tissue damage
● Leg length discrepancies from congenital defects
● Bone loss related to tumors or osteomyelitis

ADVANTAGES
● Immediate fracture stabilization
● Minimal blood loss occurring in comparison with

internal fixation
● Allowing for early mobilization and ambulation
● Maintaining alignment of closed fractures that could

not be maintained in cast or splint
● Permitting wound care with open fractures

DISADVANTAGES
● Risk of pin site infection leading to osteomyelitis
● Potential overwhelming appearance to client
● Noncompliance issues

NURSING ACTIONS
● Elevate extremity.
● Monitor neurovascular status and skin integrity.
● Assess body image.
● Perform pin care every 8 to 12 hr. Monitor site for

drainage, color, odor, and redness. Expect weeping or
drainage of clear fluid for the first 48 to 72 hr.

● Observe for manifestations of fat and
pulmonary embolism.

● Provide anti-embolism stockings and sequential
compression device to prevent deep-vein
thrombosis (DVT).

CLIENT EDUCATION
● Perform pin care as prescribed.
● Clothing might need to be altered to cover the device.
● If activity is restricted, perform deep breathing and leg

exercises and other techniques to prevent complications
to immobilization (pneumonia or thrombus formation).

Open reduction and internal fixation
● Open reduction refers to visualization of a fracture

through an incision in the skin, and internal fixation
with plates, screws, pins, rods, and prosthetics
as needed.

● After the bone heals, the hardware might be removed,
depending on the location and type of hardware.

● Circular external fixation: Technique to promote new
bone growth for malunion and nonunion fracture.
Device is turned four times per day to pull apart the
cortex of the bone and stimulate growth.

NURSING ACTIONS
● Prevent dislocation, especially of hip.
● Monitor skin integrity.
● Ensure heels are off bed at all times and inspect bony

prominence every shift.
● Perform a neurovascular assessment.

71.4 Halo fixation device

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474 CHAPTER 71 musculosKeletal trauma CONTENT MASTERY SERIES

● Observe the cast or dressing for postoperative drainage.
The cast can have a window cut in it through which
the incision can be viewed. An elastic wrap is used
to keep the window block cover in place to decrease
localized edema.

● Monitor for manifestations of fat and
pulmonary embolism.

● Provide anti-embolism stockings and a sequential
compression device to prevent DVT and administer
prescribed anticoagulants.

● Monitor the client’s pain level.
◯ Administer analgesics, antispasmodics,

and/or anti-inflammatory medication (NSAIDs) and
assess relief.

◯ Position for comfort and with ice on the surgical site.
● Monitor for manifestations of infection.

◯ Monitor vital signs, observing for fever, tachycardia,
incisional drainage, redness, and odor.

◯ Monitor laboratory values (WBC, ESR).
◯ Provide surgical aseptic wound care.

● Increase physical mobility as appropriate.
◯ Monitor orthostatic blood pressure when the client

gets out of bed for the first time.
◯ Turn and reposition the client every 2 hr.
◯ Have the client get out of bed from the

unaffected side.
◯ Position the client for comfort (within restrictions).

● Support nutrition.
◯ Encourage increased calorie intake.
◯ Ensure use of calcium supplements.
◯ Encourage small, frequent meals with snacks.
◯ Monitor for constipation.

interprofessional care
● Counseling services can assist clients experiencing

anxiety or depression from long rehabilitation or
life-altering injuries.

● Physical and occupational therapy can be required for
ambulation, particularly if crutches, a walker, or a cane
is required, and for activities of daily living.

● Physical therapy can help restore range of motion, teach
strengthening exercises, and assist the client with
accepting the injury.

● Case management can coordinate discharge planning,
especially if inpatient rehabilitative care will be required
(more common for older adults and clients who have
multiple injuries).

● Social workers assist with financial concerns, especially
if a long recovery period is expected.

● Home health care can provide follow-up care and assist
with ADLs.

● A vocational counselor if the injury affects the client’s
ability to return to prior employment.

COMPLICATIONS

Compartment syndrome
● Compartment syndrome usually affects extremities and

occurs when pressure within one or more of the muscle
compartments (covered with fascia) compromises
circulation, resulting in an ischemia-edema cycle.

● Increased edema causes pressure on the nerve endings,
resulting in pain. Blood flow is further reduced
and ischemia persists, resulting in compromised
neurovascular status.

● Pressure can result from external sources (a tight cast or
a constrictive bulky dressing).

● Internal sources (an accumulation of blood or
fluid within the muscle compartment) can cause
pressure as well.

MANIFESTATIONS
● Compartment syndrome is assessed by using the five P’s

(pain, paralysis, paresthesia, pallor, and pulselessness).
◯ Increased pain unrelieved with elevation or by pain

medication. Intense pain when passively moved.
◯ Paresthesia or numbness, burning, and tingling are

early manifestations.
◯ Paralysis, motor weakness, or inability to move

the extremity indicate major nerve damage and are
late manifestations.

◯ Pallor of the affected tissue, and nail beds
are cyanotic.

◯ Pulselessness is a late manifestation of
compartment syndrome.

◯ Palpated muscles are hard and swollen from edema.
● If untreated, tissue necrosis can result. Neuromuscular

damage occurs within 4 to 6 hr.
● Surgical treatment is a fasciotomy, which is a

surgical incision.
● A surgical incision is made through the subcutaneous

tissue and fascia of the affected compartment to relieve
the pressure and restore circulation.

● After the fasciotomy, the open wounds require sterile
packings and dressings until secondary closure occurs.
Skin grafts might be necessary. Negative pressure
wound therapy can be used to reduce edema.

NURSING ACTIONS
Prevention includes the following.

● Assess neurovascular status frequently.
● Notify the provider when compartment syndrome

is suspected.
● The provider will cut the cast on one side (univalve) or

both sides (bivalve).
● Loosen the constrictive dressing or cut the

bandage or tape.

CLIENT EDUCATION
● Report pain not relieved by analgesics or pain that

continues to increase in intensity.
● Report numbness, tingling, or a change in color of

the extremity.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 71 musculosKeletal trauma 475

Fat embolism
● Adults aged 70 to 80 and males between 20 and 40 years

are at increased risk.
● Most common following hip fracture; other cases are

within 72 hr following pelvic fracture or surgery.
● Fat embolism can occur after the injury, usually within

12 to 48 hr following long bone fractures or with total
joint arthroplasty.

● Fat globules from the bone marrow are released into
the vasculature and travel to the small blood vessels,
including those in the lungs, resulting in acute
respiratory insufficiency and impaired organ perfusion.
Careful diagnosis should differentiate between fat
embolism and pulmonary embolism.

MANIFESTATIONS
● Early manifestations

◯ Dyspnea, increased respiratory rate, decreased
oxygen saturation

◯ Headache
◯ Decreased mental acuity related to low arterial

oxygen level
◯ Respiratory distress
◯ Tachycardia
◯ Confusion
◯ Chest pain

● Late manifestation: Cutaneous petechiae: pinpoint-sized
subdermal hemorrhages that occur on the neck, chest,
upper arms, and abdomen (from the blockage of the
capillaries by the fat globules). This is a discriminating
finding from pulmonary embolism.

NURSING ACTIONS
● Maintain the client on bed rest.
● Prevention includes immobilization of fractures of the

long bones and minimal manipulation during turning if
immobilization procedure has not yet been performed.

● Treatment includes oxygen for respiratory compromise,
corticosteroids for cerebral edema, vasopressors,
and fluid replacement for shock, as well as pain and
antianxiety medications as needed.

Venous thromboembolism

Deep‑vein thrombosis and pulmonary embolism:
Deep-vein thrombosis is a common complication
following trauma, surgery, or disability related
to immobility.

NURSING ACTIONS
● Encourage early ambulation.
● Apply anti-embolism stockings, sequential

compression device.
● Administer anticoagulants as prescribed.
● Encourage intake of fluids to

prevent hemoconcentration.
● Monitor for manifestations (swollen, reddened calf).

CLIENT EDUCATION: Rotate feet at the ankles and perform
other lower extremity exercises as permitted by the
particular immobilization device.

Osteomyelitis

Osteomyelitis is an infection of the bone that begins as an
inflammation within the bone secondary to penetration by
infectious organisms (virus, bacteria, or fungi) following
trauma or surgical repair of a fracture.

MANIFESTATIONS
● Bone pain that is constant, pulsating, localized, and

worse with movement
● Erythema and edema at the site of the infection
● Fever: Older adults might not have an elevated

temperature.
● Leukocytosis and possible elevated sedimentation rate
● Many of these manifestations will disappear if the

infection becomes chronic.

DIAGNOSTIC PROCEDURES
● Bone scan using radioactive material to diagnose

osteomyelitis and MRI can also facilitate a diagnosis.
● Cultures are performed for detection of possible aerobic

and anaerobic organisms.
● If septicemia develops, blood cultures will be positive

for offending microbes.

TREATMENT
● Long course (3 months) of IV and oral antibiotic therapy.
● Surgical debridement can be indicated. If a significant

amount of the bone requires removal, a bone graft can
be necessary.

● Hyperbaric oxygen treatments can promote healing in
chronic cases of osteomyelitis.

● Surgically implanted antibiotic beads in bone cement are
packed into the wound as a form of antibiotic therapy.

● Unsuccessful treatment can result in amputation.

NURSING ACTIONS
● Administer antibiotics as prescribed to maintain a

constant blood level.
● Administer analgesics as needed.
● Conduct neurovascular assessments if

debridement is done.
● If the wound is left open to heal, standard precautions

are adequate, and clean technique can be used during
dressing changes.

Avascular necrosis
● Avascular necrosis results from the circulatory

compromise that occurs after a fracture. Blood flow is
disrupted to the fracture site and the resulting ischemia
leads to tissue (bone) necrosis.

● Commonly found in hip fractures or in fractures with
displacement of a bone.

● Risk factors for developing avascular necrosis include
long-term corticosteroid use, radiation therapy,
rheumatoid arthritis, and sickle cell disease.

● Replacement of damaged bone with a bone graft or
prosthetic replacement can be necessary.

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476 CHAPTER 71 musculosKeletal trauma CONTENT MASTERY SERIES

Failure of fracture to heal

A fracture that has not healed within 6 months of injury is
considered to be experiencing delayed union.

● Malunion: Fracture heals incorrectly
● Nonunion: Fracture that never heals

◯ Electrical bone stimulation and bone grafting can
treat nonunion.

◯ Low intensity pulse ultrasound can promote healing
to treat nonunion.

◯ Can occur more frequently in older adult clients due to
impaired healing process.

● Malunion or nonunion can cause immobilizing
deformity of the bone involved.

Hemorrhage

Because bones are highly vascular, bleeding is always
a risk following fracture. Hemorrhage can progress to
hypovolemic shock.

NURSING ACTIONS
● Monitor for bruising and swelling at the injury site with

increased pain.
● Monitor for indications of blood loss (hypotension and

tachycardia).

Complex regional pain syndrome (CRPS)
● Severe chronic pain, usually following

musculoskeletal trauma.
● More common in the feet and hands.
● Can develop if acute pain is not well managed.
● Triad of manifestations includes motor changes (muscle

spasms, paresis), autonomic nervous system changes
(temperature, sensitivity, diaphoresis), and sensory
changes (intractable burning sensation).

● Can progress to osteoporosis.

NURSING ACTIONS
● Monitor for and report manifestations early; treatment

is difficult in later stages.
● Use gentle touch when handling the skin of the site of

CRPS. Avoid blood pressure checks or venipunctures.
● Inspect the extremity, which is often edematous, and

can have a variety of color changes.
● Collaborate with PT and OT to provide a combination of

treatment interventions, including pain medications,
topical medications, and skin desensitization.

● Provide psychosocial support, and give the client
information about pain support groups.

● Therapeutic procedures can include peripheral or spinal
cord neurostimulation and sympathectomy (cutting of
sympathetic nerve branches).

Heterotopic ossification
● Growth of bone in an area that is normally made of

soft tissue.
● Findings include pain and joint stiffness.
● Surgery can be indicated if ROM is

significantly decreased.

Carpal tunnel syndrome
Compression of the median nerve in the wrist
from swollen or thickened synovium, causing pain
and numbness.

HEALTH PROMOTION
● Follow federal and state laws regarding repetitive work

and preventing stress injury.
● Set up computer workstations following ergonomic

principles to reduce stress.
● Take frequent breaks from repetitive motions to rest the

wrists and fingers and stretch them.

ASSESSMENT

risK factors
● Some metabolic and connective tissue diseases

(rheumatoid arthritis [synovitis] and diabetes mellitus
[reduced circulation])

● Occupational injury from repetitive stress of hand
activities (pinching or grasping during wrist flexion
[computer users])

● Repetitive sports injury (tennis)
● Children and adolescents due to use of computers and

handheld devices
● Growth of a space occupying lesion (a ganglia or lipoma)

eXpecteD finDings
● Diagnosis is made based on history and report of pain

and numbness in affected hand.
● Pain is often worse at night and can radiate to the arm,

shoulder, and neck or chest.
● Paresthesia (painful tingling): Sensory changes occur

weeks or months before motor.
● Phalen’s maneuver (positive in most clients who have

carpal tunnel syndrome)
◯ Ask the client to place the back of their hands

together and flex both wrists at the same time.
◯ Tinel’s sign: Tap lightly over the median nerve area of

the wrist
◯ A positive result is paresthesia in the median nerve

distribution (palmer side of thumb, index, middle and
half of ring finger)

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 71 musculosKeletal trauma 477

PATIENT‑CENTERED CARE

nursing care
● Medication therapy

◯ NSAIDs for relief of pain and inflammation
◯ Corticosteroid injections directly into the carpal tunnel

● Splint or hand brace to immobilize the wrist: can use
during the day, during the night, or both

● Laser or ultrasound therapy
● Yoga and exercise
● Surgery can relieve the pressure by decompressing

the pressure on the nerve, if nonsurgical methods
are ineffective.

◯ Endoscopic carpal tunnel release: less invasive
but a longer recovery period of postoperative pain
and numbness

◯ Open carpal tunnel release

POSTOPERATIVE CARE
● Monitor vital signs and check dressing for drainage

and tightness.
● Elevate hand above the heart to reduce swelling.
● Check neurovascular status of fingers every hour and

encourage the client to move them frequently.
● Offer pain medications.
● The client might need assistance with personal care.

CLIENT EDUCATION
● Hand movements and heavy lifting might be restricted

4 to 6 weeks.
● Expect weakness and discomfort for weeks or months.
● Report any changes in neurovascular status including

increase in pain to surgeon immediately.

Sprains and strains
Strain

● Excessive stretching or pulling of a muscle or tendon
that is weak or unstable

● Often caused by falls, lifting a heavy item, and exercise

CLASSIFICATIONS OF STRAINS
● First‑degree (mild) strain causes mild inflammation

and little bleeding. There can be swelling, ecchymosis,
and tenderness.

● Second‑degree (moderate) strain involves partial
tearing of the muscle or tendon fibers. Involves
impaired muscle function.

● Third‑degree (severe) strain involves a ruptured muscle
or tendon with separation of muscle from muscle,
tendon from muscle, or tendon from bone. Causes severe
pain and immobility.

Sprain
● Excessive stretching of a ligament. Twisting motions

from a fall or sports activity can be the cause of
the injury.

● Classification of sprains are according to severity.

PATIENT‑CENTERED CARE

Management of strain
● Cold and heat application, exercise, and

activity limitations.
● Anti-inflammatory medications and muscle relaxants to

decrease inflammation and pain.
● Surgical repair if needed for third-degree strains to

repair ruptured muscle or tendon.

Management of sprain
● RICE (rest, ice, compression, elevation) for mild sprains.
● Second-degree require immobilization and partial

weight bearing while the tear heals.
● Immobilization for 4 to 6 weeks is necessary for

third-degree sprains. Arthroscopic surgery if needed.

Active Learning Scenario

a nurse is performing a neurovascular assessment on a client
who has a cast applied following a right arm fracture. What
interventions should the nurse take? use the ati active
learning template: Basic concept to complete this item:

RELATED CONTENT: identify the purpose
of neurovascular assessment.

UNDERLYING PRINCIPLES: identify the six
components of a neurovascular assessment.

NURSING INTERVENTIONS: Describe a nursing
intervention related to each of the six components.

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT: neurovascular assessment is performed
to monitor for any compromise in the affected extremity
caused by edema and or immobilization device.

UNDERLYING PRINCIPLES
● assess for pain level, location, and type and frequency.
● assess sensation of the distal extremity.
● assess skin temperature for warmth.
● assess capillary refill.
● assess the pulses distal to the fracture.
● assess finger movement.

NURSING INTERVENTIONS
● pain: administer pain medication, elevate
the extremity, and apply ice.

● sensation: notify the provider of numbness,
tingling, or loss of sensation.

● skin temperature: notify the provider if the affected
extremity is cool compared to the unaffected extremity.

● capillary refill: notify the provider if nail beds are cyanotic.
● pulses: notify the provider if pulse is absent.
● finger movement: notify the provider if the client is unable
to perform passive or active movement of the fingers.

NCLEX® Connection: Reduction of Risk Potential, Therapeutic
Procedures

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478 CHAPTER 71 musculosKeletal trauma CONTENT MASTERY SERIES

Application Exercises

1. a nurse is teaching a client how to manage an
external fixation device upon discharge. Which of
the following statements by the client indicates
understanding? (select all that apply.)

a. “i will clean the pins more often if
drainage from the pins increases.”

B. “i will use a separate cotton swab for each pin.”

c. “i will report loosening of the pins to my doctor.”

D. “i will move my leg by lifting the
device in the middle.”

e. “i will report increased redness at the pin sites.”

2. a nurse is assessing a client who has a casted
compound fracture of the femur. Which of the
following findings is a manifestation of a fat embolus?

a. altered mental status

B. reduced bowel sounds

c. swelling of the toes distal to the injury

D. pain with passive movement of
the foot distal to the injury

3. a nurse is assessing a client who had an
external fixation device applied 2 hr ago for
a fracture of the left tibia and fibula. Which
of the following findings is a manifestation of
compartment syndrome? (select all that apply.)

a. intense pain when the client’s left
foot is passively moved

B. capillary refill of 3 sec on the client’s left toes

c. hard, swollen muscle in the client’s left leg

D. Burning and tingling of the client’s left foot

e. client report of minimal pain relief following
a second dose of opioid medication

4. a nurse is completing discharge teaching to a client
who had a wound debridement for osteomyelitis. Which
of the following information should the nurse include?

a. antibiotic therapy should continue for 3 months.

B. relief of pain indicates the infection is eradicated.

c. airborne precautions are used during wound care.

D. expect paresthesia distal to the wound.

5. a nurse in the emergency department is planning
care for a client who has a right hip fracture.
Which of the following immobilization devices
should the nurse anticipate in the plan of care?

a. skeletal traction

B. Buck’s traction

c. halo traction

D. Bryant’s traction

Application Exercises Key

1. a. CORRECT: clean the external fixation pins more
frequently than prescribed if the amount of drainage
increases or infection is suspected.

B. CORRECT: using a separate cotton swab on each
pin will decrease the risk of cross-contamination,
which could cause pin site infection.

c. CORRECT: notify the provider if a pin is loose because
the provider will know how much to tighten the pin
and prevent damage to the tissue and bone.

D. the external fixation device should never be used
to lift or move the affected leg, due to the risk of
injuring and dislocating the fractured bone.

e. CORRECT: the client should report redness, heat,
and drainage at the pin sites, which can indicate
an infection that can lead to osteomyelitis.

NCLEX® Connection: Basic Care and Comfort, Mobility/
Immobility

2. a. CORRECT: altered mental status is an early
manifestation of fat emboli. initial manifestations
include dyspnea, chest pain, and hypoxemia.

B. reduced bowel sounds is an adverse effect of opioid
narcotics and can result in constipation.

c. swelling of the toes distal to the injury is a manifestation
of reduced circulation and can be the result of a
tight cast. elevate the extremity and apply ice.

D. pain with passive movement of the foot distal to the injury
is an expected finding. severe pain or pain unrelieved by
narcotics is a manifestation of compartment syndrome.

NCLEX® Connection: Basic Care and Comfort, Mobility/
Immobility

3. a. CORRECT: intense pain of the left foot when passively
moved can indicate pressure from edema on nerve endings
and is a manifestation of compartment syndrome.

B. capillary refill of 3 seconds is within the expected reference
range. pallor is a manifestation of compartment syndrome.

c. CORRECT: a hard, swollen muscle on the affected
extremity indicates edema build-up in the area of injury
and is a manifestation of compartment syndrome.

D. CORRECT: Burning and tingling of the left foot indicates
pressure from edema on nerve endings and is an
early manifestation of compartment syndrome.

e. CORRECT: minimal pain relief after receiving
opioid medication can indicate pressure
from edema on nerve endings and is an early
manifestation of compartment syndrome.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications from Surgical Procedures and Health Alterations

4. a. CORRECT: treatment of osteomyelitis includes
continuing antibiotic therapy for 3 months.

B. relief of pain does not indicate that osteomyelitis
is resolved, and the client should continue
antibiotic therapy as prescribed.

c. When performing wound care, contact precautions are
implemented to prevent spread of the organism.

D. the client should monitor and report manifestations of
neurovascular compromise, such as paresthesia.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications from Surgical Procedures and Health Alterations

5. a. skeletal traction is an immobilization device applied
surgically to a long bone (femur, or tibia), and cervical
spine. it is not used for a hip fracture.

B. CORRECT: Buck’s traction is a temporary immobilization
device applied to a client who has a femur or hip
fracture to diminish muscle spasms and immobilize the
affected extremity until surgery is performed.

c. halo traction immobilizes the cervical spine
when a cervical fracture occurs.

D. Bryant’s traction is used for congenital
hip dislocation in children.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 72 osteoarthritis anD loW-BacK pain 479

UNIT 10 MUSCULOSKELETAL DISORDERS
SECTION: MUSCULOSKELETAL DISORDERS

CHAPTER 72 Osteoarthritis and
Low‑Back Pain

Osteoarthritis (OA), or degenerative joint
disease (DJD), is a disorder characterized
by progressive deterioration of the articular
cartilage. it is a noninflammatory (unless
localized), nonsystemic disease. it is no longer
thought to be only a wear-and-tear disease
associated with aging, but rather a process
in which new tissue is produced as a result
of cartilage destruction within the joint. the
destruction outweighs the production. the
cartilage and bone beneath the cartilage erode
and osteophytes (bone spurs) form, resulting in
narrowed joint spaces. the changes within the
joint lead to pain, immobility, muscle spasms,
and potential inflammation. early in the disease
process of oa, it can be difficult to distinguish
from rheumatoid arthritis (ra). (72.1)

Low‑back pain (LBP) occurs along the
lumbosacral area of the vertebral column. lBp
can be acute (less than 4 weeks) or chronic
(longer than 3 months or repeated episodes
of pain). lBp can be related to an injury, fall, or
heavy lifting. lBp is the leading cause of work
disability. acute pain results from muscle spasm
or strain, ligament sprains, or disk herniation
or degeneration. spinal stenosis (narrowing of
spinal canal or other spaces) can cause back pain.

Osteoarthritis

HEALTH PROMOTION AND
DISEASE PREVENTION

● Encourage the client to use joint-saving measures (good
body mechanics, labor-saving devices).

● Encourage the client to maintain a healthy weight to
decrease joint degeneration of the hips and knees.

● Encourage the client to avoid or limit repetitive strain
on joints (jogging, contact sports, risk-taking activities).

● Recommend wearing well-fitted shoes with supports to
prevent falls.

CHAPTER 72

72.1 Characteristics of osteoarthritis and rheumatoid arthritis

Osteoarthritis Rheumatoid arthritis
DISEASE PROCESS cartilage destruction with bone spur

growth at joint ends; degenerative
synovial membrane inflammation resulting in cartilage
destruction and bone erosion; inflammatory

FINDINGS pain with activity that improves at rest swelling, redness, warmth, pain at rest or
after immobility (morning stiffness)

EFFUSIONS localized inflammatory response all joints
BODY SIZE usually overweight usually underweight

NODES heberden’s and Bouchard’s nodes swan neck and boutonnière deformities of hands
SYSTEMIC INVOLVEMENT no: articular Yes: lungs, heart, skin, and extra-articular

SYMMETRICAL no Yes
DIAGNOSTIC TESTS X-rays X-rays and positive rheumatoid factor

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480 CHAPTER 72 osteoarthritis anD loW-BacK pain CONTENT MASTERY SERIES

ASSESSMENT

risK factors
● Aging: majority of adults over age 60 have joint

changes on x-ray
● Genetic factors
● Joint injury due to acute or repetitive stress on joints

predisposes to later OA
● Obesity: OA affects weight-bearing joints (knees, hips in

overweight clients)
● Metabolic disorders (diabetes and blood disorders [sickle

cell disease]) predisposes to joint degeneration
● Female sex

eXpecteD finDings
● Joint pain and stiffness
● Pain with joint palpation or range of motion (observe

for muscle atrophy, loss of function, limp when walking,
and restricted activity due to pain)

● Crepitus in one or more of the affected joints
● Enlarged joint related to bone hypertrophy
● Heberden’s nodes enlarged at the distal

interphalangeal joints
● Bouchard’s nodes located at the proximal

interphalangeal joints (OA is not a symmetrical disease,
but these nodes can occur bilaterally); nodes can be
inflamed and painful

● Inflammation resulting from secondary synovitis,
indicating advanced disease

● Joint effusion (excess joint fluid) that is easily moved
from one area of the joint to another area

● Vertebral radiating pain affected by cervical or lumbar
compression of nerve roots

● Limping gait due to hip or knee pain
● Back pain due to OA of the spine

laBoratorY tests
Laboratory tests are usually normal with OA. Erythrocyte
sedimentation rate and high-sensitivity C-reactive protein
can be increased slightly related to secondary synovitis.

Diagnostic proceDures
Radiographs (x‑ray): to determine changes to joints

CT scan and Magnetic resonance imaging: for examining
knee joint and vertebrae

PATIENT‑CENTERED CARE

nursing care
● Assist the client with pharmacological and

nonpharmacological pain relief.
● Have the client determine an acceptable level of pain as

a goal to measure progress (a rating of 3 or less on a 0
to 10 scale).

● Determine the psychosocial impact of OA for the client
(body image changes or altered ability to perform self-
care or maintain employment).

● Teach the client about joint protection: using large
joints rather than small ones, using two hands to hold
objects, bending the knees when reaching down rather
than bending the waist.

● Assess the need for assistive or adaptive devices
(mobility aids, clothing with Velcro closures).

● Warn the client about using so-called cures for
osteoarthritis, and to talk with the provider before
trying any new therapies, to reduce the risk of harm.

CLIENT EDUCATION
● Balance activity with rest.
● Heat can help with joint tenderness and muscle

stiffness. Use hot baths and showers, or hot packs and
moist heating pads to promote comfort but avoid high
temperatures to prevent burns.

● Cold therapy can help reduce inflammation and numb
nerve endings. If cold packs or ice packs are used,
limit to 20 min and wrap them in cloth before placing
on the skin.

● Maintain joints in functional position. Use good posture
when standing to maintain spinal curvature and proper
weight distribution. When lying down, use a small
pillow under the head and neck but don’t prop joints in
a flexed position.

● Achieve and maintain a healthy weight to reduce stress
on the joints.

● Follow the prescribed exercise regime consistently.
Active exercises are more beneficial than passive.

● On days when pain is increased, attempt exercise,
but reduce the number of repetitions and avoid
resistance exercises.

72.2 Heberden’s and Bouchard’s nodes

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 72 osteoarthritis anD loW-BacK pain 481

meDications

Acetaminophen

The medication of choice for managing OA.

NURSING ACTIONS
● Limit administration of acetaminophen to a maximum

of 3,000 mg/24 hr. Some experts recommend a
maximum daily dose of 2,500 to 3,000 mg/day when
used long-term to prevent liver toxicity.

● Make sure clients are aware of opioids that contain
acetaminophen (hydrocodone bitartrate 5 mg/
acetaminophen 500 mg, which contains various
amounts of hydrocodone and acetaminophen).

● Monitor liver function tests.

Topical medications
● Prescription lidocaine patches (5%) can be used to

relieve joint pain. These are contraindicated if the client
is taking a class I antidysrhythmic medication.

● Topical salicylates (gels, patches, or creams) and topical
buspirone cream can be used.

Nonsteroidal anti‑inflammatory drugs (NSAIDs)
● Analgesics and anti-inflammatories (celecoxib,

naproxen, ibuprofen) are used to relieve pain unrelieved
by acetaminophen and topical agents, and synovitis
if present.

● Baseline liver and kidney function tests and CBC are
needed if NSAIDs are to be given.

● Topical NSAID (diclofenac epolamine patch) can be used
and is non-systemic.

NURSING ACTIONS: Monitor kidney function
(BUN, creatinine).

CLIENT EDUCATION
● NSAIDs are nephrotoxic and should be taken

as prescribed.
● Report evidence of black tarry stool, indigestion, and

shortness of breath.

Opioids

Opioid analgesics (hydrocodone and oxycodone) are
appropriate for treating moderate to severe pain.

● Tramadol is considered a weak opioid that can be
used for OA.

● Monitor and intervene for adverse effects of opioid use,
especially for older adults.

● If used, opioids should be taken on a short-term basis by
most clients. Some clients who have chronic back pain
can receive prescriptions for opioids for long-term use.

Muscle relaxants
● Cyclobenzaprine hydrochloride given for muscle spasms

due to LBP
● Can cause acute confusion in older adults
● Do not drive or operate dangerous equipment

complementarY anD
alternative therapies

Topical capsaicin

Provides temporary pain relief by blocking some
pain impulses

● Cream is applied topically 3 to 4 times daily.
● Causes brief burning sensation after applications; avoid

touching face and eyes.

CLIENT EDUCATION
● Wear gloves during application and wash the hands

immediately afterwards. If application site is the hands,
leave on for 30 min without touching anything else,
then wash the hands.

● A burning sensation of the skin after application is
normal and should subside. Burning sensation becomes
less frequent the more the cream is used.

Glucosamine and chondroitin supplements
● Glucosamine and chondroitin are natural substances

that aid in repair and maintenance of cartilage.
● Glucosamine assists in reducing inflammation, and

chondroitin helps strengthen the cartilage.
● Adverse effects of glucosamine include GI upset, rash,

headache and drowsiness.
● There is an increased risk for bleeding if the client takes

anticoagulants and chondroitin.

CLIENT EDUCATION
● Consult the provider regarding use and dosage, which

should be based on weight.
● Do not take glucosamine if you have hypertension, are

pregnant, or are lactating.
● Monitor for bleeding if taking chondroitin, especially if

also taking an anticoagulant.
● Inform the provider regarding concurrent use of

chondroitin, NSAIDs, heparin, and warfarin.

interprofessional care
● Physical therapy to assist with comfort therapies

(diathermy, ultrasonography, and paraffin dips).
● Registered dietitian to assist with meal planning, if

weight loss is recommended for the client.
● Case manager or home health nurse to determine home

modifications (handrails, raised or lowered counters).

therapeutic proceDures

Intra‑articular injections
● Glucocorticoids are used to treat localized inflammation.

One joint can be injected no more than 4 times a year.
● Hyaluronic acid is sometimes used to replace the

body’s natural hyaluronic acid, which is destroyed by
joint inflammation. Evidence supporting the benefits
is unclear.

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482 CHAPTER 72 osteoarthritis anD loW-BacK pain CONTENT MASTERY SERIES

Total joint arthroplasty or replacement

When other measures fail, the client can choose to
undergo total joint arthroplasty of synovial joints to
relieve the pain and improve mobility and quality of life.

● Joint replacement is contraindicated with any type
of infection, advanced osteoporosis, or rapidly
progressive inflammation.

● Uncontrolled diabetes or hypertension can cause major
postoperative complications.

Low‑back pain
HEALTH PROMOTION AND

DISEASE PREVENTION
● Exercise to keep back healthy and strong

(swimming, walking).
● Use body mechanics and proper lifting techniques

(ergonomics).
● Maintain correct posture.
● Wear low-heeled shoes.
● Maintain a healthy weight.
● Smoking cessation, as smoking is linked to disk

degeneration.
● Avoid prolonged sitting/standing.
● Healthy diet including adequate calcium and vitamin D.

ASSESSMENT

risK factors
● Can occur at any time but most prevalent from

ages 30 to 60
● Family history of back pain or history of a back injury
● History of spine problems, back surgery, or

compression fracture
● Job or occupation that requires heavy lifting, twisting,

or repetitive motion
● Smoking (linked to disk degeneration)
● Overweight
● Having poor posture
● Osteoarthritis
● Osteoporosis
● Scoliosis
● Compression fracture

eXpecteD finDings
● Dull or sharp low back pain, usually constant
● Possible stiff, flexed posture
● Pain aggravated by coughing, sneezing, or straining
● Muscle spasms, cramping, and stiffness, often in a

location closest to the affected disk
● Pain in the buttock
● Sciatic nerve compression causes severe pain when leg

is straightened and held up, and limping when walking.
● Numbness/tingling of the leg (paresthesia); burning or

stabbing pain in the leg or foot
● Report chills/fever, bowel or bladder incontinence,

progression of decreased ability to move, and
paresthesias to the provider promptly (can indicate a
more serious condition).

Diagnostic proceDures
Radiographs (x‑ray): to determine changes to joints

CT scan and Magnetic resonance imaging: to visualize
bones nerves, disks, ligaments, spinal cord and nerves,
muscles and disks

Bone scan: provides visualization of increased vascularity
indicating tumor or infection

Myelogram and post‑myelogram CT scan: show verve
root lesions or other lesions, masses, or infection

Electromyography (EMG) with nerve conduction studies:
to determine whether motor neuron issues or peripheral
neuropathies are the cause

PATIENT‑CENTERED CARE
Evidence-based practice recommendations
include nonpharmacological interventions with an
interprofessional approach as initial management
strategies.

nursing care
● Assist with management of acute back pain. Inform

the client that unmanaged acute pain can lead to
chronic pain.

● Assist the client to change positions frequently to
minimize pain.

● Discourage prolonged time in bed and assist the client
to perform stretching exercises as soon as possible.

● Encourage stress relief.

CLIENT EDUCATION
● Heat therapy can help reduce pain.
● Acetaminophen is usually not helpful for lower

back pain.
● Use the Williams herniation for acute lower LBP

caused by herniated disk. Sitting in a recliner with
legs elevated demonstrates this position, but it can be
accomplished in bed if pillows are used to elevate the
head and legs.

● If prolonged standing is required, shoe insoles or floor
pads can provide relief.

● Achieve and maintain a healthy weight.

meDications

Nonsteroidal anti‑inflammatory drugs

Over-the-counter or prescription NSAIDs can be helpful.

Mild opioids

Tramadol can be used if NSAIDs are ineffective.

Topical creams sprays and gels

Can temporarily dull pain by using heat or cold sensations

Ziconotide

Used for severe chronic back pain

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 72 osteoarthritis anD loW-BacK pain 483

complementarY anD
alternative therapies
Massage, spinal manipulation, mindfulness, progressive
muscle relaxation, yoga, and acupuncture can be helpful.

interprofessional care
● Pain management specialists can assist with

long-term management.
● Physical therapy can assist the client in creating an

individualized exercise plan; can include water therapy.

therapeutic proceDures

Transcutaneous electrical nerve stimulator (TENS) unit

Can help minimize pain

Implantable pump with intrathecal (spinal) infusion
● Ziconotide is used in the pump for treating severe, chronic

back pain by blocking calcium channels on the nerves.
● Ziconotide is contraindicated for clients who have severe

mental health.
CLIENT EDUCATION: Contact the provider to stop the
medication if hallucinations or delusions occur.

Minimally invasive surgery

Microscopic endoscopic diskectomy or percutaneous
endoscopy diskectomy: Fluoroscopy is used to guide a
tubular device through which the herniated disk is removed
by cutting it out or suctioning out the center of the disk.

Laser‑assisted laparoscopic lumbar diskectomy:
Laparoscope and laser are used to treat the herniated disks.
Complications can include infection and nerve root injury.

Kyphoplasty: A needle is inserted into the back to inflate
a balloon to help the vertebra regain its shape. Then a
cement substance is injected into the space. Vertebroplasty
is very similar, but a balloon is not used.

Open surgical procedures

Open diskectomy: removal of the herniated disk

Laminectomy: removal of part of the laminae and facet
joints

Surgery for tumors or infection

Arthrodesis/spinal fusion: surgery to join or fuse two or
more vertebrae. Often required if the spine is unstable or
multiple laminectomies required.

● A bone graft from the pelvic bone or bone bank is used
to make a bridge between vertebrae that are next to
each other.

● Metal implants can also be used.

Interbody cage fusion: implantation of a cagelike device
following disk removal

PREPROCEDURE NURSING ACTIONS
● Instruct the client and family on methods to change

position following surgery.
● Ensure informed consent is signed. Special consent

might be needed if donor bone is used for grafting.

POSTPROCEDURE NURSING ACTIONS
● Provide standard postoperative care.
● Perform neurologic checks with vital sign measurement.
● Ensure the client is able to void. Inability can indicate

damage to the bladder muscles.
● Check incisions for bleeding and drainage. For

minimally invasive surgery, small adhesive strips are
used to cover incisions.

● Administer analgesia as needed. Patient-controlled
analgesia (PCA) can be used following open procedures.

● If a surgical drain is present, empty every shift. The
surgeon removes the drain after about 24 to 36 hr.

● Do not place an overhead trapeze on the client’s bed;
use can damage the surgical area.

● Provide a straight-back chair for the client and ensure
feet rest on the floor when sitting.

● Expect the client to be discharged within 23 to 48 hr.

CLIENT EDUCATION
● Turn the body as a unit (log roll).
● Initiate prescribed exercise plan following discharge.
● Report new sensory changes (increased numbness,

decreased movement) for any extremity to the provider
immediately.

● A back orthotic can be required for 4 to 6 weeks
following surgery. Follow provider instructions for
wearing and when removal is allowed.

● Activity limitations following minimally invasive
surgery can range from 2 days to 3 weeks. Following
open surgery, restrictions are in place for 4 to 6 weeks.

COMPLICATIONS
Include nerve injury, disk inflammation, and tears to the
dura covering the spinal cord.

Cerebrospinal fluid leakage

Examine wound dressing drainage for a halo-like
appearance. Other manifestations include sudden
headache and bulging of the incision.

Fat embolism syndrome

Report chest pain, anxiety, dyspnea, petechiae, or mental
status changes.

Nerve root pain

Document and report pain that does not respond to opioid
administration.

Failed back surgery syndrome (FBSS)

Surgery is not successful in relieving manifestations of
back pain.

NURSING ACTIONS
● Address psychosocial needs. Clients often feel

discouraged after failed therapies.
● Assist with coordination of multifaceted pain

management.

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484 CHAPTER 72 osteoarthritis anD loW-BacK pain CONTENT MASTERY SERIES

Active Learning Scenario

a nurse is providing information on collaborative and
nonpharmacologic therapies for a client who is having
continual joint pain from osteoarthritis. What information
should the nurse include? use the ati active learning
template: Basic concept to complete this item.

RELATED CONTENT: Describe two activities
each for collaborative care involving physical
therapy and nutrition therapy.

NURSING INTERVENTIONS: Describe three actions
the nurse could add to a teaching plan for this client.

Application Exercises

1. a nurse is assessing a client who has
osteoarthritis of the knees and fingers. Which
of the following manifestations should the
nurse expect to find? (select all that apply.)

a. heberden’s nodes

B. swelling of all joints

c. small body frame

D. enlarged joint size

e. limp when walking

2. a nurse is providing information to a client who
has osteoarthritis of the hip and knee. Which of
the following information should the nurse include
in the information? (select all that apply.)

a. apply heat to joints to alleviate pain.

B. ice inflamed joints for 30 min following activity.

c. reduce the amount of exercise done
on days with increased pain.

D. prop the knees with a pillow while in bed.

e. active range of motion is more
effective than passive.

3. a nurse is providing information about capsaicin
cream to a client who reports continuous knee pain
from osteoarthritis. Which of the following information
should the nurse include in the discussion?

a. continuous pain relief is provided.

B. put on gloves before applying the
cream to other parts of the body.

c. leave cream on the hands for
10 min following application.

D. apply the medication every 2 hr during the day.

4. a nurse is caring for a client who received a lower
back injury during a fall and describes sharp pain
in the back and down the left leg. in which of the
following positions should the nurse plan to place
the client to attempt to decrease the pain?

a. prone without use of pillows

B. semi-fowler’s with a pillow under the knees

c. high-fowler’s with the knees flat on the bed

D. supine with the head flat

5. a nurse is providing teaching for a client who
has a history of low back injury. Which of the
following instructions should the nurse give
the client to prevent future problems with
low back pain? (select all that apply.)

a. engage in regular exercise including walking.

B. sit for up to 10 hr each day to rest the back.

c. maintain weight within 25% of ideal body weight.

D. create a smoking cessation plan.

e. Wear low-heeled shoes.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 72 osteoarthritis anD loW-BacK pain 485

Application Exercises Key

1. a. CORRECT: heberden’s nodes are enlarged nodules
on the distal interphalangeal joints of the hands and
feet of a client who has osteoarthritis.

B. swelling and pain of all joints is a manifestation
of rheumatoid arthritis. a local inflammation
of a joint is related to osteoarthritis.

c. a small body frame is a risk factor for rheumatoid
arthritis. obesity is a risk factor for osteoarthritis.

D. CORRECT: a client can manifest enlarged
joints due to bone hypertrophy.

e. CORRECT: a client can manifest a limp when walking
due to pain from inflammation in the localized joint.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. CORRECT: applying heat to joints can
provide temporary relief of pain.

B. limit the application of ice to 20 min
at a time to prevent injury.

c. CORRECT: it is important to exercise consistently, but
the client should reduce the amount of exercises on days
of increased pain to prevent harm to the joints.

D. avoid propping the knees because it
keeps them in a flexed position.

e. CORRECT: performing active range-of-
motion of joints is more beneficial.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

3. a. capsaicin cream provides temporary relief of pain rather than
continuous relief when applied several times daily.

B. CORRECT: Because capsaicin can cause burning,
the client should put on gloves before applying it
to parts of the body other than the hands.

c. leave the cream on for 30 min following application
to the hands, then wash the hands.

D. for maximum pain relief benefit, apply
capsaicin cream up to four times a day.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. a. prone position without use of pillows has not been
found to decrease acute low back pain.

B. CORRECT: Williams position, with the client in
semi-fowler’s position with the knees flexed by pillows,
has been found to relieve low-back pain caused by
a bulging disk and nerve root involvement.

c. high-fowler’s position with the knees flat has not
been found to decrease acute low back pain.

D. supine position with the head flat has not been
found to decrease acute low back pain.

NCLEX® Connection: Basic Care and Comfort,
Non-Pharmacological Comfort Interventions

5. a. CORRECT: regular exercise, including walking or swimming,
is a strategy that can prevent low back pain.

B. long periods of sitting or standing can cause
low-back pain. advise the client to use footstools or
ergonomic chairs when sitting is necessary.

c. the client should maintain weight within 10% of ideal
body weight, as obesity can cause low-back pain.

D. CORRECT: stopping or cutting down on smoking is
a strategy that can decrease problems with low-back
pain, as smoking can cause disk degeneration.

e. CORRECT: Wearing low-heeled, well-fitting shoes can prevent
low back pain. instruct the client to avoid high-heeled shoes.

NCLEX Connection: Physiological Integrity, Mobility/Immobility

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT

physical therapy
● apply heat, diathermy, and ultrasound.
● perform stretching and strengthening exercises.
● use transcutaneous electrical nerve stimulation (tens).

nutritional therapy
● provide nutritional information on weight loss.
● provide nutritional information on a balanced diet.

NURSING INTERVENTIONS
● Balance rest with activity.
● identify need for assistive devices and mobility aids.
● apply thermal therapies (heat or cold).
● teach the client to use the large joints rather than the small ones.
● help the client set a pain goal.

NCLEX® Connection: Health Promotion and Maintenance, Health
Promotion/Disease Prevention

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RN ADULT MEDICAL SURGICAL NURSING ncleX® connections 487

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Reduction of Risk Potential
DIAGNOSTIC TESTS
Compare client diagnostic findings with pre-test results.

Perform diagnostic testing.

POTENTIAL FOR COMPLICATIONS FROM SURGICAL
PROCEDURES AND HEALTH ALTERATIONS: Apply knowledge
of pathophysiology to monitoring for complications.

THERAPEUTIC PROCEDURES: Educate client
about treatments and procedures.

Pharmacological and Parenteral Therapies
MEDICATION ADMINISTRATION: Educate client on
medication self-administration procedures.

ADVERSE EFFECTS/CONTRAINDICATIONS/SIDE
EFFECTS: Assess the client for actual or potential side
effects and adverse effects of medications.

PHARMACOLOGICAL PAIN MANAGEMENT:
Administer medications for pain management.

Physiological Adaptation
ILLNESS MANAGEMENT: Educate client
regarding an acute or chronic condition.

PHYSIOLOGY: Identify pathophysiology related
to an acute or chronic condition.

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488 ncleX® connections CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 73 integumentarY Diagnostic proceDures 489

UNIT 11 NURSING CARE OF CLIENTS WHO HAVE
INTEGUMENTARY DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 73 Integumentary
Diagnostic
Procedures

integumentary diagnostic procedures involve
identification of pathogenic micro-organisms.
the most accurate and definitive way to identify
micro-organisms and cell characteristics is
by examining blood, body fluids, and tissue
samples under a microscope.

skin lesions or changes in the skin can need
confirmation by microscope to determine if the
cause is viral, fungal, or bacterial.

always use standard precautions when handling
skin that is not intact.

Skin diagnostic studies
Wood’s light examination

● For clients who have dark skin tones, changes in skin
color (changes in underlying red tones or presence of
bluish-gray undertones) are best detected using bright
lighting. For clients who have light skin tones, or who
have areas of hypopigmentation, color changes are best
detected using the Wood’s light examination.

● The room is darkened, and ultraviolet light is used
to produce specific colors to reveal a skin infection
and discern between dermal and epidermal lesions
and to differentiate normal skin from hypo- and
hyperpigmented areas.

Diascopy

A glass slide or lens is pressed down over the skin area
to be examined to test for blanchability. It is painless
and used to determine whether the lesion is vascular
(inflammatory), or nonvascular (nevus) or hemorrhagic
(petechiae or purpura). Hemorrhagic and nonvascular
lesions do not blanch, but inflammatory lesions do.

Skin culture and sensitivity
● Culture refers to isolation of the pathogen on

culture media.
● Sensitivity refers to the effect that antimicrobial agents

have on the micro-organism.
◯ If the micro-organism is killed by the antimicrobial,

the microbe is considered to be sensitive to
that medication.

◯ If tolerable levels of the medication are unable to kill
the microbe, the microbe is considered to be resistant
to that medication.

● A culture and sensitivity can be done on a sample of
purulent drainage from a skin lesion.

● Cultures should be done prior to initiating
antimicrobial therapy.

● Results of a culture and sensitivity test usually are
available preliminarily within 24 to 48 hr, and final
results in 72 hr.

INDICATIONS

client presentation
● Skin lesions, which can be infectious, can appear raised,

reddened, edematous, and/or warm.
● There can be purulent drainage and/or fever.

CONSIDERATIONS

preproceDure
NURSING ACTIONS

● Use standard precautions when collecting and handling
specimens.

● Most specimens will be collected by the nurse
or provider.

intraproceDure

Bacterial or viral specimens

NURSING ACTIONS
● Express material from the lesion by lifting or

puncturing the crusted or scabbed area over the lesion
using a small-gauge sterile needle or 0.9% sodium
chloride and a sterile cotton swab.

● Culturette tubes are specific for specimen collection and
contain a sterile cotton-tipped applicator and a fixative
that is released after the infectious exudate is applied to
the applicator and inserted in the tube.

● A specimen obtained for a viral culture is immediately
placed on ice and sent to the laboratory.

VIRAL INFECTION: Herpes virus: A cotton–tipped
applicator is used to obtain vesicle fluid from intact
lesions for culture.

CHAPTER 73

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490 CHAPTER 73 integumentarY Diagnostic proceDures CONTENT MASTERY SERIES

Fungal specimen

NURSING ACTIONS
● Requires a sufficient quantity of scales collected using a

wooden tongue depressor to scrape the skin and placing
the specimen in a clean container.

● If a fungal culture is needed because of inconclusive
results due to a deeper fungal infection, a punch biopsy
is performed.

● Specimens must be properly labeled and delivered to the
laboratory promptly for appropriate storage and analysis.

postproceDure
NURSING ACTIONS: Teach the client interventions to
prevent the spread of an infectious skin disorder.

● Bacterial infection: Bathe daily using an
antibacterial soap.

◯ Do not squeeze bacterial lesions but remove
the crusted exudate so the antibacterial topical
medication can penetrate into the lesion.

◯ Apply warm compresses twice daily for comfort to
furuncles or areas where cellulitis is present.

◯ Use good hand hygiene at all times.
◯ Do not share personal items.
◯ Position clients on bed rest for optimal air circulation
to the area and to avoid occlusive dressings
or garments.

● Viral lesion: Apply compress of Burow’s solution
(aluminum acetate in water) for 20 min, three times a
day to promote the formation of a crust and healing.

◯ Avoid tight, restrictive clothing that can
irritate a lesion.

◯ Allow a lesion to dry between treatments, and avoid
lying on the lesion to promote circulation and comfort.

◯ Use good hand hygiene to prevent
cross-contamination of the infection.

◯ Avoid sharing personal items (combs, brushes,
clothing, footwear).

● Fungal infections
◯ Keep skin folds clean and dry.
◯ Turn and reposition frequently.

Medication therapy for bacterial infections
● Superficial skin infections are treated with topical

antibacterial cream or ointment.
● Extensive bacterial skin infections involving the

lymphatic system, or if cellulitis is present, are treated
with systemic antibiotic therapy (cephalosporins
or penicillins).

● If allergic to cephalosporins and penicillins, the provider
can prescribe tetracycline, erythromycin, azithromycin,
or tobramycin.

● If the skin lesion is cultured as having
methicillin-resistant Staphylococcus aureus,
IV vancomycin or oral linezolid or clindamycin
is prescribed.

Medication for viral infections

Topical treatment with acyclovir, valacyclovir, or
famciclovir decreases the number of active viruses on the
surface of the skin and reduces the discomfort associated
with a herpetic infection or lesion.

Recurrent infections render the use of topical antiviral
medications less effective.

Medication for fungal infections
● Yeast infections or dermatophyte infections are treated

with topical cream or powder. For example, clotrimazole
cream is applied to the infected skin twice a day and for
1 to 2 weeks after the lesions are no longer present, or as
prescribed by the provider.

● Skin must be clean and dry before applying topical
ointments or creams.

INTERPRETATION OF FINDINGS
● The microbe responsible for the infection is identified in

the culture, and the antimicrobials that are sensitive to
that microbe are listed.

Tzanck smear

A microscopic cytology examination is completed after
extracting cells from the base of a lesion. Microscopic
examination reveals multinucleated giant cells to confirm
the lesion is viral.

Potassium hydroxide (KOH) test
● The test confirms a fungal skin lesion.
● A microscopic examination of the scales scraped off

a lesion is mixed with KOH. Specimen is positive
for fungus if there is the presence of fungal hyphae
(threadlike filaments).

Biopsy
Biopsy is the removal of a sample of tissue by excision
or needle aspiration for cytological (histological)
examination.

● Biopsy confirms or rules out malignancy.
● Skin biopsies are performed under local anesthesia

and can be a punch, shave, or excisional biopsy. Punch
biopsy is the most common technique.

Punch biopsy: Removal of a small plug of tissue
approximately 2 to 6 mm is removed with a specific
cutting instrument, with or without sutures to close the
site. Most skin biopsies are obtained using the punch

Shave biopsy: Removal of only the part of the lesion that
is raised above the surrounding tissue using a scalpel or
razor blade with no suturing.

Excisional biopsy: A larger and deeper specimen is
obtained, and suturing is required.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 73 integumentarY Diagnostic proceDures 491

INDICATIONS
POTENTIAL DIAGNOSES: A biopsy is commonly performed to
establish an exact diagnosis or to rule out diseases (cancer).

CLIENT PRESENTATION: Evidence of skin lesion can
include an area of discoloration that is thickened, thinned,
raised, flat, rough, painful, open, dry, and/or itchy.

CONSIDERATIONS

preproceDure
NURSING ACTIONS

● Ensure that the client has signed the informed
consent form.

● Inform the client that a scar can form after the biopsy.

intraproceDure
NURSING ACTIONS

● Establish a sterile field.
● Place the tissue sample in a container containing

appropriate solution, label, and send to the laboratory.
● Apply pressure to the biopsy site to control bleeding

as appropriate.
● Place a sterile dressing over the biopsy site.

postproceDure
Post-biopsy discomfort usually is relieved by
mild analgesics.

NURSING ACTIONS: Monitor the biopsy site for bleeding.

CLIENT EDUCATION
● Check the biopsy site daily. Report excessive bleeding or

evidence of infection (redness, warmth, drainage, fever)
to the provider.

● Dressings can be removed after 8 hr. Use tap
water and 0.9% sterile sodium chloride to clean
the biopsy site of dried blood or crusts.

● If prescribed, apply an antibacterial topical
medication to prevent infection.

● If sutures are used, return to the provider
for removal in 7 to 10 days.

● It could take several days for the results of the biopsy.

INTERPRETATION OF FINDINGS
After a biopsy is completed, the tissue sample is sent to
pathology for interpretation.

Active Learning Scenario

a nurse is caring for a client who will have a biopsy
of a skin lesion. What should the nurse consider in
planning for the procedure? use the ati active learning
template: Basic concept to complete this item.

UNDERLYING PRINCIPLES: list and describe
the three types of integumentary biopsies.

NURSING INTERVENTIONS: Describe two
intraprocedure nursing actions.

Application Exercises

1. a nurse is caring for a client who has a
suspected viral skin lesion. Which of the
following laboratory findings should the nurse
expect to review to confirm this diagnosis?

a. potassium hydroxide (Koh)

B. Diascopy

c. tzanck smear report

D. Biopsy

2. a nurse in a clinic is preparing to obtain a skin
specimen from a client who has a suspected
herpes infection. Which of the following actions
should the nurse take? (select all that apply.)

a. scrape the site with a wooden tongue depressor.

B. use a razor to cut the scabbed area
to obtain the specimen.

c. use a cotton-tipped application to
obtain fluid from the lesion.

D. place specimen in a potassium
hydroxide (Koh) solution tube.

e. place specimen tube on ice after obtaining sample.

3. a nurse is instructing a client on home care after a
culture for a bacterial infection and cellulitis. Which of
the following information should the nurse include?

a. Bathe daily with moisturizing soap.

B. apply antibacterial topical medication
to the crusted exudate.

c. apply warm compresses to the affected area.

D. cover affected area with snug-fitting clothing.

4. a nurse is providing discharge instructions to a client
who had a skin biopsy with sutures. the nurse should
identify that which of the following client statements
indicates that the teaching has been effective?

a. “i can expect redness around
the site for 5 to 7 days.”

B. “i will most likely have a fever for the first few days.”

c. “i should apply an antibiotic ointment to the area.”

D. “i will make a return appointment in
3 days for removal of my sutures.”

5. a nurse is providing teaching to a client about a new
prescription for clotrimazole topical cream. Which of
the following statements should the nurse include?

a. “it reduces the discomfort of a herpetic
infection but does not cure the infection.”

B. “this is a cream to treat a bacterial infection.”

c. “apply the topical medication for up to
2 weeks after the fungal lesions are gone.”

D. “apply the cream to lesions while they are moist.”

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492 CHAPTER 73 integumentarY Diagnostic proceDures CONTENT MASTERY SERIES

Application Exercises Key

1. a. findings of a potassium hydroxide (Koh) test
reveal if skin lesions are fungal in origin.

B. Diascopy provides increased visibility of a skin lesion
by blanching the skin over the lesion, thus eliminating
erythema which can obscure findings.

c. CORRECT: a tzanck smear report confirms
whether a skin lesion is viral in origin.

D. findings of a biopsy report confirm or
rule out if a lesion is malignant.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

2. a. a wooden tongue depressor is used to scrape
cells of a skin lesion to test for a fungus.

B. use a razor to obtain a specimen from a superficial or
raised lesion when a shave biopsy is prescribed.

c. CORRECT: swab the moist lesion bed under
the crust with a sterile cotton-tipped applicator
to obtain a reliable specimen.

D. a Koh prep solution is used for
distinguishing fungal infections.

e. CORRECT: the culturette tube is immediately
placed in ice when obtaining a viral specimen.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

3. a. the client should use antibacterial soap to
reduce the bacteria count on the skin.

B. the client should apply topical medication
directly to the moist lesion bed. the medication
will not penetrate the crusted exudate.

c. CORRECT: the client should apply warm compresses
to the affected area to promote comfort.

D. the client should wear loose-fitting clothes
to avoid irritating the lesion.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. a. the client should report redness, pain, drainage, or
warmth at the biopsy site to the provider.

B. a fever is an indication of an infection, and
the provider should be notified.

c. CORRECT: antibiotic ointment is applied as
prescribed by the provider to prevent infection.

D. removal of the sutures following a biopsy is
done 7 to 10 days postprocedure.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. a. clotrimazole is not an antiviral medication
to treat a herpetic infection.

B. clotrimazole is not an antibacterial medication.
c. CORRECT: clotrimazole is a medication used

to treat a fungal infection and is applied for
1 to 2 weeks after the infection is resolved.

D. clotrimazole should be applied to clean, dry skin.
Wash the skin gently and pat dry before applying.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

UNDERLYING PRINCIPLES
● punch biopsy: a 2 to 6 mm plug of tissue is removed from
the skin lesion, followed with or without suturing.

● shave biopsy: a scalpel or razor blade removes only
the raised area of the lesion, with no suturing.

● excisional biopsy: a large, deep specimen of
tissue is obtained, followed with suturing.

NURSING INTERVENTIONS
● assist with setting up materials for placement of a local anesthetic.
● apply pressure to the biopsy site to control bleeding.
● prep biopsy skin area accordingly.
● label all specimens.
● place a sterile dressing over the biopsy site if needed.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 74 sKin DisorDers 493

UNIT 11 NURSING CARE OF CLIENTS WHO HAVE
INTEGUMENTARY DISORDERS
SECTION: INTEGUMENTARY DISORDERS

CHAPTER 74 Skin Disorders
psoriasis is a skin disorder characterized by scaly
dermal patches and caused by overproduction
of keratin. this overproduction can occur at a
rate up to seven times the rate of normal cells.
it is thought to be an autoimmune disorder and
has periods of exacerbations and remissions.
although lesions can appear anywhere, they
are commonly present on the elbows, knees,
trunk, scalp, sacrum, and the lateral aspects
of extremities. psoriasis can be classified as
psoriasis vulgaris, exfoliative, or palmoplantar
pustulosis. in some clients, psoriasis affects the
joints, causing arthritis-type changes and pain.

Dermatitis is an inflammation of the skin
resulting from exposure to allergens (internal
or external) that causes changes in the skin
structure or tissue destruction. manifestations
of dermatitis can be nonspecific and include
itching, lesions without distinct borders, and
different distribution
patterns. rashes can evolve
from acute to chronic, and
place the client at increased
risk for bacterial infection
resulting from breaks in the
skin caused by scratching.
Dermatitis can be classified
as nonspecific eczematous,
contact, or atopic.

Psoriasis

ASSESSMENT

risK factors
● Infections (severe streptococcal throat infection,

Candida infection, upper respiratory infection)
● Skin trauma (recent surgery, sunburn)
● Genetics
● Stress (related to overstimulation of the

immune system)
● Seasons (warm weather improves manifestations)
● Hormones (puberty or menopause)
● Medications (lithium, beta-blocker, indomethacin)
● Obesity

eXpecteD finDings
● Psoriasis vulgaris presents as reddened, thickened skin

with silvery white scales with bilateral distribution.
● Exfoliative psoriasis displays as erythema and scaling

from a severe inflammatory reaction with no obvious
lesions. The reaction can cause dehydration and
hypothermia or hyperthermia.

● Palmoplantar pustulosis manifests as reddened
hyperkeratotic areas (accelerated maturation of
epidermal cells) due to an inflammatory disorder.
Plaques form and pustules turn brown, peel, and form
a crust on the palms of the hands and soles of the feet.
The course of the disease is cyclic.

● Exacerbation and remission of pruritic lesions

CHAPTER 74

74.1 Psoriasis

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494 CHAPTER 74 sKin DisorDers CONTENT MASTERY SERIES

CLASSIFICATION OF LESIONS
● Mild: less than 5% of body surface area (BSA)
● Moderate: 5 to 10% of BSA
● Severe: greater than 10% of BSA

PHYSICAL ASSESSMENT FINDINGS
● Scaly patches
● Bleeding stimulated by removal of scales
● Pruritic skin lesions primarily on the scalp, elbows

and knees, sacrum, and lateral areas of the extremities
(psoriasis vulgaris)

● Pitting, crumbling nails

PATIENT‑CENTERED CARE

meDications
There is no cure for psoriasis. Treatment is aimed
at decreasing the severity of the manifestations and
decreasing the turnover rate of the epidermal cells.

Topical therapies

Corticosteroids (triamcinolone, betamethasone) reduce
secondary inflammatory response of lesions and
suppresses cellular division/proliferation.

● NURSING ACTIONS
◯ Observe skin for thinning, striae, or

hypopigmentation with high-potency corticosteroids.
◯ Instruct client on proper application.

● CLIENT EDUCATION
◯ Apply high-potency corticosteroids as prescribed

to prevent adverse effects and take periodic
medication vacations.

◯ The provider can recommend warm, moist, occlusive
dressings of plastic wrap (gloves, plastic garments,
booties) after applying the topical medication. These
can be left in place up to 8 hr each day.

◯ Avoid application of high-potency medication on
face or into skin folds. Medication can be applied to
the scalp.

◯ Monitor for adverse effects of the medication
(hypopigmentation, atrophy).

Tar preparations: Coal tar and tars made from trees
(juniper, birch, and pine) suppress cellular division/
proliferation and reduce inflammation.

● NURSING ACTIONS
◯ Monitor skin for irritation.
◯ Instruct the client on proper application.

● CLIENT EDUCATION
◯ Tar applications can cause stinging and burning.
◯ Tar applications can cause staining of the
skin and hair.

◯ Due to odor and staining, apply this product at night
and cover areas of the body with old pajamas, gloves,
and socks.

Vitamin D analogs (calcipotriene, calcitriol) prevent
cellular proliferation and regulate skin cell division.

● NURSING ACTIONS
◯ Monitor for itching, irritation, and erythema.
◯ Monitor for hypercalcemia (elevated blood calcium,
muscle weakness, fatigue, anorexia).

● CLIENT EDUCATION
◯ Limit sun exposure due to increased risk of
developing skin cancer.

◯ Adhere to proper application. Do not put on face.
◯ Monitor for cancerous lesions.

Vitamin A (tazarotene) slows cellular division and
reduces inflammation and causes sloughing of skin cells.

● NURSING ACTIONS
◯ Medication is contraindicated during pregnancy.
◯ Monitor for localized reactions, burning sensation,
inflammation, and desquamation of the skin.

◯ Instruct clients on proper application.
● CLIENT EDUCATION

◯ Avoid exposure to sun or artificial UV light.
◯ Use reliable forms of birth control because medication
is teratogenic.

◯ Discontinue use and notify provider if
pregnancy occurs.

Systemic medications

Cytotoxic medications (methotrexate, acitretin)
reduce turnover of epidermal cells; used for severe,
intractable cases.

● NURSING ACTIONS
◯ Monitor liver and renal function tests for toxicity if
methotrexate or acitretin therapy is being used.

◯ Methotrexate can cause bone marrow suppression
(leukopenia, thrombocytopenia, anemia).

◯ Medication is contraindicated during pregnancy and
can cause fetal death or congenital anomalies.

● CLIENT EDUCATION
◯ Avoid alcohol while taking these medications.
◯ These medications can decrease the effectiveness
of contraceptives.

Biologic agents for moderate to severe plaque psoriasis
that suppress immune function (adalimumab, etanercept,
ustekinumab, alefacept, and infliximab) suppress the
stimulation of the keratinocytes.

● NURSING ACTIONS
◯ Evaluate for latent tuberculosis and hepatitis B virus.
◯ Inspect prefilled syringe for particles or discoloration.
◯ Rotate injection sites, and do not rub
after administration.

◯ Protect medication from light.
◯ Implement infection control measures. Client is at
risk for immunosuppression.

● CLIENT EDUCATION
◯ Do not to take if pregnant or breastfeeding.
◯ Properly administer subcutaneous medication.
◯ Report manifestations of infection.
◯ Treatment is lifelong, and there is an increased risk
of cancer.

◯ Do not receive any live vaccines while taking
the medication.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 74 sKin DisorDers 495

Cyclosporine and azathioprine: Immunosuppressant
medications are administered when lesions do not respond
to other therapies.

● Nephrotoxicity occurs and increases the risk
of infections.

● These are used for short-term therapy (less than
6 months).

● CLIENT EDUCATION: Monitor blood pressure throughout
therapy. Medication can cause hypertension.

therapeutic proceDures
Photochemotherapy and ultraviolet light (PUVA therapy)

● A psoralen photosensitizing medication (methoxsalen)
is administered followed by long-wave ultraviolet A
(UVA) to decrease proliferation of epidermal cells.

● Methoxsalen is given orally 1 hr before UV treatments.
● Treatments are given two to three times per week,

avoiding consecutive days.
● NURSING ACTIONS

◯ Monitor the client’s response.
◯ Ensure that the client wears eye protection during
treatment and for 24 hr following a treatment
(indoors and outside).

● CLIENT EDUCATION
◯ Notify the provider of extreme redness, swelling,
or discomfort.

◯ Long-term effects include premature skin aging,
cataracts, and skin cancer.

◯ Obtain regular eye examinations.
◯ Protect the skin with the use of sunscreen.

Narrow‑band ultraviolet B light therapy can be
implemented without medication application, and requires
fewer treatments.

Laser light therapy is used for mild to moderate psoriasis
to target lesions directly and decrease exposure to
surrounding skin.

nursing interventions
● Teach lifestyle modifications and coping strategies.
● Discuss treatment plan with the client.

CLIENT EDUCATION
● Use comfort measures (baths with emollients, oatmeal

baths, emollient creams) to soften scales.
● Do not to scratch or pick lesions.

Dermatitis

HEALTH PROMOTION AND
DISEASE PREVENTION

● Avoid exposure to harsh chemicals.
● Move the highlighted content to patient-centered care

(replace the sentence tat is there).

ASSESSMENT

risK factors
● External skin exposure to allergens
● Internal exposure to allergens and irritants
● Stress (eczematous dermatitis)
● Genetic predisposition (eczematous dermatitis)
● Specific cause not always known

eXpecteD finDings

Nonspecific eczematous dermatitis
● Development of thickened areas of skin
● Can appear dry or moist and crusted
● Pruritus
● Symmetrical involvement anywhere on the body

Contact dermatitis
● Contact dermatitis is caused by direct exposure to

allergen, chemical, or mechanical irritation.
● Rash is well-demarcated and localized.
● Distribution varies depending upon the cause and the

exposure to the allergen.

Atopic dermatitis
● Chronic rash
● Can be caused by allergens or chronic skin disease.
● Development of thickened areas of skin along with

scaling and desquamation
● Pruritus, which can be intense
● Distribution including face, neck, and upper torso along

with skin folds (antecubital, popliteal)

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496 CHAPTER 74 sKin DisorDers CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE
Avoidance therapy if cause identified

meDications
Steroid therapy: topical, intralesional, systemic
(hydrocortisone, betamethasone, triamcinolone,
prednisone)

● Reduce secondary inflammatory response of lesions
● NURSING ACTIONS

◯ Monitor for adrenal suppression.
◯ Instruct client about proper application.

● CLIENT EDUCATION
◯ If using steroids for long periods, taper doses when
discontinuing medication.

◯ Avoid using topical steroids on lesions that
are infected.

◯ Warm, moist dressings can be used over topical
application to increase absorption of medication.

◯ Avoid the use of occlusive dressings over rash after
applying topical steroid medications.

Antihistamines: topical, systemic (diphenhydramine,
cetirizine, fexofenadine)

● Relief of redness, pruritus, and edema
● NURSING ACTIONS: Monitor for urinary retention with

the use of systemic medications.
● CLIENT EDUCATION

◯ Product can cause photosensitivity.
◯ Avoid operating machinery and driving while taking
systemic antihistamine.

◯ Take systemic form at bedtime, as product can
cause drowsiness.

Topical immunosuppressants: tacrolimus, pimecrolimus
● For use in treatment of eczematous dermatitis that has

been resistant to glucocorticoid treatment
● Relieves inflammation
● NURSING ACTIONS

◯ Instruct client on application of medication.
◯ Monitor for erythema, burning sensation.
◯ Avoid the use of occlusive dressings.

● CLIENT EDUCATION
◯ Avoid use if infection is present.
◯ Discontinue use when rash clears.
◯ Avoid direct sunlight and the use of tanning beds.

Application Exercises

1. a nurse is providing information about a new
prescription for corticosteroid cream to a client who
has mild psoriasis. Which of the following instructions
should the nurse include? (select all that apply.)

a. apply an occlusive dressing after application.

B. apply three to four times per day.

c. Wear gloves after application
to lesions on the hands.

D. avoid applying in skin folds.

e. use medication continuously over
a period of several months.

2. a nurse is teaching a client who has a history of
psoriasis about photochemotherapy and ultraviolet
light (puva) treatments. Which of the following
instructions should the nurse include in the teaching?

a. apply vitamin a cream before each treatment.

B. administer a psoralen medication
before the treatment.

c. use this treatment every evening.

D. remove the scales gently following each treatment.

3. a nurse is educating a client on the use of
calcipotriene topical medication for the
treatment of psoriasis. Which of the following
laboratory values should the nurse monitor?

a. potassium

B. calcium

c. sodium

D. chloride

4. a nurse is providing teaching to the guardian of
a child who has contact dermatitis. Which of the
following information should the nurse include?

a. use fabric softener dryer sheets when
drying the child’s clothing.

B. apply a warm, dry compress to the rash area.

c. place the child in a bath with colloidal oatmeal.

D. leave the child’s hands uncovered during the night.

5. a nurse caring for a client who has contact
dermatitis and has a new prescription for
diphenhydramine. for which of the following
adverse effects should the nurse monitor?

a. elevated blood glucose levels

B. anorexia

c. increased salivation

D. insomnia

Active Learning Scenario

a nurse is providing information to a client who
has a prescription for pimecrolimus to treat severe
eczematous dermatitis. What information should
the nurse include? use the ati active learning
template: medication to complete this item.

THERAPEUTIC USES

NURSING INTERVENTIONS: Describe two.

CLIENT EDUCATION: Describe two teaching points.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 74 sKin DisorDers 497

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

THERAPEUTIC USES: relieve itching associated with atopic dermatitis

NURSING INTERVENTIONS
● instruct client on application of medication.
● monitor for erythema, burning sensation.
● avoid the use of occlusive dressings.

CLIENT EDUCATION
● Discontinue use when rash clears.
● avoid direct sunlight and the use of tanning beds.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

Application Exercises Key

1. a. CORRECT: an occlusive dressing can enhance the efficacy
of the topical corticosteroid on the exposed lesions.

B. corticosteroid cream is applied twice daily to prevent
development of local and systemic adverse effects.

c. CORRECT: gloves worn after the medication can
enhance the efficacy of the topical corticosteroid
on the exposed lesions of the hands.

D. CORRECT: corticosteroid cream applied to lesions in
skin folds increases the risk of yeast infections.

e. the client should take periodic medication
“vacations” to minimize the risk for development
of local and systemic adverse effects.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

2. a. puva treatment does not involve the
use of vitamin a cream.

B. CORRECT: puva treatment involves the administration of
a medication (psoralen) to enhance photosensitivity.

c. puva treatments are completed two to three times
each week and not on consecutive days.

D. removal of scales can cause bleeding and is not
recommended when treating psoriasis.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. calcipotriene does not cause hypokalemia
or hyperkalemia.

B. CORRECT: hypercalcemia is a possible
adverse effect of calcipotriene.

c. calcipotriene does not cause hyponatremia
or hypernatremia.

D. calcipotriene does not cause hypochloremia
or hyperchloremia.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. a. the guardian should avoid the use of fabric softener
dryer sheets when cleaning the child’s clothing.
liquid fabric softener can be used.

B. the guardian should apply a cool, moist compress to
the child’s rash area to decrease inflammation.

c. CORRECT: the use of a colloidal oatmeal
bath will relieve the child’s itching.

D. the guardian should apply mittens on the child’s hands
at night to decrease unconscious scratching of the
rash, which can lead to a secondary infection.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

5. a. glucocorticoids (prednisone) can increase
blood glucose levels. however, this is not an
adverse effect of diphenhydramine.

B. CORRECT: monitor the client for anorexia, which is
a possible adverse effect of diphenhydramine.

c. increased salivation is not an adverse effect of
diphenhydramine. monitor the client for dry mouth.

D. Diphenhydramine is a first-generation antihistamine and
can cause excessive drowsiness rather than insomnia.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

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498 CHAPTER 74 sKin DisorDers CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 75 Burns 499

UNIT 11 INTEGUMENTARY DISORDERS
SECTION: INTEGUMENTARY DISORDERS

CHAPTER 75 Burns
Dry heat, moist heat, direct contact with hot
surfaces, chemicals, electricity, and ionizing
radiation can cause burns, which result in cellular
destruction of the skin layers and underlying
tissue. the type and severity of the burn affect
the treatment plan.

in addition to destruction of body tissue, a
burn injury results in the loss of temperature
regulation, sweat and sebaceous gland function,
and sensory function. When the dermis is
destroyed, skin can no longer regrow over the
affected area. metabolism increases to maintain
body heat as a result of burn injury and tissue
damage. every body system can be affected
following major burns.

tYpes of Burns
Dry heat injuries result from open flames and explosions.

Moist heat injuries result from contact with hot liquid or
steam. Scald injuries are more common in older adults and
younger children.

Contact burns occur when hot metal, tar, or grease
contacts the skin.

Chemical burns result from exposure to a caustic agent.
Cleaning agents in the home (drain cleaner, oven cleaner,
bleach) and agents in the industrial setting (caustic soda,
sulfuric acid) can cause chemical burns.

Electrical burns result when an electrical current
passes through the body and can cause severe damage,
including loss of organ function, tissue destruction with
subsequent need for amputation of a limb, and cardiac or
respiratory arrest.

Thermal burns result when clothes ignite from heat or
flames that electrical sparks produce.

Flash (arc) burns result from contact with an electrical
current that travels through the air from one conductor
to another.

Conductive electrical injury results when a person
touches electrical wiring or equipment.

Radiation burns most often result from therapeutic
treatment for cancer or from sunburn.

severitY of the Burns
Percentage of total body surface area (TBSA): Use
standardized charts for age groups to identify the extent
of the injury and calculate medication doses, fluid
replacement volumes, and caloric needs.

Depth of the burn: Classify burns according to the layers
of skin and tissue involved: superficial, partial, full, and
deep full thickness.

Body location of the burn: In areas where the skin is
thinner, there is more damage to underlying tissue (any
part of the face, hand, perineum, feet).

Age: Young clients and older adult clients have less reserve
capacity to deal with a burn injury. Skin thins with aging,
so more damage to underlying tissue can occur.

Causative agent: Thermal, chemical, electrical,
or radioactive.

Presence of other injuries: Fractures or other injuries
increase the risk of complications.

Involvement of the respiratory system: Inhalation of
deadly fumes, smoke, steam, and heated air can cause
respiratory failure or airway edema. Carbon monoxide
poisoning also can occur, especially if the injury took
place in an enclosed area.

Overall health of the client: A client who has a chronic
illness has a greater risk of complications and a
worse prognosis.

Burn inJurY classification
Burn injuries can be classified by combining information
about the type, severity, and body surface area. This
information is used to determine treatment and referral.

Minor burns are treated at the scene and followed up at a
local emergency department.

● Full-thickness burns of less than 2% TBSA
● Or partial-thickness of less than 10% TBSA

Moderate burns are treated at the scene, then the client
transported to a burn center or specialized medical
facility.

● Full-thickness burns of 2% to 10% TBSA
● Or partial-thickness of 15% to 25% TBSA

Major burns require emergency treatment at the closest
facility, then immediate transfer to a burn center. Clients
who meet any one of the following criteria are considered
to have a major burn, even if the depth and TBSA
percentage would place them in a lower category.

● Full-thickness burns greater than 10% TBSA
● Or partial-thickness burns greater than 25% TBSA
● Age older than 60 years
● Presence of a chronic cardiac, pulmonary, or

endocrine condition
● Presence of electrical burn injury
● Presence of inhalation injury or other complicated injury
● Burns to the eyes, ears, face, hands, feet, or perineum

CHAPTER 75

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500 CHAPTER 75 Burns CONTENT MASTERY SERIES

HEALTH PROMOTION AND
DISEASE PREVENTION

● Ensure that the number and placement of fire
extinguishers and smoke alarms in the home is
adequate and operable. Family members should know
how to use the extinguishers.

● Keep emergency numbers near the phone.
● Have a family exit and meeting plan for fires. Reinforce

that no one should ever re-enter a burning building.
● Follow the principles of “stop, drop, and roll” to

extinguish fire on clothing or skin.
● Store matches and lighters out of reach and out of

sight of children and adults who lack the ability to
protect themselves.

● Reduce the setting on water heaters to 48.9° C (120° F).
● Have an annual professional inspection and cleaning of

the chimney and fireplace.
● Turn handles of pots and pans to the side, or use

back burners.
● Don’t leave hot cups on the edge of the counter.
● Cover electrical outlets.
● Keep flammable objects away from heat sources

(candles, space heaters).
● Wear gloves when handling chemicals and keep

chemicals out of reach of children.
● Wear protective clothing during sun exposure and

use sunscreen.
● Avoid using tanning beds.
● Avoid smoking in bed and when under the influence of

alcohol or sedating medications.
● Do not smoke or have open flames in a room where

oxygen is in use.
● Never add flammable substances (gasoline, lighter fluid,

kerosene) to an open flame.

ASSESSMENT

risK factors
Exposure to sources of heat, flame, explosion, hot liquids,
chemicals, or radiation

OLDER ADULTS
● Higher risk for damage to subcutaneous tissue, muscle,

connective tissue, and bone because of thinner skin
● Higher risk for complications from burns

because of chronic illnesses (diabetes mellitus,
cardiovascular disease)

eXpecteD finDings
Report of burn agent (dry heat, moist heat, chemical,
electrical, ionizing radiation)

PHYSICAL ASSESSMENT FINDINGS (75.2)
● Inhalation damage findings include singed nasal hair,

eyebrows, and eyelashes; sooty sputum; hoarseness;
wheezing; edema of the nasal septum; and smoky
smelling breath. Indications of the impending loss of
the airway include hoarseness, brassy cough, drooling
or difficulty swallowing, and audible wheezing, crowing,
and stridor.

● Carbon monoxide inhalation (from burns in an enclosed
area) findings include headache, weakness, dizziness,
confusion, erythema (pink or cherry red skin), and
upper airway edema, followed by sloughing of the
respiratory tract mucosa.

● Hypovolemia and shock can result from fluid shifts
from the intercellular and intravascular space to
the interstitial space. Additional findings include
hypotension, tachycardia, and decreased cardiac output.

Online Images: Burn Staging

75.1 Depth of injury

Superficial
thickness

Superficial
partial thickness

Deep
partial thickness Full thickness

Deep
full thickness

AREA
INVOLVED

Damage to
epidermis

Damage to the
entire epidermis
and some parts
of the dermis

Damage to entire
epidermis and deep
into the dermis

Damage to the entire
epidermis and dermis
can extend into the
subcutaneous tissue
nerve damage

Damage to all
layers of skin
extends to muscle,
tendons, and bones

APPEARANCE

pink to red
no blisters
mild edema
no eschar

pink to red
Blisters
mild to
moderate edema
no eschar

red to white
Blisters rare
moderate edema
eschar soft and dry

red, black, brown,
yellow, or white
no blisters
severe edema
eschar hard and inelastic

Black
no blisters
no edema
eschar hard
and inelastic

SENSATION/
HEALING

painful/tender
sensitive
to heat
heals within
3 to 6 days
no scarring

painful
heals within
2 to 3 weeks
no scarring, but
minor pigment
changes

painful and sensitive
to touch
heals in 2 to 6 weeks
scarring likely
possible grafting

sensation minimal or absent
heals within weeks to months
scarring
grafting

no pain
heals within
weeks to months
scarring
grafting

EXAMPLE

sunburn
flash burn
(sudden
intense heat)

flash flame
and scalds
Brief contact
with hot object

flame and scalds
grease, tar, or
chemical burns
prolonged exposure
to hot objects

scalds
grease, tar, chemical,
or electrical burns
prolonged exposure
to hot objects

high-voltage
or prolonged
electrical burns
flames

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 75 Burns 501

methoDs to assess Burns
Rule of Nines: Quick method to approximate the extent
of burns by dividing the body into multiples of nine. The
sum equals the TBSA.

Lund and Browder method: A more exact method
estimating the extent of burn by the percentage of surface
area of specific anatomic parts, particularly the head
and legs.

Palmar method: Quick method to approximate scattered
burns using the palm of the client’s hand. The palm of the
hand (including the fingers) is equal to 1% TBSA.

laBoratorY tests
Resuscitation phase: Initial fluid shift (occurs in the first
12 hr and continues for 24 to 36 hr)

● CBC with differential
● Glucose: elevated due to stress
● BUN: elevated due to fluid loss
● Hct and Hgb: elevated (hemoconcentration) due to

the loss of fluid volume and the fluid shift into the
interstitial space (third spacing)

● Electrolytes
◯ Sodium: decreased due to third spacing
(hyponatremia)

◯ Potassium: increased due to cell destruction
(hyperkalemia)

◯ Chloride: increased due to fluid volume loss and
chlorine reabsorption in urine

● Carboxyhemoglobin: more than 10% strongly indicates
smoke inhalation

● Plasma lactate: elevated if the client has
cyanide toxicity

● Other: total protein and blood albumin (decreased),
ABGs (possible metabolic acidosis), liver enzymes,
urinalysis, and clotting studies

Fluid remobilization (starts at about 24 hr; diuretic stage
begins at 48 to 72 hr after injury)

● Hgb and Hct: decreased (hemodilution) due to the fluid
shift from the interstitial space back into vascular fluid

● Sodium: remains decreased due to renal and wound loss
● Potassium: decreased due to renal loss and movement

back into cells (hypokalemia)
● WBC count: initial increase then decrease with left shift
● Blood glucose: elevated due to the stress response
● ABGs: slight hypoxemia and metabolic acidosis
● Total protein and albumin: low due to fluid loss

Diagnostic proceDures
Diagnostic studies can include renal scans, computed
tomography, ultrasonography, bronchoscopy, and
magnetic resonance imaging to determine the extent of
the burn injury.

● Indirect calorimetry can help determine calorie needs
(on admission to a burn center and weekly).

● Evaluation of burn depth using indocyanine green video
angiography and laser Doppler imaging. Thermography
is not as reliable.

ASSESSMENT

risK factors
Exposure to sources of heat, flame, explosion, hot liquids,
chemicals, or radiation

OLDER ADULTS
● Higher risk for damage to subcutaneous tissue, muscle,

connective tissue, and bone because of thinner skin
● Higher risk for complications from burns

because of chronic illnesses (diabetes mellitus,
cardiovascular disease)

eXpecteD finDings
Report of burn agent (dry heat, moist heat, chemical,
electrical, ionizing radiation)

PHYSICAL ASSESSMENT FINDINGS (75.2)
● Inhalation damage findings include singed nasal hair,

eyebrows, and eyelashes; sooty sputum; hoarseness;
wheezing; edema of the nasal septum; and smoky
smelling breath. Indications of the impending loss of
the airway include hoarseness, brassy cough, drooling
or difficulty swallowing, and audible wheezing, crowing,
and stridor.

● Carbon monoxide inhalation (from burns in an enclosed
area) findings include headache, weakness, dizziness,
confusion, erythema (pink or cherry red skin), and
upper airway edema, followed by sloughing of the
respiratory tract mucosa.

● Hypovolemia and shock can result from fluid shifts
from the intercellular and intravascular space to
the interstitial space. Additional findings include
hypotension, tachycardia, and decreased cardiac output.

Online Images: Burn Staging

75.2 Burn staging

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502 CHAPTER 75 Burns CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

phases of Burn care

Emergent (resuscitative phase)
● This phase begins with the injury and continues for
24 to 48 hr.

● Priorities include securing the airway, supporting
circulation and organ perfusion by fluid replacement,
managing pain, preventing infection through wound
care, maintaining body temperature, and providing
emotional support.

Acute
● This phase begins 36 to 48 hr after injury when the fluid

shift resolves.
● Phases ends with closure of the wound.
● Priorities include assessment and maintenance of

the cardiovascular, respiratory, and gastrointestinal
systems (including nutrition); wound care; pain control;
and psychosocial interventions.

Rehabilitative
● This phase begins when most of the burn area

has healed.
● Phase ends when the client achieves the highest level

of functioning possible.
● Priorities include psychosocial support; prevention of

scars and contractures; and resumption of activities,
including work, family, and social roles.

● This phase can last for years.

nursing care
Stop the burning process.

● If providing care at the burn scene, extinguish flames or
remove the source of fire.

● Remove clothing or jewelry that might conduct heat.
● Apply cool water soaks or run cool water over injury; do

not use ice.
● Flush chemical burns with a large volume of water.
● Cover the burn with a clean cloth to prevent

contamination and hypothermia.
● Provide warmth.
● Perform an ABCDE primary survey and

provide treatment.

Minor burns
● Provide analgesics.
● Cleanse with mild soap and tepid water. (Avoid

excess friction.)
● Use antimicrobial ointment.
● Apply a dressing (nonadherent, hydrocolloid) if clothing

is irritating the burn.
● Educate the family to avoid using greasy lotions or

butter on the burn.
● Teach the family to observe for evidence of infection.
● Determine the need for a tetanus immunization.

Moderate and major burns

During the initial (resuscitation) phase (from the time
of injury to 12 to 48 hr later) following a major burn,
sympathetic nervous system manifestations (tachycardia,
increased respiratory rate, decreased gastrointestinal
motility, increased blood glucose) are expected findings.

Respiratory system
● Assess respiratory rate and depth. Monitor chest

expansion during respiration to ensure that eschar
or chest dressings on chest, neck, and back do not
restrict movement.

● Upper airway edema becomes pronounced 8 to 12 hr
after the beginning of fluid resuscitation. Crowing,
stridor, or dyspnea requires nasal or oral intubation.

● Provide humidified supplemental oxygen.
● Support the airway and ventilation. Mechanical

ventilation and paralytic medications (atracurium or
vecuronium) can become necessary if the PaO2 is less
than 60 mm Hg. A tracheotomy can be required when
long-term intubation is expected.

● Monitor and maintain chest tubes.
● Perform chest physiotherapy and have the client cough,

breathe deeply, and use incentive spirometry.
● Suction (endotracheal or nasotracheal) every hour or as

needed. Consider the need for additional analgesics.

Cardiovascular system: Monitor central and
peripheral pulses, capillary refill, pulse oximetry,
invasive or noninvasive blood pressure, and for
electrocardiographic changes or the presence of edema.

Fluid replacement
● Third spacing (capillary leak syndrome) is a continuous

leak of plasma from the vascular space into the
interstitial space, which results in electrolyte imbalance
and hypotension.

● Initiate IV access using a large-bore needle. If
burns cover a large area of the body, the client
requires insertion of a central venous catheter or
intraosseous catheter.

● Fluid resuscitation meets individual clients’ needs
(TBSA of burn, burn depth, inhalation injury, associated
injuries, age, urine output, cardiac output, blood
pressure, status of electrolytes).

● Administer half of the total 24-hr IV fluid volume
within the first 8 hr from the time the burn occurred
and the remaining volume over the next 16 hr.

● Infuse isotonic crystalloid solutions (0.9% sodium
chloride or lactated Ringer’s).

● Infuse colloid solutions (albumin or synthetic plasma
expanders) after the first 24 hr of burn recovery.

● Monitor vital signs.
● Assess for fluid overload: edema, engorged neck veins,

rapid and thready pulse, lung crackles, wheezes.
● Weigh the client daily.
● Monitor urine hourly for color, specific gravity, protein,

and to ensure output of 30 mL/hr (0.5 mL/kg/hr).
● Prepare to administer blood products.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 75 Burns 503

● Monitor for manifestations of shock.
◯ Alterations in sensorium (confusion)
◯ Increased capillary refill time
◯ Urine output less than 30 mL/hr
◯ Rapid elevations of temperature
◯ Decreased bowel sounds
◯ Blood pressure average or low

● If urine output is below the expected reference range,
request a prescription to increase fluid replacement, and
do not administer diuretics.

Comfort management
● Monitor pain and the effectiveness of pain treatment.
● Avoid routes other than IV during the resuscitation

phase due to decreased absorption from other routes.
● Use IV opioid analgesics (morphine, hydromorphone,

and fentanyl or anesthetics [ketamine, and
nitrous oxide]).

● Monitor for respiratory depression when administering
opioid analgesics.

● The use of patient-controlled analgesia (PCA) is
appropriate for some clients. PCA helps manage pain,
and the client benefits from having a sense of control.

● Administer pain medication prior to dressing changes
and procedures.

● Use nonpharmacologic methods for pain control
(guided imagery, music therapy, and therapeutic touch)
to enhance the effects of analgesic medications and
manage pain more effectively.

● Provide a restful environment and nonpainful touch to
help increase comfort (massage of non-burned areas)
and promote rest.

● Involve the client in decision-making (mutually
agreeing on how long painful procedure will take),
which can reduce pain-related anxiety.

● Provide relief for pruritus, which can be highly stressful
for the client. Administer oral antipruritics, keep skin
lubricated, and provide diversions.

● Instruct the client to pat rather than scratching to
relieve itching.

Thermoregulation
● The skin helps control the body’s temperature. With

skin injury, the body loses heat. Decreased temperatures
can occur in the first few hours following burn injury.

● For decreased temperature, use warm, inspired air,
a warm room, warming blankets, and warmers for
infusing fluids. Keep wounds covered or work quickly
when wounds must be exposed.

● Low-grade fever can occur later after the first few hours
following injury due to increased metabolism, and the
temperature can remain increased for several weeks.

Gastrointestinal system
● Clients might need NG tube insertion to reduce the risk

of aspiration or for bowel decompression. Some clients
experience gastroparesis and vomiting.

● Monitor stool, vomitus, and gastric secretions for blood.
● Assess for hypomotility and for tolerance of feedings.

Urinary system
● Insert an indwelling urinary catheter.
● Monitor I&O.
● Monitor for red-tinged urine as an indication of damage

to red blood cells or muscles.
● Glycosuria is expected due to breakdown of glycogen as

part of the stress response.

Infection prevention
● Maintain a protective environment.
● Restrict plants and flowers due to the risk of contact

with Pseudomonas aeruginosa.
● Check facility policy regarding consumption of fresh

fruits and vegetables, which can be restricted.
● Limit visitors; do not allow sick individuals, small

children, or other clients to visit.
● Monitor for manifestations of infection and report them

to the provider.
● Use client-dedicated equipment (blood pressure cuffs,

thermometers).
● Administer tetanus toxoid.
● Administer antibiotics to treat infection. Monitor peak

and trough levels.
● Use strict asepsis with wound care.

Nutritional support
● A loss of 10% or more body weight indicates a need for

additional calorie intake.
● Large burn areas create a hypermetabolic and

hypercatabolic state, requiring 5,000 calories/day.
Caloric needs double or triple 4 to 12 days after the burn.

● Increase caloric intake to meet increased metabolic
demands and prevent hypoglycemia.

● Increase protein intake to prevent tissue breakdown and
promote healing, and provide high carbohydrates (55%
to 60% of intake) to decrease protein catabolism.

● Decreased gastrointestinal motility and increased
caloric needs require enteral therapy or total
parenteral nutrition.

● Perform a calorie count daily.

Restoration of mobility
● Maintain correct body alignment, splint extremities,

and facilitate position changes to prevent contractures.
● Maintain active and passive range of motion.
● Assist with ambulation as soon as the client is stable.
● Apply pressure dressings to prevent contractures

and scarring.
● Monitor areas at high risk for pressure sores (heels,

sacrum, back of the head).

Psychological support of client and family
● Provide emotional support.
● Assist with coping.
● The client might require antianxiety medications.
● Address body image with the client and discuss any

concerns about altered appearance.
● Assist client through the stages of grieving.
● Provide peer support, with the client’s approval.

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504 CHAPTER 75 Burns CONTENT MASTERY SERIES

meDications

Silver nitrate 0.5%

Apply with a gauze dressing.

ADVANTAGES
● Reduces fluid evaporation
● Bacteriostatic
● Inexpensive

DISADVANTAGES
● Does not penetrate eschar
● Stains clothing and linen
● Depletes sodium and potassium

Silver sulfadiazine 1%

Apply a thin layer with a clean glove.

ADVANTAGES
● Usually pain-free
● Effective against gram-negative bacteria,

gram-positive bacteria, and yeast

DISADVANTAGES
● Can cause transient neutropenia
● Sulfa allergy, which is a contraindication
● Penetrates eschar minimally
● Can cause a gray or blue-green discoloration
● Decreases granulocyte formation

Mafenide acetate

Apply twice daily.

ADVANTAGES
● Penetrates eschar and goes into underlying tissues
● Bacteriostatic against gram-negative and

gram-positive bacteria

DISADVANTAGES
● Painful to apply and remove
● Can cause metabolic acidosis

Polymyxin B‑bacitracin

Apply every 2 to 8 hr to keep the burn moist.

ADVANTAGES
● Bacteriostatic against gram-positive organisms
● Painless and easy to apply

DISADVANTAGES: Hypersensitivity can develop.

Gentamicin topical

Aminoglycoside anti-infective agent

ADVANTAGES: Bactericidal aminoglycoside

DISADVANTAGES
● Nephrotoxic: Monitor kidney function.
● Ototoxic: Monitor for hearing loss weekly.

Mannitol

Used following some electrical burns when obstruction
of the renal tubules with protein myoglobin hinders
urine output.

Other medications
● Antianxiety and antipruritic medications
● Antimicrobial ointment
● Electrolyte replacement

therapeutic proceDures

Wound care

NURSING ACTIONS
● Premedicate the client with an analgesic.
● Remove all previous dressings.
● Assess for odors, drainage, and discharge.
Assess for sloughing, eschar, bleeding, and new
skin-cell regeneration.

● Cleanse the wound thoroughly, removing all
previous ointments.

● Assist with debridement.
◯ Mechanical: Use scissors and forceps to cut away the
dead tissue during the hydrotherapy treatment.

◯ Hydrotherapy: Assist the client into a warm tub of
water or use warm running water, as if to shower, to
cleanse the wound.

■ Use mild soap or detergent to wash burns gently,
and then rinse with room-temperature water.

■ Encourage the client to exercise the joints during
hydrotherapy treatment.

◯ Chemical: Apply a topical enzyme to break down and
remove dead tissue.

■ Apply topical enzyme agents (collagenase) to the
wound during a daily dressing change.

● Use surgical asepsis while applying a thin layer of
topical antibiotic ointment and cover it with a dressing.

Escharotomy

Incision through the eschar relieves pressure from the
constricting force of fluid buildup under circumferential
burns on the extremity or chest and improves circulation.

Fasciotomy

Incision through eschar and fascia relieves tissue pressure
when escharotomy alone does not.

Skin coverings

Biologic skin coverings temporarily promote healing of
large burns. Additionally, biologic skin coverings promote
the retention of water and protein and provide coverage of
nerve endings, thus reducing pain. The provider stipulates
whether to leave skin coverings open or protect them with
a dressing.

● Allograft (homograft): Skin donations from human
cadavers for partial- and full-thickness burn wounds

● Xenograft (heterograft): Skin from animals (pigs) for
partial-thickness burn wounds

● Amnion: From human placenta; requires
frequent changes

● Cultured skin: Grows from a small specimen of
epidermal cells from an unburned area

● Artificial skin: Two layers of skin made from beef
collagen and shark cartilage

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 75 Burns 505

Synthetic skin coverings are made from plastic or silicone
and are usually clear. They allow for wound visualization
and reduce pain.

Biosynthetic dressings contain both synthetic and
biological materials.

● Used for superficial partial-thickness burns or donor
site dressing

● Allows exudate to drain through the wound

Wound grafting can be the treatment of choice for burns
covering large areas of the body.

● Autografts: Skin from another area of the client’s body
◯ Sheet graft: Sheet of skin for covering the wound
◯ Mesh graft: Sheet of skin in which a mesher has
created small slits, so the graft can stretch over large
areas of the burn

● Artificial skin: Synthetic product for faster healing of
partial- and full-thickness burns

● Cultured epithelium: Epithelial cells to use for clients
who have few grafting sites

NURSING ACTIONS
● Maintain immobilization of graft sites.
● Elevate extremities.
● Provide wound care to the donor site.
● Administer analgesics.
● Monitor for infection before and after applying skin

coverings or grafts.
◯ Discoloration of unburned skin surrounding

burn wound
◯ Green subcutaneous fat
◯ Degeneration of granulation tissue
◯ Development of subeschar hemorrhage
◯ Hyperventilation indicating systemic involvement
of infection

◯ Unstable body temperature
● Determine the client’s level of pain, and provide

additional measures to control donor site pain.

CLIENT EDUCATION
● Keep the extremity elevated.
● Report manifestations of infection.
● Continue to perform range-of-motion exercises and

work with a physical therapist to prevent contractures.
● Observe the wound for infection and perform

wound care.

Excision of wound tissue or surgical debridement

Removal of thin layers of necrotic tissue until bleeding
occurs, which indicates viable tissue. Can be replaced
throughout the restoration process.

Cosmetic or reconstructive surgeries

The client might elect to have these procedures following
recovery, which might be years after the injury.

interprofessional care
● Initiate referrals to a dietitian, social worker (for

community support services), psychological counselor,
and physical therapist.

● Respiratory therapy can help improve
pulmonary function.

● Consult a case manager to coordinate the client’s
postdischarge care, and assist the client with
reintegration into the community, work, or school.

● Initiate a referral for home health nursing care.
● Initiate a referral to occupational therapy for evaluation

of the home environment and assistance to relearn how
to perform ADLs.

● Specialists can evaluate vision and hearing if eyes and
ears are affected.

● Speech therapy can be indicated.
● Prosthetics might be required.

client eDucation
● Infection control precautions are extremely important

to prevent harm.
● In the acute phase, it is common to experience many

feelings (confusion, anxiety, fear). Talk about these
feelings with the provider and people you care about.

● Peer or support groups can be helpful in coping.
● Anticipate changes in appearance from wounds or

surgical procedures, and understand that scarring and
discoloration will occur.

● Wear compression dressings and garments as prescribed
(usually 23 hr daily) to minimize scarring and prevent
difficulty with mobility.

● Massage scars with moisturizers daily.
● Avoid tight clothing over burned areas. Loose fitting

clothing from dye-free fabric is best.
● Participate in sexual activity as desired.
● Use splints and assistive devices as instructed.
● Follow-up appointments are often required for 2 years

following burn injury.

COMPLICATIONS

Airway injury
● Thermal injuries to the airway can result from steam

or chemical inhalation, aspiration of scalding liquid,
and external explosion while breathing. If the injury
took place in an enclosed space, suspect carbon
monoxide poisoning.

● Effects might not manifest for 24 to 48 hr. They
include progressive hoarseness, brassy cough, difficulty
swallowing, drooling, copious secretions, adventitious
breath sounds, and expiratory sounds that include
audible wheezes, crowing, and stridor.

NURSING ACTIONS: Support the airway and ventilation,
and administer supplemental oxygen.

CLIENT EDUCATION: Perform airway management (deep
breathing, coughing, and elevating the head of the bed).

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506 CHAPTER 75 Burns CONTENT MASTERY SERIES

Fluid imbalances

Hypovolemic shock is possible with inadequate fluid
replacement. Excessive or rapid replacement can lead to
heart failure.

NURSING ACTIONS
● Monitor for indications of inadequate perfusion,

confusion, hypotension, or decreased urine output.
● Monitor for indications of excessive hydration

(bounding pulse, lung crackles, persistent edema,
venous distention).

Sepsis

Most common cause of death following burn injury

NURSING ACTIONS
● Assess for discoloration, edema, odor, and drainage.
● Assess for fluctuations in temperature and heart rate.
● Obtain specimens for wound culture.
● Administer antibiotics.
● Monitor laboratory results, observing for anemia

and infection.
● Use surgical aseptic technique with dressing changes.
● Educate the client and family about the importance of

infection control.

Impaired muscle and joint mobility

Scarring and contractures: Deep burns can limit
movement of bones and joints. Scar tissue can form and
cause shortening and tightening of skin, muscles, and
tendons (contractures).

NURSING ACTIONS
● Assist with active or passive range-of-motion exercises

at least three times daily.
● Encourage neutral positions with limited flexion.

Encourage the use of splints.
● Encourage ambulation as soon as possible.
● Use compression dressings for up to 24 months to

increase mobility and reduce scarring.

Compartment syndrome

Can develop as edema increases and the skin has lost
elasticity due to damage

NURSING ACTIONS: Monitor peripheral circulation on
affected extremities, and report adverse findings to
the provider.

Paralytic ileus

NURSING ACTIONS
● Monitor bowel sounds and for abdominal distention.
● Provide NG decompression until motility returns.
● Report paralytic ileus to the provider because it can be

an indicator of systemic infection.

Post‑traumatic stress disorder

NURSING ACTION: Encourage the client to discuss
feelings regarding the event. Initiate referral to a mental
health professional.

Application Exercises

1. a nurse in a provider’s office is assessing
a client who has a severe sunburn. Which
of the following classifications should the
nurse use to document this burn?

a. superficial thickness
B. superficial partial thickness
c. Deep partial thickness
D. full thickness

2. a nurse is caring for a client who has sustained
burns over 35% of total body surface area. the
client’s voice has become hoarse, a brassy cough
has developed, and the client is drooling. the
nurse should identify these findings as indications
that the client has which of the following?

a. pulmonary edema
B. Bacterial pneumonia
c. inhalation injury
D. carbon monoxide poisoning

3. a nurse is assessing a client who sustained deep
partial-thickness and full-thickness burns over 40% of
the body 24 hr ago. Which of the following are findings
are common during this phase? (select all that apply.)

a. temperature 36.1º c (97º f)
B. Bradycardia
c. hyperkalemia
D. hyponatremia
e. Decreased hematocrit

4. a nurse is preparing to administer fentanyl to a
client who sustained deep partial-thickness and
full-thickness burns over 60% of the body 24 hr
ago. the nurse should plan to use which of the
following routes to administer the medication?

a. subcutaneous
B. oral
c. intravenous
D. transdermal

5. a nurse is planning care for an adult client who
sustained severe burn injuries. Which of the
following interventions should the nurse include
in the plan of care? (select all that apply.)

a. limit visitors in the client’s room.
B. encourage fresh vegetables in the diet.
c. increase protein intake.
D. instruct the client to consume 2,000 calories/day.
e. restrict fresh flowers in the room.

Active Learning Scenario

a nurse is reviewing the care of a client who has an autograft
skin covering over a burn injury with a nurse who will assume
care of the client at the end of the day. What should the
nurse include in the review? use the ati active learning
template: therapeutic procedure to complete this item.

DESCRIPTION OF PROCEDURE

NURSING INTERVENTIONS: Describe at least four.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 75 Burns 507

Application Exercises Key

1. a. CORRECT: a sunburn is a superficial thickness burn.
superficial burns damage the top layer of the skin.

B. a superficial partial-thickness burn results from flames or
scalds. this damages the entire epidermis layer of the skin.

c. a deep partial-thickness burn can result from contact with
hot grease. this affects the deep layers of the skin.

D. a full-thickness burn can result from contact
with hot tar. this affects the dermis and
sometimes the subcutaneous fat layer.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. Difficulty breathing and production of pink frothy
sputum indicate pulmonary edema.

B. productive cough and a fever are indicative
of a bacterial infection.

c. CORRECT: Wheezing and hoarseness indicate inhalation
injury with impending loss of the airway. these
require immediate reporting to the provider.

D. confusion and headaches indicate
carbon monoxide poisoning.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. a. CORRECT: Decreased temperature can occur in the first
few hours following a burn, because the body’s ability
to regulate temperature is compromised.

B. tachycardia occurs during the initial phase following a burn
due to sympathetic nervous system compensation.

c. CORRECT: hyperkalemia occurs during the initial
phase following a burn as a result of leakage
of fluid from the intracellular space.

D. CORRECT: hyponatremia occurs during the initial phase of a
burn as a result in sodium retention in the interstitial space.

e. hct increases during the initial phase of a
burn due to hemoconcentration.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. a. Do not give subcutaneous injections due to the difficulty of
absorption from tissue during the resuscitation phase.

B. Do not give oral (including buccal, sublingual)
medications due to decreased absorption in the
gastrointestinal tract during the resuscitation phase.

c. CORRECT: use the iv route to administer pain
medication for rapid absorption and fast pain
relief during the resuscitation phase.

D. Do not use the transdermal route of administration due to
delays in absorption during the resuscitation phase.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

5. a. CORRECT: limit visitors and ensure ill individuals do not
visit the client, to decrease the risk of infection.

B. some facilities restrict consumption of fresh
vegetables due to the presence of bacteria on the
surface and the increased risk for infection.

c. CORRECT: the client should increase protein
consumption, which promotes wound healing
and prevents tissue breakdown.

D. the client should consume up to 5,000 calories/day
because caloric needs double or triple beginning 4 to
12 days following the burn.

e. CORRECT: flowers should not be in the client’s room due to
the bacteria they carry, which increase the risk for infection.

NCLEX® Connection: Physiological Adaptation,
Illness Management

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

DESCRIPTION OF PROCEDURE: an autograft is donor skin
from another area of the client’s body. this is a permanent skin
covering and used for burns on larger areas of the body.

NURSING INTERVENTIONS
● maintain immobilization of the graft site.
● elevate the extremity.
● provide wound care to the donor site.
● administer analgesics.
● monitor for evidence of infection before and
after skin coverings or grafts are applied.

◯ Discoloration of unburned skin surrounding burn wound
◯ green color to subcutaneous fat
◯ Degeneration of granulation tissue
◯ Development of subeschar hemorrhage
◯ hyperventilation indicating systemic involvement of infection
◯ unstable body temperature

NCLEX® Connection: Physiological Adaptation,
Illness Management

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508 CHAPTER 75 Burns CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING ncleX® connections 509

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Health Promotion and Maintenance
HEALTH PROMOTION/DISEASE PREVENTION: Educate client
on actions to promote/maintain health and prevent disease.

Pharmacological and Parenteral Therapies
ADVERSE EFFECTS/CONTRAINDICATIONS/SIDE EFFECTS/
INTERACTIONS: Assess the client for actual or potential
side effects and adverse effects of medications.

MEDICATION ADMINISTRATION
Educate client on medication self-administration procedures.

Administer and document medications given by parenteral routes

Reduction of Risk Potential
POTENTIAL FOR COMPLICATIONS FROM SURGICAL
PROCEDURES AND HEALTH ALTERATIONS: Apply knowledge
of pathophysiology to monitoring for complications.

DIAGNOSTIC TESTS: Apply knowledge of related
nursing procedures and psychomotor skills when
caring for clients undergoing diagnostic testing.

LABORATORY VALUES
Notify primary health care provider about laboratory test results.

Monitor client laboratory values.

THERAPEUTIC PROCEDURES
Educate client about treatments and procedures.

Apply knowledge of related nursing procedures and psychomotor
skills when caring for clients undergoing therapeutic procedures.

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510 ncleX® connections CONTENT MASTERY SERIES

Physiological Adaptation
FLUID AND ELECTROLYTE IMBALANCES:
Manage the care of the client with a fluid and electrolyte imbalance.

Identify signs and symptoms of client fluid and/or electrolyte imbalance.

ILLNESS MANAGEMENT
Educate client about managing illness.

Apply knowledge of client pathophysiology to illness management

PATHOPHYSIOLOGY: Identify pathophysiology
related to an acute or chronic condition.

MEDICAL EMERGENCIES
Perform emergency care procedures.

Notify primary health care provider about unexpected
client response/emergency situation.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 76 enDocrine Diagnostic proceDures 511

UNIT 12 ENDOCRINE DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 76 Endocrine
Diagnostic
Procedures

Disorders of the endocrine system relate to either
the excess or deficiency of a hormone or to a
defect in a receptor site for a hormone. laboratory
tests for evaluating endocrine function vary
according to the organ or system under analysis.

many of these tests are blood, urine, or saliva
tests that determine an excess or lack of a
particular hormone in the body. some of these
tests stimulate a reaction in the body that will
facilitate diagnosis of a particular disorder.

stimulation testing involves giving hormones to
stimulate the target gland to determine if the
gland is capable of normal hormone production.
suppression testing involves giving medications
or substances to evaluate the body’s ability to
suppress excessive hormone production.

Posterior pituitary gland
The posterior pituitary gland secretes the hormone
vasopressin (antidiuretic hormone [ADH]). ADH increases
permeability of the renal distal tubules, causing the
kidneys to reabsorb water.

● A deficiency of ADH causes diabetes insipidus, which is
the excretion of a large quantity of dilute urine.

● Excessive secretion of ADH causes the syndrome of
inappropriate antidiuretic hormone (SIADH). With
SIADH, the kidneys retain water, urine becomes
concentrated, urinary output decreases, and
extracellular fluid volume increases.

● Diagnostic tests for the posterior pituitary gland include
the water deprivation test, ADH, blood and urine
electrolytes and osmolality, and urine specific gravity.

INDICATIONS

Water deprivation test

The water deprivation test measures the kidneys’ ability
to concentrate urine in light of an increased plasma
osmolality and a low blood ADH level. It requires a
controlled setting with careful observation of the client for
complications of dehydration.

This test helps identify causes of polyuria, including
diabetes insipidus (DI).

● Nephrogenic DI: failure of the kidneys to respond
to ADH for a variety of reasons (hypokalemia,
hypocalcemia, or medication use [lithium,
demeclocycline])

● Central (neurogenic) DI: head injury, tumor, irradiation
of the pituitary gland, or serious infection; the body
does not produce ADH

● Psychogenic polydipsia: compulsive fluid intake,
associated with conditions (schizophrenia)

Tests that diagnose SIADH

ADH, blood and urine electrolytes and osmolality, and
urine-specific gravity tests identify SIADH.

CONSIDERATIONS

Water deprivation test

PREPROCEDURE
● The client is either asked to withhold fluids the night

before the test, or when the test begins. No intake is
allowed during the test. Total fluid deprivation time can
be 8 to 12 hr.

● Monitor closely to identify and intervene for
severe dehydration.

INTRAPROCEDURE
● The client’s weight is measured hourly. The provider

might prescribe a desired weight loss (3% to 5%).
● Measure the client’s urine osmolality every hour,

until three separate checks show an increase of less
than 30 mOsm/kg (ensures the client is adequately
dehydrated).

● At that point, measure the blood osmolality.
● If blood osmolality is greater than 288 mOsm/kg, a dose

of ADH is administered subcutaneously.
● Measure the urine osmolality 30 to 60 min later.

POSTPROCEDURE: Assist with rehydration, and monitor
for orthostatic hypotension.

ADH
● The client should fast and avoid stress for 12 hr prior

to the test.
● Some medications (including acetaminophen,

antidepressants, diuretics, opioids, phenytoin) can
interfere with the test. Review medications with
the provider.

● Collect a blood sample and transport it to the laboratory
within 10 min.

CHAPTER 76

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512 CHAPTER 76 enDocrine Diagnostic proceDures CONTENT MASTERY SERIES

Blood electrolyte levels
● No pre- or postprocedure care is necessary.
● The laboratory analyzes samples of blood for

electrolyte components.

Urine osmolality
● No pre- or postprocedure care is necessary for random

urine sampling.
● Clients can be required to fast fluids for 12 to 14 hr

prior to testing, and to consume a high-protein diet
for 3 days.

● Urine osmolality is a better indicator of urine
concentration than specific gravity.

Urine specific gravity

The laboratory usually performs this test but nurses
can use a calibrated hydrometer or a temperature-
compensated refractometer to perform it on a clinical unit.

Urine sodium
● No pre- or postprocedure care is necessary.
● Can be random urine sample or 24 hr test.

INTERPRETATION OF FINDINGS

Water deprivation test
● Clients who have nephrogenic DI have little to no

increase in urine osmolality during the test or following
ADH administration, due to the kidneys’ inability to
concentrate urine.

● Clients who have central (neurogenic) DI have a rise in
osmolality of more than 9% following administration
of vasopressin.

● Clients who have psychogenic polydipsia have minimal
increase or no increase in urine osmolality during the
test or following DH administration, and take longer to
become dehydrated during the test than are clients who
have central DI.

ADH
● Increased ADH indicates SIADH, nephrogenic DI.
● Decreased ADH can indicate neurogenic DI.

EXPECTED REFERENCE RANGE: 1 to 5 pg/mL (1 to 5 ng/L)

Electrolytes

Low sodium and chloride are expected with SIADH.

EXPECTED REFERENCE RANGE
● Sodium: 136 to 145 mEq/L
● Potassium: 3.5 to 5.0 mEq/L
● Chloride: 98 to 106 mEq/L
● Magnesium: 1.3 to 2.1 mEq/L

Urine
● Increased urine osmolality indicates SIADH.
● Decreased urine osmolality is an expected finding of

diabetes insipidus.

EXPECTED REFERENCE RANGE
● Urine osmolality: 50 to 1,200 mOsm/kg H2O for a

random sample, depending on fluid intake; greater than
850 mOsm/kg H20 if fluid restriction prior to testing.

Urine specific gravity
● An increase in urine specific gravity is an expected

finding of SIADH.
● Decreased urine specific gravity is an expected finding

of diabetes insipidus.

EXPECTED REFERENCE RANGE: 1.010 to 1.025

Urine sodium

Increase in SIADH

EXPECTED REFERENCE RANGE
● Urine sodium: 40 to 220 mEq/24 hr in a 24 hr

collection; greater than 20 mEq/L in random sampling

COMPLICATIONS

Water deprivation test

Dehydration can occur due to a decrease in
vascular volume.

NURSING ACTIONS: Monitor closely for early indications
of dehydration, including postural hypotension,
tachycardia, and dizziness. Discontinue the test if the
client loses more than 2 kg (4.4 lb) or a specific amount of
body weight.

Adrenal cortex
● A hyperfunctioning adrenal cortex and an excess

production of cortisol characterize Cushing’s disease
and Cushing’s syndrome (hypercortisolism).

● Hypofunctioning of the adrenal cortex and a consequent
lack of adequate amounts of blood cortisol characterize
Addison’s disease.

● Diagnostic tests for the adrenal cortex include the
dexamethasone suppression test, plasma and salivary
cortisol, 24-hr urine for cortisol, adrenocorticotropic
hormone (ACTH), and ACTH stimulation tests.

● A CT scan and an MRI identify atrophy of the adrenal
glands, causing hypofunction.

● Certain medications, stress, exercise, and pregnancy
can affect testing related to the adrenal cortex. Check
individual testing requirements and notify the provider
of any concerns.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 76 enDocrine Diagnostic proceDures 513

INDICATIONS

Dexamethasone suppression test

This test determines whether dexamethasone, a synthetic
steroid similar to cortisol, has an effect on cortisol levels.

ACTH

Determines how well the adrenal glands respond to
the presence of ACTH. Used in determination of both
Cushing’s and Addison’s diseases.

CONSIDERATIONS

Dexamethasone suppression test
● For rapid testing, the client takes a dose of

dexamethasone before sleeping, and a blood sample
for cortisol is obtained after waking and before getting
out of bed. For clients who sleep during the night,
dexamethasone is administered at 11 p.m. and the blood
cortisol drawn at 8 a.m.

◯ If there is no decrease in blood cortisol level, the test
is repeated again with a higher dose.

● Prolonged testing involves baseline 24-hr urine cortisol
and blood cortisol prior to 2 continuous days of urine
collection while dexamethasone is administered every 6 hr.

● Following testing, monitor the client’s blood glucose
and potassium levels for adverse effects.

Blood cortisol

Cortisol varies according to the time (higher levels are
present in the early morning, and the lowest levels occur
around midnight, or 3 to 5 hr after the onset of sleep). The
provider determines the best time for testing, usually with
blood sampling at 8 a.m. and again at 4 p.m.

Salivary cortisol
● Salivary cortisol testing is preferred over blood or urine

for mild Cushing’s syndrome.
● Midnight is the usual time for salivary collection;

they should be lowest at this time for the client who
sleeps at night.

● The client should not brush teeth before providing the
specimen, and should not eat or drink for 15 min prior.

● The test pad is dropped from the container directly into the
client’s mouth for the prescribed time to collect the saliva.

Urinary cortisol

The laboratory measures cortisol in a 24-hr urine collection.

ACTH
● ACTH is most accurate if drawn toward the end of

the sleep cycle when the level is at its peak (between
4 to 8 a.m. with the typical sleep pattern).

● The client should be fasting prior to testing, and screened
for stress factors, which could affect the results.

ACTH stimulation test

Rapid testing: Obtain baseline blood cortisol level, then
wait 30 min. Administer cosyntropin IV, and obtain
specimens for blood cortisol levels at 30 min and 1 hr.

● Extended testing can be required for clients who do not
pass the rapid screening test, and can last 1 to 3 days.

INTERPRETATION OF FINDINGS

Dexamethasone suppression test

EXPECTED FINDING: In clients who have functioning
adrenals, pituitary, and hypothalamus, the administration
of dexamethasone should suppress ACTH, evidenced by
decreased blood cortisol level on the latter blood sample.

● Cushing’s disease: blood cortisol levels will decrease
only after the higher dose of dexamethasone is
administered (at least a 50% decrease, along with
increased ACTH).

● Adrenal adenoma/carcinoma: No change with low
or high dosing; ACTH is below the expected range
or undetectable.

● ACTH-producing tumor: Not change with low or high
dosing; ACTH is within or above the expected range.

Blood cortisol
● Cushing’s disease: increased
● Addison’s disease: decreased

EXPECTED REFERENCE RANGE: The 4 p.m. value should
be 1/3 to 2/3 of the 8 a.m. value. For the client who works
days and sleeps at night, the values might be opposite.

● 8 a.m.: 5 to 23 mcg/dL
● 4 p.m.: 3 to 13 mcg/dL

Salivary cortisol
● Cushing’s disease: increased
● Addison’s disease: decreased; diagnosis cannot be

confirmed by salivary testing

EXPECTED REFERENCE RANGE
● 11 p.m. to midnight: <100 ng/dL (<2 ng/mL) ● If results are elevated, confirmatory testing is required. Urinary cortisol ● Cushing’s disease: increased ● Addison’s disease: decreased EXPECTED REFERENCE RANGE: Less than 100 mcg/day in a 24-hr urine collection ACTH ● Cushing’s disease: increased or decreased ● Addison’s disease: decreased EXPECTED REFERENCE RANGE: ● Female: 6 to 58 pg/mL ● Male: 7 to 69 pg/mL 07/24/15 April 11, 2019 3:35 PM rm_rn_2019_ams_chp76 07/24/15 April 11, 2019 3:35 PM rm_rn_2019_ams_chp76 514 CHAPTER 76 enDocrine Diagnostic proceDures CONTENT MASTERY SERIES ACTH stimulation test ● An increase in cortisol after administration of ACTH is expected. EXPECTED REFERENCE RANGE: Rapid testing: an increase of >7 mg/dL; 24-hr or 3-day testing: an increase of >40 mcg/dL

● If the response is at or below the expected level, it
indicates Cushing’s disease due to a tumor or chronic
steroids, or it indicates primary adrenal insufficiency.

● If the response is exaggerated, it indicates Cushing’s due
to adrenal hyperplasia or secondary adrenal insufficiency.

Adrenal medulla
Disorders of the adrenal medulla (tumor) can cause
hypersecretion of catecholamines, resulting in stimulation
of a sympathetic response (tachycardia, hypertension,
diaphoresis). These tests determine whether the cause of a
client’s unrelieved hypertension is a pheochromocytoma.

● Diagnostic tests for the adrenal medulla include
plasma-free metanephrine testing and the clonidine
suppression test (Pheochromocytoma suppression test).

● Pheochromocytoma provocative testing is done
less often due to the risk of dangerously high blood
pressure, and involves administration of a substance
that will trigger catecholamine release (glucagon,
metoclopramide, naloxone).

● Some medications, stress, and exercise can affect
test results.

INDICATIONS

Plasma‑free metanephrine test
● Identification of a pheochromocytoma often indicated

as follow up testing if catecholamine level test results
are unclear.

● The laboratory tests blood samples for both
metanephrine and normetanephrine.

Clonidine suppression test
● This test is an identification of a pheochromocytoma.
● The laboratory measures plasma catecholamines levels

prior to and 3 hr after administration of clonidine.
● Hypovolemia is a contraindication due to the risk for

severe hypotension.

CONSIDERATIONS

Plasma‑free metanephrine test
● The client can be required to lie down for 15 to 30 min

prior to testing.
● Caffeine and alcohol can affect results and might be

restricted prior to testing.

Clonidine suppression test
● The client must rest for 30 min prior to specimen collection.
● Continue monitoring blood pressure for at least 1 hr

following the procedure.

INTERPRETATION OF FINDINGS

Plasma‑free metanephrine test
● Elevation of both metanephrine and normetanephrine

above the expected reference range indicates
a pheochromocytoma.

● If only one of these catecholamines is elevated,
a pheochromocytoma is probable.

● If results are unclear, urine catecholamine testing can
facilitate diagnosis, although different catecholamines
are measured.

Clonidine suppression test
● If a client does not have a pheochromocytoma, clonidine

suppresses catecholamine release and decreases the
level of catecholamines (decreases blood pressure).

● If the client has a pheochromocytoma, the clonidine has
no effect on blood pressure.

Carbohydrate metabolism
Insulin deficiency and insulin resistance can alter
carbohydrate metabolism, resulting in hyperglycemia.

● Diagnostic tests to evaluate carbohydrate metabolism
include blood glucose testing (fasting or casual), glucose
tolerance testing, and glycosylated hemoglobin (HbA1c).

● Many medications, stress, and caffeine can affect
glucose levels and alter test results.

● Elevated glucose results on a single test should be
confirmed by a second test on a different day.

CONSIDERATIONS

Fasting blood glucose
● Ensure that the client has fasted (no food or beverages

other than water) for 8 hr prior to blood sampling.
● The client should postpone taking antidiabetes

medications until after the blood sampling.

Casual (random) blood glucose
● Refers to any time of day without regard to mealtime
● No pre- or postprocedure care necessary; requires

obtaining a random blood sample

Glucose tolerance test
● This test determines the ability to metabolize a

standard amount of glucose.
● Instruct the client to consume a balanced diet for 3 days

prior to the test and fast for 10 to 12 hr prior to the test.
● The technician will obtain a specimen for a fasting blood

glucose level and urine specimen at start of the test.
● The client then consumes a prescribed amount of

glucose (weight-based). Glucose can be administered IV
rather than orally, if needed.

● The technician obtains blood samples at 30 min, 1 hr,
2 hr, 3 hr, and sometimes 4 hr after the client consumes
glucose. Urinalysis can be performed every hour.

● Observe for dizziness, weakness, sweating, or giddiness,
and obtain a blood glucose level if seen.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 76 enDocrine Diagnostic proceDures 515

Glycosylated hemoglobin (HbA1c)

No pre- or postprocedure care is necessary. The test
requires obtaining a random blood sample.

● HbA1c is the best indicator of an average blood glucose
level for the past 120 days.

● This test assists in evaluating treatment effectiveness
and adherence to the diet plan, medication regimen, and
exercise schedule.

INTERPRETATION OF FINDINGS

Fasting blood glucose
● Fasting blood glucose greater than 126 mg/dL on two

different occasions can indicate diabetes mellitus.
● Fasting blood glucose levels 100 to 125 mg/dL can

indicate prediabetes.

EXPECTED REFERENCE RANGE
● 74 to 106 mg/dL for adults through age 59
● 82 to 115 mg/dL for adults 60 to 90 years
● 75 to 121 mg/dL for adults over 90 years

Casual (random) blood glucose

EXPECTED REFERENCE RANGE: Less than 200 mg/dL

Glucose tolerance test
● Elevated blood glucose at 2 hr following glucose

ingestion can indicate diabetes. The test can be repeated
on another day to check results.

EXPECTED REFERENCE RANGE
● Less than 180 mg/dL 1 hr following glucose ingestion
● Less than 140 mg/dL 2 hr following glucose ingestion
● 70 to 115 mg/dL 3 or 4 hr following glucose ingestion

Glycosylated hemoglobin (HbA1c)
● Increased levels support new diagnosis of diabetes

mellitus when paired with other increased glucose
testing results, or poor glucose control for clients who
have existing diabetes mellitus.

● Decreased levels can be present if the client has anemia
or blood loss, or chronic kidney disease.

EXPECTED REFERENCE RANGE
● HbA1c 5.9% or less indicates no diabetes mellitus.
● HbA1c less than 7% indicates good diabetes control.
● HbA1c 8% to 9% indicates fair diabetes control.
● HbA1c 9% or greater indicates poor diabetes control.

Thyroid and anterior
pituitary gland

Hyperthyroidism and hypothyroidism are disorders in
which there are inappropriate amounts of the thyroid
hormones triiodothyronine (T3) and thyroxine (T4)
circulating. These inappropriate amounts of T3 and T4
cause an increase or decrease in metabolic rate that affects
all body systems.

● Diagnostic tests to evaluate the function of the
thyroid and anterior pituitary glands include T3
(triiodothyronine), T4 (thyroxine), TSH, thyrotropin-
releasing hormone (TRH) stimulation test, and
radioactive iodine uptake. In many facilities,
immunoassay testing for the presence of antithyroid
antibodies has replaced the need for TRH
stimulation testing.

● The anterior pituitary gland secretes thyroid stimulating
hormone (TSH) which prompts the thyroid to release
T3 and T4. Hyposecretion of TSH can lead to secondary
hypothyroidism, and hypersecretion of TSH can cause
secondary hyperthyroidism.

● Ultrasounds and CT scans determine the size, shape,
and presence of nodules and masses on these glands.

INDICATIONS

TSH, T3, and T4

Results help monitor thyroid replacement therapy and
differentiate types of thyroid disorders.

Thyroid scan
● This test evaluates size, shape, position and ability

of the thyroid gland to function following an oral
dose of 123I.

● Whole body scanning using the same method can detect
metastasis of thyroid cancer.

CONSIDERATIONS

TSH, T3, and T4

● Obtain an accurate medication list, because numerous
medications can affect the accuracy of the test.

● No pre- or postprocedure care is necessary for
these tests.

● The laboratory requires a random blood sample.

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516 CHAPTER 76 enDocrine Diagnostic proceDures CONTENT MASTERY SERIES

Thyroid scan
● The client receives an oral dose of radioactive isotope,

and an external probe or counter measures the
amount the thyroid absorbed. Areas where the isotope
was absorbed are noted as hot or warm and areas of
decreased absorption as cold.

● Pregnancy and recent exposure to iodine-containing
dye are contraindications. Thyroid or iodine-containing
medications must be withheld for 6 weeks prior
to testing.

● Explain to the client that the radioactive substance has
a very short half life, thus radiation precautions are not
necessary for this test unless high doses are required.

INTERPRETATION OF FINDINGS

T3 and T4

● Low and high levels of each indicate hypothyroidism
and hyperthyroidism, respectively.

● A high level of T3 is a better indicator hyperthyroidism
than is T4.

EXPECTED REFERENCE RANGE
● T3: 70 to 205 ng/dL in adults ages 20 to 50

◯ 40 to 180 ng/dL in clients older than 50
● T4 (total): 4 to 12 mcg/dL up to 60 years old

◯ 5 to 11 mcg/dL over 60 years old

TSH
● An increased value indicates primary hypothyroidism

due to thyroid dysfunction or thyroiditis.
● A decreased value indicates hyperthyroidism (Graves’

disease) or secondary hypothyroidism (due to pituitary
or hypothalamus dysfunction).

EXPECTED REFERENCE RANGE: 0.3 to 0.5 mU/L

Thyroid scan
● Non-functioning areas of the thyroid can indicate

the presence of lymphoma, thyroiditis, a cyst, or
other carcinoma.

● Functioning thyroid nodules can also represent toxic
goiter or a benign adenoma.

Active Learning Scenario

a nurse is planning care for a client who will
undergo a clonidine suppression test. What should
the nurse include in the plan of care? use the ati
active learning template: Diagnostic procedure to
complete this item to include the following.

INDICATIONS

INTERPRETATION OF FINDINGS

NURSING INTERVENTIONS: Describe one intraprocedure.

Application Exercises

1. a nurse is caring for a client who asks why the
provider bases the medication regimen on
hba1c results instead of the log of morning
fasting blood glucose results. Which of the
following responses should the nurse make?

a. “hba1c measures how well insulin is regulating
your blood glucose between meals.”

B. “hba1c indicates how well your have regulated
your blood glucose over the past 120 days.”

c. “hba1c is the first test your doctor prescribed
to determine that you have diabetes.”

D. “hba1c determines if the your doctor
should adjust your insulin dosage.”

2. a nurse is reviewing the laboratory findings
for a client who might have hyperthyroidism.
the nurse should identify an elevation of
which of the following substances as an
indication that the client has this disorder?

a. triiodothyronine

B. plasma-free metanephrine

c. urine cortisol

D. urine osmolality

3. a nurse is reviewing the health record of a client who
has syndrome of inappropriate antidiuretic hormone
(siaDh). Which of the following laboratory findings
should the nurse expect? (select all that apply.)

a. low sodium

B. high potassium

c. increased urine osmolality

D. high urine sodium

e. increased urine specific gravity

4. a nurse is caring for a client who has primary adrenal
insufficiency and is preparing to undergo an acth
stimulation test. Which of the following findings should
the nurse expect after an iv injection of cosyntropin?

a. no change in plasma cortisol

B. elevated fasting blood glucose

c. Decrease in sodium

D. increase in urinary output

5. a nurse is assessing a client during a water
deprivation test. for which of the following
complications should the nurse monitor the client?

a. Bradycardia

B. orthostatic hypotension

c. neck vein distention

D. crackles in lungs

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 76 enDocrine Diagnostic proceDures 517

Application Exercises Key

1. a. capillary glucose monitoring evaluates how well insulin
is regulating blood glucose between meals.

B. CORRECT: hba1c measures blood glucose
control over the past 120 days

c. a fasting blood glucose is the first test providers prescribe to
diagnose diabetes mellitus. hba1c is not a screening test.

D. capillary glucose monitoring evaluates how
well insulin regulates blood glucose.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. CORRECT: increased triiodothyronine (t3)
indicates hyperthyroidism.

B. an increase in plasma-free metanephrine indicates
the presence of a pheochromocytoma (tumor
of the cells of the adrenal medulla).

c. a high cortisol level indicates hyperfunction of the adrenal
cortex and can indicate that the client has cushing’s disease.

D. increased urine osmolality indicates siaDh.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

3. a. CORRECT: siaDh results in water retention,
causing a low sodium level.

B. siaDh does not affect potassium levels.
c. CORRECT: siaDh results in an increase in urine

osmolality due to the decreased urine volume.
D. CORRECT: siaDh results in water retention,

causing a high urine sodium level.
e. CORRECT: siaDh results in water retention,

causing an increase in urine specific gravity.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

4. a. CORRECT: no change in plasma cortisol indicates primary
adrenal insufficiency (addison’s disease or hypocortisolism)
after an iv injection of cosyntropin during an acth stimulation
test due to an inadequate production of cortisol.

B. an elevated fasting blood glucose helps
identify diabetes mellitus.

c. an increase in sodium indicates primary adrenal
insufficiency (addison’s disease or hypocortisolism).

D. a decrease in urinary output indicates primary adrenal
insufficiency (addison’s disease or hypocortisolism).

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Expected Actions/Outcomes

5. a. tachycardia is a complication to monitor for during a
water deprivation test due to dehydration.

B. CORRECT: monitor for orthostatic hypotension resulting
from dehydration during a water deprivation test.

c. flat neck veins are likely during a water
deprivation test due to dehydration.

D. monitor the client for dizziness rather than lung
crackles during a water deprivation test.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

INDICATIONS: confirms a pheochromocytoma

INTERPRETATION OF FINDINGS
● if client does not have a pheochromocytoma, clonidine
suppresses catecholamine release and decreases the blood
level of catecholamines (decreases blood pressure).

● if client has a pheochromocytoma, clonidine
has no effect on blood pressure.

NURSING ACTIONS: monitor the client for hypotension.

NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

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518 CHAPTER 76 enDocrine Diagnostic proceDures CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 77 pituitarY DisorDers 519

UNIT 12 ENDOCRINE DISORDERS
SECTION: PITUITARY DISORDERS

CHAPTER 77 Pituitary Disorders
the pituitary gland (hypophysis) is known as
the “master gland” due to its regulation of
many bodily functions. located underneath
the hypothalamus, at the base of the skull,
the pituitary gland is regulated by the
hypothalamus. it is divided into two lobes:
anterior (adenohypophysis) and posterior
(neurohypophysis), which secrete regulatory
hormones. the anterior pituitary gland secretes
six hormones while the posterior pituitary
secretes two hormones.

the hormones associated with the posterior
pituitary are produced in the hypothalamus and
stored in the posterior pituitary, where they are
released into the circulation as needed.

hormones

Anterior pituitary

Thyroid‑stimulating hormone: Stimulation of the
thyroid gland

Adrenocorticotropic hormone (ACTH): Stimulation of the
adrenal glands to secrete glucocorticoids

Luteinizing hormone
● FEMALES: stimulates maturation of ova and ovulation
● MALES: stimulates production of testosterone

Follicle‑stimulating hormone
● FEMALES: stimulates growth of ovarian follicles and

estrogen secretion
● MALES: stimulates sperm production

Prolactin: Stimulates breast milk production
during lactation

Growth hormone (GH): Stimulates protein synthesis and
growth of muscle and bone

Posterior pituitary

Antidiuretic hormone (ADH) (vasopressin): Increases
resorption of water in the kidneys

Oxytocin (OT)
● Stimulates contraction of uterus following delivery
● Stimulates ejection of breast milk during lactation

DisorDers
Altered function of the pituitary gland can be caused
by disease of the pituitary gland or the hypothalamus,
trauma, tumor, or vascular lesion. Hyperfunction or
hypofunction of the anterior and posterior pituitary gland
can occur independently of one another.

● Oversecretion of ACTH from the anterior pituitary gland
results in Cushing’s disease.

● Oversecretion of GH results in gigantism in children
and acromegaly in the adult client. In the adult client,
acromegaly manifests as enlargement of body parts
without affecting the client’s height.

● Undersecretion of GH in children results in dwarfism.
● Insufficient secretion of hormones in the anterior

pituitary typically affects all the hormones, termed
panhypopituitarism. It affects the target organs of the
hormones produced in the anterior pituitary, including
the thyroid, adrenal cortex, and gonads.

● A deficiency of ADH causes diabetes insipidus (DI). DI
is characterized by the excretion of a large quantity of
diluted urine.

● Excessive secretion of ADH causes the syndrome of
inappropriate antidiuretic hormone (SIADH). In SIADH,
the kidneys retain water, urine output decreases, and
extracellular fluid volume is increased.

● Posterior pituitary disorders result in fluid and
electrolyte imbalances.

Acromegaly
Acromegaly is characterized by excess growth hormone in
adults, which causes an increase in size of body parts but
not height.

● Manifestations are widespread, including overgrowth of
the skin; bones of the forehead, jaw, feet and hands; and
enlargement of organs including the liver and the heart.

● If left untreated, acromegaly can cause hypertension,
diabetes mellitus, and heart problems.

● Onset is gradual and can progress for years before
becoming noticeable.

ASSESSMENT

risK factors
● Age (adulthood)
● Benign tumors (pituitary adenoma)

eXpecteD finDings
● Severe headaches
● Visual disturbances (diplopia, decreased visual acuity)
● Thick lips with coarse facial structures
● Joint pain
● Decreased libido
● Enlarged hands and feet
● Hyperglycemia
● Barrel-shaped chest
● Lower jaw protrusion
● Increasing head size

CHAPTER 77

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520 CHAPTER 77 pituitarY DisorDers CONTENT MASTERY SERIES

● Change in voice characteristics
● Change in menstrual pattern
● Sleep apnea
● Increases in intracranial pressure (decreased LOC,

pupillary changes, severe hypertension, widened pulse
pressure, bradycardia, seizures)

laBoratorY tests

Growth hormone suppression test

Growth hormone level is measured as a baseline and
following administration of glucose, typically 0.5 g/kg or
100 g. Elevated glucose levels are expected to suppress GH;
however, clients who have acromegaly will show only a
slight decrease or no decrease at all in GH levels.

NURSING ACTIONS
● Obtain baseline GH and glucose levels.
● Administer prescribed glucose.
● Obtain GH and blood glucose levels at 10, 60, and
120 min after glucose administration.

CLIENT EDUCATION: Consume nothing but water for 6 to
8 hr preceding the test.

Diagnostic proceDures
X‑rays of the skull: Identify abnormalities of the sella
turcica, the location of the pituitary gland within the skull.

CT or MRI of the head: Identify soft tissue lesions.

Cerebral angiography: Evaluate for the presence of
vascular malformation or aneurysms.

PATIENT‑CENTERED CARE

nursing care
● Assess self-concept related to physical manifestations

of disorder.
● Instruct the client regarding medications or other

treatment options.

meDications
Dopamine agonists (bromocriptine mesylate, cabergoline)
inhibit the release of GH.
CLIENT EDUCATION: Notify the provider immediately if
chest pain, dizziness, or watery nasal discharge occurs
while taking bromocriptine. This can indicate cardiac
dysrhythmia, coronary artery spasms, or
leakage of CSF.

Somatostatin analogs (octreotide, lanreotide) inhibit
GH release.

Growth hormone receptor blocker (pegvisomant)
prevents GH receptor activity and blocks production of
insulin-like growth factor.

therapeutic proceDures

Hypophysectomy

Removal of the pituitary gland through an endoscopic
transnasal (most common) or oronasal (transsphenoidal)
approach. If these approaches do not provide access to the
tumor, a craniotomy is indicated.

PREOPERATIVE CLIENT EDUCATION: Do not brush teeth,
blow the nose, or bend at the waist postoperatively. These
actions can increase intracranial pressure.

POSTOPERATIVE NURSING ACTIONS
● Monitor neurologic status.
● Monitor drainage to mustache dressing (drip pad).
● Notify provider of the presence of glucose in the

drainage (indication of leakage of cerebrospinal fluid).
● Maintain the client in a high-Fowler’s position.
● Monitor fluid balance, especially greater output than

intake (DI).
● Encourage deep breathing exercises, but limit coughing

as this increases intracranial pressure and can cause a
leak of cerebrospinal fluid (CSF).

● Assess for manifestations of meningitis.
● Administer replacement hormones.

Radiation therapy

Shrinks pituitary tumor over a period of time.

client eDucation
● Hormone replacement therapy will be lifelong.
● Avoid activities that increase intracranial pressure.
● Report postnasal drip or increased swallowing.
● Rinse mouth frequently to minimize effects of

mouth breathing.
● Use oral rinses and flossing to clean teeth. Avoid

brushing teeth due to risk of trauma to the operative site.
● Consume a diet high in fiber to minimize straining

to defecate.

Diabetes insipidus
● Diabetes insipidus results from a deficiency of ADH,

which is secreted by the posterior lobe of the pituitary
gland (neurohypophysis).

● Decreased ADH reduces the ability of the distal renal
tubules in the kidneys to collect and concentrate urine,
resulting in excessive diluted urination, excessive thirst,
electrolyte imbalance, and excessive fluid intake.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 77 pituitarY DisorDers 521

tYpes of DiaBetes insipiDus
Primary neurogenic: A lack of ADH production or release,
caused by defects in the hypothalamus or pituitary gland

Secondary neurogenic: A lack of ADH production or release,
caused by infection, tumors in or near the hypothalamus or
pituitary gland, head trauma, or brain surgery

Nephrogenic: Renal tubules that do not react to ADH, can
be inherited, the result of kidney damage, or an adverse
medication effect (lithium carbonate, demeclocycline)

ASSESSMENT

risK factors
● Head injury, tumor or lesion, surgery or irradiation near

or around the pituitary gland, or infection (meningitis,
encephalitis)

● Taking lithium carbonate or demeclocycline

eXpecteD finDings
● Polyuria (abrupt onset of excessive urination, urinary

output of 4 to 30 L/day of dilute urine): failure of the
renal tubules to collect and reabsorb water

● Polydipsia (excessive thirst, consumption of 2 to 20 L/day)
● Older adult clients are at higher risk for dehydration due

to lower water content of the body, decreased thirst
response, decreased ability of the kidneys to concentrate
urine, increased use of diuretics, swallowing difficulties,
or inadequate food intake

PHYSICAL ASSESSMENT FINDINGS
● Tachycardia
● Hypotension
● Loss or absence of skin turgor
● Dry mucous membranes
● Weak, poor peripheral pulses
● Decreased cognition
● Ataxia

laBoratorY tests
Urine testing: Think DILUTE.

● Decreased urine specific gravity (less than 1.005)
● Decreased urine osmolality (less than 200 mOsm/L)
● Decreased urine pH
● Decreased urine sodium
● Decreased urine potassium
● As urine volume increases, urine osmolality decreases

Blood testing: Think CONCENTRATED.
● Increased blood osmolality (greater than 300 mOsm/L)
● Increased blood sodium
● Increased blood potassium
● As blood volume decreases, the blood

osmolality increases

Diagnostic proceDures

Water deprivation test (ADH stimulation test)
● This is an easy and reliable diagnostic test. Dehydration

is induced by withholding fluids.
● A subcutaneous injection of vasopressin produces urine

output with an increased specific gravity and osmolality.
● If the urine becomes more concentrated following

vasopressin injection, it is neurogenic DI; if little to
no change, it is either nephrogenic DI or psychogenic
polydipsia (a compulsive behavior related to excessive
fluid intake).

PATIENT‑CENTERED CARE
Treatment for neurogenic DI is different than
nephrogenic DI.

nursing care
● Monitor vital signs, urinary output, central venous

pressure, I&O, specific gravity, and laboratory studies
(potassium, sodium, BUN, creatinine, specific gravity,
osmolarity).

● Weigh the client daily.
● Promote the prescribed diet (regular diet with

restriction of foods that exert a diuretic effect [caffeine]).
● IV therapy: Hydration (I&O must be matched to prevent

dehydration) and electrolyte replacement.
● Implement fall precautions.
● Add bulk foods and fruit juices to the diet if constipation

develops. A laxative might be needed.
● Assess skin turgor and mucous membranes.
● Provide skin and mouth care using a soft toothbrush

and mild mouthwash to avoid trauma to the oral
mucosa. Use alcohol-free skin care products, and apply
emollient lotion after baths.

● Encourage the client to drink fluids in response to thirst
and to match the volume of urine output.

meDications

ADH replacement agents (or neurogenic DI)
● Desmopressin, which is a synthetic ADH, or aqueous

vasopressin administered intranasally, orally,
or parenterally.

● This results in increased water absorption from kidneys
and decreased urine output

● Chlorpropamide and thiazide diuretics facilitate
vasopressin action (for clients who have neurogenic DI).

● Clients who have nephrogenic DI are prescribed
prostaglandin inhibitors and thiazide diuretics, and
mild salt depletion.

NURSING ACTIONS
● Dose can be adjusted depending on urine output.
● Give vasopressin cautiously to clients who have

coronary artery disease because the medication can
cause vasoconstriction.

● Monitor for headache, confusion, or other indications of
water intoxication.

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522 CHAPTER 77 pituitarY DisorDers CONTENT MASTERY SERIES

CLIENT EDUCATION
● For neurogenic DI, lifelong self-administration of

vasopressin therapy is required.
● To administer intranasal vasopressin, clear nasal

passage and sit upright prior to inhalation.
● Monitor weight daily and notify the provider of a gain

greater than 0.9 kg (2 lb) in 24 hr.
● Restrict fluids if directed and notify the provider of

headache or confusion.

interprofessional care
Home assistance for fluid, medication, and dietary
management might be required.

client eDucation
● Weigh daily, eat a high-fiber diet, wear a medical alert

wristband, and monitor fluid I&O.
● Monitor for indications of dehydration (weight loss; dry,

cracked lips; confusion; weakness).
● Restrict fluids as prescribed to prevent water

intoxication, and avoid consumption of alcohol.

COMPLICATIONS
Excessive urine output from untreated DI can cause
dehydration, hyperosmolarity, hypernatremia, circulatory
collapse, unconsciousness, central nervous system
damage, and seizures.

NURSING ACTIONS: Monitor fluid balance and prevent
dehydration by providing proper fluid intake.

CLIENT EDUCATION: Seek early medical attention for any
indications of DI and follow care instructions.

Syndrome of inappropriate
antidiuretic hormone

SIADH, or Schwartz‑Bartter syndrome, is an excessive
release of ADH, also known as vasopressin, secreted by the
posterior lobe of the pituitary gland (neurohypophysis).

Excess ADH leads to renal reabsorption of water and
suppression of renin-angiotensin mechanism, causing
renal excretion of sodium leading to water intoxication,
cellular edema, and dilutional hyponatremia. Fluid shifts
within compartments causes decreased blood osmolarity.

ASSESSMENT

risK factors
Conditions that stimulate the hypothalamus to
hypersecrete ADH include malignant tumors, increased
intrathoracic pressure (positive pressure ventilation),
head injury, meningitis, stroke, tuberculosis, and
medications (chemotherapy agents, TCAs, SSRIs, opioids,
fluoroquinolone antibiotics).

eXpecteD finDings
● Early manifestations include headache, weakness,

anorexia, muscle cramps, and weight gain (without
edema because water, not sodium, is retained).

● As the blood sodium level decreases, the client
experiences personality changes, hostility, sluggish
deep tendon reflexes, nausea, vomiting, diarrhea, and
oliguria with dark yellow concentrated appearance.

PHYSICAL ASSESSMENT FINDINGS
● Confusion, lethargy, and Cheyne-Stokes respirations

herald impending crisis. When the blood sodium level
drops further, seizures, coma, and death can occur.

● Manifestations of fluid volume excess include
tachycardia, bounding pulses, possible hypertension,
crackles in lungs, distended neck veins, taut skin,
and weight gain without edema. Intake is greater
than output.

laBoratorY tests
Urine testing: Think CONCENTRATED.

● Increased urine sodium
● Increased urine osmolarity
● As urine volume decreases, urine osmolarity increases.

Blood testing: Think DILUTE.
● Decreased blood sodium (dilutional hyponatremia)
● Decreased blood osmolarity (less than 270 mEq/L)
● As blood volume increases, blood osmolarity decreases

PATIENT‑CENTERED CARE
Management includes addressing the underlying cause
and implementing fluid restriction.

nursing care
● Restrict oral fluids to 500 to 1,000 mL/day to prevent

further hemodilution (first priority). During fluid
restriction, provide comfort measures for thirst (mouth
care, ice chips, lozenges, staggered water intake).

● Use 0.9% sodium chloride, instead of water, to flush
enteral tubes, and to mix medications or dilute feedings
administered enterally.

● Monitor I&O. Report decreased urine output.
● Monitor vital signs for increased blood pressure,

tachycardia, and hypothermia.
● Auscultate lung sounds to monitor for pulmonary edema

(can develop rapidly and is a medical emergency).
● Monitor for decreased blood sodium/osmolarity and

elevated urine sodium/osmolarity.
● Weigh the client daily. A weight gain of 1 kg (2.2 lb)

indicates a gain of 1 L of fluid. Report this to the provider.
● Report altered mental status (headache, confusion,

lethargy, seizures, coma).
● Reduce environmental stimuli and position the client

as needed.
● Provide a safe environment for clients who have altered

levels of consciousness. Maintain seizure precautions.
● Monitor for indications of heart failure, which can occur

from fluid overload. Use of a loop diuretic can be indicated.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 77 pituitarY DisorDers 523

meDications

Tetracycline derivative (demeclocycline)
● Unlabeled use to correct fluid and electrolyte imbalances

in mild SIADH by stimulating urine flow.
● Contraindicated in clients who have impaired

kidney function.

NURSING ACTIONS: Monitor for effective treatment
(increased blood sodium/osmolarity and decreased urine
sodium osmolarity).

CLIENT EDUCATION
● Avoid taking demeclocycline at the same time as

calcium, iron, magnesium supplements, antacids
containing aluminum, or milk products.

● Monitor for indications of a yeast infection (a white,
cheese-like film inside the mouth).

● Avoid prolonged exposure to sunlight. Protective
clothing and sunscreen should be used.

● Notify the provider if diarrhea develops.

Vasopressin antagonists (tolvaptan, conivaptan)

Promote water excretion without causing sodium losses
used in acute (inpatient) setting because it rapidly
increases sodium levels.

NURSING ACTIONS
● Monitor blood glucose levels.
● Monitor blood sodium levels.
● Monitor intake and output.
● Monitor bowel patterns.

CLIENT EDUCATION: Perform frequent oral care.

Loop diuretic (furosemide)

Used to increase water excretion from the kidneys

NURSING ACTIONS: Use with caution because loop
diuretics cause sodium excretion and can worsen
hyponatremia.

CLIENT EDUCATION
● Change positions slowly in case of postural hypotension.
● Notify the provider of findings of hyponatremia (nausea,

decreased appetite, and vomiting).

therapeutic proceDures

Hypertonic sodium chloride IV fluid

The goal is to elevate the sodium level enough to alleviate
neurologic compromise.

NURSING ACTIONS
● In severe hyponatremia/water intoxication, administer
200 to 300 mL hypertonic IV fluid (3% sodium chloride).

● Monitor for fluid overload and heart failure (distended
neck veins, crackles in lungs).

CLIENT EDUCATION
● Report difficulty breathing or shortness of breath, which

can indicate heart failure.
● Obtain daily weights, wear a medical alert wristband,

and restrict fluid intake.
● Monitor for indications of hypervolemia (weight gain,

difficulty breathing) or any neurologic changes (tremors,
disorientation), which can lead to seizures.

● Notify the provider of indications of hyponatremia
(nausea, decreased appetite, and vomiting).

● Avoid consumption of alcohol.

interprofessional care
Home care can be required for fluid, medication, and
dietary management.

COMPLICATIONS

Water intoxication, cerebral/pulmonary
edema, and severe hyponatremia

Without prompt treatment, SIADH can lead to these
complications, which can result in coma and death.

NURSING ACTIONS
● Monitor for early manifestations of water intoxication

(lung crackles, distended neck veins, changes in
neurologic state [confusion, headaches, twitching,
disorientation], edema, and decreased urinary output).

● Maintain seizure precautions.
● Monitor blood sodium level.

CLIENT EDUCATION: Follow fluid restrictions to prevent
worsening of the condition.

Central pontine myelinolysis

Treatment for SIADH can result in this condition
characterized by nerve damage that is caused by the
destruction of the myelin sheath in the brainstem (pons).
The most common cause is a rapid change in sodium
levels in the body. This most commonly occurs when a
client is being treated for hyponatremia and the sodium
levels rise too fast.

NURSING ACTIONS: During treatment with a vasopressin
antagonist, hypertonic saline, or loop diuretics, plasma
osmolarity and blood sodium should be monitored every 2
to 4 hr. Report any deterioration in neurologic status
immediately.

CLIENT EDUCATION: Blood sodium levels will
be monitored frequently to minimize the risk of
complications from rapid increases.

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524 CHAPTER 77 pituitarY DisorDers CONTENT MASTERY SERIES

Active Learning Scenario

a nurse is planning care for a client who has siaDh and
a new prescription for demeclocycline. What should the
nurse include in the plan of care? use the ati active
learning template: medication to complete this item.

THERAPEUTIC USES

NURSING INTERVENTIONS: Describe one.

CLIENT EDUCATION: Describe two.

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

THERAPEUTIC USES: Demeclocycline is a derivative
of tetracycline and is used to treat siaDh.

NURSING INTERVENTIONS: monitor effectiveness
of treatment (increased blood sodium/osmolarity
and decreased urine sodium osmolarity).

CLIENT EDUCATION
● avoid taking demeclocycline at the same time as
calcium, iron, magnesium supplements, antacids
containing aluminum, or milk products.

● monitor for indications of a yeast infection (a
white, cheese-like film inside the mouth).

● avoid prolonged exposure to sunlight. protective
clothing and sunscreen should be used.

● notify the provider if diarrhea develops.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

Application Exercises Key

1. a. CORRECT: an increase in the secretion of aDh
leads to dilutional hyponatremia.

B. a urine specific gravity greater than 1.030 (concentrated
urine) is caused by an increase in the secretion of aDh.

c. CORRECT: a decrease in blood osmolarity is caused
by an increase in the secretion of aDh leading to water
retention and dilution of blood components.

D. reduced urine output is caused by the
increase in the secretion of aDh.

e. increased thirst is an expected finding in a
client who has diabetes insipidus.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. glucose in the urine is indicative of diabetes mellitus.
B. CORRECT: the urine of a client who has diabetes insipidus

will be dilute with a urine specific gravity of less than 1.005.
c. Ketones in the urine is indicative of diabetes mellitus.
D. red blood cells in the urine is indicative of diabetes mellitus.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

3. a. excessive thirst is a manifestation of diabetes insipidus.
consumption of 4 to 30 l/day can be expected,
and fluid intake should not be limited.

B. elevated blood glucose levels are a
manifestation of diabetes mellitus.

c. Weight loss is a manifestation of diabetes insipidus.
D. CORRECT: confusion and ataxia are

findings associated with Di.

NCLEX® Connection: Physiological Adaptation,
Illness Management

4. a. the client should be placed into a
high-fowler’s position.

B. coughing should be limited in the client who
is postoperative, as this increases intracranial
pressure and can cause a leak of csf.

c. oral care for the client who is postoperative
following a transsphenoidal hypophysectomy
includes oral rinses and flossing. Brushing teeth can
cause a leak of csf and is contraindicated.

D. CORRECT: the nurse should monitor the drainage to
the mustache dressing and observe for the presence
of glucose, which would indicate the presence
of csf. notify the provider if this occurs.

NCLEX Connection: Reduction of Risk Potential,
Therapeutic Procedures

Application Exercises

1. a nurse is caring for a client who has syndrome
of inappropriate antidiuretic hormone (siaDh).
Which of the following findings should the
nurse expect? (select all that apply.)

a. Decreased blood sodium

B. urine specific gravity 1.001

c. Blood osmolarity 230 mosm/l

D. polyuria

e. increased thirst

2. a nurse is caring for a client who has diabetes
insipidus. Which of the following urinalysis
laboratory findings should the nurse expect?

a. presence of glucose

B. Decreased specific gravity

c. presence of ketones

D. presence of red blood cells

3. a nurse is providing teaching to a client who
has a new diagnosis of diabetes insipidus.
Which of the following client statements
indicates an understanding of the teaching?

a. “i can drink up to 2 quarts of fluid a day.”

B. “i will need to use insulin to control
my blood glucose levels.”

c. “i should expect to gain weight during this illness.”

D. “i might experience confusion
or balance problems.”

4. a nurse is planning care for a client who has acromegaly
and is postoperative following a transsphenoidal
hypophysectomy. Which of the following
interventions should the nurse include in the plan?

a. maintain the client in a low-fowler’s position.

B. encourage deep breathing and coughing.

c. encourage the client to brush their
teeth when awake and alert.

D. observe dressing drainage for
the presence of glucose.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 78 hYperthYroiDism 525

UNIT 12 ENDOCRINE DISORDERS
SECTION: THYROID DISORDERS

CHAPTER 78 Hyperthyroidism
the thyroid gland produces three hormones:
thyroxine (t4), triiodothyronine (t3), and
thyrocalcitonin (calcitonin). secretion of t3 and
t4 is regulated by the anterior pituitary gland
through a negative feedback mechanism.

When blood t3 and t4 levels decrease,
thyroid-stimulating hormone (tsh) is released by
the anterior pituitary. this stimulates the thyroid
gland to secrete more hormones until normal
levels are reached. t3 and t4 affect all body
systems by regulating overall body metabolism,
energy production, and controlling tissue use
of fats, proteins, and carbohydrates. When the
thyroid is functioning appropriately, the term
euthyroid is used.

calcitonin inhibits mobilization of calcium from
bone and reduces blood calcium levels. Dietary
intake of protein and iodine is necessary for the
production of thyroid hormones.

hyperthyroidism is a clinical syndrome caused
by excessive circulating thyroid hormones.
Because thyroid activity affects all body systems,
excessive thyroid hormone exaggerates
normal body functions and produces a
hypermetabolic state.

ASSESSMENT

risK factors
CAUSES OF HYPERTHYROIDISM

● Graves’ disease (toxic diffuse goiter) is the most
common cause. Autoimmune antibodies result in
hypersecretion of thyroid hormones.

● Thyroiditis
● Toxic adenoma
● Toxic nodular goiter, a less common form of

hyperthyroidism, is caused by overproduction of thyroid
hormone due to the presence of thyroid nodules.

● Exogenous hyperthyroidism is caused by excessive
dosages of thyroid hormone.

eXpecteD finDings
● Nervousness, irritability, hyperactivity, emotional

lability, decreased attention span, change in mental or
emotional status

● Weakness, easy fatigability, exercise intolerance
● Muscle weakness
● Heat intolerance
● Weight change (usually loss) and increased appetite
● Insomnia and interrupted sleep
● Frequent stools and diarrhea
● Menstrual irregularities (amenorrhea or decreased

menstrual flow) and decreased fertility
● Libido initially increased, followed by a decrease as the

condition progresses
● Warm, sweaty, flushed skin with velvety-smooth texture
● Hair thins and develops a fine, soft, silky texture
● Tremor, hyperkinesia, hyperreflexia
● Exophthalmos (Graves’ disease only) due to edema

in the extraocular muscles and increased fatty tissue
behind the eye. Often causes blurred or double vision
and tiring of eyes due to pressure on the optic nerve

● Photophobia (sensitivity to light)
● Excessive tearing and bloodshot appearance of eyes
● Pretibial myxedema: dry waxy swelling of the front

surfaces of the lower legs that resembles benign tumors
(Graves’ disease only)

● Vision changes
◯ Eyelid retraction (lag): movement of the eyelid is
delayed when the eye moves downward

◯ Globe (eyeball) lag: upper eyelid pulls back faster than
the eyeball when the client gazes upward

● Goiter (common in Grave’s disease)
● Bruit over the thyroid gland
● Elevated systolic blood pressure and widened

pulse pressure
● Tachycardia, palpitations, and dysrhythmias
● Dyspnea
● Findings in older adult clients can be vague or assumed

to be caused by age-related changes (weight loss,
fatigue, change in bowel habit) or can be a single
manifestation (atrial fibrillation, angina or heart
failure).

laBoratorY tests
Blood TSH level: Decreased in the presence of
Graves’ disease (can be elevated in secondary or
tertiary hyperthyroidism)

Free T4 index, T4 (total) T3 : Elevated in the presence
of disease

Thyroid‑stimulating immunoglobulins: Elevated in
Graves’ disease, normal in other types of hyperthyroidism

Thyrotropin receptor antibodies: Elevation most
indicative of Graves’ disease

CHAPTER 78

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526 CHAPTER 78 hYperthYroiDism CONTENT MASTERY SERIES

Diagnostic proceDures
Ultrasound: Used to produce images of the thyroid gland
and surrounding tissue

Electrocardiogram: Used to evaluate the effects of
excessive thyroid hormone on the heart (tachycardia,
dysrhythmias); ECG changes include atrial fibrillation, and
changes in the P and T waveforms.

Thyroid scan: Nuclear medicine test
● This test clarifies size and function of the gland.
● The uptake of a radioactive isotope, administered orally
24 hr prior to the test, is measured.

● An elevated uptake is indicative of hyperthyroidism.

NURSING ACTIONS
● Confirm that the client is not pregnant prior to the scan.
● Take a medication history to determine the use of

iodides or medications that could affect results (oral
contraceptives, vitamins).

● Inform the provider if the client received any iodine
contrast recently or had other radiography testing.

CLIENT EDUCATION: Some foods and medications need
to be avoided before testing, sometimes up to 6 weeks.
Follow directions from the provider.

PATIENT‑CENTERED CARE

nursing care
● Minimize the client’s energy expenditure by assisting

with activities as necessary and by encouraging the
client to alternate periods of activity with rest.

● Promote a calm environment.
● Assess mental status and decision-making ability.

Intervene as needed to ensure safety.
● Monitor nutritional status. Provide increased calories,

protein, and other nutritional support as necessary.
● Monitor I&O and the client’s weight.
● Provide eye protection (patches, eye lubricant, tape to

close eyelids) for a client who has exophthalmos.
● Monitor vital signs and hemodynamic parameters.
● Reduce room temperature.
● Provide cool shower/sponge bath to promote comfort.
● Provide linen changes as necessary.
● Report a temperature increase of 1° F or more to the

provider immediately, because this is indicative of an
impending thyroid crisis.

● Monitor ECG for dysrhythmias.
● Assure the family that any abrupt changes in the client’s

behavior are likely disease related and should subside
with antithyroid therapy.

● Avoid excessive palpation of the thyroid gland.
● Administer antithyroid medications.

78.1 Expected findings of hyperthyroidism

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 78 hYperthYroiDism 527

meDications

Thionamides
● Methimazole and propylthiouracil inhibit the production

of thyroid hormone.
● Thionamides are used to treat Graves’ disease, as an

adjunct to radioactive iodine therapy, to decrease
hormone levels in preparation for surgery, and to
treat thyrotoxicosis.

NURSING ACTIONS
● Monitor for manifestations of hypothyroidism

(intolerance to cold, edema, bradycardia, increase in
weight, depression).

● Monitor CBC for leukopenia or thrombocytopenia.
● Monitor for indications of hepatotoxicity.

CLIENT EDUCATION
● Take the medication with meals, in divided doses

at regular intervals to maintain an even therapeutic
medication level.

● Report fever, sore throat, jaundice, or bruising to
the provider.

● Follow the provider’s instructions about dietary intake
of iodine.

● Methimazole should be stopped (under guidance from
the provider) if pregnancy occurs.

Beta‑adrenergic blockers

Propranolol, atenolol, and metoprolol treat sympathetic
nervous system effects (tachycardia, palpitations). These
medications counteract the effects of increased thyroid
hormones but do not alter the levels of the hormones.

NURSING ACTIONS
● Monitor blood pressure, heart rate, and ECG.
● Monitor for hypoglycemia in clients who have

diabetes mellitus.

CLIENT EDUCATION
● Change positions slowly, because the medication can

cause dizziness.
● Check pulse prior to taking each dose and notify the

provider if heart rate falls below 60/min.
● Discontinue the medication only on the advice of

the provider.

Iodine solutions

Lugol’s solution is a nonradioactive 5% elemental iodine
in 10% potassium iodine that inhibits the release of
thyroid hormone. These medications are for short-term
use only (taken for 10 days followed by surgery).

CLIENT EDUCATION
● Take iodine solution 1 hr after an antithyroid medication.
● These medications should not be used during pregnancy.
● Mix the medication solution with juice or other liquid to

mask the taste. Use a straw to avoid staining teeth.
Take with food.

● These medications pass into breast milk and can have
undesirable effects on a nursing infant.

● Notify the provider of fever, sore throat, metallic taste,
and mouth ulcers.

therapeutic proceDures

Radioactive iodine therapy

Radioactive iodine is taken up by the thyroid and destroys
some of the hormone-producing cells (131 I).

● One dose can be sufficient, but a second or third dose
might be needed.

● The degree of thyroid destruction varies and can require
lifelong thyroid replacement.

NURSING ACTIONS
● Radioactive iodine therapy is contraindicated in clients

who are pregnant.
● Monitor for manifestations of hypothyroidism (edema,

intolerance to cold, bradycardia, increase in weight,
depression).

CLIENT EDUCATION
● The effects of therapy might not be evident for 6

to 8 weeks.
● Continue taking antithyroid medication as directed.
● Stay at least 1 m away from pregnant individuals,

infants, or small children for the first week following
treatment. Limit contact to no more than 1 hr daily.

● Use precautions to prevent radiation exposure to others,
which can include the following.

◯ Do not use the same toilet as others for 2 weeks.
◯ Sit down to urinate to prevent splashing of urine.
◯ Flush the toilet three times after urinating
or defecating.

◯ Take a laxative 2 to 3 days after treatment to help rid
the body of stool contaminated with radiation.

◯ Wear clothing that is washable, wash clothing
separate from clothing of others, and run the
washing machine for a full cycle after washing
contaminated clothing.

◯ Avoid contamination from saliva, do not share a
toothbrush, and use disposable food service items
(paper plates).

Thyroidectomy

The surgical removal of part or all of the thyroid gland
● Subtotal thyroidectomy can be performed for the

treatment of hyperthyroidism when medication therapy
fails or radiation therapy is contraindicated. It can also
be used to correct diffuse goiter and thyroid cancer.
After a subtotal thyroidectomy, the remaining thyroid
tissue usually supplies enough thyroid hormone for
normal function.

● If a total thyroidectomy is performed, the client will
need lifelong thyroid hormone replacement therapy.

● The client can need to follow a high-protein,
high-carbohydrate diet prior to surgery.

PREPROCEDURE NURSING ACTIONS
● Explain the purpose of the thyroidectomy to the client.
● The client usually receives propylthiouracil or

methimazole 4 to 6 weeks before surgery.
● The client should receive iodine for 10 to 14 days before

surgery. This reduces the gland’s size and prevents
excess bleeding.

● Notify the provider immediately if the client does not
follow the medication regimen.

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528 CHAPTER 78 hYperthYroiDism CONTENT MASTERY SERIES

CLIENT EDUCATION
● Support the neck when performing deep breathing and

coughing exercises postoperatively.
● Some medications help prepare the body for surgery.
● Expect to have a neck incision covered with a dressing,

and a possible drain.
● Hoarseness and sore throat can occur

following intubation.
● Notify the nurse if tingling of the mouth, extremities, or

muscle twitching occurs.

POSTPROCEDURE NURSING ACTIONS
● Keep the client in a semi-Fowler’s position. Support

head and neck with pillows or sandbags. Avoid neck
extension.

● Following protocols, monitor vital signs typically every
15 min until stable, then every 30 min.

● Assist with deep breathing exercises every 30 to 60 min.
● Provide oral and tracheal suction as needed.
● Check the surgical dressing and back of the neck for

excessive bleeding.
● Respiratory distress can occur from compression of

trachea due to hemorrhage, which is most likely to
occur in the first 24 hr. Respiratory distress also can
occur due to edema. Ensure that tracheostomy supplies
are immediately available. Humidify air, assist to cough
and deep breathe, and provide oral and tracheal suction
if needed.

● Check for laryngeal nerve damage by asking the client
to speak as soon as awake from anesthesia and every
2 hr thereafter.

● Administer medication to manage pain. Reassure the
client that discomfort will resolve within a few days.

● Check for indications of hypocalcemia, which can result
from parathyroid damage intraoperatively (perioral
or extremity tingling, muscle twitching for positive
Chvostek’s and Trousseau’s signs).

◯ Ensure that IV calcium gluconate or calcium chloride
are immediately available.

◯ Keep emergency equipment near the bedside.

CLIENT EDUCATION
● Support the neck while performing coughing exercises

or changing positions.
● Do not manipulate the surgical drain, and

prevent pulling.
● Report incisional drainage, swelling, or redness which

can indicate infection.
● Monitor for manifestations of hypothyroidism

(hypothermia, lethargy, weight gain).
● Take all medications as directed. Following a

total thyroidectomy, lifelong thyroid replacement
medications will be required.

● Check with the provider prior to taking over-
the-counter medications.

● Report fever, increased restlessness, palpitations, or
chest pain.

interprofessional care
An endocrinologist, radiologist, pharmacist, and dietitian
can collaborate in providing care for the client.

COMPLICATIONS

Hemorrhage

Due to a loosened surgical tie, excessive coughing,
or movement, this can occur at the incision or in the
tissues, leading to respiratory distress.

NURSING ACTIONS
● Inspect the surgical incision and dressing for drainage

and bleeding, especially at the back of the neck, and
change the dressing as directed.

● Monitor the surgical drain. A moderate amount of
drainage is expected.

● Monitor for vocal changes as possible indications of
bleeding compressing the trachea.

● Report suspected bleeding to the provider.

Thyroid storm/crisis

Thyroid storm/crisis results from a sudden surge of large
amounts of thyroid hormones into the bloodstream,
causing an even greater increase in body metabolism. This
is a medical emergency with a high mortality rate.

● Precipitating factors include uncontrolled
hyperthyroidism occurring most often with Graves’
disease, infection, trauma, emotional stress, diabetic
ketoacidosis, and digitalis toxicity, all of which increase
demands on body metabolism. It also can occur
following a surgical procedure or a thyroidectomy as a
result of manipulation of the gland during surgery.

● Findings are hyperthermia, hypertension, delirium,
vomiting, abdominal pain, tachydysrhythmias, chest
pain, dyspnea, and palpitations.

NURSING ACTIONS
● Maintain a patent airway.
● Provide continuous cardiac monitoring

for dysrhythmias.
● Administer acetaminophen to decrease temperature.

! salicylate antipyretics (aspirin) are contraindicated
because they release thyroxine from protein-
binding sites and increase free thyroxine levels.

● Provide cool sponge baths, or apply ice packs to decrease
fever. If fever continues, obtain a prescription for a
cooling blanket for hyperthermia.

● Administer Thionamides (methimazole or
propylthiouracil) to prevent further synthesis and
release of thyroid hormones.

● Administer sodium iodide as prescribed, 1 hr after
administering thionamide medication.

● Administer beta-adrenergic blocking agents
(propranolol) to block sympathetic nervous
system effects.

● Administer glucocorticoids if adrenal insufficiency is
suspected or to treat shock.

● Administer IV fluids to provide adequate hydration
and prevent vascular collapse. Fluid volume deficit can
occur due to increased fluid excretion by the kidneys or
excessive diaphoresis. Monitor intake and output hourly
to prevent fluid overload or inadequate replacement.

● Administer supplemental O2 to meet increased
oxygen demands.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 78 hYperthYroiDism 529

CLIENT EDUCATION: Notify the provider of fever,
increased restlessness, palpitations, and chest pain.

Airway obstruction

Hemorrhage, tracheal collapse, tracheal mucus
accumulation, laryngeal edema, and vocal cord paralysis
can cause respiratory obstruction, with sudden stridor
and restlessness.

NURSING ACTIONS
● Keep a tracheostomy tray and suction equipment

available at all times during the immediate
recovery period.

● Maintain the bed in a high-Fowler’s position to decrease
edema and swelling of the neck.

● Alert the Rapid Response team and provider
immediately if respiratory manifestations occur.

● Provide humidified air.
● Medicate as prescribed to reduce swelling.

Hypocalcemia and tetany

Damage to parathyroid gland causes hypocalcemia
and tetany.

NURSING ACTIONS
● Monitor for indications of hypocalcemia (tingling of the

fingers and toes, carpopedal spasms, convulsions).
● Have IV calcium gluconate available for emergency

administration.
● Maintain seizure precautions.

Nerve damage
● Nerve damage can lead to vocal cord paralysis and

vocal disturbances.
● Incisional damage or swelling can cause nerve damage.

NURSING ACTIONS
● Monitor the client’s ability to speak every 2 hr.
● Assess the client’s voice tone and quality, and compare it

with the preoperative voice.
● Document findings, and report adverse findings to

the provider.

Application Exercises

1. a nurse in a provider’s office is reviewing the health
record of a client who is being evaluated for graves’
disease. the nurse should identify that which of the
following laboratory results is an expected finding?

a. Decreased thyrotropin receptor antibodies

B. Decreased thyroid-stimulating hormone (tsh)

c. Decreased free thyroxine index

D. Decreased triiodothyronine

2. a nurse is reviewing the manifestations of
hyperthyroidism with a client. Which of the following
findings should the nurse include? (select all that apply.)

a. anorexia

B. heat intolerance

c. constipation

D. palpitations

e. Weight loss

f. Bradycardia

3. a nurse is providing instructions to a client who
has graves’ disease and has a new prescription
for propranolol. Which of the following
information should the nurse include?

a. “an adverse effect of this medication is jaundice.”

B. “take your pulse before each dose.”

c. “the purpose of this medication is to
decrease production of thyroid hormone.”

D. “You should stop taking this medication
if you have a sore throat.”

4. a nurse is preparing to receive a client from the pacu
who is postoperative following a thyroidectomy.
the nurse should ensure that which of the following
equipment is available? (select all that apply.)

a. suction equipment

B. humidified oxygen

c. flashlight

D. tracheostomy tray

e. chest tube tray

5. a nurse in a provider’s office is planning care for a
client who has a new diagnosis of graves’ disease
and a new prescription for methimazole. Which
of the following interventions should the nurse
include in the plan of care? (select all that apply.)

a. monitor cBc.

B. monitor triiodothyronine (t3).

c. instruct the client to increase
consumption of shellfish.

D. advise the client to take the medication
at the same time every day.

e. inform the client that an adverse effect
of this medication is iodine toxicity.

6. a nurse is assessing a client who is 12 hr postoperative
following a thyroidectomy. Which of the following findings
is indicative of thyroid crisis? (select all that apply.)

a. Bradycardia

B. hypothermia

c. Dyspnea

D. abdominal pain

e. mental confusion

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530 CHAPTER 78 hYperthYroiDism CONTENT MASTERY SERIES

Active Learning Scenario

a nurse is reinforcing teaching with a client who will
have radioactive iodine therapy. What should the nurse
include in the teaching? use the ati active learning
template: therapeutic procedure to complete this item.

DESCRIPTION OF PROCEDURE: provide a
brief description of the procedure.

CLIENT EDUCATION: identify five client
instructions the nurse should include.

Application Exercises Key

1. a. in the presence of graves’ disease, elevated thyrotropin
receptor antibodies is an expected finding.

B. CORRECT: in the presence of graves’ disease,
low tsh is an expected finding. the pituitary
gland decreases the production of tsh when
thyroid hormone levels are elevated.

c. in the presence of graves’ disease, elevated free
thyroxine index is an expected finding.

D. in the presence of graves’ disease, elevated
triiodothyronine is an expected finding.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. the client who has hyperthyroidism has an increased
metabolic rate, resulting in increased hunger.

B. CORRECT: hyperthyroidism increases the client’s
metabolism, causing heat intolerance.

c. Diarrhea is an expected finding for the
client who has hyperthyroidism.

D. CORRECT: hyperthyroidism increases the client’s
metabolism, causing palpitations.

e. CORRECT: hyperthyroidism increases the
client’s metabolism, causing weight loss.

f. hyperthyroidism increases the client’s
metabolism, causing tachycardia.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. a. Yellowing of the skin is an adverse effect of methimazole.
B. CORRECT: propranolol can cause bradycardia.

the client should take their pulse before each
dose. if there is a significant change, they should
withhold the dose and consult the provider.

c. the purpose of propranolol is to suppress tachycardia,
diaphoresis, and other effects of graves’ disease.

D. sore throat is not an adverse effect of this medication. the
client should not discontinue taking this medication because
this action can result in tachycardia and dysrhythmias.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. a. CORRECT: the client can require oral or tracheal suctioning.
ensure that suctioning equipment is available.

B. CORRECT: the client can require supplemental
oxygen due to respiratory complications. humidified
oxygen thins secretions and promotes respiratory
exchange. this equipment should be available.

c. a flashlight is used to measure the reaction of the pupils to
light for a client who has an intracranial disorder. checking
pupil reaction with a flashlight is not indicated for this client.

D. CORRECT: the client can experience respiratory obstruction.
a tracheostomy tray should be available at the bedside.

e. a chest tube tray would be used for a client who
develops a hemothorax or pneumothorax. this is
not an expected complication of a thyroidectomy.
this equipment is not indicated for this client.

NCLEX® Connection: Physiological Adaptation,
Illness Management

5. a. CORRECT: methimazole can cause a number of
hematologic effects, including leukopenia and
thrombocytopenia. monitor cBc.

B. CORRECT: methimazole reduces thyroid
hormone production. monitor t3.

c. methimazole reduces thyroid hormone production
by blocking iodine. instruct the client to limit
iodine containing foods (shellfish).

D. CORRECT: methimazole should be taken at the
same time every day to maintain blood levels.

e. iodine toxicity is an adverse effect of
potassium iodide solution.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

6. a. When thyroid crisis occurs, the client experiences an extreme
rise in metabolic rate, which results in tachycardia.

B. When thyroid crisis occurs, the client experiences an extreme
rise in metabolic rate, which results in a high fever.

c. CORRECT: excessive levels of thyroid hormone
can cause the client to experience dyspnea.

D. CORRECT: When thyroid crisis occurs, the client
can experience gastrointestinal conditions
(vomiting, diarrhea, and abdominal pain).

e. CORRECT: excessive thyroid hormone levels can
cause the client to experience mental confusion.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications from Surgical Procedures and Health Alterations

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

DESCRIPTION OF PROCEDURE: radioactive iodine is
administered. While it is used for thyroid scan, it is a small
amount for testing. for therapy, larger amounts are given
for cell destruction. the thyroid absorbs the radiation, which
results in destruction of cells that produce thyroid hormone.

CLIENT EDUCATION
● the effects of the therapy might not be evident for 6 to 8 weeks.
● take medication as directed.
● follow precautions to prevent radiation exposure to others.
● follow directions from the provider, which can include the following.

◯ Do not use same toilet as others for 2 weeks.
◯ sit down to urinate.
◯ flush the toilet three times after use.
◯ take a laxative 2 to 3 days after treatment to rid the
body of stool contaminated with radiation.

◯ Wear clothing that is washable, wash clothing separate
from clothing of others, and run the washing machine
for a full cycle after washing contaminated clothing.

◯ avoid close contact with infants, young children, and
pregnant individuals for the first week following treatment.

◯ Do not share a toothbrush, and use disposable
food service items (paper plates).

NCLEX® Connection: Reduction of Risk Potential, Therapeutic
Procedures

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 79 hYpothYroiDism 531

UNIT 12 ENDOCRINE DISORDERS
SECTION: THYROID DISORDERS

CHAPTER 79 Hypothyroidism
hypothyroidism is a condition in which there
is an inadequate amount of circulating thyroid
hormones triiodothyronine (t3) and thyroxine (t4),
causing a decrease in metabolic rate that affects
all body systems. thyroid function can decline
slowly or rapidly (myxedema).

Because hypothyroidism can have
manifestations that mimic the aging process,
hypothyroidism is often undiagnosed in older
adult clients. this can lead to potentially serious
adverse effects from medications (sedatives,
opiates, anesthetics).

classifications BY etiologY
Primary hypothyroidism stems from dysfunction of
the thyroid gland. This is the most common type of
hypothyroidism and is caused by the following.

● Disease: autoimmune thyroiditis
● Use of medications that decrease the synthesis of

thyroid hormone
● Loss of the thyroid gland: iodine deficiency, radioactive

iodine or radiation treatment, surgical removal
of the gland

Secondary hypothyroidism is caused by failure of the
anterior pituitary gland to stimulate the thyroid gland
or failure of the target tissues to respond to the thyroid
hormones (pituitary tumors).

Tertiary hypothyroidism is caused by failure of the
hypothalamus to produce thyroid-releasing hormone.

Secondary and tertiary hypothyroidism is sometimes
called central hypothyroidism.

ASSESSMENT

risK factors
● Females 30 to 60 years old are affected 7 to 10 times

more often than males.
● Use of certain medications (lithium, amiodarone)
● Inadequate intake of iodine
● Radiation therapy to the head and neck

eXpecteD finDings
Hypothyroidism is often characterized by vague
and varied findings that develop slowly over time.
Manifestations can vary and are related to the severity of
the condition.

● Fatigue, lethargy (sleeping up to 16 hr/day)
● Irritability
● Intolerance to cold
● Constipation
● Weight gain without an increase in caloric intake
● Pallor
● Thick, brittle fingernails
● Depression and apathy
● Joint or muscle pain
● Bradycardia, hypotension, dysrhythmias
● Slow thought processes and speech
● Hypoventilation, pleural effusion
● Thickening of the skin
● Hair loss
● Thinning of hair on the eyebrows
● Dry, flaky skin
● Swelling in face and tongue, hands, and feet

(myxedema [non-pitting, mucinous edema])
● Decreased acuity of taste and smell
● Hoarse, raspy speech due to myxedema affecting

the larynx
● Abnormal menstrual periods (menorrhagia/amenorrhea)
● Decreased libido, impotence
● Many individuals who have mild hypothyroidism are

frequently undiagnosed, but the hormone disturbance
can contribute to an acceleration of atherosclerosis
or complications of medical treatment (intraoperative
hypotension, cardiac complications following surgery).

laBoratorY tests
EXPECTED RESULTS WITH HYPOTHYROIDISM

● T3, T4: Decreased
● Blood thyroid‑stimulating hormone (TSH)

◯ Increased with primary hypothyroidism
◯ Decreased or within the expected reference range in
secondary hypothyroidism

● Blood cholesterol: Increased
● Antithyroid antibodies: Present in some cases

Diagnostic proceDures
Thyroid scan: Clients who have hypothyroidism have a
low uptake of the radioactive preparation.

ECG: Sinus bradycardia, dysrhythmias

CHAPTER 79

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532 CHAPTER 79 hYpothYroiDism CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE
Clients older 80 years of age are not prescribed treatment
for low thyroid hormone levels unless experiencing
manifestations.

nursing care
● Monitor for cardiovascular changes (low blood pressure,

bradycardia, dysrhythmias). Monitor for chest pain
for clients who have chronic hypothyroidism because
it can lead to cardiovascular disease. Assess for
peripheral edema.

● Monitor the client’s weight.
● If mental status is compromised, orient the client

periodically, and provide safety measures.
● Increase the client’s activity level gradually, and provide

frequent rest periods to avoid fatigue and decrease
myocardial oxygen demands.

● Apply anti-embolism stockings, and elevate the client’s
legs to assist venous return.

● Monitor respiratory status including rate, depth,
pattern, oximetry, and arterial blood gases. Encourage
the client to cough and breathe deeply to prevent
pulmonary complications.

● Consult with a dietitian. Provide a low-calorie,
high-bulk diet, and encourage fluids and activity to
prevent constipation and promote weight loss.

● Administer cathartics and stool softeners as needed.
Avoid fiber laxatives, which interfere with absorption of
levothyroxine.

● Provide meticulous skin care. Turn and reposition the
client every 2 hr as prescribed bed rest. Use alcohol-free
skin care products and an emollient lotion after bathing.

● Provide extra clothing and blankets for clients who
have decreased cold tolerance. Dress the client in layers,
adjust room temperature, and encourage intake of warm
liquids if possible.

● Caution the client against using electric blankets or
other heating devices because the combination of
vasodilation, decreased sensation, and decreased
alertness can result in unrecognized burns.

● Encourage the client to verbalize feelings and fears
about changes in body image. Return to the euthyroid
(normal thyroid gland function) state takes time.
Reassure the client that most physical manifestations
are reversible.

● Use caution with medications due to alteration in
metabolism.

◯ CNS depressants (barbiturates or sedatives) are
used with caution due to the risk of respiratory
depression. If prescribed, the dose should be
significantly decreased.

◯ Hypothyroidism alters metabolism and excretion of
medications. The provider uses caution in prescribing
medications to clients who have this condition.

client eDucation
● Report chest pain or discomfort immediately.
● Take thyroid replacement as prescribed without

changing timing, dose, or brand, unless the provider
is consulted.

meDications

Thyroid hormone replacement therapy

Levothyroxine
● A synthetic thyroid hormone replacement, the most

common medication prescribed.
● Levothyroxine increases the effects of warfarin and can

increase the need for insulin and digoxin.
● Many other medications can affect the therapeutic

effectiveness of levothyroxine.
● Use caution when starting thyroid hormone replacement

with older adult clients and those who have coronary
artery disease to avoid coronary ischemia because of
increased oxygen demands of the heart. It is preferable
to start with much lower doses and increase
gradually.

NURSING ACTIONS
● Monitor for cardiovascular compromise (chest pain,

palpitations, rapid heart rate, shortness of breath).
● Inform the client that fiber supplements, calcium, iron,

and antacids interfere with absorption. Before taking
any over-the-counter medications, the client must
consult with the provider.

CLIENT EDUCATION
● Treatment begins slowly and the dosage will be

increased every 2 to 3 weeks until the desired response
is obtained. Blood TSH is monitored at scheduled times
to ensure correct dosage.

● Take the dose prescribed. Do not stop taking the
medication or change the dose or brand name.

● Take the medication on an empty stomach, typically 30
to 60 min before breakfast.

● Monitor for and report manifestations of
hyperthyroidism (irritability, tremors, tachycardia,
palpitations, heat intolerance, rapid weight loss).

● Treatment is considered to be lifelong, requiring
ongoing medical assessment of thyroid function.

interprofessional care
A home health nurse might need to visit the client and
assess for adverse effects during the first few weeks
of therapy.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 79 hYpothYroiDism 533

COMPLICATIONS

Myxedema coma

Myxedema coma is a life-threatening condition that
occurs when hypothyroidism is untreated, poorly
managed, or when a stressor (acute illness, surgery,
chemotherapy, discontinuing thyroid replacement
therapy, use of sedatives/opioids) affects a client who has
hypothyroidism.

MANIFESTATIONS
● Respiratory failure
● Hypotension
● Hypothermia
● Bradycardia, dysrhythmia
● Hyponatremia
● Hypoglycemia
● Coma

NURSING ACTIONS
● Maintain airway patency with ventilatory support

if necessary.
● Provide continuous ECG monitoring.
● Monitor ABGs to detect hypoxia, hypercapnia, and

respiratory acidosis.
● Monitor mental status.
● Cover the client with warm blankets.
● Monitor body temperature and blood pressure hourly

until stable.
● Replace fluid with 0.9% sodium chloride IV.
● Administer levothyroxine IV bolus. Absorption in the

GI tract will be decreased, so IV medication is required
until the client stabilizes. Monitor vital signs because
rapid correction of hypothyroidism can cause adverse
cardiac effects.

● Administration of T3 IV can be required until the client
is stable.

● Monitor I&O and daily weights. With treatment, urine
output should increase, and body weight should decrease.
Failure to do so should be reported to the provider.

● Treat hypoglycemia with glucose.
● Administer corticosteroids.
● Initiate aspiration precautions
● Check for possible sources of infection (blood, sputum,

urine) that might have precipitated the coma. Treat any
underlying illness.

Active Learning Scenario

a nurse is reviewing information about hypothyroidism
with a client. What information should the nurse
include in the discussion? use the ati active learning
template: system Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS): provide
a brief description of the disorder.

RISK FACTORS: identify two risk factors.

DIAGNOSTIC PROCEDURES: identify two laboratory
tests that are used to diagnose hypothyroidism.

Application Exercises

1. a nurse in a provider’s office is reviewing
laboratory results of a client who is being evaluated
for secondary hypothyroidism. Which of the
following laboratory findings is expected?

a. elevated t4

B. Decreased t3

c. elevated thyroid stimulating hormone

D. Decreased cholesterol

2. a nurse is collecting an admission history from a
client who has hypothyroidism. Which of the following
findings should the nurse expect? (select all that apply.)

a. Diarrhea

B. menorrhagia

c. Dry skin

D. increased libido

e. hoarseness

3. a nurse is reinforcing teaching with a client
who has a new prescription for levothyroxine
to treat hypothyroidism. Which of the following
information should the nurse include in
the teaching? (select all that apply.)

a. Weight gain is expected while
taking this medication.

B. medication should not be discontinued
without the advice of the provider.

c. follow-up blood tsh levels should be obtained.

D. take the medication on an empty stomach.

e. use fiber laxatives for constipation.

4. a nurse in an intensive care unit is planning care for a
client who has myxedema coma. Which of the following
actions should the nurse include? (select all that apply.)

a. observe cardiac monitor for dysrhythmias.

B. observe for evidence of urinary tract infection.

c. initiate iv fluids using 0.9% sodium chloride.

D. administer a levothyroxine iv bolus.

e. provide warmth using a heating pad.

5. a nurse in a provider’s office is assessing a client
who recently began taking levothyroxine to treat
hypothyroidism. Which of the following findings
should indicate to the nurse that the client might
need a decrease in the dosage of the medication?

a. hand tremors

B. Bradycardia

c. pallor

D. slow speech

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534 CHAPTER 79 hYpothYroiDism CONTENT MASTERY SERIES

Application Exercises Key

1. a. Decreased t4 is an expected finding for a
client who has hypothyroidism.

B. CORRECT: Decreased levels of t3 in the blood is an
expected finding for a client who has hypothyroidism.

c. Decreased thyroid stimulating hormone level is an expected
finding in a client who has secondary hypothyroidism.

D. elevated cholesterol is an expected finding
for a client who has hypothyroidism.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. constipation is a manifestation of hypothyroidism.
B. CORRECT: abnormal menstrual periods,

including menorrhagia and amenorrhea, are
manifestations of hypothyroidism.

c. CORRECT: Dry skin is a manifestation of hypothyroidism.
D. Decreased libido is a manifestation of hypothyroidism.
e. CORRECT: hoarseness is a manifestation of hypothyroidism.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. a. levothyroxine speeds up metabolism. Weight
loss is an expected effect.

B. CORRECT: the provider carefully titrates the dosage of this
medication. it should be increased slowly until the client
reaches a euthyroid state. the client should not discontinue
the medication unless directed to do so by the provider.

c. CORRECT: Blood tsh levels are used to monitor
the effectiveness of the medication.

D. CORRECT: the medication should be taken on
an empty stomach to promote absorption.

e. fiber laxatives reduce absorption of the
medication and should be avoided.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. a. CORRECT: a client who has myxedema can have a flat
or inverted t wave as well as st deviations.

B. CORRECT: an infection (in the urinary tract) can precipitate
myxedema coma. observe the client for manifestations of
infection so that the underlying illness can be treated.

c. CORRECT: hyponatremia is an expected finding
in the presence of myxedema coma. iv therapy is
administered using 0.9% sodium chloride.

D. CORRECT: myxedema coma is a severe complication
of hypothyroidism that if left untreated can lead
to coma or death. levothyroxine is administered
iv bolus to treat the condition.

e. provide warmth with extra clothing and blankets.
electric heating devices should be avoided because the
combination of vasodilation, decreased sensation, and
decreased alertness places the client at risk for burns.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

5. a. CORRECT: identify hand tremors as a manifestation
of hyperthyroidism that can result from thyroid
hormone replacement therapy. report this finding
to the provider due to the possible need for a
decrease in the dosage of medication.

B. Bradycardia is an expected finding for hypothyroidism. this
finding indicates the need for continued thyroid hormone
replacement therapy with a possible increase in dosage.

c. pallor is an expected finding for hypothyroidism. this
finding indicates the need for continued thyroid hormone
replacement therapy with a possible increase in dosage.

D. slow thought processes and speech are expected
findings for hypothyroidism. this finding indicates
the need for continued thyroid hormone replacement
therapy with a possible increase in dosage.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): hypothyroidism is a
condition in which there is an inadequate amount of circulating
thyroid hormones triiodothyronine (t3) and thyroxine (t4), causing
a decrease in metabolic rate that affects all body systems.

RISK FACTORS
● female clients age 30 to 60 years
● use of lithium or amiodarone

LABORATORY TESTS
● Blood t3

● Blood t4

● free t4 index
● thyroid antibodies
● tsh
● Blood cholesterol

NCLEX® Connection: Physiological Adaptation, Illness
Management

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 80 cushing’s Disease/sYnDrome 535

UNIT 12 ENDOCRINE DISORDERS
SECTION: ADRENAL DISORDERS

CHAPTER 80 Cushing’s
Disease/Syndrome

cushing’s disease (hypercortisolism) and
cushing’s syndrome are caused by an
oversecretion of the hormones the adrenal
cortex produces.

cushing’s disease can be the result of a tumor
in the pituitary gland, resulting in release of the
hormone acth. the acth then stimulates the
adrenal cortex to increase the secretion of the
glucocorticoid hormone cortisol. it can also be
the result of hyperplasia of the adrenal cortex.

cushing’s syndrome results from long-term
use of glucocorticoids to treat other conditions
(asthma or rheumatoid arthritis).

aDrenal corteX hormones
Mineralocorticoids: Aldosterone increases sodium
absorption, and causes potassium excretion in the kidney.

Glucocorticoids: Cortisol affects glucose, protein, and fat
metabolism; the body’s response to stress; and the body’s
immune function.

Sex hormones: Androgens and estrogens

HEALTH PROMOTION AND
DISEASE PREVENTION

● Following an adrenalectomy, hormone therapy
replacement is lifelong.

● Follow health promotion recommendations, and obtain
an annual influenza immunization.

● Wear a medical alert bracelet that lists Cushing’s as a
condition and the medications you are taking.

● Monitor blood glucose and blood pressure and report
unexpected findings.

ASSESSMENT

risK factors
Females between the ages of 20 and 40 years

Cushing’s disease

ENDOGENOUS CAUSES OF INCREASED CORTISOL
● Adrenal hyperplasia
● Adrenocortical carcinoma
● Pituitary carcinoma that secretes adrenocorticotropic

hormone (ACTH)
● Carcinomas of the lung, gastrointestinal (GI) tract, or

pancreas (these tumors can secrete ACTH)

Cushing’s syndrome

EXOGENOUS CAUSES OF INCREASED CORTISOL:
Therapeutic use of glucocorticoids for the following.

● Organ transplant
● Chemotherapy
● Autoimmune diseases
● Asthma
● Allergies
● Chronic fibrosis

eXpecteD finDings
● Weakness, fatigue, sleep disturbances
● Back and joint pain
● Altered emotional state (irritability, depression)
● Decreased libido

PHYSICAL ASSESSMENT FINDINGS
● Evidence of decreased immune function and decreased

inflammatory response (infections without fever,
swelling, drainage, erythema)

● Thin, fragile skin
● Bruising and petechiae (fragile blood vessels)
● Hypertension (sodium and water retention)
● Tachycardia
● Gastric ulcers due to oversecretion of hydrochloric acid
● Weight gain and increased appetite
● Irregular, scant menses
● Dependent edema
● Changes in fat distribution, including the characteristic

fat distribution of moon face, truncal obesity, and fat
collection on the back of the neck (buffalo hump)

● Fractures (osteoporosis)
● Bone pain and fractures with an increased risk for falls
● Muscle wasting (particularly in the extremities)
● Impaired glucose tolerance
● Frequent infections, poor wound healing
● Hirsutism
● Acne
● Red cheeks
● Striae (reddish purple lines on the abdomen,

upper arms, thighs)
● Clitoral hypertrophy
● Thinning, balding hair
● Hyperglycemia
● Emotional lability

CHAPTER 80

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536 CHAPTER 80 cushing’s Disease/sYnDrome CONTENT MASTERY SERIES

laBoratorY tests
Elevated blood cortisol levels in the absence of acute
illness or stress indicate Cushing’s disease/syndrome.

Urine (24‑hr urine collection) contains elevated levels of
free cortisol.

Plasma adrenocorticotropic hormone (ACTH) levels
● Hypersecretion of ACTH by the anterior pituitary results

in elevated ACTH levels.
● Disorders of the adrenal cortex or medication therapy

results in decreased ACTH levels.

Salivary cortisol elevations confirm the diagnosis of
Cushing’s disease.

Blood potassium and calcium levels: Decreased

Blood glucose level: Increased

Blood sodium level: Increased

Lymphocytes: Decreased

Dexamethasone suppression tests: Tests vary in length
and amount of dexamethasone to administer. Clients
might have to stay overnight and the medication is
administered orally in the evening or at bedtime.
24-hr urine collections show suppression of cortisol
excretion in clients who do not have Cushing’s disease.
Nonsuppression of cortisol excretion indicates Cushing’s
disease. Clients should stop taking medications and try
to reduce stress prior to and during testing. False positive
results can occur for clients who have acute illnesses and
alcohol use disorder.

Diagnostic proceDures
● X-ray, magnetic resonance imaging, arteriography, and

CT scans identify lesions of the pituitary gland, adrenal
gland, lung, GI tract, and pancreas.

● Radiological imaging determines the source of adrenal
insufficiency (tumor, adrenal atrophy).

PATIENT‑CENTERED CARE

nursing care
● Monitor I&O and daily weight.
● Assess for indications of hypervolemia (edema,

distended neck veins, shortness of breath, adventitious
breath sounds, hypertension, tachycardia).

● Maintain a safe environment to minimize the risk of
pathological fractures and skin trauma.

● Prevent infection by performing frequent hand hygiene.
● Encourage physical activity within the

client’s limitations.
● Provide meticulous skin care.
● Change the client’s position at least every 2 hr.
● Monitor for and protect against skin breakdown

and infection.
● Use surgical asepsis when performing dressing changes

and any invasive procedures.
● Monitor WBC count with differential daily.

client eDucation
● Take medications and watch for adverse reactions. The

need for medication therapy can be lifelong.
● Eat foods high in calcium and vitamin D.
● Assistance might be needed at home due to residual

muscle weakness.
● Monitor weight every day and report weight gain of

more than 2 lb over a 24 hr period or 3 lb over a week.

meDications
Treatment depends on the cause. For Cushing’s syndrome,
tapering off glucocorticoids and managing findings are
necessary.

Ketoconazole
● An adrenal corticosteroid inhibitor, ketoconazole is an

antifungal agent that inhibits adrenal corticosteroid
synthesis in high dosages.

● Ketoconazole supplements radiation or surgery.

NURSING ACTIONS
● Monitor liver enzymes and for indications of liver

toxicity (yellow sclera, dark-colored urine).
● Monitor fluids and electrolytes for clients who have

gastric effects.

CLIENT EDUCATION
● The medication can cause nausea, vomiting, fatigue,

skin changes, and dizziness.
● Relief is temporary. Findings will return after stopping

taking the medication.
● Take the medication with food to relieve

gastric effects.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 80 cushing’s Disease/sYnDrome 537

Mitotane

Produces selective destruction of adrenocortical cells

NURSING ACTIONS
● Mitotane treats inoperable adrenal carcinoma.
● Monitor for indications of shock, renal damage,

and hepatotoxicity.
● Monitor for orthostatic hypotension.

CLIENT EDUCATION
● The purpose of the medication is to reduce the size of

the tumor.
● Notify the provider for adverse effects (visual

disturbances, hematuria).
● Use caution when driving or operating heavy machinery.
● Lifelong replacement with glucocorticoids is likely.

Hydrocortisone

For replacement therapy for clients who have
adrenocortical insufficiency as a result of the treatment of
Cushing’s disease

NURSING ACTIONS
● This medication can be used in conjunction with

ketoconazole to avoid adrenal insufficiency.
● Monitor potassium and glucose levels.
● Measure daily weight. Notify the provider of weight

gain greater than 2.3 kg (5 lb)/week.
● Monitor blood pressure and pulse.
● Monitor for manifestations of infection (increased

temperature, increased WBC).

CLIENT EDUCATION
● Carry emergency identification about corticosteroid use.
● Report abdominal pain or black, tarry stools.
● Notify the provider for any manifestations of infection.
● Take the medication without skipping any doses.
● Consult the provider before taking any OTC medications

or supplements.
● Avoid infection by using good hygiene and avoiding

crowds or individuals who have an infection.

therapeutic proceDures

Chemotherapy

With cytotoxic agents for Cushing’s disease resulting
from a tumor

Hypophysectomy

Surgical removal of the pituitary gland (depending on the
cause of Cushing’s disease)

NURSING ACTIONS
● Monitor and correct electrolytes, especially sodium,

potassium, and chloride. Monitor and adjust glucose
levels. Monitor ECG.

● Protect the client from developing an infection by using
good hand hygiene and making sure the client avoids
contact with individuals who have infections. Use
caution to prevent a fracture by providing assistance
getting out of bed and raising side rails.

● Monitor for bleeding. Monitor nasal drainage for a
possible cerebrospinal fluid (CSF) leak. Assess drainage
for the presence of glucose or a halo sign (yellow on the
edge and clear in the middle), which can indicate CSF.

● Assess neurologic status every hour for the first 24 hr
and then every 4 hr.

● Administer glucocorticoids before, during, and after
surgery to prevent an abrupt drop in cortisol level.

● Administer stool softeners to prevent straining.
● Maintain a high caloric and protein diet.

CLIENT EDUCATION
● Use caution preoperatively to prevent infection

or fractures.
● The surgeon will perform a transsphenoidal

hypophysectomy through the sphenoid sinus via the nasal
cavity or under the upper lip and to expect nasal packing
postoperatively. There will be a drip pad under the nose
for bloody drainage, so breathing must be through the
mouth. Avoid coughing, blowing the nose, and sneezing.

● Numbness at the surgical site and a diminished sense of
smell can occur for 3 to 4 months after surgery.

● Avoid bending over at the waist and straining to prevent
increased intracranial pressure. If picking up an object
or to tying shoes, bend at the knees.

● Avoid brushing teeth for 2 weeks, and floss and rinse
the mouth with warm water.

● Notify the provider of increased swallowing, drainage
that makes a halo (yellow on the edge and clear in the
middle), or clear drainage from the nose, which can
indicate a CSF leak. Another indication is a headache.

● Notify the provider of excessive bleeding, confusion,
or headache.

● To avoid constipation, which contributes to increased
intracranial pressure, eat high-fiber food and
take docusate.

Adrenalectomy

Surgical removal of the adrenal gland can be unilateral
(one gland) or bilateral (both glands).

NURSING ACTIONS
● Inform the client that they will be monitored closely

in the ICU.
● Provide glucocorticoid and hormone replacement.
● Monitor for adrenal crisis due to an abrupt drop in

cortisol level. Findings include hypotension, tachycardia,
tachypnea, nausea, and headache.

● Monitor vital signs and hemodynamic levels initially
every 15 min.

● Monitor fluids and electrolytes.
● Monitor the incision site for bleeding.
● Monitor bowel sounds.
● Provide pain medication. Administer stool softeners.
● Slowly reintroduce foods.
● Assess the abdomen for distention and tenderness.

Monitor the incision site for redness, discharge,
and swelling.

CLIENT EDUCATION
● Perform postoperative pain management, deep

breathing, and anti-embolism care.
● Take glucocorticoids, mineralocorticoids, and

hormone replacements.

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538 CHAPTER 80 cushing’s Disease/sYnDrome CONTENT MASTERY SERIES

interprofessional care
● Request a dietary consult. Dietary alterations include

decreased sodium intake and increased intake of
potassium, protein, calcium, and vitamin D.

● Refer the client for home follow-up and care as
indicated to assist with mobility, fall reduction, and
monitoring of adherence to the medication plan.

COMPLICATIONS

Perforated viscera/ulceration

Decreases production of protective mucus in the lining of
the stomach due to an increase in cortisol

NURSING ACTIONS
● Monitor for evidence of GI bleeding (tarry, black stool;

coffee-ground emesis).
● Administer antacids or H2 receptor blockers.

CLIENT EDUCATION
● Monitor for GI bleeding and to avoid alcohol, caffeine,

and smoking.
● Avoid aspirin or NSAIDs.

Bone fractures due to hypocalcemia

NURSING ACTIONS
● Use caution when moving the client.
● Provide assistance when the client is ambulating.
● Clear floors to prevent falls.

CLIENT EDUCATION
● Adhere to a diet high in calcium and vitamin D.
● Avoid dangerous activities.

Infection due to immunosuppression

Immunosuppression and reduced inflammatory response
occur due to elevated glucocorticoid levels.

NURSING ACTIONS
● Monitor for subtle indications of infection (fatigue, fever,

localized swelling or redness).
● Monitor WBC counts and sources for infection

(urine, skin).

CLIENT EDUCATION
● Minimize exposure to infectious organisms. (Avoid

people who are ill. Avoid crowds. Use hand hygiene.)
● Report indications of infection to the provider.

Adrenal crisis (acute adrenal insufficiency)

Sudden drop in corticosteroids is due to sudden tumor
removal; stress of illness, trauma, surgery, or dehydration;
or abrupt withdrawal of steroid medication.

NURSING ACTIONS
● Indications include hypotension, hypoglycemia,

hyperkalemia, abdominal pain, weakness, and
weight loss.

● Administration of glucocorticoids treats acute
adrenal insufficiency.

● Administer insulin with dextrose, a potassium-binding
and -excreting resin (sodium polystyrene sulfonate), or
loop or thiazide diuretics to treat hyperkalemia.

● Administer glucagon or glucose via IV bolus to
treat hypoglycemia.

● Monitor vital signs and glucose levels.
● Monitor ECG.

CLIENT EDUCATION
● Taper the medication.
● During times of stress, additional glucocorticoids might

be needed to prevent adrenal crisis.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 80 cushing’s Disease/sYnDrome 539

Active Learning Scenario

a nurse is teaching a client who has bilateral
adrenal hyperplasia and a new prescription for
hydrocortisone. use the ati active learning
template: medication to complete this item.

THERAPEUTIC USES: explain why the client
needs to take this medication.

CLIENT EDUCATION: identify three teaching
points to include about this medication.

Application Exercises

1. a nurse is planning care for a client who has cushing’s
disease. the nurse should identify that clients who
have cushing’s disease are at increased risk for
which of the following? (select all that apply.)

a. infection

B. gastric ulcer

c. renal calculi

D. Bone fractures

e. Dysphagia

2. at the beginning of a shift, a nurse is assessing
a client who has cushing’s disease. Which
of the following findings is the priority?

a. Weight gain

B. fatigue

c. fragile skin

D. Joint pain

3. a nurse is reviewing the laboratory findings
of a client who has cushing’s disease. Which
of the following findings should the nurse
expect for this client? (select all that apply.)

a. sodium 150 meq/l

B. potassium 3.3 meq/l

c. calcium 8.0 mg/dl

D. lymphocyte count 35%

e. fasting glucose 145 mg/dl

4. a nurse is caring for a client who is 6 hr postoperative
following a transsphenoidal hypophysectomy.
the nurse should test the client’s nasal drainage
for the presence of which of the following?

a. rBcs

B. Ketones

c. glucose

D. streptococci

5. a nurse is providing discharge teaching for a client
who had a transsphenoidal hypophysectomy.
Which of the following instructions should
the nurse include? (select all that apply.)

a. Brush teeth after every meal or snack.

B. avoid bending at the knees.

c. eat a high-fiber diet.

D. notify the provider of increased swallowing.

e. notify the provider of a diminished sense of smell.

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540 CHAPTER 80 cushing’s Disease/sYnDrome CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: suppression of the immune system
places the client at risk for infection.

B. CORRECT: the overproduction of cortisol inhibits
the production of a protective mucus lining in the
stomach and causes an increase in the amount of gastric
acid. these factors place clients who have cushing’s
disease at increased risk for gastric ulcers.

c. clients who have cushing’s disease are not
at risk for renal calculi, but they are at risk for
neurologic and cardiovascular problems.

D. CORRECT: clients who have cushing’s disease
are at risk for bone fractures because decreased
calcium absorption leads to osteoporosis.

e. clients who have cushing’s disease are not at
risk for dysphagia, but they are at risk for other
gastrointestinal problems, including anorexia,
nausea, vomiting, and abdominal pain.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. CORRECT: the greatest risk to a client who has
cushing’s disease is fluid retention, which can lead to
pulmonary edema, hypertension, and heart failure;
therefore, this is the priority finding.

B. fatigue will reduce the client’s ability to perform self
care; however another finding is the priority.

c. fragile skin increases the client’s risk for tears or
lesions; however another finding is the priority.

D. Joint pain can reduce the client’s mobility;
however, another finding is the priority.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. a. CORRECT: this finding is above the expected
reference range. hypernatremia is an expected finding
for clients who have cushing’s disease.

B. CORRECT: this finding is below the expected
reference range. hypokalemia is an expected finding
for clients who have cushing’s disease.

c. CORRECT: this finding is below the expected
reference range. hypocalcemia is an expected
finding for clients who have cushing’s disease.

D. this finding is within the expected reference range.
a decreased lymphocyte count is an expected
finding for clients who have cushing’s disease.

e. CORRECT: this finding is above the expected
reference range. clients who have cushing’s disease
have an elevated fasting blood glucose because
the disorder affects glucose metabolism.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

4. a. cerebrospinal fluid does not contain rBcs unless the
client has a cerebral hemorrhage or the procedure was
traumatic. the nurse is not required to test for this.

B. cerebrospinal fluid does not contain ketones,
although it does contain protein and lactic acid.

c. CORRECT: cerebral spinal fluid contains
glucose. test nasal drainage for glucose.

D. cerebrospinal fluid does not contain any bacteria
unless the client has meningitis or another
infection that involves the brain and spinal cord.
the nurse is not required to test for this.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

5. a. the client should avoid brushing their teeth for
2 weeks to allow time for the incision to heal.

B. the client should avoid bending at the waist. if bending
is necessary, they should bend at the knees.

c. CORRECT: to avoid constipation, which contributes
to increased intracranial pressure, the client should
eat a high-fiber diet and take docusate.

D. CORRECT: increased swallowing is an indication of leakage of
cerebrospinal fluid. the client should notify their provider.

e. Diminished sense of smell is an expected
finding after surgery.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

THERAPEUTIC USES: hydrocortisone is a glucocorticoid that treats
adrenal insufficiency resulting from adrenalectomy surgery.

CLIENT EDUCATION
● carry emergency identification about corticosteroid use.
● report abdominal pain or black, tarry stools.
● notify the provider for any manifestations of infection.
● take the medication without skipping any doses.
● consume a diet high in calcium and vitamin D.
● consult the provider before taking any otc
medications or supplements.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 81 aDDison’s Disease anD acute aDrenal insufficiencY (aDDisonian crisis) 541

UNIT 12 ENDOCRINE DISORDERS
SECTION: ADRENAL DISORDERS

CHAPTER 81 Addison’s Disease
and Acute Adrenal
Insufficiency
(Addisonian Crisis)

addison’s disease is an adrenocortical
insufficiency. it is caused by damage or
dysfunction of the adrenal cortex. With addison’s
disease, the production of mineralocorticoids
and glucocorticoids is diminished, resulting in
decreased aldosterone and cortisol.

acute adrenal insufficiency, also known as
addisonian crisis, has a rapid onset. it is a
medical emergency. if it is not quickly diagnosed
and properly treated, the prognosis is poor.

older adult clients are less able to tolerate the
complications of addison’s disease and acute
adrenal insufficiency and need more frequent
monitoring.

proDuceD BY the aDrenal corteX
Mineralocorticoids: Aldosterone increases sodium
absorption and causes potassium excretion in the kidney.

Glucocorticoids: Cortisol affects glucose, protein, and fat
metabolism; the body’s response to stress; and the body’s
immune function.

Sex hormones: Androgens and estrogens

ASSESSMENT

risK factors
CAUSES OF PRIMARY ADDISON’S DISEASE

● Idiopathic autoimmune dysfunction (majority of cases)
● Tuberculosis
● Histoplasmosis
● Adrenalectomy
● Cancer with metastasis
● Radiation therapy of the abdomen

CAUSES OF SECONDARY ADDISON’S DISEASE
● Steroid withdrawal
● Hypophysectomy
● Pituitary neoplasm
● High dose radiation of pituitary gland or entire brain

ACUTE ADRENAL INSUFFICIENCY is a life-threatening
event in which the need for cortisol is greater than the
body’s supply and if left untreated can lead to death.
Factors that precipitate acute adrenal insufficiency are
the following.

● Sepsis
● Trauma
● Stress (myocardial infarction, surgery, anesthesia,

hypothermia, volume loss, hypoglycemia)
● Adrenal hemorrhage
● Steroid withdrawal

eXpecteD finDings
Manifestations of chronic Addison’s disease develop
slowly, and manifestations of acute adrenal insufficiency
develop rapidly.

● Weight loss
● Craving for salt
● Hyperpigmentation of the skin and mucous membranes
● Weakness and fatigue
● Nausea, anorexia, and vomiting
● Abdominal pain
● Constipation or diarrhea
● Dizziness with orthostatic hypotension
● Severe hypotension (acute adrenal insufficiency)
● Dehydration
● Hyponatremia
● Hyperkalemia
● Hypoglycemia
● Hypercalcemia

laBoratorY tests
Blood electrolytes: increased K+, increased WBC, decreased
Na+, and increased calcium

BUN and creatinine: increased

Blood glucose: normal to decreased

Blood/salivary cortisol: decreased

Adrenocorticotropic hormone (ACTH) stimulation test
(provocation test): ACTH is infused, and the cortisol
response is measured 30 min and 1 hr after the injection.
With primary adrenal insufficiency, plasma cortisol
levels do not rise. With secondary adrenal insufficiency,
plasma cortisol levels are increased. ACTH test cannot be
performed if the client is experiencing an acute crisis.

Diagnostic proceDures

Electrocardiogram (ECG)

Used to assess for ECG changes or dysrhythmias
associated with electrolyte imbalance.

X‑ray, CT scan, and MRI scan

Radiological imaging to determine source of adrenal
insufficiency (a tumor or adrenal atrophy)

CHAPTER 81

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542 CHAPTER 81 aDDison’s Disease anD acute aDrenal insufficiencY (aDDisonian crisis) CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

nursing care
● The primary goal of care is preventing circulatory shock.
● Monitor for fluid and electrolyte imbalances.
● Administer saline infusions to restore fluid volume.

Observe for dehydration. Measure orthostatic vital signs.
Monitor daily weights.

● Administer hydrocortisone IV bolus and a continuous
infusion or intermittent IV bolus.

● Monitor for and treat hyperkalemia:
◯ Measure blood potassium and obtain an ECG.
◯ Administer sodium polystyrene sulfonate, insulin,
calcium, glucose, and sodium bicarbonate.

◯ Assess vital signs frequently, and monitor
for dysrhythmias.

● Monitor for and treat hypoglycemia:
● Maintain a safe environment.

meDications

Hydrocortisone, prednisone, and cortisone

Glucocorticoids are used as adrenocorticoid replacement
for adrenal insufficiency and as an anti-inflammatory.

NURSING ACTIONS
● Monitor weight, blood pressure, and electrolytes.
● Increase dosage during periods of stress or illness

if necessary.
● Taper dose if discontinuing to avoid acute

adrenal insufficiency.
● Administer with food to reduce gastric effects.

CLIENT EDUCATION
● Avoid discontinuing the medication abruptly.
● Report manifestations of Cushing’s syndrome

(round face, edema, weight gain).
● Take the medication with food.
● Report manifestations of adrenal insufficiency (fever,

fatigue, muscle weakness, anorexia).
● Report acute illness to the provider.

Fludrocortisone

A mineralocorticoid used as a replacement in
adrenal insufficiency

● Hypertension is a potential adverse effect.
● Dosage might need to be increased during periods of

stress or illness.

NURSING ACTIONS: Monitor weight, blood pressure,
and electrolytes.

CLIENT EDUCATION
● Mild peripheral edema is expected.
● Report weight gain.

other meDications
Vasopressors: Used for clients who have
persistent hypertension

Antibiotics: Used to treat infections

interprofessional care
Home assistance for fluid, medication, and dietary
management can be required.

client eDucation
● Monitor for adverse reactions.
● Avoid using alcohol and caffeine.
● Monitor for indications of gastric bleeding

(coffee-ground emesis; tarry, black stool).
● Monitor for hypoglycemia (diaphoresis, shaking,

tachycardia, headache).
● Report manifestations of adrenal insufficiency (fever,

fatigue, muscle weakness, dizziness, anorexia).
● To prevent acute adrenal insufficiency, increase

corticosteroid doses as prescribed during times of stress.
● Medication therapy can be lifelong.
● Keep an emergency kit with hydrocortisone in case

addisonian crisis occurs; administer injection and seek
immediate medical care.

● Avoid stress and strenuous activity in hot weather.
● Replace sodium lost during episodes of nausea

and vomiting.

COMPLICATIONS

Acute adrenal insufficiency (Addisonian crisis)

Acute adrenal insufficiency (Addisonian crisis) occurs
when there is an acute drop in adrenocorticoids due to
sudden discontinuation of glucocorticoid medications or
when induced by severe trauma, infection, or stress.

NURSING ACTIONS
● Establish an IV access and initiate a rapid infusion of

0.9% sodium chloride.
● Administer hydrocortisone sodium as IV bolus,

initially and then as a continuous infusion. It can be
administered IM as well.

● Administer insulin and dextrose to move potassium
into cells.

● Administer calcium to counteract the effects of
hyperkalemia and protect the heart; and sodium
polystyrene sulfonate, a resin that absorbs potassium.

● If acidosis occurs, administer sodium bicarbonate to
promote alkalinity and increase uptake of and move
potassium into cells.

● Loop or thiazide diuretics are used to manage
hyperkalemia.

● Monitor vital signs. Monitor for manifestations
of hyperkalemia (bradycardia, heart block, and
peaked T waves).

● Monitor electrolytes.
● Administer an H2 antagonist (ranitidine) intravenously

for ulcer prevention.
● Position the client in a recumbent position with

legs elevated.
● Administer vasopressors to increase blood pressure.

CLIENT EDUCATION
● Notify the provider of any infection, trauma, or stress

that can increase the need for adrenocorticoids.
● Do not discontinue the medication abruptly.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 81 aDDison’s Disease anD acute aDrenal insufficiencY (aDDisonian crisis) 543

Hypoglycemia

Insufficient glucocorticoid causes increased insulin
sensitivity and decreased glycogen, which leads
to hypoglycemia.

NURSING ACTIONS
● Monitor glucose levels.
● Administer glucagon as needed.

CLIENT EDUCATION
● Monitor for hypoglycemia. Manifestations can include

diaphoresis, shaking, tachycardia, and headache.
● Have a 15 g carbohydrate snack readily available.

Hyperkalemia/Hyponatremia

Decrease in aldosterone levels can cause an increased
excretion of sodium and a decreased excretion
of potassium.

NURSING ACTIONS
● Monitor electrolytes and ECG.
● Administer insulin (IV), kayexalate, or loop diuretics.

CLIENT EDUCATION: Report indications of hyperkalemia
(muscle weakness, tingling sensation, irregular
heartbeat).

Application Exercises

1. a nurse is providing medication teaching for a
client who has addison’s disease and is taking
hydrocortisone. Which of the following instructions
should the nurse include? (select all that apply.)

a. take the medication on an empty stomach.

B. notify the provider of any illness or stress.

c. report any manifestations of weakness or dizziness.

D. Do not discontinue the medication suddenly.

e. eat a low-sodium diet.

2. a nurse is reviewing laboratory results for a
client who has addison’s disease. Which of the
following laboratory results should the nurse
expect for this client? (select all that apply.)

a. sodium 130 meq/l

B. potassium 6.1 meq/l

c. calcium 11.6 mg/dl

D. Blood urea nitrogen (Bun) 28 mg/dl

e. fasting blood glucose 148 mg/dl

3. a nurse is admitting a client who has acute adrenal
insufficiency. Which of the following prescriptions
should the nurse expect? (select all that apply.)

a. iv therapy with 0.45% sodium chloride

B. regular insulin

c. hydrocortisone sodium succinate

D. sodium polystyrene sulfonate

e. furosemide

4. a nurse is planning to teach a client who is
being evaluated for addison’s disease about
the adrenocorticotropic hormone (acth)
stimulation test. the nurse should base the
instructions on which of the following?

a. the acth stimulation test measures the
response by the kidneys to acth.

B. in the presence of primary adrenal
insufficiency, plasma cortisol levels rise in
response to administration of acth.

c. acth is a hormone produced
by the pituitary gland.

D. the client is instructed to take a dose of acth
by mouth the evening before the test.

Active Learning Scenario

a nurse in provider’s office is reviewing the health history
of a client who has addison’s disease. use the ati active
learning template: system Disorder to complete this item.

RISK FACTORS: identify the most common cause and
two additional causes of primary addison’s disease.

EXPECTED FINDINGS: identify three
manifestations of addison’s disease.

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544 CHAPTER 81 aDDison’s Disease anD acute aDrenal insufficiencY (aDDisonian crisis) CONTENT MASTERY SERIES

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS
● most common: autoimmune dysfunction
● additional causes: tuberculosis, histoplasmosis,
adrenalectomy, cancer

● expected findings
● hyperpigmentation
● Weight loss
● craving for salt
● Weakness
● fatigue
● nausea
● vomiting
● Dizziness upon standing or moving from lying to sitting position

NCLEX® Connection: Physiological Adaptation, Pathophysiology

Application Exercises Key

1. a. the client should take hydrocortisone with
food to decrease gi distress.

B. CORRECT: physical and emotional stress increase
the need for hydrocortisone. the provider can
increase the dosage when stress occurs.

c. CORRECT: Weakness and dizziness are indications
of adrenal insufficiency. the client should report
these indications to the provider.

D. CORRECT: rapid discontinuation can result in adverse effects,
including acute adrenal insufficiency. if hydrocortisone
is to be discontinued, the dose should be tapered.

e. addison’s disease causes hyponatremia. the client
might require sodium supplementation, especially
if experiencing diaphoresis or vomiting..

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

2. a. CORRECT: this finding is below the expected reference
range. in the presence of addison’s disease, insufficient
glucose can cause sodium and water excretion.
hyponatremia is an expected finding.

B. CORRECT: this finding is above the expected
reference range. hyperkalemia is an expected
finding for a client who has addison’s disease.

c. CORRECT: this finding is above the expected
reference range. hypercalcemia is an expected
finding for a client who has addison’s disease.

D. CORRECT: this Bun level is above the expected
reference range, which is an expected finding for a client
who has addison’s disease due to dehydration.

e. this finding is above the expected reference range
for a fasting blood glucose level. hypoglycemia or
blood glucose in the normal range is an expected
finding for a client who has addison’s disease.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

3. a. 0.45% sodium chloride is hypotonic. clients who
have acute adrenal insufficiency are hyponatremic.
anticipate a prescription for a solution that
contains 0.9% sodium chloride.

B. CORRECT: clients who have acute adrenal
insufficiency are hyperkalemic. insulin is
administered to shift potassium into the cells.

c. CORRECT: hydrocortisone sodium succinate is
administered as replacement therapy of both
glucocorticoid and mineralocorticoid.

D. CORRECT: clients who have acute adrenal insufficiency
are hyperkalemic. sodium polystyrene sulfonate is
administered because it absorbs potassium.

e. CORRECT: loop and thiazide diuretics promote potassium
excretion and are administered to treat hyperkalemia.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. a. the acth stimulation test measures the response
by the adrenal glands to acth.

B. in the presence of primary adrenal insufficiency,
plasma cortisol levels do not rise in response
to administration of acth.

c. CORRECT: secretion of corticotropin-releasing
hormone from the hypothalamus prompts
the pituitary gland to secrete acth.

D. acth is administered iv during the testing
process, and plasma cortisol levels are measured
30 min and 1 hr after the injection.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 82 DiaBetes mellitus management 545

UNIT 12 ENDOCRINE DISORDERS
SECTION: DIABETES MELLITUS

CHAPTER 82 Diabetes Mellitus
Management

Diabetes mellitus is a metabolic disorder
resulting from either an inadequate production
of insulin (type 1) or an inability of the body’s
cells to respond to insulin that is present (type 2).

type 1 diabetes mellitus is an autoimmune
dysfunction involving the destruction of beta
cells, which produce insulin in the islets of
langerhans of the pancreas. immune system
cells and antibodies are present in circulation
and can also be triggered by certain genetic
tissue types or viral infections.

type 2 diabetes mellitus is a progressive
condition due to increasing inability of cells
to respond to insulin (insulin resistance) and
decreased production of insulin by the beta
cells. it is linked to obesity, sedentary lifestyle,
and heredity. metabolic syndrome often
precedes type 2 diabetes mellitus.

Diabetes mellitus has wide ranging systemic
effects and is a contributing factor to
development of cardiovascular disease,
hypertension, kidney disease, neuropathy,
retinopathy, peripheral vascular disease,
and stroke.

Diabetes mellitus is significantly more prevalent
in african american, native american, and
hispanic populations and is more common in
males than females.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Diabetes mellitus type 1 cannot be prevented. Lifestyle
modifications can reduce the risk of diabetes mellitus
type 2, and minimize the risk of complications for
clients who develop diabetes mellitus.

● Try to maintain weight appropriate for body build
and height.

Diabetic screening
● Screen clients who have a BMI above 25 and one or more

of these factors.
◯ A first-degree relative who has diabetes mellitus
◯ Age 45 years or older
◯ Report of sedentary lifestyle
◯ History of vascular disease, polycystic ovary
syndrome, gestational diabetes, or giving birth to an
infant weighing more than 9 lb

◯ Reports African, Hispanic, Asian, American Indian, or
Pacific Islander heritage

◯ Has a blood pressure consistently greater than
140/90 mm Hg

◯ HgA1C greater than 5.7%, impaired fasting glucose, or
impaired glucose tolerance

◯ HDL level less than 35 mg/dL or triglyceride level
greater than 250 mg/dL

● Screening is done with fasting blood glucose levels or
glycosylated hemoglobin (A1C).

CLIENT EDUCATION
● Exercise and good nutrition are necessary for preventing

or controlling diabetes.
◯ Carbohydrates: 45% of total daily intake
◯ Protein: 15% to 20% of total daily intake, depending
upon kidney function

◯ Unsaturated and polyunsaturated fats: 20% to 35% of
total daily intake

● Consistency in the amount of food consumed and
regularity in meal times promotes blood glucose control.

● Consume a diet low in saturated fats to decrease
low-density lipoprotein (LDL), assist with weight loss
for secondary prevention of diabetes, and reduce risk of
heart disease.

● Modify the diet to include sources of omega-3 fatty
acids and fiber to lower cholesterol, improve blood
glucose for clients who have diabetes, for secondary
prevention of diabetes, and to reduce the risk of
heart disease.

● Perform physical activity at least three times per week
(150 min/week).

CHAPTER 82

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546 CHAPTER 82 DiaBetes mellitus management CONTENT MASTERY SERIES

ASSESSMENT
Clients are considered to have prediabetes when the
glucose level is above the expected range and below levels
that indicate diabetes mellitus (impaired fasting glucose
or impaired glucose tolerance).

risK factors
Metabolic syndrome
The presence of at least three factors that increase the
client’s risk for cardiovascular events and developing
diabetes mellitus type 2.

● Central obesity: waist circumference greater than
100 cm (40 in) for males; greater than 88 cm (35 in)
for females

● Hyperlipidemia: triglyceride level greater than
150 mg/dL or taking medication for triglycerides;
decreased HDL level (less than 50 mg/dL for females;
less than 40 mg/dL for males)

● Blood pressure consistently greater than 130 mm Hg
systolic, or 85 mm Hg diastolic; taking medication for
hypertension

● Hyperglycemia (fasting blood glucose at or greater than
100 mg/dL, or taking medication for hyperglycemia)

Insulin resistance: Impaired fasting glucose levels
100 to 125 mg/dL, impaired glucose tolerance 140 mg/dL,
or A1C level 5.7% to 6.4%

Pancreatitis and Cushing’s syndrome: Secondary causes
of diabetes

Age
● Older adult clients might not be able to drive to the

provider’s office, grocery store, or pharmacy. Assess
support systems available for older adult clients.

● Older adults are at risk for altered metabolism of
medication due to decreased kidney and liver function
because of the aging process.

● Older adults can have vision alterations (yellowing
of lens, decreased depth perception, cataracts),
which can affect ability to read information and
administer mediation.

● Vision and hearing deficits can interfere with the
understanding of teaching, reading of materials, and
preparation of medications.

● Tissue deterioration secondary to aging can affect
the client’s ability to prepare food, care for self,
perform ADLs, perform foot/wound care, and perform
glucose monitoring.

● A fixed income can mean that there are limited funds for
buying diabetic supplies, wound care supplies, insulin,
and medications. This can result in complications.

eXpecteD finDings
Polyuria: Excess urine production and frequency from
osmotic diuresis

Polydipsia: Excessive thirst due to dehydration
● Loss of skin turgor, skin warm and dry
● Dry mucous membranes
● Weakness and malaise
● Rapid weak pulse and hypotension

Polyphagia: Excessive hunger and eating caused from
inability of cells to receive glucose (because of a lack
of insulin or cellular resistance to available insulin)
and the body’s use of protein and fat for energy (which
causes ketosis)

● The client can display weight loss.

Kussmaul respirations: Increased respiratory rate and
depth in attempt to excrete carbon dioxide and acid due to
metabolic acidosis

Recurrent infections: Ask clients about the occurrence of
vaginal yeast infections

OTHER MANIFESTATIONS: Acetone/fruity breath odor
(due to accumulation of ketones), headache, nausea,
vomiting, abdominal pain, inability to concentrate,
fatigue, weakness, vision changes, slow healing of wounds,
decreased level of consciousness, seizures leading to coma

laBoratorY tests
Diagnostic criteria for diabetes include two findings (on
separate days) of at least one of the following.

● Manifestations of diabetes plus casual blood glucose
concentration greater than 200 mg/dL (without regard
to time since last meal)

● Fasting blood glucose greater than 126 mg/dL (no caloric
intake within 8 hr of testing)

● 2-hr glucose greater than 200 mg/dL with oral glucose
tolerance test

● Glycosylated hemoglobin (A1C) greater than 6.5%

Fasting blood glucose

NURSING ACTIONS: Postpone administration of
antidiabetic medication until after the level is drawn.

CLIENT EDUCATION: Fast (no food or drink other than
water) for the 8 hr prior to the blood test.

Oral glucose tolerance test
● This test is often used to diagnose gestational diabetes

mellitus during pregnancy.
● This is not generally used for routine diagnosis.
● A fasting blood glucose level is drawn at the start of the

test. The client is then instructed to consume a specified
amount of glucose. Blood glucose levels are obtained
every 30 min for 2 hr. The clients must be assessed for
hypoglycemia throughout the procedure.

● The fasting glucose should be less than 110 mg/d; less
than 180 mg/dL at 1 hr; and less than 140 mg/dL at 2 hr.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 82 DiaBetes mellitus management 547

CLIENT EDUCATION
● Consume a balanced diet for 3 days prior to the test.

Then, fast for 10 to 12 hr prior to the test.
● Only water can be taken during the testing period. Food

or other liquids will affect the test results.

Glycosylated hemoglobin (HbA1c)
● The expected reference range is 4% to 6%, but an

acceptable reference range for clients who have diabetes
can be 6.5% to 8%, with a target goal of less than 7%.

● HbA1c is the best indicator of the average blood glucose
level for the past 120 days. It assists in evaluating
treatment effectiveness and compliance.

CLIENT EDUCATION
● The test evaluates treatment effectiveness

and compliance.
● The test is recommended quarterly or twice yearly

depending on the glycemic levels.

Urine ketones
● Ketones accumulate in the blood due to breakdown of

fatty acids when insulin is not available.
● High ketones in the urine associated with

hyperglycemia (exceed 300 mg/dL) is a
medical emergency.

Lipid profile

Obtain a baseline measurement at diagnosis, then every 1
to 2 years.

Other laboratory testing

C-peptide levels, autoantibodies for insulin, islet cells,
and glutamic acid decarboxylase

Diagnostic proceDures

Self‑monitored blood glucose (SMBG)

NURSING ACTION: Ensure that the client follows the
proper procedure for blood sample collection and use of a
glucose meter. Supplemental short-acting insulin can be
prescribed for elevated premeal glucose levels.

CLIENT EDUCATION
● Check the accuracy of the strips with the control

solution provided.
● Use the correct code number in the meter to match the

strip bottle number.
● Store strips in the closed container in a dry location.
● Obtain an adequate amount of blood sample when

preforming the test.
● Perform appropriate hand hygiene.
● Use fresh lancets, and avoid sharing glucose monitoring

equipment to prevent infection.
● Keep a record of the SMBG that includes time, date,

blood glucose level, insulin dose, food intake, and
other events that can alter glucose metabolism (activity
level, illness).

MEDICATIONS
Antidiabetic medications are started at a low dose and
increased every few weeks until effective control or
maximum dosage is reached. Additional medications are
added as needed.

● Insulin regimens are established for clients who have
type 1 diabetes mellitus.

◯ More than 1 type of insulin: rapid-, short-,
intermediate-, and long-acting

◯ Given one or more times a day based on blood
glucose results

● Insulin can be required by some clients who have type 2
diabetes or gestational diabetes if glycemic control is not
obtained with diet, exercise, and oral hypoglycemic agents.

◯ Continuous infusion of insulin can be accomplished
using a small pump that is worn externally. The pump
is programmed to deliver insulin through a needle in
subcutaneous tissue. The needle should be changed at
least every 2 to 3 days to prevent infection.

◯ Complications of the insulin pump are accidental
cessation of insulin administration, obstruction of the
tubing/needle, pump failure, and infection.

● Insulin pens are prefilled cartridges of 150 to 300 units of
insulin in a programmable device with disposable needles.

◯ Convenient for travel
◯ Used for clients who have vision impairment or

problems with dexterity
● Oral antidiabetic medications are used, along with diet

and exercise, by clients who have type 2 diabetes to
regulate blood glucose.

Insulin

Also see the RN PHARMACOLOGY REVIEW MODULE:

CHAPTER 39: DIABETES MELLITUS.

A normally functioning pancreas releases insulin
continuously (basal) and as needed following carbohydrate
intake (prandial). Insulin therapy is prescribed to mimic
the pancreas.
Therapy can range from a single daily injection containing
an intermediate- to long-acting insulin, to two injections
daily with combination insulins, to an intense regime of
a basal insulin dose and subsequent injections for meal
intake and glucose levels.

Rapid‑acting insulin: Insulin lispro, insulin aspart,
insulin glulisine, inhaled human insulin

● Administer before meals to control postprandial rise in
blood glucose.

● Onset is rapid (10 to 30 min), depending on which
insulin is administered.

● Administer in conjunction with intermediate- or
long-acting insulin to provide glycemic control between
meals and at night.

Short‑acting insulin: Regular insulin
● Administer 30 to 60 min before meals to control

postprandial hyperglycemia.
● Regular insulin is available in two concentrations.

◯ U-500 is reserved for the client who has insulin
resistance. It is never administered IV.

◯ U-100 is prescribed for most clients and can be
administered IV.

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548 CHAPTER 82 DiaBetes mellitus management CONTENT MASTERY SERIES

Intermediate‑acting insulin: NPH insulin
● Administered for glycemic control between meals

and at night
● Not administered before meals to control postprandial

rise in blood glucose
● Contains protamine (a protein), which causes a delay

in the insulin absorption or onset and extends the
duration of action of the insulin

● Administered subcutaneous only and as the only insulin
to mix with short-acting insulin

Long‑acting insulin: Insulin glargine, insulin detemir
● Administer once daily, anytime during the day but

always at the same time each day.
● Glargine insulin forms microprecipitates that dissolves

slowly over 24 hr and maintains a steady blood sugar
level with no peaks or troughs.

● Insulin detemir has an added fatty-acid chain that
delays absorption. Although it does not have a peak,
duration is dose-dependent (12 to 24 hr).

● Administer glargine insulin and insulin detemir
subcutaneous only. Never administer IV.

Ultra long‑acting insulin: U-300 insulin glargine,
insulin degludec

● Duration is longer than 24 hr.
● Both medications are available only as a prefilled pen.
● U-300 insulin glargine is three times more concentrated

than standard insulin glargine. It is useful for clients
who do not receive 24 hr effective glucose with the
standard concentration.

● Insulin degludec comes in U-100 and U-200 concentrations.

NURSING ACTIONS
● Observe the client perform self-administration of

insulin, and offer additional instruction as indicated.
● Monitor for hypoglycemic reactions (sweating,

weakness, dizziness, confusion, headache, tachycardia,
slurred speech) at insulin peak times.

● Dosage can be adjusted when the client is scheduled for
procedures that require fasting.

CLIENT EDUCATION
● Perform self-administration of subcutaneous

insulin injections.
◯ Rotate injection sites (to prevent lipohypertrophy)
within one anatomic site (to prevent day-to-day
changes in absorption rates).

◯ Inject at a 90° angle (45° angle if the client is thin).
Aspiration for blood is not necessary.

◯ When mixing a rapid- or short-acting insulin with
a longer-acting insulin, draw up the shorter-acting
insulin into the syringe first and then the
longer-acting insulin. This reduces the risk of
introducing the longer-acting insulin into the
shorter-acting insulin vial.

● Perform self-administration of inhaled human insulin.
◯ Cartridges containing the powdered insulin are
available in 4, 8, or 12 units.

◯ Use multiple cartridges if needed to administer the
prescribed dose.

● Eat at regular intervals, avoid alcohol intake, and adjust
insulin to exercise and diet to avoid hypoglycemia.

● Wear a medical identification wristband.

Oral antidiabetics

Biguanides: Metformin
● Reduces the production of glucose by the liver

(gluconeogenesis)
● Increases tissue sensitivity to insulin
● Slows carbohydrate absorption in the intestines

NURSING ACTIONS
◯ Monitor significance of gastrointestinal (GI) effects
(flatulence, anorexia, nausea, vomiting).

◯ Monitor for lactic acidosis, especially in clients who
have kidney disorders or liver dysfunction.

◯ Stop medication for 24 to 48 hr before any type of
elective radiographic test with iodinated contrast dye
and restart 48 hr after (can cause lactic acidosis due
to acute kidney injury).

82.1 Hypoglycemia and hyperglycemia manifestations and management

Hypoglycemia
● teach the client measures to take in response to manifestations of hypoglycemia
(mild shakiness, mental confusion, sweating, palpitations, headache, lack of
coordination, blurred vision, seizures, and coma). When glucose declines
slowly, manifestations relate to the central nervous system (headache,
confusion, fatigue, drowsiness). With rapid glucose decline, the sympathetic
nervous system is affected (tachycardia, diaphoresis, nervousness).

● if the client is unconscious, place the client in a lateral position to prevent
aspiration and administer glucagon subcutaneous or im, and notify
the provider. repeat in 10 min if the client is still unconscious.

● glucagon or iv 50% dextrose is appropriate for clients who cannot swallow.
● to avoid hypoglycemia, avoid excess insulin, exercise, and alcohol consumption on an
empty stomach, and eat about the same amounts and at the same time periods daily.

● measure blood glucose level if manifestations occur; if it confirms hypoglycemia
(below 70 mg/dl), follow the steps below, or other protocol outlined by the provider.

◯ provide 15 to 20 g of a readily
absorbable carbohydrate (4 to 6 oz
of fruit juice or regular soft drink,
glucose tablets or glucose gel per
package instructions, 6 to 10 hard
candies, or 1 tbsp of honey). 10 g
of glucose will increase the blood
glucose by 40 mg/dl over 30 min.

◯ recheck the blood glucose 15 min
following intervention, and retreat the
client if manifestations continue or
the glucose is not above 70 mg/dl.

◯ if blood glucose is within the
expected reference range, have a
snack containing a carbohydrate
and protein (if the next meal
is more than 1 hr away).

◯ once consciousness occurs and the
client is able to swallow, have the
client ingest oral carbohydrates.

Hyperglycemia
● teach the client manifestations of
hyperglycemia (hot, dry skin, and
fruity breath) and measures to take
in response to hyperglycemia.

● encourage oral fluid intake of sugar-free
fluids to prevent dehydration.

● administer insulin as prescribed.
● test urine for ketones and report if
outside of the expected reference range.

● consult the provider if
manifestations progress.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 82 DiaBetes mellitus management 549

CLIENT EDUCATION
◯ Take with food to decrease adverse GI effects.
◯ Take vitamin B12 and folic acid supplements.
◯ Contact the provider if manifestations of lactic
acidosis develop (myalgia, sluggishness, somnolence,
and hyperventilation).

Second‑generation sulfonylureas: Glipizide,
glimepiride, glyburide

● Stimulates insulin release from the pancreas causing a
decrease in blood sugar levels

● Increases tissue sensitivity to insulin following
long-term use

NURSING ACTIONS
◯ Monitor for hypoglycemia.
◯ Beta-blockers can mask tachycardia typically seen
during hypoglycemia.

CLIENT EDUCATION
◯ Administer 30 min before meals.
◯ Monitor for hypoglycemia and report frequent
episodes to the provider.

◯ Avoid alcohol due to disulfiram effect.
◯ Avoid alcohol consumption while taking metformin to
reduce the risk for lactic acidosis.

Meglitinides: Repaglinide, nateglinide
● Stimulates insulin release from pancreas
● Administered for post-meal hyperglycemia

NURSING ACTIONS: Monitor for hypoglycemia.

CLIENT EDUCATION
◯ Take within 30 min before meals.
◯ Omit the dose if skipped a meal to prevent

hypoglycemic crisis.

Thiazolidinediones: Pioglitazone
● Reduces the production of glucose by the liver

(gluconeogenesis)
● Increases tissue sensitivity to insulin

NURSING ACTIONS
◯ Monitor for fluid retention, especially in clients who

have a history of heart failure.
◯ Monitor for elevation of ALT, LDH, and
triglycerides levels.

◯ Monitor for hepatotoxicity.

CLIENT EDUCATION
◯ Report rapid weight gain, shortness of breath,
decreased exercise tolerance, jaundice, or dark urine.

◯ Use additional contraception methods because
the medication reduces the blood levels of oral
contraceptives and stimulate ovulation.

◯ Have liver function tests at baseline and every
3 to 6 months thereafter.

Alpha‑glucosidase inhibitors: Acarbose, miglitol
● Slow carbohydrate absorption from the intestinal tract
● Reduces post-meal hyperglycemia

NURSING ACTIONS
◯ Monitor liver function every 3 months.
◯ Treat hypoglycemia with glucose, not table sugar
(prevents table sugar from breaking down).

● CLIENT EDUCATION
◯ Have liver function tests performed every 3 months or
as prescribed.

◯ Take the medication with the first bite of each meal in
order for the medication to be effective.

◯ GI discomfort is common with these medications.

Dipeptidyl peptidase‑4 (DPP‑4) inhibitors: Sitagliptin,
saxagliptin, linagliptin, alogliptin

● Augments naturally occurring intestinal incretin
hormones, which promote release of insulin and
decrease secretion of glucagon

● Lowers fasting and postprandial glucose levels
● Few adverse effects, but upper respiratory manifestations

(nasal and throat inflammation) and pancreatitis can occur.

CLIENT EDUCATION
◯ Report persistent upper respiratory manifestations.
◯ Report severe abdominal pain, with or without emesis.
◯ Medication only works when blood sugar is rising.

82.3 Insulin subcutaneous injection sites

82.2 Insulin pen

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550 CHAPTER 82 DiaBetes mellitus management CONTENT MASTERY SERIES

Sodium‑glucose cotransporter 2 inhibitors: Canagliflozin,
dapagliflozin

● Blocks reabsorption of glucose by kidneys, thus
increasing urinary glucose excretion so that glucose is
excreted in the urine

NURSING ACTIONS
◯ Monitor for development of urinary tract infections
and genital yeast infection.

◯ Monitor for postural hypotension in older adult clients,
especially if taking diuretics concurrently.

CLIENT EDUCATION
◯ Take the medication before the first meal of the day.
◯ Change positions slowly.
◯ Monitor and report genital burning, itching, or
increased drainage.

Non‑insulin injectable medications

Incretin mimetic: Exenatide, liraglutide
● Mimics the function of intestinal incretin hormone

by decreasing glucagon secretion, promoting insulin
release, and gastric emptying

● Decreases insulin demand by reducing fasting and
postprandial hyperglycemia

NURSING ACTIONS
◯ Administer exenatide subcutaneously 60 min before
morning and evening meal.

◯ Monitor for gastrointestinal distress.

CLIENT EDUCATION
◯ Do not administer after a meal.
◯ Oral medications should never be taken within 1 hr of
oral exenatide or 2 hr after an injection of exenatide
because it will decrease effectiveness. Use caution,
particularly with oral contraceptives and antibiotics.

◯ Decreased appetite and weight loss can occur.
◯ Report severe abdominal pain, with or without emesis,
as a possible indication of pancreatitis.

Amylin mimetic: Pramlintide
● A synthetic amylin hormone found in the beta cells

of the pancreas, suppresses glucagon secretion and
controls postprandial blood glucose levels

● Used for clients who are taking insulin, to provide more
effective glucose control

● The provider should reduce the premeal doses of rapid-
or short-acting insulins by 50% when pramlintide
therapy begins to reduce risk of hypoglycemia.

NURSING ACTIONS
◯ Administer subcutaneously immediately before each
major meal.

◯ Do not administer if client has hypoglycemia
unawareness, or noncompliance/poor adherence to
treatment regimens and self-monitoring blood glucose.

CLIENT EDUCATION
◯ Monitor and report frequent periods of hypoglycemia.
◯ Administer the injection at least 5 cm (2 in) from any
insulin injection given at the same time. Monitor for
injection site reactions.

PATIENT‑CENTERED CARE

nursing care
● Monitor the following.

◯ Blood glucose levels and factors affecting levels
(other medications)

◯ I&O and weight
◯ Skin integrity and healing status of any wounds for

presence of recurrent infections (feet and folds of the
skin should be monitored)

◯ Sensory alterations (tingling, numbness)
◯ Visual alterations
◯ Dietary practices
◯ Exercise patterns
◯ SMBG skill proficiency
◯ Self-medication administration proficiency

● Adjustments to the client’s antidiabetic therapy might
be required if the client is placed NPO, on a clear liquid
diet, or is receiving enteral or parenteral nutrition.
Ensure clients who are prescribed clear liquids have
sufficient calorie intake.

◯ Clients who have diabetes mellitus type 1 will
need continued insulin administration while NPO
to prevent diabetic ketoacidosis. This can include
elimination of rapid-acting insulin but continuing to
provide a basal insulin dose.

◯ Monitor blood glucose levels consistently; the timing
should coincide with meal or intermittent feeding
administration.

◯ Short-acting insulin is often given at the time of
clear liquid meals or enteral feedings to prevent
hyperglycemia.

◯ Clients receiving continuous feeding (enteral or
parenteral) require blood glucose monitoring and
possible insulin injections at evenly spaced times
(every 6 hr).

● Teach the client to follow facility policies or
recommendations of a podiatrist for nail care. Some
protocols allow for trimming toenails straight across
with clippers and filing edges with an emery board
or nail file to prevent soft tissue injury. If clippers or
scissors are contraindicated, the client should file the
nails straight across.

CLIENT EDUCATION
● Practice appropriate techniques for SMBG, including

obtaining blood samples, recording and responding to
results, and correctly handling supplies and equipment.

● Perform self-administration of insulin.
● Rotate injection sites to prevent lipohypertrophy

(increased swelling of fat) or lipoatrophy (loss of fat
tissue) within one anatomic site (prevents day-to-day
changes in absorption rates).

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 82 DiaBetes mellitus management 551

Foot care

CLIENT EDUCATION
● Inspect feet daily. Wash feet daily with mild soap and

warm water. Test water temperature with the arms or a
thermometer before washing feet. Do not soak the feet.

● Pat feet dry gently, especially between the toes, and
avoid lotions between toes to decrease excess moisture
and prevent infection.

● Use mild foot powder (powder with cornstarch) on
sweaty feet.

● Do not use commercial remedies for the removal of
calluses or corns, which can increase the risk for tissue
injury and infection.

● Consult a podiatrist.
● Separate overlapping toes with cotton or lamb’s wool.
● Avoid open-toe, open-heel shoes. Leather shoes are

preferred to plastic. Wear shoes that fit correctly. Wear
slippers with soles. Do not go barefoot.

● Wear clean, absorbent socks or stockings that are made
of cotton or wool and have not been mended. Wear
socks at night if the feet get cold.

● Do not use hot water bottles or heating pads to warm
feet. Wear socks for warmth.

● Avoid prolonged sitting, standing, and crossing of legs.
● Cleanse cuts with warm water and mild soap, gently

dry, and apply a dry dressing. Monitor healing and seek
intervention promptly.

Nutritional guidelines

CLIENT EDUCATION
● Consult a dietitian for collaborative education with the

client and family on meal planning to include food
intake, weight management, and lipid and glucose
management.

● Plan meals to achieve appropriate timing of food intake,
activity, onset, and peak of insulin. Calories and food
composition should be similar each day. Eat at regular
intervals, and do not skip meals.

● Count grams of carbohydrates consumed for
glycemic control.

● 15 g carbohydrates is equal to 1 carbohydrate exchange.
● Restrict calories and increase physical activity as

appropriate to facilitate weight loss (for clients who are
overweight or obese) or to prevent obesity.

● Include fiber in the diet to increase carbohydrate
metabolism and to help control cholesterol levels.

● Use artificial sweeteners. If caloric sweeteners are used,
add this to daily carbohydrate intake.

● Read and interpret fat content information on food
labels. Reduce intake of saturated and trans fats.

Exercise

CLIENT EDUCATION
● Only exercise when glucose levels are between 80 to
250 mg/dL; do not exercise if ketones are present in
the urine.

● If more than 1 hr has passed since eating and
high-intensity exercise is planned, consume a
carbohydrate snack first.

● Wear comfortable shoes, and always carry identification
information regarding diabetic status.

● Check blood glucose more often 24 hr after intensive
exercise; a reduced medication dose might be required.

Illness

CLIENT EDUCATION
● Notify the provider when ill.
● Monitor blood glucose every 2 to 4 hr.
● Continue to take insulin or oral hypoglycemic agents.
● Consume 8 to 12 oz (240 to 260 mL) of sugar-free,

noncaffeinated liquid every hour to prevent dehydration.
If the blood glucose is below the prescribed range,
drinking fluids containing sugar is acceptable.

● Meet carbohydrate needs through soft food (custard,
cream soup, gelatin, graham crackers) six to eight times
per day, if possible. If not, consume liquids equal to
usual carbohydrate content.

● Test urine for ketones as prescribed and report to
provider if they are outside the expected reference
range. Testing is recommended every 3 to 4 hr or if the
blood glucose exceeds 240 mg/dL.

● Rest.
● Call the provider for the following.

◯ Presence of moderate to large urine ketones or
ketonuria for more than 24 hr

◯ Blood glucose greater than 250 mg/dL that does not
resolve with treatment

◯ Fever greater than 38.6° C (101.5° F), does not respond
to acetaminophen, or lasts more than 24 hr

◯ Feeling disoriented or confused
◯ Experiencing rapid breathing
◯ Persistent nausea, vomiting, or diarrhea
◯ Inability to tolerate liquids
◯ Illness that lasts longer than 2 days

interprofessional care
Refer the client to a diabetes educator for comprehensive
education in diabetes management.

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552 CHAPTER 82 DiaBetes mellitus management CONTENT MASTERY SERIES

COMPLICATIONS
Consistent maintenance of blood glucose within the
expected reference range is the best protection against
the complications of diabetes mellitus. Expected reference
ranges can vary.

Cardiovascular and cerebrovascular disease

Hypertension, myocardial infarction, and stroke

NURSING ACTIONS
● Ensure the client’s blood pressure is measured at each

visit; the target blood pressure is less than 140/90 mm
Hg, or less than 130/80 mm Hg for young adult clients.

● Facilitate tobacco cessation.
● Promote adherence to prescriptions for lipid-lowering

medications and aspirin.

CLIENT EDUCATION
● Perform checks of cholesterol (HDL, LDL, and

triglycerides) yearly and HbA1c every 3 months.
● Participate in regular activity for weight loss

and control.
● Consume a diet of low-fat meals that are high in fruits,

vegetables, and whole grains.
● Report shortness of breath, headaches (persistent and

transient), swelling of feet, and infrequent urination.

Diabetic retinopathy

Impaired vision and blindness

CLIENT EDUCATION
● Perform yearly eye exams to ensure the health of the

eyes and to protect vision.
● Conduct management of blood glucose levels.
● Hypoglycemia causes temporary blurred vision;

report other vision changes that do not fluctuate with
glucose levels.

Diabetic neuropathy

Caused from damage to sensory nerve fibers resulting in
numbness and pain

● Peripheral neuropathy includes focal neuropathies,
caused by acute ischemic damage or diffuse
neuropathies, which are more widespread and involve
slow, progressive loss. This can lead to complications
(foot deformities, ulcers).

● Autonomic neuropathy can affect nerve conduction of
the heart (exercise intolerance, painless myocardial
infarction, altered left ventricular function, syncope),
gastrointestinal system (gastroparesis, reflux,
early satiety), and urinary tract (decreased bladder
sensation, urinary retention). It affects the autonomic
nervous system, which minimizes manifestations of
hypoglycemia (diaphoresis, tremors, palpitations), which
can be dangerous for the client.

NURSING ACTIONS
● Monitor for tolerance to activity and other indicators of

cardiac insufficiency.
● Administer medications to promote gastric motility as

prescribed (metoclopramide).
● Check for urinary retention.
● Provide foot care.

CLIENT EDUCATION
● Conduct annual exams by a podiatrist.
● Practice regular follow-up with provider to assess and

treat neuropathy.
● Report numbness and tingling, joint problems, or

difficulties with digestion or urinary elimination.
● Traditional indication of a heart attack might not be

present (chest, back, or jaw pain). Monitor for and report
other manifestations.

● If there is reduced awareness of hypoglycemia, monitor
blood glucose more carefully.

Diabetic nephropathy

Damage to the kidneys from prolonged elevated blood
glucose levels and dehydration. The blood vessels near the
kidneys become more permeable, allowing fluids to escape
and can become scarred over time.

NURSING ACTIONS
● Monitor hydration and kidney function (I&O,

blood creatinine level).
● Report an hourly output less than 30 mL/hr.
● Monitor blood pressure.

CLIENT EDUCATION
● Conduct yearly urine analysis, BUN, microalbumin, and

blood creatinine level.
● Avoid soda, alcohol, and toxic levels of acetaminophen

or NSAIDs.
● Consume 2 to 3 L/day of fluid from food and beverages

with artificial sweetener, and drink an adequate
amount of water.

● Report decrease in output to the provider.

82.4 Diabetic retinopathy

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 82 DiaBetes mellitus management 553

Sexual dysfunction

Damage to nerve and vascular tissue of the sexual organs
● Females can experience decreased libido or

sexual response, or dyspareunia from decreased
vaginal secretions.

● Males can experience retrograde ejaculation or
erectile dysfunction.

NURSING ACTIONS: Discuss sexual concerns and
recommend options or referral, if the client desires.

CLIENT EDUCATION: Report concerns or difficulties with
the provider.

Other complications

Periodontal disease, integumentary disorders (infections,
patchy color changes, sclerosing)

Active Learning Scenario

a nurse is providing guidelines to a client who has
type 1 diabetes mellitus about self-care during
illness. What information should the nurse include
in the guidelines? use the ati active learning
template: system Disorder to complete this item.

LABORATORY TESTS: Discuss parameters for
testing urine and notifying the provider.

CLIENT EDUCATION: Describe six teaching points.

Application Exercises

1. a nurse is caring for a client who has blood glucose
52 mg/dl. the client is lethargic but arousable. Which
of the following actions should the nurse perform first?

a. recheck blood glucose in 15 min.

B. provide a carbohydrate and protein food.

c. provide 15 g of simple carbohydrates.

D. report findings to the provider.

2. a nurse is preparing to administer a morning
dose of insulin aspart to a client who has
type 1 diabetes mellitus. Which of the
following actions should the nurse take?

a. check blood glucose immediately after breakfast.

B. administer insulin when breakfast arrives.

c. hold breakfast for 1 hr after insulin administration.

D. clarify the prescription because insulin
should not be administered at this time.

3. a nurse is preparing to administer morning doses
of insulin glargine and regular insulin to a client
who has a blood glucose 278 mg/dl. Which of
the following actions should the nurse take?

a. Draw up the regular insulin and then the
glargine insulin in the same syringe.

B. Draw up the glargine insulin then the
regular insulin in the same syringe.

c. Draw up and administer regular and
glargine insulin in separate syringes.

D. administer the regular insulin, wait 1 hr, and
then administer the glargine insulin.

4. a nurse is presenting information to a group of clients
about nutrition habits that prevent type 2 diabetes
mellitus. Which of the following should the nurse
include in the information? (select all that apply.)

a. eat at regular intervals.

B. Decrease intake of saturated fats.

c. increase daily fiber intake.

D. limit saturated fat intake to 15%
of daily caloric intake.

e. include omega-3 fatty acids in the diet.

5. a nurse is teaching foot care to a client who
has diabetes mellitus. Which of the following
information should the nurse include in
the teaching? (select all that apply.)

a. remove calluses using over-the-counter remedies.

B. apply lotion between toes.

c. test water temperature with the
fingers before bathing.

D. trim toenails straight across.

e. Wear closed-toe shoes.

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554 CHAPTER 82 DiaBetes mellitus management CONTENT MASTERY SERIES

Application Exercises Key

1. a. recheck the blood glucose in 15 min after a
rapidly absorbed carbohydrate is ingested;
however, another action is the priority.

B. give the client a carbohydrate and protein food if the next
meal is more than 1 hr away after the blood glucose returns
to a normal range; however, take another action first.

c. CORRECT: the greatest risk to the client is injury
from hypoglycemia; therefore, the priority action
to take is to administer 15 to 20 g of a rapidly-
absorbed carbohydrate (grape juice).

D. report the findings to the provider;
however, take another action first.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

2. a. Blood glucose should be checked prior to insulin
administration to prevent an episode of hypoglycemia.

B. CORRECT: administer insulin aspart when breakfast arrives to
avoid a hypoglycemic episode. insulin aspart is rapid-acting
and should be administered 5 to 10 min before breakfast.

c. the client should eat within 5 to 15 min of taking
insulin aspart to prevent hypoglycemia.

D. insulin aspart is administered at mealtimes.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

3. a. these insulins are not compatible and should
not be drawn up in the same syringe.

B. these insulins are not compatible and should
not be drawn up in the same syringe.

c. CORRECT: administer each insulin as a separate
injection. these insulins are not compatible and
should not be drawn up in the same syringe.

D. there is no need for the nurse to separate the
timing of administration for the two insulins.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

4. a. CORRECT: the client should eat at regular intervals
throughout the day to maintain blood glucose levels.

B. CORRECT: healthy nutrition should include lowering
lDl by decreasing intake of saturated fats, which
can prevent diabetes and hyperlipidemia.

c. CORRECT: healthy nutrition should include increasing
dietary fiber to control weight gain and decrease
the risk of diabetes and hyperlipidemia.

D. the recommended saturated fat intake is no
more than 7% of total daily caloric intake.

e. CORRECT: healthy nutrition should include
omega-3 fatty acids for secondary prevention
of diabetes and heart disease.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

5. a. a podiatrist should remove calluses or corns.
over-the-counter remedies can increase the risk
for tissue injury and an infection.

B. applying lotion between the toes increases moisture for
growth of micro-organisms, which can lead to infection.

c. the client should check bathwater with the wrist or
a thermometer to ensure it is a safe temperature.
the fingers might not be as sensitive.

D. CORRECT: trim toenails straight across to
prevent injury to soft tissue of the toes.

e. CORRECT: Wear closed-toe shoes to prevent
injury to soft tissue of the toes and feet.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

LABORATORY TESTS: test urine for ketones if blood glucose
is above 240 mg/dl. report the presence of moderate to
large ketones, or ketonuria that lasts more than 24 hr.

CLIENT EDUCATION
● monitor blood glucose every 3 to 4 hr.
● continue to take insulin as prescribed.
● Drink 8 to 12 oz (240 to 360 ml) of sugar-free liquid
every hour. use fluids containing sugar if blood
glucose is below the provider’s parameters.

● call the provider if unable to tolerate liquids.
● if unable to eat soft foods, consume liquids
equal to usual carbohydrate content.

● call the provider for illness longer than 2 days, if unable
to take fluids, and the blood glucose remains greater
than 250 mg/dl despite treatment.

● call the provider for fever that is greater than
38.6° c (101.5° f) or increasing.

NCLEX® Connection: Physiological Adaptation, Illness
Management

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 83 complications of DiaBetes mellitus 555

UNIT 12 ENDOCRINE DISORDERS
SECTION: DIABETES MELLITUS

CHAPTER 83 Complications of
Diabetes Mellitus

Diabetic ketoacidosis (DKa) is an acute,
life-threatening condition characterized by
uncontrolled hyperglycemia (greater than
300 mg/dl), metabolic acidosis, and an
accumulation of ketones in the blood and urine.
the onset is rapid, and the mortality rate is
up to 10%.

hyperglycemic hyperosmolar state (hhs) is an
acute, life-threatening condition characterized
by profound hyperglycemia (greater than
600 mg/dl), hyperosmolarity that leads to
dehydration, and an absence of ketosis. onset
generally occurs gradually over several days,
and if left untreated can lead to coma and death.

ASSESSMENT

risK factors

Diabetic ketoacidosis
● Lack of sufficient insulin related to undiagnosed or

untreated type 1 diabetes mellitus or nonadherence to a
diabetic regimen

● Reduced or missed dose of insulin (insufficient dosing of
insulin or error in dosage)

● Any condition that increases carbohydrate metabolism
(physical or emotional stress, illness)

● Infection is the most common cause
● Increased hormone production (cortisol, glucagon,

epinephrine) that stimulates the liver to produce glucose
and decreases the effect of insulin

Hyperglycemic hyperosmolar state
● Sustained osmotic diuresis results in a hyperglycemic

hyperosmolar state, resulting from one of the following.
◯ Lack of sufficient insulin related to undiagnosed
or poorly managed diabetes mellitus. There is
sufficient endogenous insulin present to prevent
the development of ketosis, but not enough to
prevent hyperglycemia.

◯ Inadequate fluid intake or poor kidney function.
● Most common in adult clients age 50 to 70 years old.
● Mortality rates in older clients are 40% to 70%, given

older clients often seek medical attention later when
much sicker, and have age-related changes that affect
the body’s ability to recover (decreased ability for urine
concentration, decreased thirst perception).

● Other factors that contribute to the development of HHS
include infection, stress, medical conditions (myocardial
infarction, cerebral vascular injury, sepsis), and some
medications (glucocorticoids, thiazide diuretics,
phenytoin, beta blockers, calcium channel blockers).

eXpecteD finDings
DKA HHS

Polyuria: osmotic diuresis resulting
in excess urine production ✔ ✔

Polydipsia (excess thirst): osmotic diuresis
causing excess loss of fluids resulting
in dehydration and increased thirst

✔ ✔

Polyphagia: cell starvation due to inability to
receive glucose resulting in increased appetite ✔ ✔

Weight loss: cells are unable to use
glucose because of insulin deficiency. the
body is placed in a catabolic state.

✔ ✔

GI effects (nausea, vomiting, abdominal
pain): increased ketones and acidosis lead
to nausea, vomiting, and abdominal pain

✔

Blurred vision, headache, weakness: fluid
volume depletion caused from osmotic
diuresis resulting in dehydration

✔ ✔

Orthostatic hypotension: fluid
volume depletion caused by osmotic
diuresis resulting in dehydration

✔ ✔

Fruity odor of breath: elevated ketone bodies
(small fatty acids) used for energy that collect in
the blood, which leads to metabolic acidosis

✔

Kussmaul respirations: Deep rapid respirations
occur in an attempt to excrete carbon dioxide
and acid when in metabolic acidosis

✔

Metabolic acidosis: Breakdown
of stored glucose, protein, and fat
to produce ketone bodies

✔

Mental status changes: lack of glucose
circulating to the brain can cause neuron
dysfunction and even cell death of the brain.
the brain cannot produce or store glucose.

✔ ✔

Seizures, myoclonic jerking: related to
blood osmolarity greater than 350 mosm/l ✔

Reversible paralysis: related to how
elevated the blood osmolarity becomes
(coma occurs once blood osmolarity
is greater than 350 mosm/l)

✔

CHAPTER 83

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556 CHAPTER 83 complications of DiaBetes mellitus CONTENT MASTERY SERIES

laBoratorY tests
Therapeutic management is guided by serial
laboratory analysis.

Blood glucose

DKA: Greater than 300 mg/dL (up to 800 mg/dL is typical)
HHS: Greater than 600 mg/dL

Blood electrolytes: Sodium (Na+) and potassium (K+)

DKA
● Na+: below, within, or above the expected

reference range
● K+: within or above the expected reference range

HHS
● Na+: normal or low
● K+: normal to high as a result of dehydration; must

monitor for decrease when treatment started

Kidney function studies: BUN and
creatinine blood levels

DKA
● Increased secondary to dehydration
● BUN greater than 30 mg/dL
● Creatinine greater than 1.5 mg/dL

HHS
● Increased secondary to dehydration
● BUN greater than 30 mg/dL
● Creatinine greater than 1.5 mg/dL

Ketones: Blood and urine

DKA: Present in blood and urine
HHS: Absent in blood and urine

Blood osmolarity

DKA: High

HHS: Greater than 320 mOsm/L
● With DKA, mild to moderate hyperkalemia is common

for clients who have hyperglycemia. Insulin therapy,
correction of acidosis, and volume expansion decrease
blood potassium concentration.

● Potassium replacement needs to be initiated when
potassium levels fall below 5.0.

● Monitor for fatigue, malaise, confusion, muscle
weakness, shallow respirations, abdominal distention,
paralytic ileus, hypotension, and weak pulse.

Arterial blood gases

DKA
● Metabolic acidosis with respiratory compensation

(Kussmaul respirations)
● pH less than 7.35
● Sodium bicarbonate 0 to 15 mEq/L
● Bicarbonate 1 to 15 mEq/L

HHS
● Absence of acidosis
● pH greater than 7.4
● Bicarbonate greater than 20 mEq/L

PATIENT‑CENTERED CARE

nursing care
● Check vital signs every 15 min until stable, then

every 4 hr.
● Check for indications of dehydration (weight loss,

decreased skin turgor, oliguria, rapid, weak pulse).
● Always treat the underlying cause (infectious process).
● Provide isotonic fluid replacement to maintain perfusion

to vital organs. The client can require 6 to 10 L
of IV fluid.

◯ Physiological changes in cardiac and pulmonary
function can place older adult clients at greater risk
for fluid overload (precipitate heart failure
exacerbation) from fluid replacement therapy.

● Start with a rapid infusion of 0.9% sodium chloride
for the first 1 to 3 hr. (Clients who have elevated blood
sodium levels might require 0.45% sodium chloride.)

● Follow with a hypotonic fluid (0.45% sodium chloride) to
continue replacing losses to total body fluid.

● When blood glucose levels decrease to 250 mg/dL,
change the IV solution to one containing 5% dextrose
to minimize the risk of cerebral edema associated
with drastic changes in blood osmolarity and
prevent hypoglycemia.

● Administer regular insulin 0.1 to 0.15 unit/kg as an
IV bolus dose and then follow with a continuous IV
infusion of regular insulin at 0.1 unit/kg/hr.

● Insulin is administered IV rather than subcutaneously
to provide immediate treatment. The client who has
DKA will absorb subcutaneous insulin slowly and
erratically, making it difficult to adjust dosages of
insulin appropriately. Monitor blood glucose hourly.
Blood glucose of less than 200 mg/dL is the goal for
resolution, with a pH greater than 7.3, blood bicarbonate
level greater than 18 mEq/L, and calculated anion gap
less than 12 mEq/L. In DKA, IV administration of insulin
and dextrose must continue even when glucose is less
than 200 mg/dL until the acidosis resolves and the
client is able to take subcutaneous insulin.

● Monitor blood potassium levels. Potassium levels might
initially be increased because potassium has been pulled
out of the cells, but with insulin therapy potassium will
shift into cells, and the client will need to be monitored
for hypokalemia.

◯ Provide potassium replacement therapy in all
replacement IV fluids, as indicated by laboratory
values; potassium replacement usually begins when
the level falls below 5 mEq/L.

◯ Monitor cardiac rhythm constantly. Monitor for weak
pulse, shallow respirations, malaise, muscle weakness,
and confusion.

◯ Make sure urinary output is adequate before
administering potassium.

● Administer sodium bicarbonate by slow IV infusion for
severe acidosis (pH less than 7.0). Infuse potassium
along with bicarbonate because bicarbonate promotes
hypokalemia, unless the client has hyperkalemia.

● Monitor for and report changes in neurologic status in
clients who have HHS.

● Provide the client with education to prevent recurrence.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 83 complications of DiaBetes mellitus 557

OLDER ADULT CLIENTS
● Teach older adult clients to monitor blood glucose every
1 to 4 hr when ill.

● Emphasize the importance of not skipping an insulin
dose when ill.

● Maintain hydration because older adult clients can have
a diminished thirst sensation.

● Changes in mental status can prevent older adult clients
from seeking treatment.

client eDucation
● Wear a medical alert bracelet.
● Take measures to decrease the risk of dehydration.

◯ Unless contraindicated by other health problems,
consume 2 to 3 L/day of fluid from food and beverages
with artificial sweetener, and drink an adequate
amount of water.

◯ If blood glucose levels are low, consume liquids
with sugar.

● Monitor glucose every 4 hr when ill and continue to
take insulin.

● Check urine for ketones if blood glucose is greater
than 240 mg/dL

● Consume liquids with carbohydrates and electrolytes
(sports drinks) when unable to eat solid food.

● Notify the provider for the following.
◯ Illness that lasts longer than 24 hr
◯ Blood glucose greater than 250 mg/dL
◯ Inability to tolerate food or fluids
◯ Ketones in urine for more than 24 hr
◯ Temperature of 38.6° C (101.5° F) for 24 hr

Active Learning Scenario

a nurse is planning care for a client who has diabetic
ketoacidosis. What should the nurse include in
the plan of care? use the ati active learning
template: Basic concept to complete this item.

RELATED CONTENT: list three treatments. Describe
the nursing actions for each treatment.

Application Exercises

1. a nurse is reviewing the health history of a client
who has diabetes mellitus type 2. Which of the
following are risk factors for hyperglycemic
hyperosmolar state (hhs)? (select all that apply.)

a. evidence of recent myocardial infarction

B. Bun 35 mg/dl

c. takes a calcium channel blocker

D. age 77 years

e. Daily insulin injections

2. a nurse is assessing a client who has diabetic
ketoacidosis and ketones in the urine. the
nurse should expect which of the following
findings? (select all that apply.)

a. Weight gain

B. fruity odor of breath

c. abdominal pain

D. Kussmaul respirations

e. metabolic acidosis

3. a nurse is reviewing laboratory reports of a
client who has hhs. Which of the following
findings should the nurse expect?

a. Blood ph 7.2

B. Blood osmolarity 350 mosm/l

c. Blood potassium 3.8 mg/dl

D. Blood creatinine 0.8 mg/dl

4. a nurse is reviewing the medical record for a client
who is to begin therapy for DKa. Which of the
following prescriptions should the nurse expect?

a. administer an iv infusion of regular
insulin at 0.3 unit/kg/hr.

B. administer a slow iv infusion of
3% sodium chloride.

c. rapidly administer an iv infusion
of 0.9% sodium chloride.

D. add glucose to the iv infusion when
blood glucose is 350 mg/dl.

5. a nurse is providing discharge teaching to a client
who had diabetic ketoacidosis. Which of the
following information should the nurse include
about preventing DKa? (select all that apply.)

a. Drink 2 l fluids daily.

B. monitor blood glucose every 4 hr when ill.

c. administer insulin as prescribed when ill.

D. notify the provider when blood
glucose is 200 mg/dl.

e. report ketones in the urine after 24 hr of illness.

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558 CHAPTER 83 complications of DiaBetes mellitus CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: the client who has type 2 diabetes mellitus
and had a myocardial infarction is at risk for developing
hhs. this is due to the increased hormone production
during illness or stress, which can stimulate the liver to
produce glucose and decrease the effects of insulin.

B. CORRECT: the client who has type 2 diabetes mellitus
can be at risk for developing hhs when the Bun is
35 mg/dl because it is an indication of decreased
kidney function and inability of the kidney to filter
high levels of blood glucose into the urine.

c. CORRECT: a calcium channel blocker is one of
several medications that increase the risk for hhs
in a client who has type 2 diabetes mellitus.

D. CORRECT: the older adult client is at risk for developing
type 2 diabetes mellitus and can be unaware of associated
manifestations, increasing the risk for hhs.

e. taking insulin does not increase the risk for hhs.
When a client is experiencing hyperglycemia, insulin
prevents the client from developing DKa.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. Weight loss occurs when the cells are unable to use
glucose because of insulin deficiency and places
the body in a catabolic state, and fluid loss from
dehydration decreases body weight.

B. CORRECT: fruity odor of breath is a manifestation of
elevated ketone levels that lead to metabolic acidosis.

c. CORRECT: abdominal pain is a gi manifestation
of increased ketones and acidosis.

D. CORRECT: Kussmaul respirations are an attempt to excrete
carbon dioxide and acid when in metabolic acidosis.

e. CORRECT: metabolic acidosis is caused by glucose,
protein, and fat breakdown, which produces ketones.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. a. Blood ph of 7.2 is an indication of diabetic ketoacidosis
and is not an expected finding for hhs.

B. CORRECT: a client who has hhs would have a
blood osmolarity greater than 320 mosm/l.

c. potassium 3.8 meq/l is within the expected reference
range. a client who has hhs would initially have a
decreased blood potassium due to diuresis.

D. creatinine 0.8 mg/dl is within the expected reference
range. a client who has hhs would have a blood creatinine
of greater than 1.5 mg/dl, secondary to dehydration.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

4. a. expect to administer an iv infusion of regular
insulin at 0.1 unit/kg/hr to gradually lower blood
glucose to prevent cerebral edema.

B. expect to administer a 3% sodium chloride
solution to a client who has hyponatremia.

c. CORRECT: expect to rapidly administer an iv
infusion of 0.9% sodium chloride, an isotonic fluid, as
prescribed to maintain blood perfusion to vital organs.
the initial infusion for a client who has an elevated
sodium would be 0.45% sodium chloride.

D. add glucose to the iv infusion when the blood
glucose is 250 mg/dl, not 350 mg/dl, to prevent
hypoglycemia and minimize cerebral edema.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Parenteral/Intravenous Therapies

5. a. CORRECT: Drinking 2 l fluids daily can prevent dehydration
if the client develops diabetic ketoacidosis.

B. CORRECT: Blood glucose tends to increase during illness.
Blood glucose should be monitored every 4 hr.

c. CORRECT: illness often causes blood glucose to increase.
regular doses of insulin should be administered.

D. notify the provider when blood glucose remains
greater than 250 mg/dl despite treatment.

e. CORRECT: the provider should be notified if there
are ketones in the urine after 24 hr of illness.

NCLEX® Connection: Physiological Adaptation,
Illness Management

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT

fluid replacement
● rapidly infuse the prescribed amount of iv 0.9% sodium chloride.
● follow with iv infusion of 0.45% sodium
chloride as maintenance fluids.

● monitor laboratory tests.
● monitor and replace potassium as prescribed.
● review Bun and creatinine levels for expected improvement.
● monitor blood osmolarity.
● evaluate blood glucose hourly.

insulin administration
● administer regular insulin iv bolus dose as prescribed.
● follow with regular insulin iv infusion as prescribed.

NCLEX® Connection: Physiological Adaptation, Illness
Management

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RN ADULT MEDICAL SURGICAL NURSING ncleX® connections 559

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Basic Care and Comfort
NON-PHARMACOLOGICAL COMFORT INTERVENTIONS:
Plan measures to provide comfort interventions to clients
with anticipated or actual impaired comfort.

NUTRITION AND ORAL HYDRATION: Provide/
maintain special diets based on the client diagnosis/
nutritional needs and cultural considerations.

Health Promotion and Maintenance
AGING PROCESS: Provide care and education for
the adult client ages 18 through 64 years.

HEALTH PROMOTION/DISEASE PREVENTION
Educate the client on actions to promote/
maintain health and prevent disease.

Identify risk factors for disease/illness.

HEALTH SCREENING: Apply knowledge of
pathophysiology to health screening.

Pharmacological and Parenteral Therapies
ADVERSE EFFECTS/CONTRAINDICATIONS/SIDE EFFECTS/
INTERACTIONS: Assess the client for actual or potential
side effects and adverse effects of medications.

EXPECTED ACTIONS/OUTCOMES: Obtain
information on a client’s prescribed medications.

PHARMACOLOGICAL PAIN MANAGEMENT: Administer
and document pharmacological pain management
appropriate for client age and diagnoses.

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560 ncleX® connections CONTENT MASTERY SERIES

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS
Provide care to a client with an infectious disease.

Educate client on methods to prevent complications
associated with activity level/diagnosed illness/disease.

ILLNESS MANAGEMENT
Educate client about managing illness.

Apply knowledge of client pathophysiology to illness management.

PATHOPHYSIOLOGY: Identify pathophysiology
related to an acute or chronic condition.

Reduction of Risk Potential
LABORATORY TESTS: Compare client laboratory
values to normal laboratory values.

DIAGNOSTIC TESTS: Compare client diagnostic
findings with pretest results.

THERAPEUTIC PROCEDURES: Apply knowledge of related
nursing procedures and psychomotor skills when caring
for clients undergoing therapeutic procedures.

POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC
TESTS/TREATMENTS/PROCEDURES
Position the client to prevent complications
following tests/treatments/procedures.

Apply knowledge of nursing procedures and psychomotor skills
when caring for a client with potential for complications

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 84 Immune and InfectIous dIsorders dIagnostIc Procedures 561

UNIT 13 IMMUNE SYSTEM AND CONNECTIVE
TISSUE DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 84 Immune and
Infectious Disorders
Diagnostic
Procedures

diagnostic procedures for immune and
infectious disorders involve identification of
pathogenic micro‑organisms. the most accurate
and definitive way to identify micro‑organisms
and cell characteristics is by examining blood,
body fluids, and tissue samples under a
microscope. effective treatment of infectious
disease begins with identification of the
pathogenic micro‑organism.

White blood cells
● WBCs, or leukocytes, stimulate the inflammatory

response and offer protection against various types of
infection and foreign antigens.

● There are fives types of WBCs—neutrophils,
lymphocytes, monocytes, eosinophils, and basophils—
used in laboratory analysis. Circulating WBCs is the
differential, which lists the percentages of the types
of WBCs for a total of 100%. The percentages represent
the proportion of each type of cell in a sample of WBCs.
If the percentage of one type of cell increases, the
percentages of other types decrease accordingly.

INTERPRETATION OF FINDINGS
The expected reference range for WBCs is 5,000 to
10,000/mm3.

Leukopenia is a total WBC count less than 4,000/mm3.
It can indicate drug toxicity, autoimmune disease, bone
marrow failure, and some overwhelming infections.

Leukocytosis is a total WBC count greater than
10,000/mm3. It can indicate inflammation, infection, some
malignancies, trauma, dehydration, stress, steroid use,
and thyroid storm. The WBCs involved in inflammation
are neutrophils, macrophages, eosinophils, monocytes,
and basophils.

● A client who has had a splenectomy can have a
persistently increased WBC count.

● Older adult clients can have a severe bacterial infection
without leukocytosis. Manifestations of infection, such
as fever, can be absent in an older adult who has an
infection. The nurse should monitor older adult clients
carefully for infection risks.

Neutropenia is a neutrophil count less than 2,000/mm3.
Neutropenia occurs in clients who have viral infections,
overwhelming bacterial infections, or are undergoing
radiation or chemotherapy. A client who has neutropenia
is at an increased risk for infection.

● The absolute neutrophil count (ANC) of a client who has
neutropenia can help determine severity of the client’s
risk for infection. Multiplying the total WBC count by
the percentage of neutrophils plus the percentage of
bands determines the ANC.

● An ANC less than 1,000 means that neutropenic
precautions are essential.

● Neutropenic precautions (a protective environment)
include the following.

◯ Restricting visitors
◯ Prohibiting visits by people who have an infection
◯ Restricting exposure to live (cut or potted) plants
◯ Restricting ingestion of fresh fruits and vegetables
◯ Avoiding contamination from the client’s own

bacterial flora by avoiding the measurement of rectal
temperature and administering IM injections.

Left shift is an increase in immature neutrophils (bands
or stabs) that occurs with an acute infection. Neutrophil
production increases, allowing the release of immature
neutrophils that are not capable of phagocytosis (ingesting
and destroying bacteria).

tYPes of WBcs

Neutrophils

The majority of neutrophils are segmented (mature) with
others being banded (not fully mature). Percentage and
number of circulating neutrophils is used to measure a
client’s risk for infection.

PERCENTAGE OF CIRCULATING NEUTROPHILS: 55% to 70%

INCREASED WITH
● Acute bacterial infection
● Myelocytic leukemia
● Trauma
● Rheumatoid arthritis

DECREASED WITH
● Sepsis
● Radiation therapy, aplastic anemia, chemotherapy
● Influenza

Lymphocytes (T cells and B cells)
● T‑lymphocytes initiate cell‑mediated immunity.
● B‑lymphocytes initiate humoral immunity.

PERCENT OF CIRCULATING LYMPHOCYTES: 20% to 40%

INCREASED WITH
● Chronic bacterial or viral infection
● Viruses (mononucleosis, mumps, measles)
● Bacteria such as hepatitis
● Lymphocytic leukemia, multiple myeloma

DECREASED WITH
● Leukemia
● Sepsis

CHAPTER 84

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562 CHAPTER 84 Immune and InfectIous dIsorders dIagnostIc Procedures CONTENT MASTERY SERIES

Monocytes

PERCENT OF CIRCULATING MONOCYTES: 2% to 8%

INCREASED WITH
● Chronic inflammation
● Protozoal infections
● Tuberculosis
● Viral infections such as mononucleosis

DECREASED WITH
● Corticosteroid therapy
● Aplastic anemia
● Hairy cell leukemia

Eosinophils

Eosinophils are active against infection and limit
inflammatory response.

PERCENT OF CIRCULATING EOSINOPHILS: 1% to 4%

INCREASED WITH
● Allergic reactions
● Parasitic infection
● Eczema
● Leukemia
● Autoimmune diseases

DECREASED WITH
● Stress
● Corticosteroids

Basophils

Basophils stimulate general inflammation and the
response of allergy and hypersensitivity reactions.

PERCENT OF CIRCULATING BASOPHILS: 0.5% to 1%

INCREASED WITH: Leukemia

DECREASED WITH
● Acute allergic/hypersensitivity reactions
● Hyperthyroidism
● Stress reactions

Blood allergy test
(IgE antibody test)

Blood allergy testing can determine sensitivity to various
allergens. The technician mixes specific allergens with
the blood and incubates it with radiolabeled anti‑IgE
antibodies. Blood allergy testing can complement
skin testing or be an alternative when the risk of a
hypersensitivity reaction to an allergen exists. The
radioallergosorbent test (RAST) is one form of blood
allergy testing.

ADVANTAGES
● Will not precipitate a dangerous allergic reaction
● Quicker than skin testing

DISADVANTAGES
● Usually only tests for a small amount of allergens at a

time, such as a panel for meat allergens, or panel for
fruit allergens

● Can be less sensitive than skin testing

INDICATIONS
POTENTIAL DIAGNOSES: Environmental and food allergies

EXPECTED FINDINGS
● Report of hypersensitivity reactions
● Hives, asthma, gastrointestinal (GI) dysfunction,

rhinitis, dermatitis, angioedema

CONSIDERATIONS
● Clients who have a condition that raises IgG levels can

have falsely negative test results.
● Taking corticosteroids prior to testing can elevate

IgE levels.

INTRAPROCEDURE: Obtain a blood sample.

INTERPRETATION OF FINDINGS
Results reflect allergen‑specific IgE levels and thus the
degree of sensitivity on a 0 to 6 scale.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 84 Immune and InfectIous dIsorders dIagnostIc Procedures 563

Skin testing for allergens
● Skin testing for allergens involves the use of

intradermal injections or scratching the superficial layer
(scratch or prick test) of the skin with small amounts of
potential allergens.

● Intradermal testing runs a higher risk of
hypersensitivity reactions and follows inconclusive
scratch‑test results.

INDICATIONS
POTENTIAL DIAGNOSES: Environmental and food allergies

EXPECTED FINDINGS: Hives, asthma, GI dysfunction,
rhinitis, dermatitis, angioedema

INTERPRETATION OF FINDINGS
● A localized reaction (wheal and flare) to an allergen is a

positive reaction to that allergen.
● The larger the reaction, the more severe the allergy.

CONSIDERATIONS

PreProcedure
NURSING ACTIONS

● Prepare the skin on the client’s back or forearm for
application of various allergens using soap and water.

● Use alcohol to remove any oil.
● Have equipment available to treat anaphylaxis.

CLIENT EDUCATION: Prior to testing, withhold
corticosteroids and antihistamines for 48 hr to 2 weeks, as
instructed by the provider.

IntraProcedure
NURSING ACTIONS

● Scratch or prick the skin with a needle after applying a
drop of an allergen.

● Use a standard pattern of application to help identify
the allergen.

● Apply control drops (substances that should not produce
a reaction, such as 0.9% sodium chloride irrigation,
and substances that should produce a reaction, such
as histamine).

● Assess for reactions after 15 to 20 min.

PostProcedure
NURSING ACTIONS

● Assess skin for areas of reaction, and document the
allergen that is responsible.

● Remove all solutions from the skin.
● Recommend an antihistamine or topical corticosteroid if

skin itches after testing.

CLIENT EDUCATION
● Follow instructions for desensitizing and avoidance

therapies for allergens.
● Follow a diet that eliminates some allergens

(gluten‑free).

Active Learning Scenario

a nurse is caring for a client who will have a
radioallergosorbent test (rast). use the atI active Learning
template: diagnostic Procedure to complete this item.

INDICATIONS: List two.

INTERPRETATION OF FINDINGS: describe one.

NURSING INTERVENTIONS (PRE, INTRA, POST):
describe one intraprocedure nursing action.

Application Exercises

1. a nurse is caring for a client who has a WBc
count of 20,000/mm3. the nurse should conclude
that the client has which of the following?

a. neutropenia

B. Leukocytosis

c. Left shift

d. Leukopenia

2. a nurse is reviewing the laboratory findings of a client
who has measles. the nurse should expect to find an
increase in which of the following types of WBcs?

a. neutrophils

B. Basophils

c. Lymphocytes

d. eosinophils

3. a nurse is preparing to administer a scratch
test to a client who has possible food and
environmental allergies. Which of the following
actions should the nurse perform prior to
the procedure? (select all that apply.)

a. cleanse the client’s skin with povidone‑iodine.

B. ask the client about previous reactions to allergens.

c. ask the client about medications
taken over the past several days.

d. Inform the client to expect itching at one site.

e. obtain emergency resuscitation equipment.

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564 CHAPTER 84 Immune and InfectIous dIsorders dIagnostIc Procedures CONTENT MASTERY SERIES

Application Exercises Key

1. a. neutropenia is a neutrophil count less than 2,000/mm3.
B. CORRECT: Leukocytosis is a WBc count greater than

10,000/mm3, which can indicate inflammation or infection.
c. a left shift is an increase in immature neutrophils

(bands or stabs) that occurs with acute infection.
d. Leukopenia is a total WBc count of less than 4,000/mm3,

which can indicate overwhelming infection or drug toxicity.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. neutrophils increase with an acute bacterial
infection. measles is a viral infection.

B. Basophils increase with leukemia.
c. CORRECT: Lymphocytes increase with viral

infections (measles, mumps, mononucleosis).
d. eosinophils increase with allergic reactions,

leukemia, eczema, and parasitic infections.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

3. a. use soap and water to cleanse the skin. Povidone‑iodine
could interfere with an allergen and elicit a response.

B. CORRECT: ask the client about any previous
reactions to allergens, which could indicate an
increased risk of an anaphylactic reaction.

c. CORRECT: ask the client about medications taken
over the past several days. antihistamines and
corticosteroids can suppress reactions.

d. CORRECT: Histamine will be applied at a control site,
so the client will probably have itching at this site.

e. CORRECT: emergency equipment should be available,
even if the client denies previous anaphylactic reactions.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

INDICATIONS
● Possible environmental and food allergies
● report of hypersensitivity reactions
● Hives, asthma, gastrointestinal dysfunction,
rhinitis, dermatitis, angioedema

INTERPRETATION OF FINDINGS: the technician mixes
specific allergens with the blood and incubates it with
anti‑Ige antibodies. results reflect allergen‑specific Ige levels
and thus the degree of sensitivity on a 0 to 6 scale.

NURSING INTERVENTIONS (PRE, INTRA,
POST): obtain a blood sample.

NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 85 ImmunIzatIons 565

UNIT 13 NURSING CARE OF CLIENTS WHO HAVE IMMUNE
SYSTEM AND CONNECTIVE TISSUE DISORDERS
SECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES

CHAPTER 85 Immunizations
administration of a vaccine causes production
of antibodies that prevent illness from a specific
microbe. Vaccines can be made from killed
viruses or live, attenuated (weakened) viruses.

for additional information, refer to PHARMACOLOGY

REVIEW MODULE, CHAPTER 41: IMMUNIZATIONS.

ImmunItY
ACTIVE IMMUNITY is an adaptive process that allows
the body to make antibodies in response to the entry of
antigens into the body. Active immunity develops over
several weeks to months and is long‑lasting.

● Active‑natural immunity develops when the body
produces antibodies in response to exposure to a
live pathogen that enters the body naturally.

● Active‑artificial immunity develops when a vaccine is
given and the body produces antibodies in response to
exposure to a killed or attenuated virus.

PASSIVE IMMUNITY develops when antibodies that are
created by another human or animal are transferred to the
client. Because the client does not independently develop
antibodies, passive immunity is temporary.

● Passive‑natural immunity occurs when antibodies are
passed from the mother to the fetus/newborn through
the placenta and breast milk.

● Passive‑artificial immunity occurs after antibodies in
the form of immune globulins are administered to an
individual who requires immediate protection against
a disease where exposure has already occurred, such as
following a bite from a poisonous snake or an animal
who has rabies. After several weeks or months, the
individual is no longer protected.

admInIstratIon
The Centers for Disease Control and Prevention (CDC)
immunization recommendations for adults (19 years and
older) follows. Go to www.cdc.gov/vaccines for updates.

Tetanus, diphtheria (Td) booster: Give booster every
10 years. For adults 19 and older who did not receive a
dose of tetanus, diphtheria, pertussis (Tdap) previously,
substitute one dose with Tdap.

● Pregnant clients should receive the vaccine between
27 and 36 weeks gestation. Pregnant clients should get
Tdap vaccine with each pregnancy to protect the fetus
from pertussis.

Measles, mumps, and rubella (MMR) vaccine: Follow
recommendations for administering one or two doses
to clients between the ages of 19 and 49 who lack
documentation of immunization or prior infection, or
laboratory proof of immunity. People born before 1957 are
considered immune to measles and mumps.

● A client who is pregnant should not receive the
MMR vaccine.

● Anaphylactic‑like reaction to gelatin or neomycin
is also a contraindication for not administering the
MMR vaccine.

● Use caution when administering to a client
who has history of thrombocytopenia or
thrombocytopenic purpura.

Varicella vaccine: Give two doses to adults who do
not have evidence of a previous infection (or one dose,
depending on the type of zoster vaccine). Give a second
dose to adults who have had only one previous dose.

● Varicella vaccine is contraindicated for clients who are
pregnant, have some cancers, or have hypersensitivity
to neomycin and gelatin.

● The vaccine is not recommended for clients who have
HIV, congenital immune deficiencies, or those taking
immunosuppressive medications.

Pneumococcal vaccine: Two types are available:
13‑valent pneumococcal conjugate vaccine (PCV‑13) and
23‑valent pneumococcal polysaccharide vaccine (PPSV23).

● Follow recommendations for administration to adults
who are immunocompromised, have specific chronic
diseases, smoke cigarettes, or live in long‑term
care facilities.

● PPSV23 does not work in children younger than
2 years old.

● For adults 65 years and older who have not been
immunized with PCV13 or PPSV23, administer PCV13
first and then give PPSV23 in 6 to 12 months; do not
administer both during the same visit. For adults who
received a dose of PPSV23 at age 65 or older, an
additional dose is not indicated.

Hepatitis A: Two doses for high‑risk individuals.
● One month after the first dose of hepatitis A vaccine,
94% to 100% of adults and children develop a protective
level of antibodies. Adults who receive the second dose
have 100% protective levels of antibodies after 1 month.

Hepatitis B: Administer three doses to high‑risk
individuals who lack completion of the series. There must
be at least 1 month between doses one and two, and at
least 2 months between doses two and three. A minimum
of 4 months are required between doses one and three.

● Clients have greater than 85% protection after the
second dose of hepatitis B vaccine and more than 90%
after the third dose.

● The antibody duration of protection is 5 to 7 years.

CHAPTER 85

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566 CHAPTER 85 ImmunIzatIons CONTENT MASTERY SERIES

Influenza vaccine
● Recommended for all adults annually.
● Inactivated influenza vaccine (IIV) is approved for

clients who are pregnant.
● Recombinant influenza vaccine (RIV) is approved for

adults 18 years and older.
● The live attenuated vaccine (LAIV), given as a nasal

spray, is indicated only for adults under age 50 who are
not pregnant or immunocompromised.

● Clients who have an allergy to chicken eggs, previous
severe reaction to the influenza vaccine, or previous
Guillain‑Barré syndrome should not receive the
influenza vaccine.

● Administration recommendations can change yearly,
because the vaccine is created with different influenza
strains each year. The vaccine is typically available
beginning in early fall.

Meningococcal conjugate polysaccharide vaccines
(MPSV4) and meningococcal conjugate polysaccharide
vaccines (MCV4)

● MPSV4 is not effective in children. It should be
administered only to adults older than 55 years of age.

● MCV4 is recommended for infants to adults under
56 years of age, and all children between the age of
11 through 12 should receive an initial dose with a
booster at age 16 years.

● Administer a dose of MCV4 to students up to age
21 years entering college and living in dormitories if
a dose was not received on or after the 16th birthday.
Two doses of MCV4 at least 2 months apart are
recommended for individuals who have anatomical
or functional asplenia, and one dose is recommended
for military recruits and those traveling to or living
in areas of hyperendemic or epidemic rates of
meningococcal disease.

● MPSV4 is preferred for adults who are 56 years of
age or older, require a single dose, and have not had
MCV4 previously.

● Reimmunization with MCV4 is recommended every
5 years for adults who remain at high risk for infection
and were previously immunized with MCV4 or MPSV4.

Human papilloma virus vaccine
● There are three types of vaccines; only the 9‑valent

vaccine is available for use in the U.S.
● 9‑valent human papillomavirus (9vHPV) prevents HPV

6, 11, 16, 18, plus HPV 31, 33, 45, 52, and 58 noninfectious
virus‑like particles (VLP). Administered to adolescents
as young as age 9 years but usually at ages 11 to 12 years.

● If initial dose is administered before age 15, only 2
doses are required, and the second should be given 6 to
12 months after the first.

● If the initial dose is administered after the 15th birthday,
3 doses are required. The second dose is recommended 1
to 2 months after the first, and the third dose 6 months
from the first.

Zoster vaccine: Recommended as a one‑time dose for all
adults older than 60 years.

PURPOSE

eXPected PHarmacoLogIcaL actIon
Immunizations produce antibodies that provide active
immunity. Immunizations can take months to have an
effect, but they provide long‑lasting protection against
infectious diseases.

tHeraPeutIc uses
● Eradication of infectious diseases
● Prevention of childhood and adult infectious diseases

and their complications (tetanus, pneumococcal
pneumonia, hepatitis)

CONTRAINDICATIONS/PRECAUTIONS
● An anaphylactic reaction to a vaccine is a

contraindication to further doses of that vaccine.
● An anaphylactic reaction to a vaccine is a

contraindication to use of other vaccines containing the
same substance.

● Moderate or severe illnesses with or without fever are
precautions to receiving immunizations. The common
cold and other minor illnesses are not contraindications.
Severe febrile illness is a contraindication to
all immunizations.

● Do not administer live virus vaccines, such
as varicella or MMR, to a client who is
severely immunocompromised.

● Precautions to immunizations require the provider to
analyze data and weigh the risks that come with and
without immunizations.

Td, DTaP, Tdap

ADVERSE EFFECTS
● Mild: Redness, swelling, and tenderness at the injection

site; low fever; behavioral changes (drowsiness,
irritability, anorexia)

● Moderate: Fever 40.6° C (105° F) or greater; seizures
(with or without fever); shock‑like state

● Severe: Acute encephalopathy (rare)

CONTRAINDICATIONS: Occurrence of encephalopathy
within 7 days following prior dose of the vaccine

PRECAUTIONS
● Occurrence of Guillain‑Barré syndrome within 6 weeks

of prior dose of tetanus toxoid
● Progressive neurologic disorders; uncontrolled seizures
● Fever 40.6° C (105° F) or greater within 48 hr of

prior dose
● Shock‑like state within 48 hr of prior dose
● Seizures within 3 days of prior dose

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 85 ImmunIzatIons 567

MMR

ADVERSE EFFECTS
● Mild: Local reactions (rash; fever; swollen glands in

cheeks or neck)
● Moderate: Joint pain and stiffness lasting for days to

weeks, febrile seizure, low platelet count
● Severe: Transient thrombocytopenia, deafness,

long‑term seizures, brain damage

CONTRAINDICATIONS: Pregnancy

PRECAUTIONS
● Transfusion with blood product containing antibodies

within the prior 11 months
● Simultaneous tuberculin skin testing

Varicella

ADVERSE EFFECTS
● Mild: Tenderness and swelling at injection site, fever,

rash (mild) for up to 1 month after immunization
● Moderate: Seizures
● Severe: Pneumonia, low blood count (extremely rare),

severe brain reactions (extremely rare)

PRECAUTIONS
● Transfusion with blood product containing antibodies

within the prior 11 months
● Treatment with antiviral medication within 24 hr prior

to immunization (avoid taking antivirals for 14 days
following immunization)

● Extended use (2 weeks or longer) of corticosteroids or
other medications that affect the immune system

● Cancer

Pneumococcal conjugate

ADVERSE EFFECTS
● Swelling, redness and tenderness at site of injection
● Fever
● Irritability
● Drowsiness
● Anorexia

CONTRAINDICATIONS: Anaphylactic reaction to any
vaccine containing diphtheria toxoid

Pneumococcal polysaccharide

ADVERSE EFFECTS
● Redness and tenderness at site of injection
● Fever
● Myalgia

PRECAUTION: Pregnancy

Hepatitis A

ADVERSE EFFECTS
● Local reaction at injection site
● Headache
● Loss of appetite
● Mild fatigue

CONTRAINDICATIONS: Severe allergy to latex

PRECAUTION: Pregnancy

Hepatitis B

ADVERSE EFFECTS
● Local reaction at injection site
● Temperature of 37.7° C (99.9° F) or greater

CONTRAINDICATIONS: Severe allergy
(anaphylaxis) to yeast

Inactivated influenza

ADVERSE EFFECTS
● Swelling, redness, and tenderness at the injection site
● Hoarseness
● Fever
● Malaise
● Headache
● Cough
● Aches
● Increased risk for Guillain‑Barré syndrome

PRECAUTIONS: Occurrence of Guillain‑Barré syndrome
within 6 weeks of prior influenza vaccine

Live, attenuated influenza

ADVERSE EFFECTS
● Vomiting, diarrhea
● Cough
● Fever
● Headache
● Myalgia
● Nasal congestion/runny nose

CONTRAINDICATIONS
● Age 50 years or older
● Pregnancy

PRECAUTIONS
● Occurrence of Guillain‑Barré syndrome within 6 weeks

of prior influenza vaccine
● Treatment with antiviral medication within 48 hr prior

to immunization (avoid taking antivirals for 14 days
following immunization)

● Some chronic conditions

clients who have a history of a severe egg allergy,
having any manifestation of allergy other than hives,
should receive the immunization where a provider
is present and emergency equipment is available.

Meningococcal MPSV4 and MCV4

ADVERSE EFFECTS
● Mild local reaction and rare risk of allergic response
● Possible mild fever

Zoster

ADVERSE EFFECTS
● Local reaction at injection site
● Headache

CONTRAINDICATIONS
● Clients who are immunocompromised
● Pregnancy
● Treatment with medications that alter the

immune system

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568 CHAPTER 85 ImmunIzatIons CONTENT MASTERY SERIES

Human papilloma virus (9vHPV)

ADVERSE EFFECTS
● Mild local reaction and fever
● Mild to moderate fever
● Headache
● Fainting shortly after receiving vaccine

CONTRAINDICATIONS
● Pregnancy
● Severe allergy (anaphylaxis) to yeast

INTERACTIONS
None significant

NURSING ADMINISTRATION
● Have emergency medications and equipment on standby

in case the client experiences an allergic response such as
anaphylaxis (rare) or serious reaction at injection site.

● Follow storage and reconstitution directions.
● Provide written, vaccine information sheets (VIS),

and review the content with clients. Document the
publication date of each VIS given to the client.

● Administer antipyretic for fever, apply cool
compress for localized tenderness, and mobilize the
affected extremity.

● Instruct clients to observe for complications and to
notify the provider if adverse effects occur.

● Document administration of vaccines including date,
route, site, type, manufacturer, lot number, and
expiration date. Also document the client’s name,
address, and signature. Include the name, title of the
person administering the vaccine, and the address of
the facility where the permanent record is located.

aduLts
● Give subcutaneous immunizations in outer aspect of the

upper arm or anterolateral thigh.
● Give IM immunizations into the deltoid muscle.

NURSING EVALUATION OF
MEDICATION EFFECTIVENESS

Depending on therapeutic intent, effectiveness can be
evidenced by development of immunity.

Active Learning Scenario

a nurse at a community health clinic is administering
influenza vaccines for a group of clients. What information
should the nurse take into consideration when selecting
the type of vaccine to administer? use the atI active
Learning template: medication to complete this item.

NURSING INTERVENTIONS: Identify the three
types of influenza vaccine and which clients
should receive each of the three types.

Application Exercises

1. a nurse is preparing to administer an Im injection
of immune globulin to a client who has been
exposed to hepatitis a. Which of the following
statements by the nurse is appropriate?

a. “this medication offers permanent
immunity to hepatitis a.”

B. “this medication involves three
injections over several months.”

c. “this medication provides you with
an immune response more quickly
than your body can produce it.”

d. “this medication contains an attenuated virus
to help your body create antibodies.”

2. a nurse is preparing to administer a varicella
immunization to a client. Which of the following
questions by the nurse is appropriate?

a. “are you allergic to eggs?”
B. “are you allergic to baker’s yeast?”
c. “are you pregnant?”
d. “do you have a history of

guillain‑Barré syndrome?”

3. a nurse is reviewing strategies to promote comfort
with a client who received an immunization.
Which of the following information should
the nurse include? (select all that apply.)

a. massage the injection site.
B. apply a cool compress to the injection site.
c. take acetaminophen or ibuprofen.
d. use the affected extremity.
e. apply an antimicrobial ointment

to the injection site.

4. a nurse is preparing to document administration
of a meningococcal vaccine to a client. Which of
the following information should the nurse include
in the documentation? (select all that apply.)

a. age of client receiving the vaccine
B. name of vaccine manufacturer
c. Vaccine expiration date
d. date of administration
e. serial number of the vaccine

5. a nurse in a clinic is caring for a client who is to
receive an immunization. the client asks about
contraindications to immunizations. Which of the
following responses should the nurse make?

a. “the use of insulin is a contraindication.”

B. “an anaphylactic reaction is a contraindication
for administration of any type of immunization.”

c. “the common cold is a contraindication
for receiving an immunization.”

d. “Your provider will weigh the risks if you
have experienced any adverse effects.”

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 85 ImmunIzatIons 569

Application Exercises Key

1. a. this medication produces passive‑artificial immunity
that lasts only several weeks or months.

B. this medication produces passive‑artificial immunity
and is given one time after exposure to hepatitis a.

c. CORRECT: this medication produces passive‑artificial
immunity and contains antibodies to help protect
against hepatitis a for several weeks or months.

d. this medication contains antibodies,
not an attenuated virus.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Parenteral/Intravenous Therapies

2. a. allergy to eggs should be reviewed if the client is
to receive an influenza immunization.

B. allergy to yeast should be reviewed if the
client is to receive HPV immunization.

c. CORRECT: ask whether the client is pregnant because the
varicella immunization is contraindicated during pregnancy.

d. guillain‑Barré syndrome is not a contraindication
for varicella immunization.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

3. a. massaging the injection site for any extended period
of time can increase localized discomfort.

B. CORRECT: applying a cool compress to the injection site
can relieve discomfort from the localized reaction.

c. CORRECT: taking an antipyretic can relieve a low‑grade
fever and localized discomfort at the injection site.

d. CORRECT: mobilizing the affected extremity will help
relieve discomfort due to a localized reaction.

e. applying an antimicrobial ointment at the
injection site is not indicated.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Parenteral/Intravenous Therapies

4. a. age of the person receiving an
immunization is not included.

B. CORRECT: document the name of the vaccine manufacturer.
c. CORRECT: document the expiration date of the vaccine.
d. CORRECT: document the date the

vaccine was administered.
e. document the lot number, not the serial

number, of the vaccine.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

5. a. the client who takes insulin is able to receive immunizations
unless other contraindications are present.

B. the client who has experienced an anaphylactic
reaction can receive other immunizations
that contain different substances.

c. the client who has a common cold can receive an
immunization because the client is not immunosuppressed.

d. CORRECT: the client who has experienced
adverse effects should inform the provider, who
can weigh the risks of an immunization.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

Active Learning Scenario Key

Using the ATI Active Learning Template: Medication

NURSING INTERVENTIONS
● Inactivated influenza vaccine (IIV) is approved
for clients who are pregnant.

● recombinant influenza vaccine (rIV) is approved
for adults 18 years of age and older.

● the live attenuated vaccine (LaIV), given as a nasal
spray, is indicated only for adults under age 50 who
are not pregnant or immunocompromised.

NCLEX® Connection: Health Promotion and Maintenance,
Aging Process

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570 CHAPTER 85 ImmunIzatIons CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 86 HIV/aIds 571

UNIT 13 IMMUNE SYSTEM AND CONNECTIVE
TISSUE DISORDERS
SECTION: IMMUNE DISORDERS

CHAPTER 86 HIV/AIDS
Human immunodeficiency virus (HIV) is a
retrovirus that is transmitted through blood and
body fluids (semen, vaginal secretions).

HIV targets cd4+ lymphocytes, also known
as t‑cells or t‑lymphocytes. t‑cells work in
concert with B‑lymphocytes. Both are part
of specific acquired (adaptive) immunity. HIV
integrates its rna into host cell dna through
reverse transcriptase, reshaping the host’s
immune system.

HIV is found in feces, urine, tears, saliva,
cerebrospinal fluid, cervical cells, lymph
nodes, corneal tissue, and brain tissue, but
epidemiologic studies indicate that these are
unlikely sources of infection.

all women who are pregnant should be
screened for HIV.

dIsease Process stages
HIV infection is one continuous disease process with
three stages.

Progression of HIV infection
● Manifestations occur within 2 to 4 weeks of infection.
● Manifestations are similar to those of influenza and
can include a rash and a sore throat.

● Manifestations of acute HIV infection can include
the following: fever, night sweats, chills, headaches,
muscle aches, sore throat, and rash. The findings are
temporary and resolve with the client returning to
previous level of health.

● This stage is marked by a rapid rise in the HIV viral
load, decreased CD4+ cells, and increased CD8 cells.

● The resolution of manifestations coincides with the
decline in viral HIV copies.

● Lymphadenopathy persists throughout the
disease process.

Chronic asymptomatic infection
● This stage can be prolonged and clinically silent

(asymptomatic).
● The client can remain asymptomatic for 10

years or more.
● Anti‑HIV antibodies are produced (HIV positive).
● Over time, the virus begins active replication using the

host’s genetic machinery.
◯ CD4+ cells are destroyed.
◯ The viral load increases.
◯ Dramatic loss of immunity begins.

AIDS
● This stage is characterized by life‑threatening

opportunistic infections.
● This is the end stage of HIV infection. Without

treatment, death occurs within 5 years.
● All people with AIDS have HIV, but not all people who

have HIV have AIDS.

CHAPTER 86

86.1 HIV infection stages
a confirmed case classification meets the
laboratory criteria for a diagnosis of HIV infection
and one of the four HIV infection stages.
to read more about HIV, go to www.cdc.gov.

Stage 1
DEFINING
CONDITIONS: none

CD4+ T‑LYMPHOCYTE
COUNT: 500 cells/mm3
or more

CD4+ T‑LYMPHOCYTE
PERCENTAGE OF TOTAL
LYMPHOCYTES: 29% or more

Stage 2
DEFINING
CONDITIONS: none

CD4+ T‑LYMPHOCYTE
COUNT: 200 to 499 cells/mm3

CD4+ T‑LYMPHOCYTE
PERCENTAGE OF TOTAL
LYMPHOCYTES: 14% to 28%

Stage 3 (AIDS)
documentation of an aIds‑defining condition
supersedes a cd4+ t‑lymphocyte count of
200 cells/mm3 or more and a cd4+ t‑lymphocyte
percentage of total lymphocytes of more than 14%.

DEFINING CONDITIONS: one or more of the following
● candidiasis of the
esophagus, bronchi,
trachea, or lungs

● Herpes simplex: chronic
ulcers (more than
1 month duration)

● HIV‑related
encephalopathy

● disseminated or
extrapulmonary
histoplasmosis

● Kaposi’s sarcoma

● Burkitt’s lymphoma
● mycobacterium
tuberculosis of any site

● Pneumocystis jirovecii
pneumonia

● recurrent pneumonia
● Progressive multifocal
leukoencephalopathy

● recurrent salmonella
septicemia

● Wasting syndrome
attributed to HIV

CD4+ T‑LYMPHOCYTE COUNT: Less than 200 cells/mm3

CD4+ T‑LYMPHOCYTE PERCENTAGE OF
TOTAL LYMPHOCYTES: Less than 14%

Stage 4
no information available

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572 CHAPTER 86 HIV/aIds CONTENT MASTERY SERIES

HEALTH PROMOTION AND
DISEASE PREVENTION

● Teach the client how the virus is transmitted and
ways to prevent infection, such as the use of condoms,
abstinence, and avoiding sharing needles. (REFER TO

FUNDAMENTALS FOR NURSING REVIEW MODULE: CHAPTER 34:

SELF CONCEPT AND SEXUALITY.)
● Encourage the client to maintain up‑to‑date

immunizations, including yearly seasonal influenza and
pneumococcal polysaccharide vaccine.

● Providers should use standard precautions when caring
for the client.

ASSESSMENT

rIsK factors
● Unprotected sex (vaginal, anal, oral)
● Multiple sex partners
● Occupational exposure (health care workers)
● Perinatal exposure
● Blood transfusions (not a significant source of infection

in the U.S.)
● IV drug use with a contaminated needle
● Older adult clients

◯ HIV infection can go undiagnosed in older adult
clients due to the similarity of its manifestations to
other illnesses that are common in this age group.

◯ Older adults are more susceptible to fluid and
electrolyte imbalances, malnutrition, skin alterations,
and wasting syndrome than younger adults.

◯ Older adult women experience vaginal dryness
and thinning of the vaginal wall, increasing their
susceptibility to HIV infection.

eXPected fIndIngs
● Chills
● Rash
● Anorexia, nausea, weight loss
● Weakness and fatigue
● Headache and sore throat
● Night sweats

LaBoratorY tests
CBC and differential: Abnormal (anemia,
thrombocytopenia, leukopenia)

Platelet count: Decreased less than 150,000/mm3

dIagnostIc Procedures
● Positive result from an HIV antibody screening test

(enzyme‑linked immunosorbent assay [ELISA])
confirmed by a positive result from a supplemental
HIV antibody test (Western blot or indirect
immunofluorescence assay [IFA])

● Home test kits are also available using a drop of
blood. These provide anonymous registration and
counseling before the test via a telephone call. (REFER TO

FUNDAMENTALS FOR NURSING REVIEW MODULE: CHAPTER 34:

SELF CONCEPT AND SEXUALITY.)
● Two noninvasive tests are available using either

mucosal fluid or urine.
● Clients who have a positive result from a confirmatory

test (such as Western blot) should then be tested for
viral load.

HIV RNA quantification (HIV viral load test)
● Determines viral load before beginning treatment
● Can be repeated at intervals to monitor disease

progression, identify compliance with treatment and
determine HIV medication resistance

HIV drug resistance testing
(HIV genotype or HIV tropism)

● Guides changes in medication therapy when
resistance occurs

● Useful with CD4 counts fall despite therapy

Liver profile, biopsies, and testing
of stool for parasites

NURSING ACTIONS: Prepare the client for the test.

CLIENT EDUCATION
● Understand the details of the test, such as length and

what to expect.
● A positive Western blot or IFA test means the client has

been exposed to and has the AIDS virus in their body,
but this does not mean the client has clinical AIDS.

● Ask questions or express emotions.
● Understand and adhere to safe sexual practices.

Brain or lung MRI or CT scan

Detailed image of the brain or lung to detect abnormalities

NURSING ACTIONS: Prepare the client for the procedure.

CLIENT EDUCATION: Be aware of the length of time the
test takes (up to 1 hr).

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 86 HIV/aIds 573

PATIENT‑CENTERED CARE

nursIng care
● Assess risk factors (sexual practices, IV drug use).
● Monitor fluid intake/urinary output.
● Obtain daily weights to monitor weight loss.
● Monitor nutritional intake.
● Monitor electrolytes.
● Assess skin integrity (rashes, open areas, bruising).
● Assess pain status.
● Monitor vital signs (especially temperature).
● Assess lung sounds/respiratory status (diminished

lung sounds).
● Assess neurologic status (confusion, dementia,

visual changes).
● Encourage activity alternated with rest periods.
● Administer supplemental oxygen as needed.
● Provide analgesia as needed.
● Provide skin care as needed.

medIcatIons
Highly active antiretroviral therapy involves using three
to four HIV medications in combination with other
antiretroviral medications to reduce medication resistance,
adverse effects, and dosages.

Fusion inhibitors: Enfuvirtide blocks the fusion of HIV
with the host cell.

Entry inhibitors: Maraviroc blocks the CCR5 receptor
on the CD4 T cell to prevent further progression of the
infection.

Nucleoside reverse transcriptase inhibitors: Zidovudine
interferes with the virus’s ability to convert RNA into DNA.

Non‑nucleoside reverse transcriptase inhibitors:
Delavirdine and efavirenz inhibit viral replication in cells.

Protease inhibitors: Atazanavir, nelfinavir, saquinavir,
and indinavir inhibit an enzyme needed for the virus
to replicate.

Integrase inhibitors: Raltegravir, elvitegravir, and
dolutegravir inhibit viral replication by stopping the HIV
enzyme integrase from inserting into the host cell DNA.

Antineoplastic medication: Interleukin is an
immunostimulant that enhances the immune response
and reduces the production of cancer cells (used
commonly with Kaposi’s sarcoma).

NURSING ACTIONS
● Monitor laboratory results (CBC, WBC, liver function

tests). Antiretroviral medications can increase alanine
aminotransferase, aspartate aminotransferase, bilirubin,
mean corpuscular volume, high‑density lipoproteins,
total cholesterol, and triglycerides.

● Monitor total CD4+ T lymphocyte count as well as CD4
percentage and ratio of CD4 to CD8 cells.

◯ Normal CD4‑to‑CD8 ratio is 2:1. A ratio of less than
1 indicates more severe disease manifestations.

◯ Low CD4 T lymphocyte counts and steadily
decreasing counts indicate poor prognosis or
medication resistance.

CLIENT EDUCATION
● Be aware of the adverse effects of the medications and

ways to decrease the severity of adverse effects.
● Take medications on a regular schedule and do not

miss doses. Missed medication doses can cause
drug resistance.

InterProfessIonaL care
● Infectious disease services may be consulted to

manage HIV.
● Respiratory services may be consulted to improve

respiratory status and provide portable oxygen.
● Nutritional services may be consulted for dietary

supplementation. Food services can be indicated for
clients who are homebound and need meals prepared.

● Rehabilitation services may be consulted for
strengthening and improving the client’s level of energy.

● Refer the client to local AIDS support groups as
appropriate.

● Home health services can be indicated for clients who
need help with strengthening and assistance regarding
ADLs. Home health services may also provide assistance
with IVs, dressing changes, and total parenteral
nutrition (TPN).

● Long‑term care facilities can be indicated for clients
who have chronic HIV.

● Hospice services can be indicated for clients who have a
late stage of HIV.

Alternative therapy

Vitamins, herbal products, and shark cartilage can help
alleviate manifestations of HIV. Ask the client if they
are taking herbal products. These can alter the effects of
prescribed medications.

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574 CHAPTER 86 HIV/aIds CONTENT MASTERY SERIES

cLIent educatIon
● Practice good hygiene and frequent hand hygiene to

reduce the risk of infection.
● Avoid crowded areas or traveling to countries with

poor sanitation.
● Avoid raw foods (fruits, vegetables) and undercooked

foods (meat, fish, eggs).
● Avoid cleaning pet litter boxes to reduce the risk

of toxoplasmosis.
● Keep the home environment clean and avoid being

exposed to family and friends who have colds or
flu viruses.

● Wash dishes in hot water using a dishwasher if available.
● Bathe daily using antimicrobial soap.
● Understand the following teachings.

◯ Transmission, infection control measures, and safe
sex practices

◯ Importance of maintaining a well‑balanced diet
◯ Self‑administration of prescribed medications and

potential adverse effects
◯ Findings that need to be reported immediately
(infection)

● Adhere to the antiretroviral dosing schedules.
● Conduct frequent follow‑up monitoring of CD4+ and

viral load counts.
● Perform constructive coping mechanisms.
● Identify primary support systems.
● Report manifestations of infection immediately to

the provider.

COMPLICATIONS

Opportunistic infections
● Bacterial diseases, such as tuberculosis, bacterial

pneumonia, and septicemia (blood poisoning,
nocardiosis)

● HIV‑associated malignancies, such as Kaposi’s sarcoma,
lymphoma, Hodgkin’s lymphoma, non‑Hodgkin’s
lymphoma, invasive cell carcinoma, and squamous
cell carcinoma

● Viral diseases, such as those caused by cytomegalovirus,
herpes simplex, and herpes zoster virus

● Fungal diseases, such as pneumocystis jiroveci
pneumonia (PCP), candidiasis, cryptococcosis,
coccidioidomycosis, and penicilliosis

● Protozoal diseases, such as PCP, toxoplasmosis,
microsporidiosis, cryptosporidiosis, isosporiasis,
giardiasis, and leishmaniasis

NURSING ACTIONS
● Implement and maintain antiretroviral medication

therapy as prescribed.
● Administer antineoplastics, antibiotics, analgesics,

antifungals, and antidiarrheals.
● Administer appetite stimulants (to enhance nutrition).
● Monitor for skin breakdown.
● Maintain fluid intake.
● Maintain nutrition.

CLIENT EDUCATION: Report indications of infection
immediately to the provider.

Wasting syndrome

NURSING ACTIONS
● Maintain nutrition orally or by TPN if indicated.
● Monitor weight, calorie counts, and I&O.
● Provide between‑meal supplements/snacks.
● Decrease fat content of foods to prevent complications

of fat intolerance.
● Rinse the client’s mouth several times daily with saline

or sodium bicarbonate and sterile water to reduce mouth
pain and increase appetite.

● Serve at least six small feedings with high
protein value.

Fluid/electrolyte imbalance

NURSING ACTIONS
● Monitor fluid/electrolyte status.
● Report abnormal laboratory data promptly.
● Encourage the client to drink 2,000 to 3,000 mL of

fluid daily.
● Make dietary adjustments to reduce diarrhea.

Seizures (HIV encephalopathy)

NURSING ACTIONS
● Maintain client safety.
● Implement seizure precautions.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 86 HIV/aIds 575

Active Learning Scenario

a nurse is planning care for a client who has
aIds. use the atI active Learning template:
system disorder to complete this item.

NURSING CARE: describe at least three nursing actions.

Application Exercises

1. a nurse in an outpatient clinic is assessing a client
who reports night sweats and fatigue. the client
reports having a cough along with nausea and
diarrhea. their temperature is 38.1° c (100.6° f)
orally. the client is concerned about the possibility
of having HIV. Which of the following actions
should the nurse take? (select all that apply.)

a. Perform a physical assessment.

B. determine when manifestations began.

c. teach the client about HIV transmission.

d. draw blood for HIV testing.

e. obtain a sexual history.

2. a nurse is caring for a client who is suspected of
having HIV. the nurse should identify that which of the
following diagnostic tests and laboratory values are
used to confirm HIV infection? (select all that apply.)

a. Western blot

B. Indirect immunofluorescence assay

c. cd4+ t‑lymphocyte count

d. HIV rna quantification test

e. cerebrospinal fluid (csf) analysis

3. a nurse is providing teaching for a client who
has stage 3 HIV disease. Which of the following
statements by the client should indicate to the
nurse an understanding of the teaching?

a. “I will wear gloves while changing
the pet litter box.”

B. “I will rinse raw fruits with water
before eating them.”

c. “I will wear a mask when around
family members who are ill.”

d. “I will cook vegetables before eating them.”

4. a nurse is assessing a client for HIV. the nurse should
identify that which of the following are risk factors
associated with this virus? (select all that apply.)

a. Perinatal exposure

B. Pregnancy

c. monogamous sex partner

d. older adult woman

e. occupational exposure

5. a nurse is providing teaching for a client who
has stage 2 HIV disease and is having difficulty
maintaining a normal weight. Which of the following
statements by the client should indicate to the
nurse an understanding of the teaching?

a. “I will choose a diet high in fat to help gain weight.”

B. “I will be sure to eat three large meals daily.”

c. “I will drink up to 1 liter of liquid each day.”

d. “I will add high‑protein foods to my diet.”

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576 CHAPTER 86 HIV/aIds CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: Perform a physical assessment to
gather data about the client’s condition.

B. CORRECT: gather more data to determine whether
the manifestations are acute or chronic.

c. teaching the client about HIV transmission is
not an appropriate action at this time.

d. drawing blood for HIV testing is not an
appropriate action at this time.

e. CORRECT: obtain a sexual history to determine
how the virus was transmitted.

NCLEX® Connection: Physiological Adaptation,
Illness Management

2. a. CORRECT: Positive results of a Western blot test
confirm the presence of HIV infection.

B. CORRECT: Positive results of an indirect immunofluorescence
assay confirm the presence of HIV infection.

c. cd4+ t‑lymphocyte count assists with
classifying the stage of HIV infection.

d. HIV rna quantification tests are used to determine
vial level and to monitor treatment.

e. a csf analysis can be used to confirm meningitis.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

3. a. a client who has aIds should avoid changing the litter
box to prevent acquiring toxoplasmosis.

B. a client who has aIds should avoid consuming
raw fruits due to the presence of bacteria that
can cause opportunistic infections.

c. due to compromised immune response, a client who has
aIds should avoid contact with family members who are ill.

d. CORRECT: a client who has aIds should
cook vegetables before eating to kill bacteria
that cause opportunistic infections.

NCLEX® Connection: Physiological Adaptation,
Illness Management

4. a. CORRECT: Perinatal exposure is a risk factor associated
with HIV. Women who are pregnant should take
precautionary measures to prevent HIV exposure.

B. Women who are pregnant should be tested for HIV, but
pregnancy is not a risk factor associated with this virus.

c. Having a monogamous sex partner is not a risk
factor associated with the HIV virus.

d. CORRECT: Being an older adult woman is a risk
factor associated with the HIV virus due to vaginal
dryness and the thinning of the vaginal wall.

e. CORRECT: occupational exposure, such as being a health
care worker, is a risk factor associated with the HIV virus.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

5. a. the client should be taught to avoid high‑fat foods to gain
weight because fat intolerance—causing flatus, bloating, and
diarrhea—is common in clients who have HIV/aIds.

B. the client should be taught that small frequent meals (such as
six meals daily) are better tolerated than three large meals.

c. the client should be taught to drink 2 to 3 L of
liquids daily to maintain nutrition status.

d. CORRECT: the client should be taught to add
high‑protein, high‑calorie foods to the diet daily as
the best way to gain weight and maintain health.

NCLEX® Connection: Physiological Adaptation, Illness Management

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

NURSING CARE
● assess risk factors (sexual practices, IV drug use).
● monitor fluid intake/urinary output.
● obtain daily weights to monitor weight loss.
● monitor nutritional intake.
● monitor electrolytes.
● assess skin integrity (rashes, open areas, bruising).
● assess pain status.
● monitor vital signs (especially temperature).
● assess lung sounds/respiratory status (diminished lung sounds).
● assess neurologic status (confusion, dementia, visual changes).

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 87 LuPus erYtHematosus, gout, and fIBromYaLgIa 577

UNIT 13 IMMUNE SYSTEM AND CONNECTIVE
TISSUE DISORDERS
SECTION: CONNECTIVE TISSUE DISORDERS

CHAPTER 87 Lupus Erythematosus,
Gout, and
Fibromyalgia

Lupus erythematosus (lupus) is an autoimmune
disorder in which an atypical immune response
results in chronic inflammation and destruction
of healthy tissue. other autoimmune disorders
include rheumatoid arthritis, vasculitis, multiple
sclerosis, scleroderma (including raynaud’s
phenomenon), and psoriasis.

In autoimmune disorders, small antigens
can bond with healthy tissue. the body then
produces antibodies that attack the healthy
tissue. this can be triggered by toxins,
medications, bacteria, and viruses. control of
manifestations and a decrease in the number
and frequency of exacerbations is the goal
of treatment, because there is no cure for
autoimmune disorders.

gout, also known as gouty arthritis, is a systemic
disorder caused by hyperuricemia (increase in
serum uric acid). urate levels can be affected
by medications, diet, and overproduction in the
body. this can cause uric crystal deposits to
form in the joints, and a gout attack can occur.

fibromyalgia is a chronic pain syndrome that
involves stiffness, sleep disturbance, generalized
muscle weakness, and chronic fatigue. It is
estimated that 25% to 65% of people who
have fibromyalgia have another form of a
rheumatologic disorder, such as ra or sLe.

occurrence of autoimmune disorders increases
with age.

Lupus erythematosus
● Lupus varies in severity and progression. It is generally

characterized by periods of exacerbations (flares)
and remissions.

● Lupus is classified as discoid or systemic. A temporary
form of lupus can be medication‑induced.

◯ Discoid lupus erythematosus (DLE) only
affects the skin.

◯ Systemic lupus erythematosus (SLE) affects the
connective tissues of multiple organ systems and can
lead to major organ failure.

◯ Medication‑induced lupus erythematosus can be
caused by medications (procainamide, hydralazine,
isoniazid). Findings resolve when the medication
is discontinued.

● Lupus can be difficult to diagnose because of the vague
nature of early manifestations.

ASSESSMENT

rIsK factors
● Females age 20 to 40 years old
● Asian, Hispanic, or Native American descent
● Lupus can be caused from a combination of

environmental and genetic factors.
● The incidence of lupus declines in females following

menopause but remains steady in males.
● Diagnosis of lupus can be delayed in older adult clients

because many of the manifestations mimic other
disorders or can be associated with reports common to
the normal aging process. Joint pain and swelling can
significantly limit ADLs in older adult clients who have
comorbidities.

eXPected fIndIngs
● Fatigue/malaise
● Alopecia
● Blurred vision
● Pleuritic pain
● Anorexia/weight loss
● Depression
● Joint pain, swelling, tenderness
● Weakness

PHYSICAL ASSESSMENT FINDINGS
● Fever (also a major indication of exacerbation)
● Anemia
● Lymphadenopathy
● Pericarditis (presence of a cardiac friction rub or pleural

friction rub)
● Raynaud’s phenomenon (arteriolar vasospasm in

response to cold/stress)
● Erythematous “butterfly” rash on the nose and cheeks

(raised, dry, scaly)
● Few to no manifestations if lupus is in remission
● With exacerbation of lupus, multiple body systems are

often affected (kidney, heart, lungs, gastrointestinal
tract, vasculature)

CHAPTER 87 Online Image: Raynaud’s Syndrome

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578 CHAPTER 87 LuPus erYtHematosus, gout, and fIBromYaLgIa CONTENT MASTERY SERIES

LaBoratorY tests
Skin biopsy: Used to diagnose DLE by confirming the
presence of lupus cells and cellular inflammation.

Immunologic tests: Used to diagnose SLE
● Antinuclear antibodies (ANAs): antibodies produced

against one’s own DNA; positive titers in 95% of clients
who have lupus

◯ SLE prep
◯ dsDNA (very specific for SLE; assists
with differentiation between SLE and
medication‑induced lupus)

◯ ssDNA
◯ Anti‑DNP

● Serum complement (C3, C4): decreased
◯ The complement system is made of proteins (there are
nine major complement proteins). These proteins affect
the immune system’s development of inflammation. C3
and C4 are diagnostic for SLE because the exaggerated
immune response in SLE depletes C3 and C4, leading to
a decrease from the expected amount.

● Erythrocyte sedimentation rate (ESR): elevated due to
systemic inflammation

● Anti‑SS‑a
● Anti‑SS‑b
● Anti‑Smith
● Extractable nuclear antigens (ENAs)

BUN and blood creatinine: Increased (with kidney
involvement)

Urinalysis: Positive for protein and RBCs (kidney
involvement)

CBC: Pancytopenia

PATIENT‑CENTERED CARE

nursIng care
● Assess/monitor the following.

◯ Pain, mobility, and fatigue
◯ Vital signs (especially blood pressure)
◯ Systemic manifestations

■ Hypertension and edema (renal compromise)
■ Urine output (renal compromise)
■ Diminished breath sounds (pleural effusion)
■ Tachycardia and sharp inspiratory chest pain
(pericarditis)

■ Rubor, pallor, and cyanosis of hands/feet (vasculitis/
vasospasm, Raynaud’s phenomenon)

■ Arthralgias, myalgias, and polyarthritis (joint and
connective tissue involvement)

■ Changes in mental status that indicate neurologic
involvement (psychoses, paresis, seizures)

■ BUN, blood creatinine level, and urinary output for
renal involvement

■ Nutritional status
● Provide small, frequent meals if anorexia is a concern.

Offer between‑meal supplements.
● Encourage the client to limit salt intake for fluid

retention secondary to steroid therapy.
● Provide emotional support to the client and family.

medIcatIons

NSAIDs
● Used to reduce inflammation and arthritic pain.
● Contraindicated for clients who have impaired

kidney function.

NURSING ACTIONS: Monitor for NSAID‑induced hepatitis.

Corticosteroids

Prednisone is used for immunosuppression and to reduce
inflammation.

NURSING ACTIONS: Monitor for fluid retention,
hypertension, and impaired kidney function.

CLIENT EDUCATION
● Do not stop taking steroids abruptly. Gradually taper the

dosage as prescribed.
● Older adult clients are at an increased risk for fractures

if corticosteroid therapy is used.

Immunosuppressant agents
● Methotrexate and azathioprine are used to suppress the

immune response.
● Belimumab is a human monoclonal antibody

administered with other medications for SLE that
inhibits the stimulation of B‑cells, reducing the
autoimmune response.

NURSING ACTIONS: Monitor for toxic effects and infection
(bone marrow suppression, increased liver enzymes).

CLIENT EDUCATION: Avoid live vaccine administration for
30 days before beginning immunosuppressant therapies.

87.1 Butterfly rash

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Antimalarial

Hydroxychloroquine is used for suppression of synovitis,
fever, and fatigue, and decreases the risk of developing
skin lesions from the absorption of ultraviolet light from
sun exposure.

NURSING ACTIONS: Encourage frequent eye examinations.

InterProfessIonaL care
● Physical and occupational therapy services can be used for

strengthening exercises and adaptive devices as needed.
● Refer clients to support groups as appropriate.

cLIent educatIon
● Wear a wide‑brimmed hat, long‑sleeve shirt, and long

pants when outdoors.
● Avoid UV and prolonged sun exposure. Use sunscreen

when outside and exposed to sunlight.
● Use mild protein shampoo and avoid harsh hair treatments.
● Use steroid creams for skin rash.
● Report peripheral and periorbital edema promptly.
● Report evidence of infection related to immunosuppression.
● Avoid crowds and individuals who are sick, because

illness can precipitate an exacerbation.
● Understand the risks of pregnancy with lupus and

treatment medications.
● Cleanse skin with mild soap, and inspect for open areas

and rashes daily.
● Apply lotion to dry skin.
● Avoid applying drying agents to skin, such as powder or

rubbing alcohol.
● Pat skin dry rather than rubbing.
● Understand the effect of the disease on lifestyle.

COMPLICATIONS

Lupus nephritis

Clients whose SLE cannot be managed with
immunosuppressants and corticosteroids can experience
chronic kidney disease, resulting in the possible need for a
kidney transplant. Lupus nephritis is the leading cause of
death related to SLE.

NURSING ACTIONS: Monitor for periorbital and lower
extremity swelling and hypertension. Monitor renal status
(creatinine, BUN).

CLIENT EDUCATION
● Take immunosuppressants and corticosteroids

as prescribed.
● Avoid stress and illness.

Pericarditis and myocarditis

Inflammation of the heart, its vessels, and the
surrounding sac can occur secondary to SLE.

NURSING ACTIONS: Monitor for chest pain, fatigue,
arrhythmias, and fever.

CLIENT EDUCATION
● Report chest pain.
● Take immunosuppressants and corticosteroids

as prescribed.
● Avoid stress and illness.
● Report chest pain to the provider.

Gout
Gout or gouty arthritis is the most common inflammatory
arthritis. Gout is a systemic disease caused by a disruption
in purine metabolism in which uric acid crystals are
deposited in joints and body tissues. Gout is classified as
either primary or secondary.

Primary gout
● Most common.
● Primary gout has three stages: asymptomatic

hyperuricemia, acute gouty arthritis, and chronic gout.
● Uric acid production is greater than excretion of it by

the kidneys.
● Can have genetic component.
● Middle‑ and older‑adult males (peak onset between

ages 40 and 50 years), as well as postmenopausal clients
are commonly affected.

Secondary gout
● Caused by another disease or condition (chronic kidney

failure, some carcinomas, excessive diuretic use) that
causes excessive uric acid in the blood.

● Treatment is based on treating the underlying condition.
● Can affect people of any age.

ASSESSMENT

rIsK factors
● Obesity
● Heredity
● Postmenopause
● Cardiovascular disease
● Trauma
● Alcohol ingestion
● Starvation dieting
● Diuretic use
● Some chemotherapy agents
● Chronic kidney failure

eXPected fIndIngs
● Severe joint pain, especially in the metatarsophalangeal

joint of the great toe
● Redness, swelling, and warmth of affected joint

PHYSICAL ASSESSMENT FINDINGS
● Painful, swollen joint that is very painful if

touched or moved
● Appearance of tophi (deposits of sodium urate crystals

under the skin) with chronic gout

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580 CHAPTER 87 LuPus erYtHematosus, gout, and fIBromYaLgIa CONTENT MASTERY SERIES

LaBoratorY tests
Erythrocyte sedimentation rate (ESR): Elevated

Serum uric acid: Repeated measurements obtained due to
the effect of dietary intake on results. Consistent elevation
above 6.5 mg/dL is associated with gout.

Urinary uric acid: Elevated

Blood urea nitrogen (BUN), blood creatinine: Elevated

dIagnostIc Procedure
Aspiration of synovial fluid for analysis or uric acid
crystals in affected joints

PATIENT‑CENTERED CARE

nursIng care
Assess/monitor the following.

● Pain
● Redness/swelling of affected joint
● Serum uric acid levels

medIcatIons

Acute gout

Antigout agent
● Colchicine (PO or parenteral) is used to decrease pain

and inflammation.
● Use cautiously in clients who have impaired

kidney function.

NSAIDs
● Indomethacin or ibuprofen is used to decrease pain

and inflammation.
● Contraindicated for clients who have impaired

kidney function.
● CLIENT EDUCATION: Do not take on an empty stomach.

Corticosteroids
● Prednisone used to treat inflammation.
● NURSING ACTIONS: Monitor for fluid retention,

hypertension, and impaired kidney dysfunction.
● CLIENT EDUCATION: Do not stop taking the medication

abruptly. Gradually taper dosage as prescribed.

Chronic gout

Xanthine oxidase inhibitor
● Allopurinol or febuxostat is used as a maintenance

medication to promote uric acid excretion and decrease
its production.

● CLIENT EDUCATION: Take after meals and with a full
glass of water. Increase fluid intake.

Uricosuric
● Probenecid is used as a maintenance medication to

promote uric acid excretion.
● NURSING ACTIONS: Monitor uric acid levels.
● CLIENT EDUCATION: Do not use aspirin because it will

decrease the effectiveness of the medication.

Enzymes
● Enzyme treatment is used with refractory gout, when

acute or chronic gout does not respond to other
medication treatment.

● Pegloticase is administered as an IV dose every other
week. It converts uric acid to allantoin, so it can be
excreted by the kidneys.

● NURSING ACTIONS: Monitor closely for allergic reaction
or anaphylaxis. The risk is increased because of the
protein component in the medication.

● CLIENT EDUCATION: Report allergic reaction to health
care provider immediately.

Combination medications
● Probenecid and colchicine are available as a

combination medication.

cLIent educatIon
● Stay on a low‑purine diet, which includes no organ

meats or shellfish.
● Limit alcohol intake.
● Avoid starvation diets, aspirin, and diuretics.
● Limit physical or emotional stress.
● Increase fluid intake.
● Practice medication adherence.
● Use stress‑management techniques.

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Fibromyalgia
● Fibromyalgia, also known as fibromyalgia syndrome,

is a chronic pain syndrome which manifests as pain,
stiffness, and tenderness at trigger points in the body.

● The pain is typically described as a burning, gnawing
pain that can be elicited by palpating trigger points.

● The client can also experience chronic fatigue, sleep
disturbances, and functional impairment.

● Pain and tenderness vary depending on stress, activity,
and weather conditions.

ASSESSMENT

rIsK factors
● Females between ages of 30 and 50 years
● History of rheumatologic conditions, chronic fatigue

syndrome, Lyme disease, influenza‑like illness,
and trauma

● Deep sleep deprivation

eXPected fIndIngs
● Cardiovascular manifestations: chest pain,

dysrhythmia, dyspnea
● Dysrhythmias
● Mild to severe fatigue
● Sleep disturbances
● Numbness/tingling of extremities
● Sensitivity to noxious smells, loud noises, and bright lights
● Headaches
● Jaw pain
● Depression
● Concentration and memory difficulties
● GI manifestations: abdominal pain, heartburn,

constipation, diarrhea
● Genitourinary manifestations: frequency, urgency,

dysuria, pelvic pain
● Visual changes

PATIENT‑CENTERED CARE

nursIng care
● Assess/monitor pain, mobility, and fatigue.
● Provide emotional support to the client and family

medIcatIons

Serotonin‑norepinephrine reuptake
inhibitors (SNRIs) and anticonvulsants

Pregabalin (anticonvulsant) and duloxetine (SNRI)
are used to increase the release of serotonin and
norepinephrine, resulting in decreased nerve pain.

CLIENT EDUCATION
● Do not drink alcohol while on this medication.
● SNRIs can cause drowsiness/sleepiness.

NSAIDs
● Used to decrease pain and inflammation
● Contraindicated for clients who have impaired

kidney function.

CLIENT EDUCATION: Do not take on an empty stomach.

Tricyclic antidepressants

Amitriptyline, nortriptyline, and trazodone are used to
help induce sleep and decrease pain.

● Amitriptyline and nortriptyline can cause confusion and
orthostatic hypotension in older adult clients.

● Trazodone is often the medication of choice for the older
adult clients due to decreased adverse effects.

Combination medications

Tramadol has tricyclic and opioid components to
reduce pain. Opioid component can lead to physical or
psychological dependence or tolerance over time.

InterProfessIonaL care
● Physical therapy can be helpful to decrease pain.
● Refer the client to national foundations and local

support groups.

cLIent educatIon
● Limit intake of caffeine, alcohol, and other substances

that interfere with sleep.
● Develop a routine for sleep.
● Engage in regular, low‑impact exercise.
● Complementary and alternative therapies can be helpful

(acupuncture, stress management, tai chi, hypnosis).

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582 CHAPTER 87 LuPus erYtHematosus, gout, and fIBromYaLgIa CONTENT MASTERY SERIES

Application Exercises

1. a nurse is reviewing the plan of care for a client who
has systemic lupus erythematosus (sLe). the client
reports fatigue, joint tenderness, swelling, and difficulty
urinating. Which of the following laboratory findings
should the nurse anticipate? (select all that apply.)

a. Positive ana titer

B. Increased hemoglobin

c. 2+ urine protein

d. Increased serum c3 and c4

e. elevated Bun

2. a nurse is teaching a client who has sLe about
self‑care. Which of the following statements by the
client indicates an understanding of the teaching?

a. “I should limit my time to 10 minutes
in the tanning bed.”

B. “I will apply powder to any skin rash.”

c. “I should use a mild hair shampoo.”

d. ”I will inspect my skin once a month for rashes.”

3. a nurse is discussing gout with a client who is
concerned about developing the disorder. Which of
the following findings should the nurse identify as
risk factors for this disease? (select all that apply.)

a. diuretic use

B. obesity

c. deep sleep deprivation

d. depression

e. cardiovascular disease

4. a nurse is assessing a client who has a new
diagnosis of sLe. Which of the following
findings should the nurse expect?

a. Weight gain

B. Petechiae on thighs

c. systolic murmur

d. alopecia

5. a nurse is caring for a client who has sLe
and is experiencing an episode of raynaud’s
phenomenon. Which of the following
findings should the nurse anticipate?

a. swelling of joints of the fingers

B. Pallor of toes with cold exposure

c. feet that become reddened with ambulation

d. client report of intense feeling of heat in the fingers

Active Learning Scenario

a nurse is teaching a client who has a new diagnosis
of fibromyalgia. What should the nurse include in
the teaching? use the atI active Learning template:
system disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)

RISK FACTORS: describe two.

EXPECTED FINDINGS: Include three findings.

MEDICATIONS: Identify two types of medications
used to treat fibromyalgia along with their
purpose and specific nursing considerations.

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Application Exercises Key

1. a. CORRECT: a positive antinuclear antibody (ana)
titer is an expected finding in a client who has sLe.
the ana test identifies the presence of antibodies
produced against the client’s own dna.

B. Pancytopenia, rather than an elevated hemoglobin,
is an expected finding in a client who has sLe.

c. CORRECT: Increased urine protein is an expected
finding due to kidney injury as a result of sLe.

d. the client who has sLe is expected to have a
decreased level of serum c3 and c4.

e. CORRECT: elevated Bun is an expected finding
due to kidney injury in a client who has sLe.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. a client who has sLe should avoid the use of tanning
beds, as well as prolonged sun exposure.

B. a client who has sLe should apply steroid‑based
creams to skin rashes, not a powder.

c. CORRECT: a client who has sLe should use a mild
hair shampoo that does not irritate the scalp.

d. a client who has sLe should inspect their skin
daily for any open areas or rashes.

NCLEX® Connection: Physiological Adaptation,
Illness Management

3. a. CORRECT: the use of diuretics is a risk factor for gout.
B. CORRECT: obesity is a risk factor for gout.
c. deep sleep deprivation is a manifestation of

fibromyalgia and is not a risk factor for gout.
d. depression is a manifestation of sLe and

is not a risk factor for gout.
e. CORRECT: cardiovascular disease is a risk factor for gout.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

4. a. Weight loss, rather than weight gain, is an expected
finding in a client who has a new diagnosis of sLe.

B. a butterfly rash on the face is a finding
in a client who has lupus.

c. a cardiac friction rub is an expected finding of sLe.
d. CORRECT: alopecia (hair loss) is an expected

finding in a client who has sLe.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

5. a. swelling, pain, and joint tenderness are findings
in a client who has sLe and is not specific to an
episode of raynaud’s phenomenon.

B. CORRECT: Pallor of the extremities occurs in
raynaud’s phenomenon in a client who has sLe
and has been exposed to cold or stress.

c. the extremities becoming red, white, and blue when
exposed to cold or stress is characteristic of an episode
of raynaud’s phenomenon in a client who has sLe.

d. a client report of intense pain in the hands and
feet is characteristic of an episode of raynaud’s
phenomenon in a client who has sLe.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS)
● fibromyalgia, also known as fibromyalgia syndrome, is a
chronic pain syndrome which manifests as pain, stiffness,
and tenderness at certain “trigger points” in the body.

● the pain is typically described as a burning or gnawing
pain that can be elicited by palpating “trigger points”.

● the client can also experience chronic fatigue, sleep
disturbances, and functional impairment.

● Pain and tenderness vary depending on stress,
activity, and weather conditions.

RISK FACTORS
● females between ages of 30 and 50 years
● History of rheumatologic conditions, chronic
fatigue syndrome, or Lyme disease

● deep sleep deprivation

EXPECTED FINDINGS
● mild to severe fatigue
● sleep disturbances
● numbness/tingling of extremities
● sensitivity to noxious smells, loud noises, and bright lights
● Headaches
● Jaw pain
● depression
● concentration and memory difficulties
● gI manifestations: abdominal pain, heartburn, constipation, diarrhea
● genitourinary manifestations: frequency, urgency, dysuria, pelvic pain
● Visual changes

MEDICATIONS

serotonin‑norepinephrine reuptake
inhibitors (snrIs) and anticonvulsants

● Pregabalin (anticonvulsant) and duloxetine (snrI)
are used to increase the release of serotonin and
norepinephrine, resulting in decreased nerve pain.

● nursing actions: can cause drowsiness/sleepiness.
● client education: do not drink alcohol while on this medication.

nsaIds
● used to decrease pain and inflammation.
● nursing actions: contraindicated for clients
who have impaired kidney function.

● client education: do not take on an empty stomach.

tricyclic antidepressants
● amitriptyline, nortriptyline, and trazodone are used
to help induce sleep and decrease pain.

● nursing actions: amitriptyline and nortriptyline can cause
confusion and orthostatic hypotension in older adult
clients. trazodone is often the medication of choice for the
older adult client due to decreased adverse effects.

NCLEX® Connection: Physiological Adaptation,
Illness Management

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UNIT 13 IMMUNE SYSTEM AND CONNECTIVE
TISSUE DISORDERS
SECTION: CONNECTIVE TISSUE DISORDERS

CHAPTER 88 Rheumatoid Arthritis
rheumatoid arthritis (ra) is a chronic, progressive
inflammatory disease that can affect tissues and
organs but principally attacks the joints, producing
an inflammatory synovitis. It involves joints
bilaterally and symmetrically, and typically affects
several joints at one time. ra typically affects
upper joints first.

ra is an autoimmune disease that is precipitated
by WBcs attacking synovial tissue. the WBcs
cause the synovial tissue to become inflamed
and thickened. the inflammation can extend to
the cartilage, bone, tendons, and ligaments that
surround the joint. Joint deformity and bone
erosion can result from these changes, decreasing
the joint’s range of motion and function.

ra is also a systemic disease that can affect any
connective tissue in the body. common structures
affected are the blood vessels, pleura surrounding
the lungs, and pericardium. Iritis and scleritis can
also develop in the eyes.

the natural course of the disease is one
of exacerbations and remissions. If ra is
diagnosed and treated early, it is possible to
avoid permanent joint damage.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Use adaptive devices that prevent development of
deformity of inflamed joints during ADLs.

● Continue using affected joints and ambulating to
maintain function and range of motion.

ASSESSMENT

rIsK factors
● Female sex (3:1 compared to male clients)
● Age 30 to 60 years
● Genetic predisposition
● Bacterial or viral infection, particularly

Epstein‑Barr virus
● Stress and smoking
● Environmental factors
● Older age

eXPected fIndIngs
Findings depend on the area affected by the
disease process.

● Pain at rest and with movement
● Morning stiffness
● Pleuritic pain (pain upon inspiration)
● Xerostomia (dry mouth)
● Anorexia/weight loss
● Fatigue
● Paresthesias
● Recent illness/stressor
● Joint pain
● Lack of function
● Joint swelling and deformity

◯ Joint deformities are late manifestations of RA.
◯ Joint swelling, warmth, and erythema are common.
◯ Finger, hands, wrists, knees, and foot joints are
generally affected.

◯ Finger joints affected are the proximal
interphalangeal and metacarpophalangeal joints.

◯ Joints can become deformed merely by
completing ADLs.

◯ Ulnar deviation, swan neck, and boutonnière
deformities are common in the fingers.

● Subcutaneous nodules
● Fever (generally low‑grade)
● Muscle weakness/atrophy
● Reddened sclera and/or abnormal shape of pupils
● Lymph node enlargement
● Early manifestations of RA (fatigue, joint discomfort)

are vague and can be attributed to other disorders in
older adult clients.

CHAPTER 88

Online Image: Rheumatoid Arthritis Changes

88.1 Rheumatoid arthritis changes

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586 CHAPTER 88 rHeumatoId artHrItIs CONTENT MASTERY SERIES

LaBoratorY tests

Anti‑CCP antibodies

This test detects antibodies to cyclic citrullinated peptide
(anti‑CCP). The result is positive in most people who have
rheumatoid arthritis, even years before manifestations
develop. The test is more sensitive for RA than rheumatoid
factor (RF) antibodies.

Rheumatoid factor antibody

Diagnostic level for rheumatoid arthritis is 1:40 to 1:60
(expected reference range 1:20 or less).

● High titers correlate with severe disease.
● Other autoimmune diseases also can increase

RF antibody.

Erythrocyte sedimentation rate (ESR)

Elevated ESR is associated with the inflammation or
infection in the body.

● 20 to 40 mm/hr is mild inflammation.
● 40 to 70 mm/hr is moderate inflammation.
● 70 to 150 mm/hr is severe inflammation.
● Other autoimmune diseases also can increase

ESR antibody.

C‑reactive protein (CRP)
● This test may be done in place of ESR.
● This test is useful for diagnosing disease or monitoring

disease activity, and for monitoring the response to
anti‑inflammatory therapy.

● Elevated levels indicate inflammation in the body
(expected reference range is less than 1.0 mg/dL).

Antinuclear antibody (ANA) titer

Antibody produced against one’s own DNA
● A positive ANA titer is associated with RA. (It is

normally negative at 1:20 dilution.)
● Other autoimmune diseases also can increase ANA.

Elevated WBCs
● WBC count can be elevated during an exacerbation

secondary to the inflammatory response.
● Decreased RBCs due to anemia.

dIagnostIc Procedures

Arthrocentesis
● Arthrocentesis is synovial fluid aspiration by needle.
● With RA, increased WBCs and RF are present in fluid.

NURSING ACTIONS: Monitor for bleeding or a synovial
fluid leak from the needle biopsy site.

CLIENT EDUCATION
● Take acetaminophen for pain.
● Apply ice and rest the joint for 24 hr.

X‑ray

X‑rays are used to determine the degree of joint
destruction and monitor its progression. They can provide
adequate visualization and reveal bony erosions and
narrowed joint spaces. This negates the need for more
expensive radiologic tests, such as a CT scan or magnetic
resonance imaging (MRI).

NURSING ACTIONS: Assist the client into position.

CLIENT EDUCATION: Minimize movement during the
procedure.

PATIENT‑CENTERED CARE

nursIng care
● Assist with and encourage physical activity to maintain

joint mobility (within the capabilities of the client).
● Monitor for indications of fatigue.
● Teach the client measures to do the following.

◯ Maximize functional activity.
◯ Minimize pain.
◯ Monitor skin closely.

● Provide a safe environment.
◯ Provide referrals for physical therapy and
occupational therapy.

◯ Provide information for support organizations.
◯ Facilitate the use of assistive devices.
◯ Remove unnecessary equipment and supplies.

● Monitor for medication effectiveness (reduced pain,
increased mobility).

Nutritional teaching
● Encourage foods high in vitamins, protein, and iron.
● Eat small, frequent meals.

medIcatIons

NSAIDs
● Treatment begins with NSAIDs.
● NSAIDs provide analgesic, antipyretic, and

anti‑inflammatory effects.
● NSAIDs can cause considerable gastrointestinal

(GI) distress.

NURSING ACTIONS
● Request a concurrent prescription for a GI‑acid lowering

agent (histamine2‑receptor antagonist, proton pump
inhibitor) if GI distress is reported.

● Monitor for fluid retention, hypertension, and
renal dysfunction.

CLIENT EDUCATION
● Take the medication with food or with a full glass

of water or milk. If taking routinely, an H2‑receptor
antagonist can also be prescribed.

● Observe for GI bleeding (coffee‑ground emesis; dark,
tarry stools).

● Avoid alcohol, which can increase the risk of
GI complications.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 88 rHeumatoId artHrItIs 587

COX‑2 enzyme blockers
● Cause less GI distress but carry a risk of cardiac disease
● COX‑2 inhibiting medications, such as celecoxib,

are not recommended if the client has a history of
myocardial infarction.

Corticosteroids

Corticosteroids (prednisone) are strong anti‑inflammatory
medications that can be given for acute exacerbations
or advanced forms of the disease. They are not given
for long‑term therapy due to significant adverse effects
(osteoporosis, hyperglycemia, immunosuppression,
cataracts).

NURSING ACTIONS
● Observe for Cushingoid changes.
● Monitor weight and blood pressure.

CLIENT EDUCATION
● Observe for changes in vision; blood glucose; impaired

healing; black, tarry stools; or weight gain.
● Avoid crowds.
● Follow the prescription (alternate‑day dosing, tapering,

discontinuing medication).

Disease modifying anti‑rheumatic drugs (DMARDs)

DMARDs work in a variety of ways to slow the progression
of RA and suppress the immune system’s reaction
to RA that causes pain and inflammation. Relief of
manifestations might not occur for several weeks.

● Antimalarial agent: Hydroxychloroquine
● Antibiotic: Minocycline
● Sulfonamide: Sulfasalazine
● Biologic response modifiers: Etanercept, infliximab,

adalimumab, and chelator penicillamine
● Cytotoxic medications: Methotrexate, leflunomide,

cyclophosphamide, and azathioprine can cause severe
adverse effects.

NURSING ACTIONS
● Monitor for allergic reactions and low WBC counts.
● Monitor lab results for decreased WBCs and

platelets, and increased liver enzymes for clients
taking leflunomide.

CLIENT EDUCATION
● Avoid crowds, which increase the risk of infection.
● Monitor for an allergic reaction.
● If taking leflunomide, report hair loss or diarrhea to

the provider.
● Leflunomide is contraindicated during pregnancy,

because it increases the risk of fetal birth defects.
● Many DMARDs can affect the liver; avoid alcohol

consumption to prevent additional harm to the liver.

tHeraPeutIc Procedures

Plasmapheresis
● Removes circulating antibodies from plasma, decreasing

attacks on the client’s tissues
● May be done for a severe, life‑threatening exacerbation

Total joint arthroplasty

Surgical repair and replacement of a joint may be done
for a severely deformed joint that has not responded to
medication therapy.

Synovectomy

Surgical removal of the synovial membrane surrounding
the affected joints.

InterProfessIonaL care
● Refer the client to support groups as appropriate.
● Refer the client to occupational therapy for adaptive

devices that can facilitate carrying out ADLs and
prevent deformities.

● A home health aide can be necessary for assistance
with ADLs.

cLIent educatIon
● Apply heat or cold to the affected areas as indicated

based on client response.
◯ Morning stiffness (hot shower)
◯ Pain in hands/fingers (heated paraffin)
◯ Edema (cold therapy)

● Conserve energy (space out activities, take rest periods,
ask for additional assistance when needed).

● Follow routine health screenings.
● Use progressive muscle relaxation.
● Report manifestations that can indicate early or

late exacerbation of the RA that need to be reported
immediately (fever, infection, pain upon inspiration,
pain in the substernal area of the chest).

● Express feelings regarding effect of the disease on body
image and self‑esteem.

● Use nonpharmacologic pain relief through therapies
such as hypnosis, acupuncture, imagery, music therapy,
and spiritual practices.

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588 CHAPTER 88 rHeumatoId artHrItIs CONTENT MASTERY SERIES

COMPLICATIONS

Sjögren’s syndrome
● Triad of manifestations: dry eyes, mouth, and vagina
● Caused by obstruction of secretory ducts and glands

NURSING ACTIONS
● Provide eye drops and artificial saliva, and recommend

vaginal lubricants as needed.
● Provide fluids with meals.

Secondary osteoporosis

Immobilization caused by arthritis can contribute to the
development of osteoporosis.

NURSING ACTIONS: Encourage weight‑bearing exercises
as tolerated.

Vasculitis (organ ischemia)

Inflammation of arteries can disrupt blood flow, causing
ischemia. Smaller arteries in the skin, eyes, and brain are
most commonly affected in RA.

NURSING ACTIONS: Monitor for skin lesions, decrease in
vision, and manifestations of cognitive dysfunction.

Respiratory

The inflammatory process can lead to lung tissue
complications (pleurisy, pneumonitis, diffuse interstitial
fibrosis, pulmonary hypertension).

NURSING ACTIONS: Monitor for dyspnea. Administer
oxygen therapy.

CLIENT EDUCATION: Take time to rest between activities.

Cardiac

The inflammatory process can affect cardiac tissue,
leading to issues such as pericarditis and myocarditis.

NURSING ACTIONS: Administer anti‑inflammatory agents.

Active Learning Scenario

a nurse is providing information about rheumatoid arthritis
(ra) to a client who has a new diagnosis of ra. use the atI
active Learning template: system disorder and the atI
Pharmacology review module to complete this item.

POTENTIAL COMPLICATIONS: name two.

CLIENT EDUCATION: List five instructions for the
client regarding self‑management of ra.

Application Exercises

1. a nurse working in an outpatient clinic is assessing
a client who has rheumatoid arthritis (ra). the
client reports increased joint tenderness and
swelling. Which of the following findings should
the nurse expect? (select all that apply.)

a. recent influenza

B. decreased range of motion

c. Hypersalivation

d. Increased blood pressure

e. Pain at rest

2. a nurse is teaching a client who has a new diagnosis
of rheumatoid arthritis. Which of the following
statements should the nurse include in the teaching?

a. “You can experience morning stiffness
when you get out bed.”

B. “You can experience abdominal pain.”

c. “You can experience weight gain.”

d. “You can experience low blood sugar.”

3. a nurse is caring for a client who has rheumatoid
arthritis. Which of the following laboratory tests are
used to diagnose this disease? (select all that apply.)

a. urinalysis

B. erythrocyte sedimentation rate (esr)

c. Bun

d. antinuclear antibody (ana) titer

e. WBc count

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 88 rHeumatoId artHrItIs 589

Application Exercises Key

1. a. CORRECT: exacerbating factors, such as a recent illness
like influenza, are indicative in clients who have ra.

B. CORRECT: a decrease in range of motion is
indicative in clients who have ra.

c. clients who have ra can experience
xerostomia, not hypersalivation.

d. Increased blood pressure is not indicative of ra.
e. CORRECT: Pain at rest is indicative of ra.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. a. CORRECT: Include in the teaching that the client who has
ra can experience stiffness in the joints upon rising.

B. the client who has ra can experience pleuritic
pain upon inspiration, not abdominal pain.

c. the client who has ra can experience
weight loss, not weight gain.

d. the client who has ra does not
experience a low blood sugar.

NCLEX® Connection: Physiological Adaptation,
Illness Management

3. a. a urinalysis is not a laboratory test used to diagnose ra.
this test can used for detecting kidney failure.

B. CORRECT: esr is a laboratory test used to
diagnose ra. this laboratory test will show an
elevated result in clients who have ra.

c. a Bun is not a laboratory test used to diagnose ra.
this test can be used for detecting kidney failure.

d. CORRECT: ana titer is a laboratory test used
to diagnose ra. this laboratory test will show a
positive result in clients who have ra.

e. CORRECT: WBc count is a laboratory test used
to diagnose ra. this laboratory test will show a
decreased result in clients who have ra.

NCLEX® Connection: Reduction of Risk Potential,
Diagnostic Tests

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

POTENTIAL COMPLICATIONS
● sjögren’s syndrome, a triad of manifestations including
dryness of the mouth, eyes and vagina.

● Vasculitis, or ischemia to the organs resulting form
insufficient arterial blood flow. usually affects the
small arteries of the brain, eyes, and skin.

CLIENT EDUCATION
● to treat dryness, ensure adequate fluid intake, and use eye
drops, artificial saliva, or vaginal lubricants as needed.

● report changes in vision or cognition as
possible indications of vasculitis.

● use heat therapy (hot shower, paraffin treatments)
or cold to relieve discomfort.

● remain physically active to promote joint mobility.
● report indications of an acute exacerbation of ra (fever,
infection, pain with breathing or in the center of the chest).

● consider other nonpharmacologic pain strategies
(hypnosis, acupuncture, imagery, music therapy,
progressive relaxation) with the provider’s approval.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

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590 CHAPTER 88 rHeumatoId artHrItIs CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 89 generaL PrIncIPLes of cancer 591

UNIT 13 IMMUNE SYSTEM AND CONNECTIVE
TISSUE DISORDERS
SECTION: CANCER‑RELATED DISORDERS

CHAPTER 89 General Principles
of Cancer

cancer is a neoplastic disease process that
involves abnormal cell growth and differentiation.
normal body cells grow, divide, and die in an
orderly fashion. In cancer, dying cells grow and
form new abnormal cells and can form new blood
vessels to provide nourishment for continued
growth. genetic mutations are responsible for
abnormal cancerous growth. these mutations are
either inherited, or caused by something external.
Viruses, physical and chemical agents, hormones,
familial history, and lifestyle are thought to be
factors that trigger abnormal cell growth.

cancer cells can invade surrounding tissues and
spread to other areas of the body through lymph
and blood vessels (metastasis). no matter where
cancer spreads, it always is named based on the
origin in which it started. for example, colon cancer
that spreads to the liver is called metastatic colon
cancer. metastasis is usually diagnosed when there
is onset of new findings (bone pain indicative of
bone metastasis; change in bowel or bladder tone
indicative of nervous system involvement).

screening and early diagnosis are the most
important aspects of health education and care.
the nurse should prevent, recognize, and treat
complications associated with carcinoma.
clients of african, Hispanic, or native american
descent have an increased risk of death from
cancer than white americans, despite a lower
risk for developing many cancer types.

a tumor is an abnormal collection of cells, but
not all tumors are cancers. noncancerous
tumors are benign. they do have the potential
of pressing on healthy organs and tissues as
they grow, but they do not invade other tissues
and they do not metastasize.

BodY tIssues
Cancers can arise from almost any tissue in the body.
Cancerous cells decrease the functional ability of the
tissue in which they are located.

● Epithelial tissue: carcinomas
● Glandular organs: adenocarcinomas
● Mesenchymal tissue: sarcomas
● Blood‑forming cells: leukemias
● Lymph tissue: lymphomas
● Plasma cells: myelomas

HEALTH PROMOTION AND
DISEASE PREVENTION

● Consume a healthy diet (low‑fat with increased
consumption of fruits, vegetables, and lean protein).

● Limit intake of sugar, salt, nitrates, nitrites, and
processed and red meats.

● Maintain a healthy body weight/body mass index.
● Avoid use of tobacco products.
● Limit alcohol consumption to one drink per day for

females and two drinks per day for males.
● Avoid risky lifestyle choices (recreational drug use,

needle sharing, unprotected sexual intercourse).
● Avoid exposure to environmental hazards (radiation,

chemicals). Use personal protective equipment
when available.

● Breastfeed infants exclusively for the first 6
months of life.

● Engage in physical activity or exercise routinely.
● Protect skin and eyes from UVA and UVB rays.
● Remove at‑risk tissue such as moles to prevent

conversion to skin cancer.
● Chemoprevention is the use of medications or other

substances to disrupt cancer development.
◯ Aspirin and celecoxib to reduce the risk of
colon cancer

◯ Vitamin D and tamoxifen to reduce the risk of
breast cancer.

● Immunization to prevent human papilloma virus
(HPV), which is associated with cervical, head, and
neck cancers.

● Immunization for Hepatitis B to prevent liver disease
which can progress to liver cancer.

CHAPTER 89

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592 CHAPTER 89 generaL PrIncIPLes of cancer CONTENT MASTERY SERIES

Screening recommendations

Instruct clients to discuss benefits and risks for each
screening exam with their provider to determine if and
when screening should take place. Clients at increased risk
for specific cancer types might need to start screenings
earlier or have them more frequently.

Mammogram: Annually for female clients 45 to 54 years.
At 55 years, clients can transition to every two years.
Clients in good health should continue screening as long
as there is at least 10 years continued life expectancy.

Clinical breast exam: Every 3 years for clients 20 to
39 years. Annually for clients older than 40 years.

Colonoscopy: At age 50 and then every 10 years

Fecal testing: Guaiac‑based fecal occult blood test or fecal
immunochemical test annually; or stool DNA test every
3 years.

Prostate screening: Prostate‑specific antigen testing
annually for males 70 years and older. Clients younger
than 70 years should make an individual decision with the
provider when to initiate screening.

Screening for gene mutations: For clients who have a
strong family history of breast or colon cancer

Pap test: Clients age 21 to 29, every 3 years. Clients age 30
to 65, every 5 years with an HPV DNA test, or every 3 years
with Pap test alone.

Low‑dose helical CT: For healthy adults who are current
or former smokers aged 55 to 74 years with a 30‑year pack
history, either currently smoking or abstained within the
last 15 years.

ASSESSMENT

rIsK factors
Age: Highest incidence of cancer occurs in older adults.

● Female older adults most commonly develop colorectal,
breast, lung, pancreatic, and ovarian cancers.

● Male older adults most commonly develop lung,
colorectal, prostate, pancreatic, and gastric cancers.

Immune function: Cancer incidence increases among
clients who are immunosuppressed.

Chronic irritation and tissue trauma: Incidence of skin
cancer is higher in people who have burn scars or other
types of severe skin injury.

Race
● Non‑Hispanic white American females are more likely

to develop breast cancer than any other group.
● Non‑Hispanic white American males are at an increased

risk for testicular cancer than any other group.
● African American males are at an increased risk for

prostate cancer than any other group.

● African American clients have increased risk of
colorectal and pancreatic cancers.

● Hispanic American and African American clients have a
higher occurrence rate of liver cancer.

● Native American and African American clients have a
higher occurrence rate of renal pelvis cancer.

Genetic predisposition

Exposure to chemicals, tobacco, and alcohol

Exposure to some viruses and bacteria
● Liver cancer can develop after many years of infection

with hepatitis B or hepatitis C.
● Infection with human T‑cell leukemia virus increases

the risk of lymphoma and leukemia.
● Infection with Epstein‑Barr virus has been linked to an

increased risk of lymphoma.
● HPV infection is the main cause of cervical cancer.
● HIV increases the risk of lymphoma and

Kaposi’s sarcoma.
● Helicobacter pylori can increase the risk of stomach

cancer and lymphoma of the stomach lining.

Diet: A diet high in fat, red meat, processed meat,
preservatives, and additives, and low in fiber

Sun, ultraviolet light, or radiation exposure:
Ionizing (radon, x‑ray) and UV (sun, tanning beds)

Sexual lifestyles: Multiple sexual partners or STIs

Poverty, obesity, and chronic GERD

Chronic disease

Air pollution

eXPected fIndIngs
● Benign tumors are often slower growing, have cells that

closely resemble the surrounding area, and primarily
have localized effects unless they compress blood
vessels or nerves.

● Malignant tumors have cells that are different from
the cells around them, and can grow very rapidly
if they are more abnormal. These cells continually
proliferate toward the outer edges of the tumor, so that
they can take over other tissue and access vasculature
and lymphatics.

● The findings associated with the presence of a tumor
are dependent on the tissue in which they are located;
clients will report pain and possible physiological
changes if organ or tissue function has been disrupted.

Laboratory tests

Laboratory testing can help identify cancerous tumors.
Tests include tumor markers and tests used for screening,
such as PSA testing.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 89 generaL PrIncIPLes of cancer 593

Diagnostic procedures

Diagnostic procedures help determine the size and
location of tumors, and can include imaging tests used for
screening in addition to biopsy and other types of imaging
(MRI, CT scan, fluoroscopy, PET scan, nuclear imaging).

Staging of cancer

The tumor‑node‑metastasis (TNM) system is used to
stage cancer.

TUMOR (T)
● TX: Unable to evaluate the primary tumor
● TØ: No evidence of primary tumor
● Tis: Tumor in situ
● T1, T2, T3, and T4: Size and extent of tumor

NODE (N)
● NX: Unable to evaluate regional lymph nodes
● NØ: No evidence of regional node involvement
● N1, N2, and N3: Number of nodes that are involved

and/or extent of spread

METASTASIS (M)
● MX: Unable to evaluate distant metastasis
● MØ: No evidence of distant metastasis
● M1: Presence of distant metastasis

Grading

Grading is needed because some cancer cells are more
malignant than others. Well‑differentiated means the
cells look much like normal cells and tend to grow slowly.
Undifferentiated, or poorly differentiated, means the cells do
not look like normal cells and tend to grow quickly and spread.

● GX: Grade cannot be determined.
● G1: Tumor cells are well differentiated.
● G2: Tumor cells are moderately differentiated.
● G3: Tumor cells are poorly differentiated but the tissue

of origin can be established.
● Tumor cells are poorly differentiated, and determination

of the tissue of origin is difficult.

Prognosis
● Early diagnosis of cancer usually results in a better

prognosis. Many cancers spread or metastasize before
any manifestations are noted.

● Minority populations tend to have a worse prognosis
for cancer related to several factors (low socioeconomic
status, lack of access to health care, or reluctance to
seek treatment).

● For the client who has successful cancer treatment,
the nurse should help create a survivorship plan. The
client will need to continue prevention and screening
for new cancer or recurrence of the original cancer, as
well as watch for manifestations of metastasis. The
client might require ongoing therapy for the effects of
cancer and cancer treatment, such as pain management
or fertility treatments. The nurse should assist with
management and help the client coordinate care among
various providers.

COMPLICATIONS

Malnutrition

Clients who have cancer are at increased risk for weight
loss and anorexia.

● The presence of carcinoma in the body increases the
amount of energy required for metabolic function.

● Cancer can impair the body’s ability to ingest, digest,
and absorb nutrients.

● Adverse effects of cancer treatment can affect the desire
for food or the ability to eat. Findings include nausea,
vomiting, changes in taste, anorexia, pain, diarrhea,
early satiety, dry mouth, thickened saliva, and irritation
to the gastrointestinal tract.

NURSING ACTIONS
● Administer antiemetics and antacids as prescribed.
● Monitor relevant laboratory data (albumin, ferritin,

and transferrin).
● Encourage frequent oral hygiene.
● Incorporate client preferences into meal planning

when possible.
● Avoid early satiety by limiting liquids during meals.
● Teach the client to collaborate with dietary services.

CLIENT EDUCATION
● Understand how to manage the expected effects

of treatment.
● Consume adequate protein, carbohydrates, and calories.

Constipation/gastric stasis/intestinal obstruction

NURSING ACTIONS
● Can be related to cancer or cancer treatment.
● Opioids can cause delayed emptying, slowed

bowel motility.
● Administer stool softener or laxative as needed.
● Encourage fluids, fiber, and activity as tolerated.

Paraneoplastic syndromes
● Paraneoplastic syndromes result when T cells in

the body attack normal cells rather than cancerous
ones. They result in changes in neurologic function
(movement, sensation, mental function).

● Management includes minimizing the immune system
response by administration of steroids, immune factors,
plasmapheresis, or irradiation.

NURSING ACTIONS
● Recognize manifestations of paraneoplastic syndrome.
● Administer medications as prescribed.
● Provide a safe environment until client returns to

baseline mental status.
● Use aids for vision or hearing deficits, as indicated.

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594 CHAPTER 89 generaL PrIncIPLes of cancer CONTENT MASTERY SERIES

oncoLogIc emergencIes

Syndrome of inappropriate
antidiuretic hormone (SIADH)

SIADH occurs when excessive levels of antidiuretic
hormones are produced. Because antidiuretic hormones
help the kidneys and body to conserve the correct amount
of water, SIADH causes the body to retain water. This
results in a dilution of electrolytes (such as sodium) in the
blood. It is most commonly associated with lung and brain
cancers. Key findings include nausea and vomiting (early);
lethargy, hostility, seizures, and coma.

NURSING ACTIONS
● Monitor for hyponatremia and low blood osmolality.
● Administer furosemide, 0.9% sodium chloride IV, and

hypertonic sodium chloride solution as prescribed for
severe hyponatremia.

● Monitor vital signs and blood sodium level because
furosemide promotes sodium excretion and hypertonic
sodium chloride can cause fluid overload.

Hypercalcemia

A common complication of breast, lung, head, and neck
cancers; leukemias and lymphomas; multiple myelomas;
and bony metastases of any cancer

MANIFESTATIONS: Anorexia, nausea, vomiting, shortened
QT interval, kidney stones, bone pain, and changes in
mental status

NURSING ACTIONS: Administer 0.9% sodium chloride IV,
furosemide, pamidronate, and phosphates as prescribed.

Superior vena cava syndrome

Results from obstruction (metastases from breast or lung
cancers) of venous return and engorgement of the vessels
from the head and upper body

MANIFESTATIONS: Periorbital and facial edema,
erythema of the upper body, dyspnea, and epistaxis

NURSING ACTIONS
● Position the client in a high‑Fowler’s position initially

to facilitate lung expansion.
● Use high‑dose radiation therapy for emergency

temporary relief.

Hematologic disorders

Hematologic problems can be caused by the cancer itself
or chemotherapy.

Anemia: When cancer invades the bone marrow, it
decreases the number of red blood cells, platelets
(thrombocytopenia) and white blood cells (neutropenia).

Disseminated intravascular coagulation: Secondary to
leukemia or adenocarcinomas

NURSING ACTIONS
● Observe for bleeding, and apply pressure as needed.
● Be prepared to administer blood clotting factors that

have been lost through bleeding and need to be replaced
with plasma transfusions. Heparin also can be used to
slow the cascade of events that makes the body overuse
its blood clotting factors.

Sepsis
● Pathogens in the body can lead to septicemia and septic

shock, which are life‑threatening.
● Clients who are neutropenic are at an increased risk.

NURSING ACTIONS: Institute resuscitation measures,
including obtaining blood cultures, measuring blood
lactate, and administering antibiotics and crystalloid
fluids. Vasopressors can be required if fluid administration
is insufficient.

Spinal cord compression

Occurs when vertebrae degrade secondary to cancer, or
tumors invade the spinal column. Without immediate
intervention, permanent neurologic damage can occur.

MANIFESTATIONS: Changes in sensation, muscle strength,
reduced deep tendon reflexes, worsening back pain, and
bowel or bladder retention

NURSING ACTIONS
● Plan to administer high‑dose IV corticosteroids to

reduce inflammation around the spinal cord.
● Prepare the client for possible radiation therapy or

surgery to relieve cord compression.

CLIENT EDUCATION: An MRI usually confirms diagnosis.

Tumor lysis syndrome (TLS)

TLS occurs when tumors are rapidly destroyed, releasing
intracellular content into the bloodstream faster than
the body can process them. This rapid release causes
hyperkalemia, hyperphosphatemia, and hyperuricemia.
Without correction, TLS leads to kidney injury and
changes in cardiac function that can lead to death. Older
age increases risk, as well as certain chemotherapy agents
and types of cancer.

MANIFESTATIONS: Gastrointestinal distress, flank pain
muscle cramps and weakness, seizures, and mental
status changes

NURSING ACTIONS
● Administer IV fluids and encourage fluid intake of 3 L

daily, including consumption of alkaline fluids to lower
uric acid levels.

● Administer medications (diuretics, allopurinol, sodium
polystyrene) to reduce potassium, uric acid, and
phosphorus levels.

CLIENT EDUCATION: Hemodialysis and intensive care
might be required.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 89 generaL PrIncIPLes of cancer 595

Active Learning Scenario

a nurse is preparing an in‑service about identifying risk
factors for cancer to a group of adults at a community
health fair. What information should the nurse
include in the in‑service? use the atI active Learning
template: system disorder to complete this item.

RISK FACTORS
● Identify two types of cancer with increased
incidence in female older adults.

● Identify two types of cancer with increased
incidence in male older adults.

● Identify one type of cancer with a risk
factor related to racial background.

● describe three diet‑related risk factors.
● describe at least three lifestyle‑related risk factors.

PATHOPHYSIOLOGY RELATED TO CLIENT
PROBLEM: describe at least three viruses/bacteria
and the type of cancer they can cause.

Application Exercises

1. a nurse is caring for a client who has lung cancer
and is exhibiting manifestations of syndrome
of inappropriate antidiuretic hormone (sIadH).
Which of the following findings should the nurse
report to the provider? (select all that apply.)

a. Behavioral changes

B. client report of headache

c. urine output 40 mL/hr

d. client report of nausea

e. Increased urine specific gravity

2. a nurse is teaching a client about screening prevention
for cancer. Which of the following statements by the
client indicates an understanding of the teaching?

a. “I will need to have a mammogram
every 2 years beginning at age 45.”

B. ”I should have a colonoscopy every
15 years beginning at age 60.”

c. “I will need to have an annual breast
examination every year after 40.”

d. ”I should have a fecal occult test
done every 3 years.”

3. a nurse is planning care for a client who has
malnutrition due to cancer. Which of the
following interventions should the nurse include
in the plan of care? (select all that apply.)

a. advise the client to keep a food diary.

B. encourage the client to brush teeth
before and after meals.

c. assess the laboratory report of ferritin.

d. eat nutrient‑dense foods last at meal time.

e. encourage the client to limit
drinking fluids during meals.

4. a nurse is reviewing the medical record of a client who
had surgery to stage ovarian cancer. the nurse reviews
the following diagnostic notation on the pathology
report: t2‑n3‑mX. Which of the following findings
should the nurse identify as a supporting diagnosis?

a. the tumor is moderate in size.

B. no lymph nodes contain cancer cells.

c. the tumor is receptive to current
medication therapy.

d. the cancer has metastasized to
other areas in the body.

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596 CHAPTER 89 generaL PrIncIPLes of cancer CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: Behavioral changes indicate cerebral
edema due to sIadH. this finding should
be reported to the provider.

B. CORRECT: a client report of headache indicates
cerebral edema due to sIadH. this finding
should be reported to the provider.

c. urine output of 40 mL/hr is a finding consistent
with suspected sIadH and does not need
to be reported to the provider.

d. CORRECT: a client report of nausea can
indicate cerebral edema due to sIadH and
should be reported to the provider.

e. an increased urine specific gravity is a finding consistent with
sIadH and does not need to be reported to the provider.

NCLEX® Connection: Physiological Adaptation,
Illness Management

2. a. the client should begin annual mammograms
beginning at age 40.

B. the client should begin to have a colonoscopy at
age 50 and then every 10 years thereafter.

c. CORRECT: Instruct the client that after the age of 40,
they should have annual clinic breast exams.

d. the client should have a fecal occult test done every
year. the client can have the stool dna test every
3 years in place of fecal occult blood testing.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

3. a. CORRECT: the use of a food diary assists in
monitoring changes in eating habits that occur
in malnutrition due to cancer.

B. CORRECT: oral hygiene before and after meals promotes
increased salivation and improves taste perception.

c. CORRECT: ferritin is an indicator of the protein intake
of a client who has malnutrition due to cancer.

d. Instruct the client to eat nutrient‑dense foods first to
increase adequate nutritional intake to treat malnutrition.

e. CORRECT: encourage the client to limit drinking fluids
with meals because fluids can cause early satiety and
decrease adequate intake of food, causing malnutrition,
when the client has cancer. some fluids are needed
to treat dry mouth and thickened saliva.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

4. a. CORRECT: a t2 designation describes the size and extent
of the ovarian tumor using the tumor‑node‑metastasis
(tnm) staging system. a t1 tumor is smallest
in size, and a t4 tumor is largest.

B. a n3 designation indicates that three adjacent
lymph nodes show evidence of spread of
cancer using the tnm staging system.

c. the tnm diagnostic notation of the staging system
is not used to indicate the response of a tumor to a
medication therapy regimen used for treatment.

d. the mX designation indicates there is no
evidence of distant metastasis to other areas of
the body using the tnm staging system.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

RISK FACTORS
● older adult women: colorectal, breast, lung,
pancreatic, and ovarian cancers

● older adult men: Lung, colorectal, prostate,
pancreatic and gastric cancers

● risk related to racial background: testicular, breast,
colorectal, pancreatic, liver, and renal pelvis cancers

● diet‑related: diet high in fat and red meat, low in fiber
● Lifestyle‑related

◯ multiple sexual partners or stIs
◯ sun, ultraviolet light, and radiation exposure
◯ use of tobacco and alcohol

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM
● Hepatitis B or c: Liver cancer
● Human t‑cell leukemia virus: Lymphoma and leukemia
● epstein‑Barr virus: Lymphoma
● Human papilloma virus: cervical cancer
● HIV: Lymphoma and Kaposi’s sarcoma
● Helicobacter pylori: stomach cancer and
lymphoma of the stomach lining

NCLEX® Connection: Health Promotion and Maintenance, Health
Promotion/Disease Prevention

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 90 cancer screenIng and dIagnostIc Procedures 597

UNIT 12 IMMUNE SYSTEM AND CONNECTIVE
TISSUE DISORDERS
SECTION: CANCER‑RELATED DISORDERS

CHAPTER 90 Cancer Screening
and Diagnostic
Procedures

screening and diagnostic procedures provide
objective and subjective client data. screening
and diagnosis for cancer can involve the use
of hands‑on assessment techniques, invasive
procedures, radiography and imaging studies,
and laboratory testing. the type and location of
the suspected cancer dictate which methods are
used. Identification of tumor cells is required for
definitive diagnosis and the development of a
targeted treatment plan.

INDICATIONS

cLIent PresentatIon
Cancer

● Altered body function (fatigue, weakness, anorexia)
● Change in body structure (weight loss, masses)
● Change in body symmetry or onset of recent findings

(pain, nausea, vomiting)

Metastasis
● Secondary sites of discomfort
● Swelling and/or tenderness of lymph nodes or areas

of the body
● Presence of masses
● Altered function of another body system
● Bone pain

CONSIDERATIONS
● Complete a health history and physical assessment

including client report of findings and family history of
cancer or genetic disorder.

● Inspect for changes in color, symmetry, movement, or
body function.

● Auscultate for adventitious sounds that indicate altered
body system function.

◯ Heart, lung, and bowel sounds
◯ Main arteries (carotid, femoral, renal, iliac)
◯ Masses or areas of discomfort

● Palpate to detect masses or tissue abnormalities.
◯ Use light, medium, and deep pressure as appropriate.
◯ Some palpation assessments should be performed

by the provider only (digital rectal exam for
colorectal cancer).

● Percuss for changes in expected sound over organs.
◯ Dullness in the lungs or bowel can indicate areas of
consolidation or tumor.

◯ Increased liver size (noted by measurement of borders
[dullness]) can indicate inflammation or tumor.

● Report unexpected findings to the provider.
● Provide explanation when there is need for further

testing or evaluation of unexpected findings.

CLIENT EDUCATION
● Perform self‑examination practices at home.
● Understand the general findings that could

indicate cancer. If found, notify the provider for
further screening.

◯ Change in bowel or bladder habits, change in shape or
texture of a body or skin region.

◯ Difficulty eating, chewing, swallowing, or
decreased appetite.

◯ Non‑healing sores or wounds, or a cough or
hoarseness that does not go away.

◯ Unexplained pain, night sweats, fatigue, weight loss,
or weight gain.

◯ Unusual bleeding.

BIoPsY
Provides definitive diagnosis indicating the site of origin
(specific cell type) and cell characteristics (specific
receptors on cell surface).
Can be obtained during other procedures (endoscopy,
laparoscopy, thoracotomy).

Shave biopsy (basal or squamous cell skin cancer):
Sampling of outer skin layers (raised lesions) using a
scalpel or razor blade.

Needle biopsy (fine or core): Aspiration of tumor close
to the skin surface for fluid and tissue sampling. Bone
marrow aspiration is a form of needle biopsy used to
diagnose leukemia and lymphoma.

Incisional or excisional (open) biopsy: Cutting through
skin to remove part (incisional) or all (excisional) of a
tumor. Punch biopsy is a form of excisional biopsy used
to diagnose skin cancer. A circular instrument punches a
2 to 6 mm sample of subcutaneous fat.

Sentinel lymph node biopsy: Biopsy of lymph node
closest to the cancer. A dye or colloid is used to create a
map of affected nodes.

● If the lymph node is negative, the lymph nodes in the
surrounding area are assumed to be cancer‑free.

● If the lymph node is positive, surgical excision of lymph
nodes in the area is performed (lymph node dissection).

NURSING ACTIONS
● Obtain a signed informed consent form from the client.
● Assemble supplies and facilitate aseptic technique.
● Prevent bleeding. Withhold anticoagulants as prescribed.

Monitor findings of coagulation studies.
● Monitor for bleeding (visible staining of dressing,

hypotension, tachycardia).
● Provide a safe environment until effects of sedation are

minimal. (Maintain bed rest. Withhold oral intake.)
● Ensure adequate oxygenation during the recovery period.
● Position the client in a recovery position appropriate to

the procedure (lay on right side following liver biopsy).

CHAPTER 90

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598 CHAPTER 90 cancer screenIng and dIagnostIc Procedures CONTENT MASTERY SERIES

LaBoratorY tests
Performed to assess for possible cancer or effects on the
body (electrolyte imbalance, altered function)

Liver function tests: Elevation can indicate primary liver
cancer or metastasis of another cancer (colorectal cancer).

Tumor marker assays: Detect the presence of normal body
proteins at higher than expected levels (carcinoembryonic
antigen, prostate‑specific antigen [PSA], alpha fetoprotein).

● Samples of urine, stool, tissue, blood, or other body
fluids are tested for an excess of specific proteins or
DNA patterns.

● Used to detect cancer, measure the severity of cancer, or
monitor for a positive response to the cancer treatment
regimen (expected finding is a decrease in the tumor
marker or return to expected reference range).

Genetic tests: Identify the presence of certain genes in a
sample of blood or saliva.

● Genetic overexpression or the existence of extra
genes can increase the risk of cancer or cause rapid
tumor growth.

● Genetic mutations can be inherited. Positive results
indicate the client is at high risk for development of
certain types of cancer (presence of BRCA1 and BRCA2
genes associated with breast cancer).

● Informed consent might be required prior to some types
of testing.

● The client might want to talk with a genetic counselor
to clarify misconceptions regarding positive results and
cancer risk.

Other testing: Can be done in addition to biopsy to
identify tumor cell type (sputum analysis, cytology of
fluid sampling).

NURSING ACTIONS: Explain the purpose of testing, as
appropriate.

CLIENT EDUCATION: Laboratory testing can continue
throughout treatment (to monitor progress) and following
treatment (to screen for return of cancer).

ImagIng studIes
Common imaging techniques are used as secondary tools
to assist in the treatment of cancer. Imaging is completed
around the time of diagnosis to measure the severity
of cancer.

CT scan, MRI, PET scan, ultrasound, and x‑ray
● Provide visualization of tumors and their borders.
● Detect metastasis to organs and other body structures.
● Clients can be given dye (IV pyelogram) or contrast

(barium enema) to enhance visualization.
● Monitor the client during remission.

Digital imaging: Usually more accurate. Digital storage of
images and results allows for information to be easily
shared among members of the interprofessional
treatment team.

X‑rays: Provide visualization of body structures
(chest x‑ray, mammogram)

● With angiography, the client is injected with dye and
then x‑rays are taken to map vascular structures,
such as arterial, venous, or lymphatic mapping.

● NURSING ACTIONS
◯ Monitor for allergic reaction to contrast dye
(dyspnea, tachycardia, restlessness).

Computerized axial tomography (CT) scanning: Combines
x‑ray images taken from different angles and uses
computer processing to create cross‑sectional images. Can
be performed with or without contrast. Contrast can be
administered orally or intravenously.

MRI: Uses magnetic field and radio waves rather than
radiation to generate pictures of tissue and organs.
Contrast can be added to enhance the images. Clients who
have any type of metal inside the body (clips, pacemaker,
metal implants) should not have a MRI.

Ultrasound: High‑energy sound waves bounce off internal
tissues and organs to produce an echo pattern that can be
seen as an ultrasound image. A biopsy can be performed
during the ultrasound.

Nuclear imaging: Evaluates the function of organs and
structures by detecting the presence of radiation in the
body after the client is given a radioactive tracer (IV or
oral). Used for detection and staging of cancer. Cancerous
tissues can absorb more or less tracer than expected.
These tissues are distinguishable by nuclear imaging.

Positron emission tomography (PET): Measures positrons
released with tissue uptake of radioactive sugar (more
rapid in cancer). Mammography (PEM) can be performed
this way. CT can be used with PET scans.

Electrocardiogram, echocardiogram, or multigated
acquisition scan: Used to evaluate heart function prior
to cancer treatment or to identify damage following
chemotherapy or radiation to the upper body.

Other types of imaging: Bone scan, gallium scan, and
thyroid scan

Endoscopy

Permits visualization inside the body using flexible
scopes and cameras. Tumors can be visualized in the
joints (arthroscopy), respiratory system (laryngoscopy,
bronchoscopy), body cavity (mediastinoscopy,
thoracoscopy), or gastrointestinal system (enteroscopy,
sigmoidoscopy). Organs can be visualized as well
(hysteroscopy, cystoscopy).

NURSING ACTIONS
● Obtain signed informed consent form.
● Prepare the client as indicated for the type of procedure

to be performed.
● Provide a safe environment until effects of sedation are

minimal (maintain bed rest, withhold oral intake).
● Ensure adequate oxygenation during the recovery period.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 90 cancer screenIng and dIagnostIc Procedures 599

INTERPRETATION OF FINDINGS
● Findings that indicate or increase suspicion of cancer

must be further evaluated.
● A variety of imaging and laboratory tests can be used to

detect the following.
◯ Degree of tumor involvement
◯ Type of tumor
◯ Areas of metastasis
◯ Complications of cancer

nursIng actIons
● Educate the client about routine cancer screenings as

part of health promotion and disease prevention.
● Provide care before, during, and after the procedure as

indicated by procedure type.
● Provide teaching and resources for client about self‑care

in the home environment.

Active Learning Scenario

a nurse manager is discussing collection of findings
as part of screening for cancer with a group of nurses.
What information should the nurse manager include in
the discussion? use the atI active Learning template:
diagnostic Procedure to complete this item.

INTERPRETATION OF FINDINGS
● describe at least three findings indicating
the presence of metastasis.

● describe four assessment techniques and possible findings.

CLIENT EDUCATION: describe two self‑assessment
techniques that can identify data.

Application Exercises

1. a nurse in a clinic is talking with a client scheduled
for a sentinel lymph node biopsy. Which of the
following information should the nurse include?

a. dye is used during the procedure.

B. the lymph nodes closest to the tumor
are removed during the biopsy.

c. a small amount of chemotherapy is used
to test the lymph node response.

d. a 2 mm plug of tissue is removed
during the biopsy.

2. a nurse is teaching a client who is scheduled for
nuclear imaging for suspected cancer. Which of
the following statements should the nurse give?

a. “the presence of a liver enzyme will be identified.”

B. “You will be given an injection of
a radioactive substance.”

c. “an endoscope will be inserted
through your mouth.”

d. “the tumor will be aspirated.”

3. a nurse is collecting information from a client
in a provider’s office. Which of the following
findings should the nurse identify as an indication
of possible cancer? (select all that apply.)

a. temperature 102° f (38.9° c) for more than 48 hr

B. sore that does not heal

c. difficulty swallowing

d. unusual discharge

e. Weight gain 4 lb (1.8 kg) in 2 weeks

4. a nurse is teaching a client who is scheduled
for a shave biopsy for suspected cancer.
Which of the following client statements
indicates understanding of the procedure?

a. “a test of my bone marrow will be performed.”

B. “a lymph node will be removed.”

c. “a needle will be inserted into the mass.”

d. “a small skin sample will be obtained.”

5. a nurse is planning care for a client who is
scheduled for genetic testing for suspected
cancer. Which of the following interventions
should the nurse include in the plan of care?

a. determine the need for informed consent.

B. send testing results to the
client’s insurance agency.

c. Verify the prescription for a tumor marker assay.

d. ensure the client is placed in a
recovery position after testing.

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600 CHAPTER 90 cancer screenIng and dIagnostIc Procedures CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: the client will receive a dye or colloid
as a tracer to help identify lymph nodes during
a sentinel lymph node biopsy.

B. the lymph nodes close to the tumor might be
removed in a later procedure if the sentinel
lymph node is positive for cancer.

c. chemotherapy is not administered during
a sentinel lymph node biopsy.

d. a punch biopsy involves removing a
2 to 6 mm plug of tissue.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

2. a. Liver function tests involve the identification of altered
liver enzymes, which can be present in a client who has
cancer. they are not nuclear imaging tests.

B. CORRECT: nuclear imaging involves the administration of an
oral or IV radioactive tracer to identify cancerous tissue.

c. endoscopy permits visualization inside the
body. It is not a form of nuclear imaging.

d. a needle biopsy is performed to aspirate fluid and tissue
samples for cancer cells. It is not a form of nuclear imaging.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

3. a. Presence of a fever for an extended period is not a
finding of possible cancer. unexplained night sweats
can indicate a need to have a cancer screening.

B. CORRECT: a sore that does not heal is
a finding of possible cancer.

c. CORRECT: difficulty swallowing is a
finding of possible cancer.

d. CORRECT: the presence of unusual discharge
is a finding of possible cancer.

e. CORRECT: Weight gain or loss can indicate possible cancer.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

4. a. Bone marrow aspiration is a type of needle biopsy.
B. sentinel node biopsy involves excision of a lymph node.
c. needle biopsy involves aspiration of a tumor

for fluid and tissue sampling.
d. CORRECT: a shave biopsy is a sampling of the outer

skin layer using a scalpel or razor blade.

NCLEX® Connection: Physiological Adaptation,
Illness Management

5. a. CORRECT: a signed informed consent form should
be obtained prior to the procedure.

B. genetic testing information is confidential. do not
send the information unless the client requests it.

c. a tumor marker assay is a laboratory test to identify the
presence of specific body proteins in blood, body secretions,
and tissue. It is not a component of genetic testing.

d. genetic testing involves collection of blood or saliva.
recovery positioning is not required following testing.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

Active Learning Scenario Key

Using the ATI Active Learning Template: Diagnostic Procedure

INTERPRETATION OF FINDINGS

metastasis
● discomfort at secondary sites
● swelling and/or tenderness of lymph nodes or areas of the body
● Presence of masses
● altered function of another body system
● Bone pain

assessment techniques
● Inspection for changes in color, symmetry,
movement, or body function

● auscultation for adventitious sounds, which can
indicate altered body system function

● Palpation to detect masses or tissue abnormalities
● Percussion to detect changes in expected sound over
organs, which can indicate inflammation or tumor

CLIENT EDUCATION: testicular and breast self‑examinations

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 91 cancer treatment oPtIons 601

UNIT 13 IMMUNE SYSTEM AND CONNECTIVE
TISSUE DISORDERS
SECTION: CANCER‑RELATED DISORDERS

CHAPTER 91 Cancer Treatment
Options

cancer treatment is based on the cell of
origin of the cancer. When metastasis occurs,
treatment is still based on the primary tumor
origin even though the malignancy is located
elsewhere in the body. many cancers are curable
when diagnosed early.

cancer treatment options focus on removing
or destroying cancer cells and preventing
the continued abnormal cell growth and
differentiation. treatment can be curative or
palliative. the treatment plan is guided by client
factors (age, childbearing desire, pregnancy,
current state of health, expected lifespan) and
can involve several treatment methods.

adjuvant treatment is what is given in addition
to the primary treatment standard, and can
include hormone, radiation, and targeted
therapies; immunotherapy; and chemotherapy.

nursing care for clients who have cancer should
include collaboration with supportive therapies
and services, counseling, and transfer of care to
another provider at discharge.

PROCEDURES
Cancer treatment includes manipulation or removal of
the tumor.

Tumor reduction can be done through topical procedures
(cryosurgery, laser therapy, ablation) or by destruction
of the main arteries that provide blood flow to the tumor
(artery embolization).

Tumor excision can be open or endoscopic (curettage and
electrodissection for skin cancer).

● The tumor and tissue immediately surrounding it
(tumor margin) are removed. The goal is that all of the
outermost tissue that was removed does not contain
cancer cells (a negative margin).

● Surgery can be done for biopsy (diagnosis and staging),
or relief (palliation) based on findings.

Lymph node dissection or sentinel lymph node biopsy
is done to determine if the cancer has spread or there is
added risk of spread.

Prophylactic surgery involves removing precancerous
tissue, or normal tissue, for a client at high risk for
developing cancer.

Rehabilitative or reconstructive surgeries improve
appearance or functional ability for clients following
cancer treatment.

More extensive surgeries (tumors involving multiple
organs or structures, lymph node involvement, deep
lesions) increase the risk of complications and typically
require longer recovery periods. Intensive care can
be required.

NURSING ACTIONS
● Provide perioperative care as indicated by tumor

location and procedure type.
● Prevent general postoperative complications

(infection, fluid or electrolyte imbalance, hemorrhage,
thromboembolism, inadequate oxygenation, shock).

● Prevent and treat pain as prescribed using
pharmacological and nonpharmacological measures.

● Educate the client on care for drains, wounds, and
implanted devices.

● Provide psychological support to the client to facilitate
coping with diagnosis and body image changes
following surgery.

● Assist the client to develop strategies to compensate for
loss of function of organs, tissue, or limbs.

CLIENT EDUCATION: Monitor for complications after
discharge.

INTERPROFESSIONAL COLLABORATION
● Support groups for clients who have cancer, as well as

their family and friends.
● Therapy services as indicated for the client’s

condition, such as physical, speech, respiratory, and
occupational therapies.

CHAPTER 91

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602 CHAPTER 91 cancer treatment oPtIons CONTENT MASTERY SERIES

Chemotherapy
Chemotherapy involves administration of systemic or local
cytotoxic medications that damage a cell’s DNA or destroy
rapidly dividing cells.

● Chemotherapeutic agents are often selected in relation
to their effect on various stages of cell division.
Subsequently, combinations of anticancer medications
are used to enhance destruction of cancer cells.

● Most chemotherapy agents are cytotoxic. The adverse
effects of these agents are related to the unintentional
harm done to normal rapidly proliferating cells, such
as those found in the mucous membranes of the
gastrointestinal (GI) tract, hair follicles, and bone marrow.

● For some cancer medications, agents that protect healthy
cells (cytoprotectants or chemoprotectants) are given
before or with chemotherapy to decrease the effect on
normal tissues. Examples include amifostine and mesna.

● Chemotherapy can be administered in a health care
setting, provider’s office, clinic, or home.

● Most chemotherapy medications, including
oral, are absorbed through the skin and mucous
membranes. Anyone preparing, giving, or disposing
of these medications must wear proper personal
protective equipment.

● Return unused chemotherapeutic agents to the dispensary
or dispose of them per agency policy. Do not dispose of
medications in the regular trash or sewage system.

route
● Depending on the agent, it can be given by the topical

(for skin lesions); oral; parenteral; IV; intra‑arterial;
intraventricular (into the ventricles of the brain);
intracavitary, which includes intraperitoneal (into the
abdominal cavity); intravesicular (into the bladder);
intrapleural (into the pleural space); or intrathecal (into
the spinal cavity) route. Specialized training/certification
is necessary for the administration of some agents.

● Oral anticancer medications are just as toxic to the
client taking the medication and the nurse handling the
medication as are standard chemotherapy medications.

● Oral medications should not be crushed, split, broken,
or chewed.

catHeters
● A central catheter is usually placed for IV chemotherapy

administration or blood testing.
● Some medications can cause serious damage to the skin

and muscle tissue if they leak outside a vein (vesicants).
Getting these through a central venous catheter rather
than a short‑term peripheral IV reduces the risk that the
medication will leak and damage tissues. Many different
types of central venous catheters can be used. Two of the
more commonly used included the peripherally inserted
central catheter and implanted port. (Refer to CHAPTER 27:

CARDIOVASCULAR DIAGNOSTIC AND THERAPEUTIC PROCEDURES.)
● A port is implanted when therapy is intended to be

given on a long‑term basis. The port is comprised of a
small reservoir that is covered by a thick septum.

categorIes of medIcatIons
● There are several categories of chemotherapy

medications based on how they work and the chemical
structure. Medications are selected based on the
sensitivity of cancer cells to the medications and the
stage of the cancer. Understanding the mechanism
of the medication’s action can help with predicting
possible adverse effects.

● Categories include alkylating agents, antimetabolites,
antimitotic agents, antitumor antibiotics, topoisomerase
inhibitors, and other miscellaneous medications.

nursIng actIons
● Instruct the client/family in the proper use of vascular

access devices.
● Instruct family to dispense oral medications directly

into a cup and not to touch pills or liquids with
the hands.

● Closely monitor IV infusions and provide immediate
treatment for extravasation. Care includes identifying
the antidote (neutralizing solution) for the specific
medication the client is receiving.

IntracaVItarY cHemotHeraPY
Involves the administration of chemotherapy directly into
a body cavity (abdomen, pleural space, or bladder)

● A small catheter can be used.
● Local irritation can be increased, but systemic adverse

effects are usually prevented.
● In some cases, the medication can be removed following

a dwell time.

CLIENT EDUCATION
● Some discomfort can be present during infusion.
● Monitor for evidence of infection at the site

of administration.

INDICATIONS
● Chemotherapy can be used to cure a disease, help

control its progression, or as palliative treatment for
individuals who have a terminal disease.

● Chemotherapy is most commonly used for treatment of
cancer. It can also be used for other disorders, such as
autoimmune diseases.

CONSIDERATIONS

PreProcedure
● Because administration of chemotherapeutic

medications is limited to certified individuals,
management of adverse effects is the primary focus of
health care personnel.

● Instruct the client on findings that indicate
potential complications. The client should report
findings immediately.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 91 cancer treatment oPtIons 603

COMPLICATIONS

Immunosuppression/neutropenia
● Due to bone marrow suppression by cytotoxic medications
● The most significant adverse effect of chemotherapy
● Clients who have neutropenia might not develop a high

fever or have purulent drainage, even when an infection
is present.

● The risk of serious infection increases as the absolute
neutrophil count (ANC) falls. An ANC less than
1,000/mm3 indicates a weak immune system and the
need to initiate neutropenic precautions.

NURSING ACTIONS
● Monitor temperature, white blood cell (WBC)

count, and ANC.
● Report a fever greater than 37.8° C (100° F) to the

provider immediately.
● Monitor skin and mucous membranes for infection

(breakdown, fissures, and abscess).
● Obtain prescribed cultures prior to initiating

antimicrobial therapy.

NEUTROPENIC PRECAUTIONS
● Assign the client a private room. Have the client remain

in the room unless they need to leave for a diagnostic
procedure or therapy. In this case, place a mask on the
client during transport.

● Protect the client from possible sources of infection (live
plants, stagnant water, contaminated equipment).

● Have client, staff, and visitors perform frequent hand
hygiene. Restrict visitors who are ill.

● Avoid invasive procedures that could cause a break
in tissue (rectal temperatures, injections, indwelling
urinary catheters) unless necessary.

● Keep dedicated equipment (blood pressure machine,
thermometer, stethoscope) in the client’s room.

● Administer colony‑stimulating factors (filgrastim) as
prescribed to stimulate WBC production.

● Follow agency policy regarding prohibitions of fresh
flowers and plants in the room.

CLIENT EDUCATION
● Avoid crowds while undergoing chemotherapy.
● Take temperature daily. Report elevated

temperature to the provider.
● Avoid food sources that could contain bacteria

(fresh fruits and vegetables; undercooked
meat, fish, and eggs; pepper and paprika).

● Avoid yard work, gardening, or changing a pet’s
litter box. Wear disposable gloves when working
with house plants or doing outdoor gardening.

● Discard liquid beverages that have been sitting
at room temperature for longer than 1 hr.

● Wash all dishes in hot, soapy water or a dishwasher.
Wash glasses and cups after each use.

● Wash toothbrush daily in the dishwasher
or rinse in a bleach solution.

● Do not share toiletry or personal hygiene items with others.
● Report manifestations of bacterial or viral

infections immediately to the provider.

Nausea, vomiting, anorexia
● Many medications used for chemotherapy are

emetogenic (induce vomiting) or cause anorexia and an
altered taste in the mouth.

● A combination of medications can help treat
chemotherapy‑induced nausea and vomiting (CINV).
These include:

◯ Serotonin blockers (ondansetron, palonosetron)
◯ Neurokinin receptor antagonists (aprepitant)
◯ Corticosteroids (dexamethasone, methylprednisolone)
◯ Dopamine antagonists (promethazine, prochlorperazine)
◯ Histamine blockers (omeprazole)
◯ Proton pump inhibitors (ranitidine)
◯ Prokinetic agents (metoclopramide)
◯ Benzodiazepines (lorazepam)
◯ Cannabinoids (dronabinol, nabilone)
◯ Pneurokinin‑1 receptor antagonists (netupitant)

NURSING ACTIONS
● Ensure antiemetics are given before chemotherapy and

repeated based on the response and duration of CINV.
● Administer antiemetic medications for several days after

each treatment, even when CINV appears to be controlled.
● Remove vomiting cues, such as odor and emesis basins.
● Implement nonpharmacological methods to reduce nausea

(visual imagery, relaxation, acupuncture, distraction).
● Perform calorie counts to determine intake. Provide

liquid nutritional supplements as needed. Add protein
powders to food or tube feedings.

● Administer megestrol to increase appetite if prescribed.
● Assess for findings of dehydration or

fluid and electrolyte imbalance.
● Perform mouth care prior to serving

meals to enhance appetite.

CLIENT EDUCATION
● Some antiemetics can provide prophylactic

treatment if given before meals.
● Eat several small meals a day if better tolerated.

Eating low‑fat dry foods (crackers, toast) and avoiding
drinking liquids during meals can prevent nausea.

● Select foods that are served cold and do
not require cooking. Cooking food can
emit odors that stimulate nausea.

● Encourage consumption of high‑protein, high‑calorie,
nutrient‑dense foods and avoidance of low‑ or
empty‑calorie foods. Use meal supplements as needed.

● Use plastic eating utensils, suck on hard candy,
and avoid consuming red meats to prevent or
reduce the sensation of metallic taste.

● Create a food diary to identify items
that can trigger nausea.

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604 CHAPTER 91 cancer treatment oPtIons CONTENT MASTERY SERIES

Alopecia

An adverse effect of certain chemotherapeutic medications
that is usually temporary. The amount of hair lost can
vary, and can occur anywhere on the body.

NURSING ACTIONS
● Discuss the effect of alopecia on self‑image.
● Discuss options (hats, turbans, wigs) deal with hair loss.

The American Cancer society has information on a
variety of products. Recommend clients select a head
covering prior to treatment.

● Reinforce that hair should return about 1 month after
chemotherapy is discontinued. The new hair can differ
from the original hair in color, texture, and thickness.

CLIENT EDUCATION
● Hair loss occurs 7 to 10 days after treatment begins (for

some agents).
● Avoid the use of damaging hair care measures

(electric rollers, curling irons, hair dye, permanent
waves). A soft hair brush or wide‑tooth comb for
grooming is preferred.

● Consider cutting the hair short before treatment to
decrease weight on the hair follicle.

● Consider collaborating with a hairdresser to assist with
wig selection. Wearing a wig before therapy begins can
reduce appearance changes.

● After hair loss, protect the scalp from sun exposure and
use a diaper rash ointment/cream for itching.

● Use head coverings to reduce body heat loss and protect
skin while wearing helmets, headphones, headsets, or wigs.

● The oncologist might prescribe a cold cap during
treatment to decrease hair loss.

Hypersensitivity

A client taking chemotherapy medication has an increased
risk for hypersensitivity reactions. Reactions can occur as
early as 1 hr following infusion but are also possible after
several doses.

NURSING ACTIONS
● Stop the medication immediately if manifestations of a

hypersensitivity reaction occur.
● Assist with the administration of emergency treatment,

following facility protocol for hypersensitivity reactions.

CLIENT EDUCATION
● Watch for and report indications of a hypersensitivity

reaction immediately.
● If hypersensitivity occurs, desensitization to the

medication might be required so that the client can
continue to receive the treatment most appropriate to
combat the cancer.

Oral effects

Mucositis refers to inflammation in the mucous lining of
the upper GI tract from the mouth to the stomach.

Stomatitis refers to inflammation of tissues in the oral
cavity (gums, tongue, roof and floor of mouth, inside lips
and cheeks).

NURSING ACTIONS
● Examine the client’s mouth several times a day, and

inquire about the presence of oral lesions.
● Document the location and size of lesions. For new

lesions, obtain a specimen for culture and report them to
the provider.

● Avoid using glycerin‑based mouthwashes or mouth
swabs for client care. Nonalcoholic, anesthetic
mouthwashes are recommended.

● Administer a topical anesthetic prior to meals.
● Discourage consumption of salty, acidic, or spicy foods.
● Offer oral hygiene before and after each meal. Use

lubricating or moisturizing agents to counteract dry mouth.

CLIENT EDUCATION
● Rinse the mouth with a solution of 0.9% sodium chloride,

room‑temperature tap water, or salt and soda water.
Frequency is guided by the intensity of the mucositis.

● Perform gentle flossing and brushing using a
soft‑bristled toothbrush or foam swabs to avoid
traumatizing the oral mucosa.

● Rinse the mouth before and after meals. Avoid
mouthwash that contains alcohol or other irritants.

● Take medications to control infection as prescribed
(nystatin suspension, acyclovir).

● Follow recommendations regarding the use of coating
agents, topical analgesics, topical anesthetics, or oral or
parenteral analgesics that can be prescribed.

● Choose soft, bland foods and supplements that are high
in calories (mashed potatoes, scrambled eggs, cooked
cereal, milk shakes, ice cream, frozen yogurt, bananas,
and breakfast mixes). Avoid spicy, salty, acidic, rough, or
hard food.

● Avoid drinking alcohol and the use of tobacco.
● Drink at least 2 L of water per day, as long as there is no

fluid restriction prescribed by the provider.

Anemia and thrombocytopenia

Secondary to bone marrow suppression (myelosuppression)

Anemia

NURSING ACTIONS
◯ Monitor for fatigue, pallor, dizziness, and shortness
of breath.

◯ Help the client manage anemia‑related fatigue by
scheduling activities with rest periods in between and
using energy saving measures (sitting during showers
and ADLs).

◯ Administer erythropoietic medications (darbepoetin
alfa, epoetin alfa) and antianemic medications (such
as ferrous sulfate) as prescribed.

◯ Monitor Hgb values to determine response to
medications. Be prepared to administer blood
if prescribed.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 91 cancer treatment oPtIons 605

Thrombocytopenia

NURSING ACTIONS
◯ Monitor for petechiae, ecchymosis, bleeding of the
gums, nosebleeds, and occult or frank blood in stools,
urine, or vomitus.

◯ Institute bleeding precautions.
■ Avoid IVs and injections. When needlesticks are

necessary, use the smallest gauge needle possible.
■ Apply pressure for approximately 10 min after blood
is obtained.

■ Handle client gently and avoid trauma.
◯ Administer thrombopoietic medications such as
oprelvekin to stimulate platelet production. Monitor
platelet count, and be prepared to administer platelets
if the count falls below 10,000/mm3.

CLIENT EDUCATION
● Understand how to manage active bleeding.
● Understand measures to prevent bleeding (use electric

razor and soft‑bristled toothbrush, avoid blowing nose
vigorously, ensure that dentures fit appropriately). Avoid
participation in contact sports or any activity in which
injury is likely.

● Avoid the use of NSAIDs.
● Understand how to prevent injury when ambulating

(wear closed‑toes shoes, remove tripping hazards in the
home) and apply cold if injury occurs.

Chemotherapy‑induced peripheral neuropathy

Loss of sensory or motor function of peripheral nerves
is caused by exposure to certain anticancer medications.
Higher doses of medication lead to greater neuropathy.

NURSING ACTIONS
● Monitor for loss of sensation in hands and feet,

orthostatic hypotension, loss of taste, and constipation.
● Monitor for orthostatic hypotension.
● Monitor for early manifestations including numbness,

tingling, and redness.
● Teach the client how to prevent injury, including falls.
● Inform regarding risk of erectile dysfunction and

treatment options.

CLIENT EDUCATION
● Protect the skin because loss of sensation makes the

client unaware of heat, cold, or pressure.
● Inspect the feet daily for any open areas.

Cognitive impairment

Cognitive changes occurring during and after
chemotherapy treatment, including difficulty learning,
decreased concentration, and memory loss.

NURSING ACTIONS: Support the client who reports
cognitive changes by providing cognitive training resources.

CLIENT EDUCATION
● Avoid behaviors that could contribute to cognitive

dysfunction, including excessive intake of alcohol,
recreational drug use, and activities that are high‑risk
for head injury.

● Engage in strategies to improve memory and
concentration, such as repeating challenging tasks.

Radiation therapy
Radiation therapy involves high‑energy radiation to target
tissues and destroy cells. Some cells are not destroyed
but might become weakened and unable to divide, while
others might be able to recover from the radiation damage.

● Radiation therapy is usually given as a series of divided
small doses on a daily basis for a set period of time. The
dose of radiation the client receives is determined by
considering the duration of exposure, the intensity of
the radiation, and the distance the radiation source is
from the target cells.

● Radiation therapy can be given preoperatively to
decrease the size of a tumor.

● Adverse effects on tissues within the radiation path
include skin changes, hair loss, and debilitating fatigue.
Radiation effects can also cause long‑term changes for
the client.

● Radiation therapy can be administered internally
(brachytherapy) with an implant or externally
(teletherapy) with a radiation beam. The type used
depends on the health of the client and shape, size, and
location of the tumor.

● External beam radiation therapy does not cause the
client to become radioactive.

● Internal radiation causes body fluids to be contaminated
with radiation, and body wastes should be disposed of
appropriately, as directed by the facility.

● Cytoprotectants, such as amifostine, are sometimes
used to protect against harmful effects of radiation
therapy, such as dryness of the mouth caused by
radiation treatment for head and neck cancer.

● Radiation exposure to health care personnel and
visitors is reduced by limiting indirect contact time,
maintaining indicated distances from sources of
radiation, and preventing direct contact with the source.

Internal radiation therapy

Brachytherapy describes internal radiation that is placed
close to the target tissue. This is done via placement in a
body orifice (vagina) or body cavity (abdomen) or delivered
via IV such as with radionuclide iodine, which is absorbed
by the thyroid.

● Brachytherapy provides radiation to the tumor and a
limited amount to surrounding normal tissues.

● Most clients remain in a medical facility until
brachytherapy is complete. Clients who receive seed
implants might go home with the implants.

● The client’s excretions are radioactive until the isotope
has been completely eliminated from the body. Ensure
no on touches the client’s excretions.

NURSING ACTIONS
● Place the client in a private room. Keep the door closed

as much as possible.
● Place a sign on the door warning of the

radiation source.
● Wear a dosimeter film badge that records personal

amount of radiation exposure.
● Limit visitors to 30‑min visits, and have visitors

maintain a distance of 6 feet from the source.

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606 CHAPTER 91 cancer treatment oPtIons CONTENT MASTERY SERIES

● Individuals who are pregnant, trying to conceive,
or under the age of 16 years should not enter the
client’s room.

● Wear a lead apron while providing care, keeping the
front of the apron facing the source of radiation.

● Keep a lead container in the client’s room if the delivery
method could allow spontaneous loss of radioactive
material. Tongs are available for placing radioactive
material into this container.

● Follow protocol for proper removal of dressings and
bed linens from the room. In most cases, all linens
and dressings are kept in the client’s room until the
radiation source is removed, to ensure it is not lost in
the trash or laundry.

CLIENT EDUCATION
● Remain in the position prescribed by the provider to

prevent dislodgement of the radiation implant.
● Call the nurse for assistance with elimination.
● Follow radiation precautions in health care and

home environments.

External beam radiation therapy

External beam radiation (EBRT) or teletherapy is delivered
in relatively small doses over the course of several weeks
and aimed at the body from an external source. Unlike
internal radiation, the client is not radioactive and is
not hazardous to others. Three‑dimensional imaging
facilitates visualization of the tumor for more effective
treatment delivery.

● Intensity‑modulated radiation therapy involves
delivering radiation from several angles so that it is
intense at the tumor but has minimal damage to the
surrounding tissue.

● Stereotactic body radiotherapy (SBRT) is effective for
deep tumors and involves high radiation doses gingiva
in a short time span. A treatment that normally occurs
5 days a week for 6 to 8 weeks can be given in 1 to
5 days using SBRT.

● Proton therapy involves the use of charged protons to
transfer energy to deep tumors with minimal effects
on the tissue above the tumor, and minimal transfer of
energy beyond the tumor.

NURSING ACTIONS
● The skin over the targeted area is marked with
“tattoos” that guide the positioning of the external
radiation source.

● Provide a well‑balanced diet that does not contain red
meat. Radiation can cause dysgeusia (altered taste),
making foods such as red meat unpalatable.

● Help the client manage fatigue by scheduling activities
with rest periods in between and using energy‑saving
measures (sitting during showers and ADLs).

● Monitor for radiation injury to skin and mucous
membranes and implement a skin care regimen.

◯ Skin: blanching, erythema, desquamation, sloughing,
hemorrhage

◯ Mouth: mucositis, xerostomia (dry mouth)
◯ Neck: difficulty swallowing
◯ Abdomen: gastroenteritis

● Monitor CBC (possible decreased platelets and WBCs).

CLIENT EDUCATION
● Adverse effects depend on which part of the body is

being exposed to the radiation and how much radiation
is being administered.

● If mucositis occurs:
◯ Avoid spicy, salty, acidic foods.
◯ Try eating foods that are cold rather than hot.

● Gently wash the skin over the irradiated area with mild
soap and water. Dry the area thoroughly using patting
motions. Use the hand to clean the skin rather than a
washcloth.

● Do not remove or wash off radiation tattoos (markings)
used to guide therapy. Do not apply powders, ointments,
lotions, deodorants, or perfumes to the irradiated skin.

● Wear soft clothing. Avoid tight or constricting clothes.
● Do not expose the irradiated skin to sun or a

heat source.
● Inspect skin for evidence of damage and report to

the provider.

Hormone therapy
Hormone therapy is effective against tumors that are
supported or suppressed by hormones, such as in breast or
prostate cancer.

● By giving a similar hormone, uptake of the support
hormone is blocked, or production reduced. Luteinizing
hormone‑releasing hormone (LH‑RH) agonists like
leuprolide and goserelin are effective against tumors
that require a particular hormone for support.

◯ The use of androgenic hormones in a client who has
estrogen‑dependent cancer can suppress growth of
this type of cancer.

◯ The use of estrogenic hormones for a
testosterone‑dependent cancer can suppress growth
of this type of cancer.

● Hormone antagonists compete with the support
hormone for binding sites on or in the tumor cell and
are effective against tumors that require a particular
hormone for support.

◯ The use of an anti‑estrogen hormone in a client
who has estrogen‑dependent cancer can suppress
growth of this type of cancer. The same is true for
anti‑testosterone hormones.

LH‑RH agonists

NURSING ACTIONS: Monitor cardiac status and blood
pressure and for pulmonary edema.

CLIENT EDUCATION
● If male, understand the effect on sexual functions

(decreased libido, erectile dysfunction) and feminizing
effects of hormone therapy (gynecomastia, hot flashes,
bone loss).

● Increase intake of calcium and vitamin D.
● If female, understand the masculinizing effects

(chest and facial hair growth, amenorrhea, decreased
breast tissue).

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 91 cancer treatment oPtIons 607

Androgen antagonists (bicalutamide)

NURSING ACTIONS: Monitor laboratory findings (CBC
[anemia], calcium, increased liver enzymes).

CLIENT EDUCATION
● If male, understand the feminizing effects of hormone

therapy (gynecomastia, erectile dysfunction).
● Notify the provider of sore throat or bruising.

Estrogen receptor down‑regulators

Estrogen receptor down‑regulators (such as fulvestrant)
induce degradation of estrogen receptors.

Estrogen antagonists

Tamoxifen, anastrozole, trastuzumab

NURSING ACTIONS
● Monitor CBC, clotting times, lipid profiles, calcium

and cholesterol blood levels, and liver function for
medication‑related changes.

● Monitor neurologic and cardiovascular functioning
for changes.

CLIENT EDUCATION
● Understands the adverse effects, which include nausea,

vomiting, hot flashes, weight gain, vaginal bleeding,
and increased risk of thrombosis.

● Understand the need for yearly gynecologic exams and
the need to take calcium and vitamin D supplements.

Immunotherapy
Immunotherapy (biotherapy) alters a client’s biological
response to cancerous tumor cells. Antibodies, cytokines,
and other immune substances normally produced by
the immune system are administered to increase the
body’s defense against cancer. Immunotherapy includes
biological response modifiers (BRM), monoclonal antibody
targeted therapy, and cancer vaccines.

● The most common types of BRM are interleukins
and interferons.

● Interleukins help coordinate the inflammatory
and immune responses of the body, particularly
the lymphocytes.

● Interferons, when stimulated, can exert an antitumor
effect by activating a variety of responses.

● Monoclonal antibodies are a type of targeted therapy
that binds to cancer cell proteins to inhibit cell division,
make the cells more sensitive to treatment, and improve
the body’s ability to attack the cancer cells.

● Cancer vaccines can prevent infections that predispose
a client to cancer (HPV), stop cancer from developing
further, or kill cancer cells. Sipuleucel‑T is the only
FDA‑approved therapeutic cancer vaccine, and is
appropriate for males who have metastatic prostate
cancer that does not respond to other treatments.

NURSING ACTIONS
● Interleukins: Monitor for generalized edema, which

can impair organ function. The client might require
intensive care monitoring.

● Interferons: Monitor for peripheral neuropathy that can
affect vision, hearing, balance, and gait.

● Take precautions for orthostatic hypotension.
● Monitor the client receiving BRM therapy for

manifestations of inflammation (rigors, chills, malaise,
fever, nausea, diarrhea, and anorexia).

● Observe for indication of neurologic effects of BRM
therapy (agitation, hallucinations, sleep disorders,
nightmares, mood swings, somnolence).

● Check the client’s skin while taking BRM therapy for
peeling, pruritus, or dryness. Protect the skin from
sunlight, and use mild cleansers and moisturizers.

CLIENT EDUCATION
● Report influenza‑like manifestations or changes

consistent with peripheral neuropathy immediately.
● Use a perfume‑free moisturizer can be helpful in

managing skin discomfort.
● Avoid sun exposure and swimming if skin

manifestations develop.

Targeted therapy
● Target therapy acts on components produced by cancer

cells and includes small molecule medications and
monoclonal antibodies (discussed in the prior section).
A targeted therapy that is effective for one client might
not be effective for another client.

● Small molecule inhibitor targeted therapies are effective
in affecting mainly cancer cells while not affecting
healthy cells. These agents affect the replication process
of cancer cells.

● Targeted therapy agents are classified based upon
their mechanism of action (tyrosine kinase inhibitors,
epidermal growth factor/receptor inhibitors, vascular
endothelial growth factor/receptor inhibitors,
multikinase inhibitors, protease inhibitors, and
angiogenesis inhibitors).

NURSING ACTIONS: Monitor for adverse effects specific to
type of agent administered.

CLIENT EDUCATION: Do not view the medication as “just
a pill,” but that it is a significant part of treatment, and to
take it as prescribed.

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608 CHAPTER 91 cancer treatment oPtIons CONTENT MASTERY SERIES

Photodynamic therapy
Photodynamic therapy involves injection of a
photosensitizing agent that is absorbed by all cells in the
body. 1 to 3 days later when the agent remains in only the
cancer cells, the tumor is exposed to a specific wavelength
of light via an endoscope. Cells are subsequently destroyed,
and tumors are eliminated or reduced in size.

● Used to treat esophageal cancer, ocular tumors, upper
airway tumors, and nonmelanoma skin cancer.

● Adverse effects are related to the area of the body
being treated.

NURSING ACTIONS
● Photodynamic therapy is contraindicated for clients

who have a tumor with known major blood vessel
involvement. When the tumor rapidly dies, the client
might begin bleeding.

● Use caution for clients who have a history of radiation
therapy or coagulation disorders.

CLIENT EDUCATION: Avoid sun exposure for 6 weeks.
(Limit time outdoors, and wear sunglasses.)

Supportive treatment
In addition to cancer treatment, the client can require
assistance for altered body function or to meet emotional
and spiritual needs.

● Facilitate safe activity, providing assistive devices when
necessary for clients who have altered mobility or
require assistance with self‑care activities.

● Coordinate transfer of client care to home health,
hospice, or a tertiary care setting (rehabilitation center)
as appropriate.

● Provide alternate means of communication for clients
who have cancer affecting the mouth, throat, larynx, or
vocal cords.

● Use assistive aids and devices for clients who have
visual or hearing impairments.

● Consult physical therapy and genetic or other
counseling services as indicated.

● Consult pain management for persistent or uncontrolled
pain. (See CHAPTER 93: PAIN MANAGEMENT FOR CLIENTS

WHO HAVE CANCER.)
● Monitor client’s nutritional intake and weight. Consult

a dietitian or nutritionist if indicated, and provide
meal supplements.

● Determine whether the client has body image concerns,
and assist the client in promoting a positive body
image (touching affected body areas, use of prosthetics,
choosing clothing, head coverings, or makeup).

● Discuss common effects of treatment on sexual
function. Assist the client with discussing any concerns,
and arrange for counseling, if desired.

● Instruct the client about medications to promote
erection or manage pain sensation.

● Check the client’s coping ability, and help the
client use prior positive coping mechanisms or to
identify new ones.

● Inquire about whether the client uses complementary or
alternative therapies to prevent or treat cancer, or the
associated manifestations. Ensure the client is aware of
any safety issues, and incorporate the client’s preferred
strategies into the plan of care when possible.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 91 cancer treatment oPtIons 609

Active Learning Scenario

a nurse is teaching a client who is receiving
chemotherapy and has alopecia. What should the
nurse include in the teaching? use the active Learning
template: system disorder to complete this item.

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM

CLIENT EDUCATION: describe at least four teaching points.

NURSING CARE: describe at least two nursing actions.

Application Exercises

1. a nurse is planning care for a client who
has a platelet count of 10,000/mm3. Which
of the following interventions should the
nurse include in the plan of care?

a. apply prolonged pressure to puncture
site after blood sampling.

B. administer epoetin alfa as prescribed.

c. Place the client in a private room.

d. Have the client use an oral topical
anesthetic before meals.

2. a nurse is caring for a client who is receiving
chemotherapy and has mucositis. Which of the
following actions should the nurse take?

a. use a glycerin‑soaked swab to
clean the client’s teeth.

B. encourage increased intake of citrus fruit juices.

c. obtain a culture of the lesions.

d. Provide an alcohol‑based
mouthwash for oral hygiene.

3. a nurse is planning care for a client who is undergoing
chemotherapy and is on neutropenic precautions.
Which of the following interventions should be
included in the plan of care? (select all that apply.)

a. encourage a high‑fiber diet.

B. eliminate standing water in the room.

c. Have the client wear a mask when leaving the room.

d. Have client‑specific equipment remain in the room.

e. eliminate raw foods from the client’s diet.

4. a nurse is caring for a client who is undergoing
chemotherapy and reports severe nausea. Which of
the following statements should the nurse make?

a. “Your nausea will lessen with each
course of chemotherapy.”

B. “Hot food is better tolerated due to the aroma.”

c. “try eating several small meals
throughout the day.”

d. “Increase your intake of red meat as tolerated.”

5. a nurse is caring for a client who has cervical
cancer and is scheduled for brachytherapy.
Which of the following actions should the
nurse take? (select all that apply.)

a. Permit visitors to stay with the
client 30 min at a time.

B. Warn pregnant individuals to visit
the room only once daily.

c. Wear a dosimeter when in the client’s room.

d. Place soiled dressings in a biohazard bag
before discarding in the regular trash.

e. dispose soiled linens in the hamper
outside the client’s room.

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610 CHAPTER 91 cancer treatment oPtIons CONTENT MASTERY SERIES

Application Exercises Key

1. a. CORRECT: Implement bleeding precautions for
the client who has thrombocytopenia.

B. epoetin alfa is administered to the client who has anemia.
c. the client who has neutropenia is placed in a private room.
d. a topical oral anesthetic is used for the

client who has mucositis.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

2. a. glycerin‑based swabs should be avoided when providing
oral hygiene to a client who has mucositis.

B. acidic foods should be discouraged for a
client who has oral mucositis.

c. CORRECT: obtain a culture of the oral lesions to identify
pathogens and determine appropriate treatment.

d. nonalcoholic mouthwashes are recommended
for a client who has mucositis.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

3. a. there is no benefit to a high‑fiber diet for
a client who has neutropenia.

B. CORRECT: neutropenic precautions include the client not
having contact with flowers and plants due to the presence
of surface infectious agents in the water and soil.

c. CORRECT: neutropenic precautions include
having the client wear a mask when leaving the
room to reduce the incidence of infection.

d. CORRECT: neutropenic precautions include having
equipment available that is only for use in caring for
the client to reduce the incidence of infection.

e. CORRECT: a client who has neutropenia should
avoid consuming raw foods due to the presence of
surface infectious agents on peeling and rind.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

4. a. nausea usually occurs to the same extent with
each session of chemotherapy.

B. cold foods are better tolerated than warm or hot foods
because odors from heated foods can induce nausea.

c. CORRECT: several small meals a day are usually
better tolerated by the client who has nausea.

d. red meat is not tolerated well by the client
undergoing chemotherapy because the taste of
meat is frequently altered and unpalatable.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

5. a. CORRECT: Visitors should remain for no more than 30 min
at a time and maintain a distance of at least 6 ft.

B. CORRECT: Pregnant individuals should not enter
the room of a client receiving brachytherapy.

c. CORRECT: Healthcare personnel should wear a
dosimeter when there is potential exposure to
radiation, such as in the radiology department or in
the room of a client receiving brachytherapy.

d. do not discard the client’s dressings in the regular trash,
because the client’s secretions are radioactive.

e. do not place objects from the client’s room in the
hallway because they are radioactive, but should
dispose of them following facility policy.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

Active Learning Scenario Key

Using the Active Learning Template: System Disorder

PATHOPHYSIOLOGY RELATED TO CLIENT PROBLEM: alopecia
occurs as an adverse effect of chemotherapy medications. the
medications interfere with the life cycle of rapidly proliferating
cells, such as those found in hair follicles, resulting in hair loss.

CLIENT EDUCATION
● Wear head coverings to protect the skin when using
headphones, or wearing helmets or wigs.

● avoid the use of damaging hair‑care measures (electric rollers,
curling irons, hair dye, permanent waves).

● use a soft hair brush or wide‑tooth comb for grooming.
● avoid sun exposure. use a diaper rash ointment or cream for itching.
● alopecia is temporary, and hair will return
when chemotherapy is discontinued.

NURSING CARE
● discuss the effect of alopecia on self‑image.
encourage the client to express feelings.

● recommend use of information from the american
cancer society on managing alopecia.

● Provide referral to a cancer support group.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 611

UNIT 13 IMMUNE SYSTEM AND CONNECTIVE
TISSUE DISORDERS
SECTION: CANCER‑RELATED DISORDERS

CHAPTER 92 Cancer Disorders
the various types of cancer share general
cancer principles: abnormal cell growth, tumor
formation, and potential for invasion to other
locations. each type of cancer has distinguishing
characteristics related to risk, manifestations,
screening, and diagnosis. the prognosis and
treatment varies by type.

Skin cancer
● Sunlight exposure is the leading cause of skin cancer.

The most effective strategy for prevention of skin cancer
is avoidance or reduction of skin exposure to ultraviolet
light from sunlight and synthetic sources.

● Precancerous skin lesions, called actinic keratoses, are
common in people who have chronically sun‑damaged
skin, such as older adults.

tYPes of sKIn cancer

Squamous cell (epidermis)

CHARACTERISTICS
● Rough, scaly lesion with central ulceration and crusting
● Bleeding (possible)
● Usually present on sun‑exposed areas

COURSE: Localized; can metastasize.

Basal cell (basal epidermis or nearby dermal cells)

CHARACTERISTICS
● Small, waxy nodule with superficial blood vessels,
well‑defined borders

● Erythema and ulcerations
● Usually present on sun‑exposed areas

COURSE: Invades local structures (nerves, bone, cartilage,
lymphatic and vascular tissue); rarely metastatic but high
rate of recurrence.

Malignant melanoma (cancer of melanocytes) (92.1)

CHARACTERISTICS
● Irregular shape and borders with multiple colors
● New moles or change in an existing mole (can occur
in intestines or any other body structure that contains
pigment cells)

● Itching, cracks, ulcerations, or bleeding (possible)
● Common on upper back and lower legs, and on palms

and soles for clients who have dark skin

COURSE: Rapid invasion and metastasis with high
morbidity and mortality

HEALTH PROMOTION AND
DISEASE PREVENTION

● Limit exposure to sunlight, especially between
1000 and 1600.

● Apply sunscreen when near reflective surfaces (sand,
snow, water, concrete).

● Use sunblock that has an SPF of at least 15, with both
UVA and UVB protection. Apply 30 min before exposure
to sun. Sunblock should be reapplied at least every 2 hr.

● Wear protective clothing, hats, sunglasses, and lip balm
that has an SPF of at least 15.

● Avoid indoor tanning (tanning beds, booths, sunlamps).
● Teach clients the “ABCDE” system to evaluate moles.

◯ A: Asymmetry: One side does not match the other
◯ B: Borders: Ragged, notched, irregular, or

blurred edges
◯ C: Color: Lack of uniformity in pigmentation (shades
of tan, brown, or black)

◯ D: Diameter: Width greater than 6 mm, or about the
size of a pencil eraser or a pea

◯ E: Evolving: Change in appearance (shape, size, color,
height, texture) or condition (bleeding, itching)

● Because of the cumulative effects of sun damage over
the lifespan, screening for suspicious lesions is an
essential part of the routine physical assessment of
older adult clients.

CHAPTER 92 Online Images: Squamous Cell Cancer, Basal Cell Cancer

92.1 Melanomas

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612 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

ASSESSMENT

rIsK factors
● Occupational history of chemical carcinogens
● History of severe skin injury
● Immunosuppression therapy
● Exposure to ultraviolet light (natural light or indoor

tanning) over long periods of time
● Chronic skin inflammation, burns, or scars
● Light‑skinned people (blonde or red hair, fair skin,

freckles, blue eyes) with a tendency to burn easily
● Presence of several large or many small moles
● Family or personal history of melanoma
● Residing in higher elevations or in close proximity to

the equator (thinner layer of ozone)
● Age older than 55 years

eXPected fIndIngs
Report of change in appearance of mole or lesion

dIagnostIc Procedures

Assessment (self or clinician)

EXPECTED FINDINGS
● New or suspicious lesions
● Recent changes in size, color, or sensation of any mole,

birthmark, wart or scar

CLIENT EDUCATION: Develop a body map (diagram of
scars or lesions) and monitor monthly for changes. Inspect
skin between fingers and toes and on scalp.

Biopsy (punch, shave, or excisional)

EXPECTED FINDINGS: Cancerous cells

CLIENT EDUCATION
● Monitor for infection.
● Conduct wound care, including care of sutures (punch,

excisional biopsy).

Lymph node biopsy/dissection

EXPECTED FINDINGS: Tissue examined microscopically for
the spread of cancer

NURSING ACTIONS
● Monitor site of lymph node biopsy or removal for

bleeding or infection.
● If melanoma is diagnosed, blood tests are prescribed

(CBC, CMP, liver) to check for organ involvement.

PATIENT‑CENTERED CARE

tHeraPeutIc Procedures

Chemotherapy

Topical chemotherapy with 5‑fluorouracil cream
● For treatment of actinic keratoses or for widespread

superficial basal cell carcinoma.
● CLIENT EDUCATION

◯ Prepare for extended treatment that will cause the
lesion to weep, crust, and erode.

◯ The appearance of the lesion will improve
after treatment.

Topical chemotherapy with imiquimod
● Treatment option for basal cell carcinoma
● Stimulates production of interferon, which attacks

cancer cells

Interferon therapy
● For postoperative treatment of stage III or

greater melanomas.
● NURSING ACTIONS: Report and provide relief for

adverse or toxic effects of chemotherapy.
● CLIENT EDUCATION

◯ Perform adequate nutrition and fluid intake.
◯ Understand the self‑injection procedure.

Targeted therapy (92.2)

● Blocks or slows the spread of cancer by interfering with
specific molecules (targets) that are involved in growth,
progression, and spread of cancer.

● Vemurafenib is an oral medication used for targeted
therapy to treat melanoma.

Biotherapy

Monoclonal antibody therapy: Stimulates T‑cell
lymphocyte activity, which can produce antitumor
immune response.

Radiation
● Limited to older clients who have large, deeply invasive

tumors and those who are poor surgical candidates.
● Melanoma is relatively resistant to radiation therapy.

Cryosurgery
● Freezes and destroys isolated lesions by applying liquid

nitrogen (‑200° C).
● Skin becomes edematous and tender.
● CLIENT EDUCATION: Cleanse with hydrogen peroxide

and apply a topical antimicrobial until healed.

Online Images: Melanomas

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 613

Curettage and electrodessication

Removes cancerous cells with the use of a curette to
scrape away cancerous tissue, followed by the application
of an electric probe to destroy remaining tumor tissue.

Excision

The incision will be closed with sutures if possible. A skin
graft can be necessary for large areas.

● CLIENT EDUCATION: Perform postoperative wound care
and care of the skin graft if used.

Mohs surgery
● Used with basal and squamous cell carcinoma
● Tissue is sectioned horizontally in layers and each layer

is examined for presence of residual cancer; the process
is continued until the samples are free of cancer

● COMPLICATIONS: Skin abscess and cellulitis

Leukemias and lymphomas
LeuKemIas

● Leukemias are cancers of white blood cells or of cells
that develop into white blood cells. In leukemia, the
white blood cells are not functional. They invade and
destroy bone marrow, and they can metastasize to the
liver, spleen, lymph nodes, testes, and brain.

● Leukemias are divided into acute (acute lymphocytic
leukemia and acute myelogenous leukemia) and
chronic (chronic lymphocytic leukemia and chronic
myelogenous leukemia) and are further classified by the
type of white blood cells primarily affected.

● The goal of treatment is to eliminate all leukemic cells.
● The exact cause of leukemia is not known.
● Overgrowth of leukemic cells prevents growth of other

blood components (platelets, erythrocytes, mature
leukocytes).

◯ Lack of mature leukocytes leads to
immunosuppression. Infection is the leading cause of
death among clients who have leukemia.

◯ Lack of platelets increases the client’s risk of bleeding.

92.2 Cancer therapies at a glance

Ablation procedures
can be used to destroy cancerous cells.
Radiofrequency ablation delivers an
electric current directly to the tumor via
thin needles. this current is converted
into heat waves that kill the cancer cells.
Cryotherapy (cryoablation) uses
liquid nitrogen injected directly into
the tumor to destroy the tumor.
Microwave thermotherapy uses
microwaves transmitted through a probe
to heat and destroy the abnormal tissue.

Chemotherapy
chemotherapy uses anti‑cancer drugs
administered orally or intravenously
to destroy cancer cells.

Photodynamic therapy
Photodynamic therapy involves the
injection of a photosensitizing agent that is
absorbed by all the cells in the body. one
to three days later when the agent remains
in only the cancer cells, the tumor is
exposed to a laser light via an endoscope.
cells are subsequently destroyed and
tumors are eliminated or reduced in size.
used with small, noninvasive lesions.

Radiation
With extensive disease, radiation is
combined with chemotherapy.
Brachytherapy is radiation
delivered inside the body.
External beam radiation therapy (EBRT)
uses radiation from a source outside
of the body to destroy cancer cells.
Intensity‑modulated radiation uses
thousands of beams and angles of varying
intensity that are even more controlled
to target the cancer tissues and reduce
exposure of radiation to healthy tissue.

Targeted therapy
targeted therapy is a newer molecular‑based medication therapy that targets specific receptors or other processes that produce cancer
cells. Because this therapy has specific targets, it often causes less adverse effects than regular cancer chemotherapy, which typically
kills large numbers of normal cells along with cancer cells.
examples of targeted therapy includes biologic response modifiers, monoclonal antibodies, cytokines, growth factors, and
gene therapy.
Immunotherapy (biotherapy) uses biologic response modifiers (Brms), which alter a client’s biological response to cancerous tumor
cells. cytokines work to enhance the immune system. they help the client’s immune system recognize cancer cells and use the body’s
natural defenses to destroy them. Interleukins and interferons are the two primary cytokines (immune response modulators) used
in immunotherapy.

● Interleukins help coordinate the inflammatory and immune responses of the body, in particular, the lymphocytes.
● Interferons, when stimulated, can exert an antitumor effect by activating a variety of responses.
● tumor necrosis factor

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614 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

Incidence and cure rates

Acute lymphocytic leukemia (ALL): Various factors
influence the prognosis for children, but the 5‑year survival
rate is approximately 85% (age at diagnosis, gender, cell
type involved); less than 50% of adults can be cured.

Acute myelogenous leukemia (AML): Most common
leukemia among adults; prognosis is poor.

Acute promyelocytic leukemia (APL): Subtype of AML.
Most curable of adult leukemias.

Chronic lymphocytic leukemia (CLL): Most cases
involve people older than 50 years of age. This is the
most common adult leukemia and rarely seen in Native
Americans persons of Asian descent. CLL has a strong
genetic link.

Chronic myelogenous leukemia (CML): Most prevalent
after age 50 years. The disease is uncommon in children.
Prognosis is less than 2 years of survival from the time of
diagnosis. Three phases: chronic (slow growing with mild
manifestations); accelerated (more rapid growing with
severe manifestations and failure to respond to therapy);
and blast (very aggressive with metastasis to organs).

LYmPHomas
● Lymphomas are cancers of lymphocytes (a type of white

blood cell) and lymph nodes (which produce antibodies
and fight infection).

● Lymphomas can metastasize to almost any organ.

Types of lymphoma

Hodgkin’s lymphoma (HL)
● Peaks in two age groups: teens and young adults; adults

in their 50s and 60s.
● Possible causes include viral infections and exposure to

chemical agents.
● Typically starts in a single node or chain of nodes that

contain the Reed‑Sternberg cell.
● HL spreads predictably from one group of lymph nodes

to the next.
● One of the most treatable types of cancer

Non‑Hodgkin’s lymphoma (NHL)
● More common in men and older adults.
● Possible causes include gene damage, viral infections,

autoimmune disease, and exposure to radiation or
toxic chemicals.

● Includes all lymphoid cancers that do not have the
Reed‑Sternberg cell; there are 60 subtypes.

● Generally spreads through the lymphatic system in an
erratic pattern.

● There is an increased incidence in clients exposed to
pesticides, insecticides, and dust.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Use protective equipment, such as a mask, and ensure
proper ventilation while working in environments that
contain carcinogens or particles in the air.

● Influenza and pneumonia vaccinations are important for
all clients who are immunosuppressed.

ASSESSMENT

rIsK factors
● Immunosuppression
● Exposure to chemotherapy agents or medications that

suppress bone marrow
● Genetic factors (hereditary)
● Ionizing radiation (radiation therapy, environmental)

OLDER ADULT CLIENTS
● Often have diminished immune function and decreased

bone marrow function, which increase the risk of
complications of leukemia and lymphoma.

● Have decreased energy reserves and can tire more easily
during treatment. Safety is a concern with ambulation.

eXPected fIndIngs

Acute leukemia
● Bone pain
● Joint swelling
● Enlarged liver and spleen
● Weight loss
● Fever
● Poor wound healing (infected lesions)
● Manifestations of anemia (fatigue, pallor, tachycardia,

dyspnea on exertion)
● Evidence of bleeding (ecchymoses, hematuria,

bleeding gums)
● Headaches, behavior changes, decreased attention

Hodgkin’s and non‑Hodgkin’s lymphoma
● Most clients only experience an enlarged lymph node

(usually in the neck with HL), which is a typical finding
in clients who have indolent (slow‑growing) lymphomas.

● Other possible manifestations include fever, night
sweats, unplanned weight loss, fatigue, and infections.

dIagnostIc Procedures
Staging of lymphoma involves extensive testing to ensure
proper treatment is prescribed. HL has two main subtypes;

“classic” HL is further distinguished into four categories.
NHL has more than 60 subtypes. Treatment must be
specific to the client’s needs.

CBC

EXPECTED FINDINGS
● WBC can be high, low, or normal (leukemia)
● Hemoglobin, hematocrit, and platelets decreased

NURSING ACTIONS: Explain unexpected findings to client.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 615

Coagulation time

EXPECTED FINDINGS: Increased with acute leukemia

NURSING ACTIONS: Monitor for bleeding.

Cytogenic studies

Leukemic cells are analyzed for marker chromosomes to
help diagnose as well as determine therapy and prognosis.

Biopsy of bone marrow
(core or fine‑needle aspiration)

EXPECTED FINDINGS
● Large quantities of immature leukemic blast cells

(confirms diagnosis)
● Typing of protein markers (to differentiate myeloid or

lymphoid leukemia)

NURSING ACTIONS
● Administer pain medication as prescribed.
● Apply pressure for 5 to 10 min, then a pressure dressing.
● Monitor for bleeding and infection for 24 hr.

CT scan (always used for HL staging)

EXPECTED FINDINGS: Guide for lymphoma staging
procedures: identify presence, size, and shape of
nodes, tumors.

NURSING ACTIONS: Prepare the client for the procedure.

Biopsy of lymph nodes

EXPECTED FINDINGS
● Hodgkin’s lymphoma: presence of Reed‑Sternberg cells

(cancerous B‑lymphocytes)
● Non‑Hodgkin’s lymphoma: any other lymph node

malignancy

NURSING ACTIONS: Provide information specific to
the diagnosis.

Chest x‑ray, CT scan, PET scan, bone scan

EXPECTED FINDINGS: Confirms diagnosis or metastatic disease

NURSING ACTIONS: Provide information specific to
the diagnosis.

PATIENT‑CENTERED CARE

nursIng care
● Monitor for evidence of infection. Assess for other

physiological indicators of infection (lung crackles,
cough, urinary frequency or urgency, oliguria, lesions of
skin or mucous membrane).

● Manifestations that stem from the immune response
(increased WBC, fever, pus, redness, inflammation) are
not likely due to immunosuppression.

● Prevent infection. (Implement neutropenic precautions.)
These interventions are especially important during
chemotherapy induction and for clients who have received
a bone marrow transplant.

◯ Frequent, thorough hand hygiene is a priority intervention.
◯ Place the client in a private room.
◯ Allow only healthy visitors; when unavoidable, visitors

who are ill must wear a mask.
◯ Screen visitors carefully.
◯ Restrict foods that can be contaminated with bacteria
(no fresh or raw fruits, vegetables).

◯ Monitor WBC.
◯ Prevent transmission of bacteria and viruses
(high‑efficiency particulate air [HEPA] filtration).
Eliminate standing water (humidifiers, denture cups,
vases) to prevent bacteria breeding. Live plants and
flowers might not be allowed in the client’s room,
depending on facility policy.

◯ Encourage good personal hygiene.
● Prevent injury.

◯ Monitor platelets.
◯ Assess frequently for obvious and occult bleeding.
◯ Protect the client from trauma (avoid injections
and venipunctures, apply firm pressure, increase
vitamin K intake).

◯ Teach the client how to avoid trauma (use electric
shaver, soft bristled toothbrush, avoid contact sports).

● Conserve the client’s energy.
◯ Encourage rest, adequate nutrition, and fluid intake.
◯ Ensure the client gets adequate sleep.
◯ Assess the client’s energy resources/capability.
◯ Plan activities as appropriate.

92.3 Phases of chemotherapy to treat leukemia

GOAL PROCEDURE LENGTH OF TIME

Induction therapy:
intensive

combination therapy

Induce remission: absence
of all findings of leukemia,
including less than 5%
blasts in bone marrow.

aggressive treatment
(possible continuous infusion);
IV infusion; cns and csf
infusion prophylaxis (aLL)

4 to 6 weeks (hospitalization
required due to increased risk
for infection and hemorrhage)

Consolidation or
intensification therapy

cure by eradicating any
residual leukemic cells.

same medications as induction
phase at lower dosage or different
combination of medications

about 6 months

Maintenance therapy Prevent relapse. Lower doses of oral or
IV chemotherapy months to years

Reinduction therapy:
for a client who relapses

Place the client back
in remission.

combinations of chemotherapy
used to achieve remission

Probability of relapse
occurring decreases over time

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616 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

tHeraPeutIc Procedures

Chemotherapy
● Chemotherapy can be used to treat lymphoma in

combination with other therapies.
● There are three phases of chemotherapy used to treat

leukemia. (92.3)

CLIENT EDUCATION: Report manifestations of infection or
illness immediately to the provider.

Colony‑stimulating medications

Medications such as filgrastim stimulate the production
of leukocytes.

NURSING ACTIONS: Monitor for report of bone pain.
Monitor CBC twice weekly to check leukocytes. Use
cautiously with clients who have bone marrow cancer.

CLIENT EDUCATION: Report bone discomfort.

Immunotherapy (92.2)

Monoclonal antibodies are man‑made proteins that
attack a specific target to treat lymphoma. Includes
such medications as ofatumumab and alemtuzumab
used for CLL.

Targeted therapy (92.2)

Radiation
● External lymph node radiation is the primary form of

treatment for HL. Radiation therapy or radiolabeled
antibodies can be used as part of treatment for NHL.

● With extensive disease, radiation is combined
with chemotherapy.

● Radiation is not typically a treatment used for clients
who have leukemia.

Hematopoietic stem cell (bone
marrow) transplantation (HSCT)

Bone marrow is destroyed or ablated using radiation or
chemotherapy and later replaced with healthy stem cells.
The body is able to resume normal production of blood cells.

● Autologous cells are the client’s own cells that are
collected before chemotherapy.

● Matching of donor to recipient stem cells compares
certain human leukocyte antigens (HLA) to reduce risk
of rejection.

◯ Syngeneic cells are donated from the client’s identical
twin (HLA identical).

◯ Allogeneic cells are obtained from an HLA‑matched
donor, such as a relative or from umbilical cord blood
(closely matched HLA).

● Without transplantation, the client will likely die from
infection or bleeding.

● Following transplantation, the client is at high risk for
infection and bleeding until the transfused stem cells
begin producing white blood cells again.

● Clients who have neuroblastoma, germ cell tumors, and
Ewing sarcoma might benefit from autologous HSCT.

COMPLICATIONS

Pancytopenia

Decrease in white and red blood cells and platelets
● Neutropenia secondary to disease or treatment greatly

increases the client’s risk for infection.
● The risk of serious infection increases as the ANC falls. An

ANC less than 1,000/mm3 indicates a weak immune system.
The nurse should implement neutropenic precautions,
including placing the client in a private room.

NURSING ACTIONS
● Maintain a hygienic environment and encourage the

client to do the same.
● Monitor for infection (cough, alterations in breath

sounds, urine, or feces). Report temperature greater
than 37.8° C (100° F).

● Administer antimicrobial, antiviral, and antifungal
medications as prescribed.

● Administer blood products (granulocytes) as needed.

Thrombocytopenia
● Secondary to disease and/or treatment; greatly increases

the client’s risk for bleeding.
● The greatest risk is at platelet counts less than
50,000/mm3, and spontaneous bleeding can occur at less
than 20,000/mm3.

NURSING ACTIONS
● Monitor for petechiae, ecchymosis, bleeding of the

gums, nosebleeds, and occult or frank blood in stool,
urine, or vomitus.

● Institute bleeding precautions. (Avoid IVs and injections;
apply pressure for approximately 10 min after blood is
obtained; and handle client gently and avoid trauma.)

● Minimize the risk of trauma (safe environment).
● Administer blood products (platelets) if platelet count is

less than 10,000/mm3.

Hypoxemia

Anemia secondary to disease or treatment significantly
increases the client’s risk for hypoxemia.

NURSING ACTIONS
● Plan client care to balance rest and activity and use

assistive devices, as indicated.
● Monitor RBC.
● Provide a diet high in protein and carbohydrates.
● Administer colony‑stimulating factors, such as epoetin

alfa, as prescribed.
● Administer blood products (packed red blood cells)

as needed.

Hsct comPLIcatIons

Failure of stem cells to engraft (grow)

Bone marrow transplant must be repeated.

Graft‑versus‑host disease (graft rejection)

NURSING ACTIONS: Administer immunosuppressants
as prescribed.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 617

Veno‑occlusive disease

Blockage/inflammation of veins in the liver can occur up
to 1 month after bone marrow transplant.

NURSING ACTIONS
● Monitor for jaundice, abdominal pain, and

liver enlargement.
● Monitor daily weights and abdominal girth to assess for

fluid retention.

Thyroid cancer
As thyroid tumors increase in size or spread, they
impact the function of surrounding structures (larynx,
pharynx, esophagus).

The four types of thyroid cancer

Papillary carcinoma grows slowly and is the most
common form. It usually occurs in young adult females.

Follicular carcinoma affects blood vessels, bone, and
lung tissues. It often attaches to the trachea, muscles,
vasculature, and skin. It occurs most often in clients aged
65 years and over.

Medullary carcinoma is often the result of an endocrine
disorder, which causes multiple tumor. It is most often
found in clients 50 years and older.

Anaplastic carcinoma replicates quickly, invading the
area surrounding the tumor. It usually metastasizes
before diagnosis.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Avoid or stop smoking.
● Wear a thyroid guard to protect the neck during upper

body x‑rays.

ASSESSMENT

rIsK factors
● Female sex
● Diet low in iodine (follicular carcinoma)
● Radiation exposure
● Older adults have higher incidence of follicular and

medullary carcinoma.

eXPected fIndIngs
● Dyspnea
● Hoarse voice
● Dysphasia
● Stridor
● Change in size, shape of thyroid
● Palpable nodules or irregularities
● Dehydration (hormone imbalance)
● Thyroid bruits (possible with enlargement)

dIagnostIc Procedures

Serum thyroglobulin

EXPECTED FINDINGS: Elevated

CLIENT EDUCATION: The result can indicate remaining
cancer cells after treatment or return of cancer.

TSH, T3, T4

Indicates function of the thyroid

EXPECTED FINDINGS
● T3, T4 levels, and TSH are usually normal in

thyroid cancer

CLIENT EDUCATION: Results indicate the function of the
thyroid. Consider additional testing needed.

Biopsy (fine‑needle plus open or core, if indicated)

EXPECTED FINDINGS: To identify presence of cancer cells
in thyroid nodules or lymph nodes

NURSING ACTIONS
● Instruct client that lesions greater than 1 cm and

suspicious lymph nodes are tested.
● Administer pain medication as prescribed.
● Apply pressure for 5 to 10 min, then a pressure dressing.
● Monitor for bleeding and infection for 24 hr.

Ultrasound

EXPECTED FINDINGS
● Used to guide biopsy
● Reveals whether nodules are fluid‑filled (typically

benign) or solid (typically cancerous).

NURSING ACTIONS: Instruct and prepare client for
the procedure.

Radioiodine scan

EXPECTED FINDINGS
● Presence of radioactive cells (cells that

retained radioiodine)
● Not useful with medullary carcinoma

CLIENT EDUCATION: Dye will be administered (injection or
oral) then the thyroid and other suspicious areas are scanned.

Chest x‑ray, MRI, PET scan, CT scan

EXPECTED FINDINGS: Presence of disease or
metastatic disease

PATIENT‑CENTERED CARE

nursIng care
● Monitor airway patency in client who has a tumor

affecting or compressing the trachea.
● Assess swallowing in client who has a tumor affecting

or compressing the esophagus.
● Administer medications as prescribed to treat

hypertension, dysrhythmia, or tachycardia.

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618 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

medIcatIons

Thyroid suppression therapy
● Involves administration of synthetic thyroxine

(T4, levothyroxine sodium).
● Suppression therapy replaces T4 needed for body

function. It also prevents or slows growth of cancerous
thyroid cells.

● Therapy is typically prescribed for several months
following thyroid surgery.

CLIENT EDUCATION
● Never stop taking levothyroxine sodium, unless

instructed by the provider.
● Take levothyroxine sodium on an empty stomach.

tHeraPeutIc Procedures

Radiation

Used to treat anaplastic carcinoma.

Radioactive iodine (RAI) therapy

Used to destroy papillary or follicular carcinoma and can
be used to treat hyperthyroidism.

● RAI therapy works similarly to radioactive scanning
(used to diagnose thyroid cancer).

● The client ingests RAI in liquid or tablet form, which is
absorbed by thyroid cells which are then destroyed.

● Client can benefit from RAI therapy following thyroid
suppression therapy.

NURSING ACTIONS
● Teach the client about radioactive precautions to reduce

risk of radiation exposure.
● Provide information on nutrition supplements for client

experiencing altered taste. Consult nutrition services.

CLIENT EDUCATION: Chew gum or suck on hard candy to
relieve dry mouth or reduced salivation.

Surgical interventions

Papillary, follicular, and medullary carcinoma are
treated surgically.

● Thyroidectomy (total or partial) or thyroid lobectomy is
the treatment of choice for papillary carcinoma that is
limited to the thyroid gland.

● Involved lymph nodes in the neck are removed
during surgery.

● During surgery, the parathyroid glands or laryngeal
nerve can be damaged.

● A wound drain can be placed intraoperatively.
● Refer to CHAPTER 78: HYPERTHYROIDISM for information on

thyroidectomy surgery.

cLIent educatIon
Take thyroid replacement therapy as prescribed.
It is lifelong therapy for those who have had
thyroidectomy surgery.

Lung cancer
● Lung cancer is one of the leading causes of

cancer‑related deaths for all genders.
● Prognosis of lung cancer is poor because it is often

diagnosed in an advanced stage, when metastasis
has occurred. Palliative care is often the focus at the
advanced stage (III, IV).

● Most lung cancers arise from bronchogenic carcinomas
(arising from the bronchial epithelium)

● Most lung cancers are non‑small cell lung cancer
(NSCLC), which includes squamous, adeno, and large
cell carcinomas.

● Small cell lung cancer (SCLC) is fast‑growing and is
consistently linked to a history of cigarette smoking.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Promote smoking cessation. Instruct the client that
the safety of electronic nicotine devices is unknown,
and there could be risk from inhaling the vapor of
these devices.

● Use protective equipment (mask) and ensure proper
ventilation while working in environments that can
contain carcinogens or particles in the air.

● Screening (annual CT) for early detection for those at
high risk for lung cancer development

ASSESSMENT
● Determine the pack‑year history (number of packs of

cigarettes smoked per day times the number of years
smoked) for clients who smoke.

● Evaluate use of other tobacco products (cigars, pipes,
and chewing tobacco).

● Ask about exposure to secondhand smoke.
● Monitor for a cough that changes in pattern.

rIsK factors
● Exposure to cigarette smoke (including

secondhand smoke)
● Radiation exposure
● Chronic exposure to inhaled environmental irritants (air

pollution, asbestos, coal, other talc dusts)
● Older adult clients have decreased pulmonary reserves

due to normal lung changes (decreased lung elasticity
and thickening alveoli), contributing to impaired
gas exchange.

● Structural changes in the skeletal system decrease
diaphragmatic expansion, thereby restricting ventilation

● Inherited or acquired genetic change

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 619

eXPected fIndIngs
Clients can experience few manifestations early in the
disease. Monitor for manifestations that often appear late
in the disease.

● Fatigue, weight loss, or anorexia
● Fever (pneumonitis or bronchitis that occurs

with obstruction)
● Persistent cough, with or without hemoptysis

(rust‑colored or blood‑tinged sputum)
● Hoarseness
● Altered breathing pattern: dyspnea, prolonged

exhalation alternated with shallow breaths (obstruction),
rapid, shallow breaths (pleuritic chest pain,
elevated diaphragm)

● Altered breath sounds (wheezing)
● Diminished or absent breath sounds (obstruction)
● Chest pain or tightness
● Chest wall masses
● Muffled heart sounds
● Pleural friction rub
● Clubbing of fingers
● Increased work of breathing (retractions, use of

accessory muscle, stridor, nasal flaring)
● Decreased bone density

dIagnostIc Procedures

Cytologic testing

EXPECTED FINDINGS: Sputum specimen
contains cancer cells

CLIENT EDUCATION:
● Conduct sputum specimen collection.
● Cancer cells might not always be found in
sputum specimens when cancer is present.

Thoracoscopy, bronchoscopy,
mediastinoscopy

EXPECTED FINDINGS
● Presence of cancer cells
● Can include biopsy of tumor or
lymph nodes

NURSING ACTIONS
● Keep client NPO after midnight.
● Provide throat lozenges or sprays for
report of a sore throat once the gag reflex
returns following procedure.

X‑ray, CT scan (92.4)

Most lung lesions are first found on
chest x‑ray.

EXPECTED FINDINGS: Presence of tumor.

Thoracentesis with pleural
biopsy; MRI, PET scan

EXPECTED FINDINGS: Presence of cancer
and metastatic disease

Pulmonary function tests and arterial blood gases

EXPECTED FINDINGS: Compromised respiratory status

PATIENT‑CENTERED CARE

nursIng care
● Monitor nutritional status, weight loss, and anorexia.

◯ Promote adequate nutrition to provide needed calories
for increased work of breathing and prevention
of infection.

◯ Encourage fluids to promote adequate hydration.
● Maintain a patent airway and suction as needed.
● Position the client in Fowler’s position to

maximize ventilation.

medIcatIons
Bronchodilators and corticosteroids can be given to help
decrease inflammation and to dry secretions.

92.4 Lung cancer chest x‑ray

Online Image: Lung Cancer Chest X‑ray

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620 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

tHeraPeutIc Procedures

Chemotherapy

Chemotherapy is the primary choice of treatment for lung
cancers. It is often used in combination with radiation
and/or surgery. Platinum compounds, such as cisplatin,
are commonly used.

ADVERSE EFFECTS: Nausea, vomiting, hair loss, mucositis,
neutropenia, thrombocytopenia, peripheral neuropathy

Photodynamic therapy (92.2)

Photodynamic therapy is performed through bronchoscopy
to treat small, accessible tumors.

Radiation therapy (92.2)

Radiation therapy is effective for lung cancer that has
not spread beyond the chest wall and is used as an
adjuvant therapy.

Radiofrequency ablation (92.2)

Most commonly used with NSCLC.

Targeted therapy (92.2)

Commonly used to treat non‑small cell lung cancer

Surgical interventions
● The goal of surgery is to remove all tumor cells,

including involved lymph nodes.
● Often involves removal of a lung (pneumonectomy), lobe

(lobectomy), segment (segmentectomy), or peripheral
lung tissue (wedge resection).

● Surgery is reserved for early stage lung cancer (I or II)
with no metastasis.

NURSING ACTIONS
● Monitor vital signs, oxygenation (SaO2, ABG values), and

for evidence of hemorrhage.
● Manage the client’s chest tube. Clients who have a

pneumonectomy might have a clamped chest tube on
the operative side without a drainage system. For other
lung surgeries, the chest tube should have a drainage
system attached. (Refer to CHAPTER 18: CHEST TUBE

INSERTION AND MONITORING.)
● Administer oxygen and manage the ventilator

if appropriate.
● Manage pain. Teach the client regarding PCA use

if prescribed.

CLIENT EDUCATION: Understand the surgical procedure
and chest tube placement.

Palliative procedures
● Thoracentesis or pleurodesis to ease breathing
● Laser therapy and photodynamic therapy can be used

in treatment and palliative therapy to open airways
blocked by tumors.

● Pericardiocentesis or pericardial window to improve
cardiac function

● Oxygen therapy to correct hypoxemia

InterProfessIonaL care
● Respiratory services should be consulted for

inhalers, breathing treatments, and suctioning for
airway management.

● Rehabilitation care can be consulted if the client
has prolonged weakness and needs assistance with
increasing the level of activity.

● Provide information for psychosocial support,
particularly for clients who have a poor prognosis.

cLIent educatIon
● Take rest periods as needed.
● Eat high‑calorie foods to promote energy.
● Consider cessation if smoking tobacco or using

tobacco products.

COMPLICATIONS

Empyema

Presence of purulent fluid collecting in the pleural space.

Bronchopleural fistula

Development of a tunnel between the pleura and
bronchial tree.

NURSING ACTIONS: Position the client according to the
prescription to prevent complications. The prescription
should specify whether to lay on the operative or
nonoperative side.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 621

Oral cavity and
oropharyngeal cancer

● Oral and pharyngeal carcinoma are more lethal than
many types of cancer (cervical, testicular, thyroid,
Hodgkin’s lymphoma).

● Mouth lesions that do not heal within 2 weeks can be
cancerous and should be reported to a provider.

● Oropharyngeal cancer has a high rate of recurrence.

Main types of oropharyngeal cancer

Squamous cell carcinoma is the most common oral cancer
and can be present on the lips, tongue, buccal mucosa,
and oropharynx.

Basal cell carcinoma affects the lips and skin around
the mouth.

Kaposi’s sarcoma is a form of cancer that affects the
endothelial cells of small blood vessels. Oropharyngeal
lesions can be found on the hard palate, gums, tongue,
or tonsils. Lesions can also occur on the skin, and in the
gastrointestinal tract and lungs. Lesions appear as raised,
purple nodules or plaques.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Schedule dental visits twice yearly for cleaning and
inspection of mouth tissues.

● Limit exposure to ultraviolet rays (mid‑day sun
exposure, indoor tanning).

● Eliminate tobacco use.
● Limit alcohol consumption.

ASSESSMENT

rIsK factors
● Male sex
● Tobacco use
● Alcohol consumption (alcohol use combined with

tobacco use significantly increases risk)
● Radiation exposure, including x‑rays of head and neck
● Inadequate oral hygiene
● Lack of fruits and vegetables in the diet
● Occupation in textile, coal, metal, and plumbing industries
● Age older than 40 years
● Human papilloma virus (HPV16) infection
● Periodontal disease with mandibular bone loss
● TP53 gene mutation
● Weakened immune system

eXPected fIndIngs
● Mucosal erythroplasia (red, raised, eroded patches):

earliest finding
● Color changes in the mouth
● Oral bleeding
● Difficulty chewing or swallowing
● Speech changes
● Thick or absent saliva
● Palpable masses or thickening lump in the cheek
● Facial paresthesia
● Lesions that do not heal within 2 weeks
● Lesions in the buccal mucosa and gingiva for clients

who smoke pipes or cigars, or use smokeless tobacco
● Lesions in the floor of the mouth, soft palate complex,

or ventrolateral tongue in clients who smoke cigarettes
and drink alcohol

dIagnostIc Procedures

Biopsy: fine‑needle, incisional, excisional

EXPECTED FINDINGS: Presence of cancer

Cell brushing

EXPECTED FINDINGS: Presence of cancer

CLIENT EDUCATION: A brush will be used to collect cells
from suspicious areas in the mouth.

Toluidine blue 1% staining

EXPECTED FINDINGS: Malignant oral lesions retain
blue stain

CLIENT EDUCATION: False positives are possible with
inflammatory lesions.

MRI, CT scan

EXPECTED FINDINGS
● Presence of cancer
● Thickness of lesion
● Presence of nerve involvement
● Possible metastasis

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622 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE
Protecting the airway and providing adequate nutrition are
priority interventions in managing oropharyngeal cancer.

nursIng care
● Monitor for adequate clearance of secretions (have the

client turn, cough, deep breathe; suction as needed).
● Auscultate for adventitious lung sounds: wheezes (due to

aspiration) or stridor (due to obstruction).
● Consult respiratory therapy to provide chest

physiotherapy, as indicated.
● Position the client in semi‑ or high‑Fowler’s position to

promote chest expansion.
● Use a cool mist face tent to promote clearance of

secretions and reduce inflammation.
● Assess for difficulty swallowing.
● Administer steroids to reduce inflammation; administer

antibiotic if infection is present
● Perform oral hygiene every 2 hr (use an ultra‑soft brush

or foam brush for a client who has a platelet count less
than 40,000/mm3).

medIcatIons
● Medications that block growth factor receptors prevent

tumor growth (cetuximab, erlotinib).
● Antibiotics for infection as indicated

InterProfessIonaL care
● Provide alternate means of communication for clients

who have impaired communication (pen and paper,
picture boards). Consult speech therapy, as indicated.

● Consult nutrition services to assess swallowing and
provide nutrition recommendations, as needed.

tHeraPeutIc Procedures
Radiation and/or chemotherapy is used to treat
oral lesions.

Chemotherapy

Used in conjunction with other treatments

Targeted therapy (92.2)

Ablation (cryotherapy, photodynamic therapy) (92.2)

Used to remove lesions.

Radiation (external, implanted, or both)

Commonly used prior to surgery to reduce tumor size.
● External radiation is used cautiously to minimize

radiation dose to the brain and spinal cord.
● Implanted radiation is used to cure early lesions on the

floor of the mouth or anterior tongue.
● Hospitalization is typically required until radiation

dosing is complete.
● Place client on radiation transmission precautions. See

CHAPTER 91: CANCER TREATMENT OPTIONS.
● Provide tracheostomy care if needed. Tracheostomy can

be required due to edema and increased oral secretions.

Photodynamic therapy (92.2)

Tumor excision

Used to remove lesions through the inside of the mouth or
through external entry into the head and neck.

● The larger the tumor, the greater the risk to the client
for disfigurement and loss of function.

● Composite resections are the most extensive form of
oral carcinoma surgery. They can include partial or total
glossectomy and partial mandibulectomy.

● Combined neck dissection, mandibulectomy,
and oropharyngeal resection can be used
(“commando” procedure).

● Radical neck dissection can include removal of the
sternocleidomastoid muscle, internal jugular vein,
cranial nerve XI (accessory nerve), and all cervical
lymph nodes on the affected side.

● Surgery to remove large lesions can also include
placement of a tracheostomy or wound drain.

NURSING ACTIONS
● Provide clear liquid diet for 24 hr (clients having small

lesions removed locally).
● Maintain NPO status until intraoral suture lines heal

(clients who have large tumors).
● Provide routine tracheostomy care and suctioning,

as appropriate.
● Monitor wounds, incision sites, and donor grafting sites

for evidence of infection.
● Consult a speech language pathologist for clients who

have slurred speech or difficulty speaking.
● Provide comfort to clients who have permanent loss of

voice or disfigurement. Make a referral to counseling
services, as indicated.

● Monitor for effective swallowing and adequate nutrition
once oral intake begins.

CLIENT EDUCATION
● Avoid mouthwashes containing alcohol or lemon‑glycerin

swabs (acidic) to prevent pain and worsening of
condition.

● Rinse mouth frequently with warm sodium bicarbonate or
0.9% sodium chloride solution.

● Alternate means of communication, such as message
boards, will be required following surgery.

● Keep the head of the bed elevated to reduce edema.
● Report leakage of fluid from the suture line, swallowing

difficulty, or coughing once oral intake is resumed.
● Perform swallowing exercises regularly, as prescribed.
● Thicken liquids prior to consumption, as indicted.
● Continue thorough, frequent oral hygiene at home,

cleansing the toothbrush after each use.
● Temporary or permanent loss or changes in taste (dislike

of meats, metallic taste) can occur with treatment.
● Follow up regularly with the provider to screen for other

disorders, due to an increased risk of cancer of the lung,
mouth, or throat.

COMPLICATIONS
Osteonecrosis (bone death) and issues related to motor
impairment of jaw structure

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 623

Colorectal cancer
● Colorectal cancer (CRC) is cancer of the rectum or colon.

Most CRCs are adenocarcinoma, a tumor that arises
from a gland in the epithelial layer of the colon.

● Adenocarcinoma begins as a polyp and is benign in the
early stages. If left untreated, the polyp will grow and
the risk of malignancy increases.

● CRC can metastasize (through blood or lymph) to
the liver (most common site), lungs, brain, or bones.
Spreading can occur as a result of peritoneal seeding
(during surgical resection of tumor).

● The most common location of CRC is the
rectosigmoidal region.

HEALTH PROMOTION/
DISEASE PREVENTION

● Consume a diet rich in calcium (calcium binds
to free fatty acids and bile salts in the lower
gastrointestinal tract).

● Consume diet low in fat and simple carbohydrates but
high in fiber.

● Age‑specific regular colorectal cancer screening
● Genetic testing for familial adenomatous polyposis

and hereditary nonpolyposis colorectal cancer for
those whose family members have had hereditary
colorectal cancer

● Engage in a healthy lifestyle, including regular physical
exercise and no smoking or excessive alcohol use.

ASSESSMENT

rIsK factors
● Adenomatous colon polyps
● African American descent
● Inflammatory bowel disease (ulcerative colitis,

Crohn’s disease)
● High‑fat, low‑fiber diet
● Age older than 50 years; 1 in 7 new diagnoses are in

adults younger than 50
● Long‑term smoking
● Physical inactivity
● Heavy alcohol consumption
● Infection exposure to Helicobacter pylori, Streptococcus

bovis, John Cunningham virus, and human
papilloma virus

● Personal or family history of cancer

eXPected fIndIngs
● Changes in stool consistency or shape (with or without

noticeable blood)
● Blood in stool (many times the only finding)

◯ Left‑sided tumors are more likely to produce frank
bleeding and change in bowel pattern, consistency.

◯ Right‑sided tumors cause stools to be darker due to
ulceration of the colon and intermittent bleeding.

● Cramps and/or gas

● Palpable mass (elicited by provider only through
abdominal palpation or digital rectal exam)

● Weight loss and fatigue
● Vomiting
● Abdominal fullness, distention or pain
● Abnormal bowel sounds indicative of obstruction

(high‑pitched tinkling bowel sounds)
● Rectal pain
● Sensations of bowel fullness after defecation

dIagnostIc Procedures
● Virtual colonoscopy can be performed using CT scan

or MRI. Imaging is performed after air is injected into
the colon. The procedure is otherwise noninvasive. No
sedation is required.

● Fecal testing is recommended every year if the
guaiac‑based fecal occult blood testing or fecal
immunochemical testing is used, or every 3 years if the
stool DNA test is used.

● Screening guidelines for individuals with polyps or a
family history of CRC should be initiated at an earlier
age and possibly performed more frequently.

Guaiac‑based fecal occult blood testing (FOBT)

EXPECTED FINDINGS: Two positive stools within 3 days

NURSING ACTIONS
● Do not use stool from digital rectal examination to

avoid false‑positive results.
● Negative results to not completely rule out the

possibility of CRC.

CLIENT EDUCATION: Avoid red meat, anti‑inflammatory
medications, and vitamin C for 48 hr prior to testing (to
prevent false positives).

Fecal immunochemical test

Stool DNA

Biopsy (endoscopic)

EXPECTED FINDINGS: Definitive diagnosis

Endoscopy: colonoscopy, sigmoidoscopy

EXPECTED FINDINGS: Visualization of polyps or lesions
(CT guided scan more accurate)

CLIENT EDUCATION: Conduct screening between ages 50
and 75 (colonoscopy every 10 years, sigmoidoscopy every
5 years). At age 40 years, discuss individual risk with the
provider to determine the need to screen earlier or more
often. At 75 years, discuss with the provider whether to
continue screenings.

Double contrast barium enema

This procedure uses the two contrasts of air and barium.

EXPECTED FINDINGS: Visualization and location of tumor

NURSING ACTIONS: Administer stimulant laxative
following procedure as prescribed (facilitates evacuation
of barium, which can harden in the intestine).

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624 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

CBC

EXPECTED FINDINGS: Decreased hemoglobin, hematocrit

Carcinoembryonic antigen (CEA)

EXPECTED FINDINGS: Positive (denotes malignancy; not
specific to CRC)

CLIENT EDUCATION: Positive CEA can be indicative of
many types of cancer.

CT, MRI

EXPECTED FINDINGS: Visualization and location of tumor
and/or metastasis

PATIENT‑CENTERED CARE

tHeraPeutIc Procedures

Chemotherapy

Typically prescribed for clients who have stage III and IV
tumors; prescribed for some clients who have a stage I
tumor, depending on genetic findings.

Targeted medication therapy (92.2)

Monoclonal antibodies
● Angiogenesis inhibitors (inhibit growth of new blood

vessels to tumors): bevacizumab
● Tyrosine kinase inhibitors (decrease cell proliferation

and increase cell death of certain cancers): cetuximab
and panitumumab

Adjuvant therapy

Given to decrease the chance of metastases for stage II
and distant metastases for type III cancers.

Radiation therapy

Radiation therapy helps to minimize localized
manifestations around the tumor. Radiation can also be
used as a palliative measure to control pain, hemorrhage,
bowel obstruction, or metastatic disease.

Surgical interventions

Colon surgery is performed using an open or laparoscopic
approach. Following tumor excision, the colon might
be reconnected (end‑to‑end anastomosis), a colostomy
created (temporary or permanent), or a coloanal reservoir,
or J‑pouch, created temporarily.

Colon resection (colectomy): Involves removal of a portion
of the colon to excise the tumor

Colectomy: Removal of the colon with a temporary or
permanent colostomy or ileostomy

Abdominal‑perineal (AP) resection: The tumor, sigmoid
colon, rectum, and anal sphincter are removed, and the
client has a permanent sigmoidostomy.

PREOPERATIVE CLIENT EDUCATION
● Understand the preoperative diet (clear liquids several

days prior to surgery).
● Complete bowel prep with cathartics as prescribed.
● Understand the administration of antibiotics (neomycin,

metronidazole) to eradicate intestinal flora.

POSTOPERATIVE NURSING ACTIONS
● Assess the stoma (should be reddish pink, moist, small

amount of blood postoperatively) and report ischemia,
necrosis, or frank bleeding. (92.5)

● Manage pain and teach the client regarding PCA.
● Maintain nasogastric suction (decompression).
● Progress the diet slowly after suctioning is discontinued

and monitor the client’s response (bowel sounds present,
no nausea or vomiting).

● Discuss possible incontinence and sexual dysfunction
with the client. Ask if the client has body
image concerns.

● Provide ostomy teaching (findings of ischemia
to be reported to the provider, expected output,
appliance management) if applicable. See CHAPTER 47:

GASTROINTESTINAL THERAPEUTIC PROCEDURES for care of
an ostomy.

● Management of a colostomy can be more difficult for
the older adult client due to impaired vision and a
decline in fine motor skills.

POSTOPERATIVE CLIENT EDUCATION
● Understand the care of the incision, activity limits, and

ostomy care, if applicable.
● Avoid heavy lifting. Plan to resume normal activity

in 1 to 2 weeks following laparoscopy, or 4 to 6 weeks
following open surgery.

● Consider joining an ostomy support group, locally
or online.

InterProfessIonaL care
● Ostomy nurse referral for instruction on care

of colostomy
● Referral to ostomy support group
● Case manager or social worker for ongoing client and

family support

COMPLICATIONS
Second primary colorectal tumor or complete
intestinal obstruction.

Online Image: Healthy Stoma

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 625

Pancreatic cancer
● Pancreatic carcinoma has vague manifestations and

is usually diagnosed in late stages after liver or gall
bladder involvement.

● Tumors are usually adenocarcinoma, originate in the
pancreatic head, and grow rapidly in glandular patterns.

● It has a high mortality rate. Five year survival
rates are low.

ASSESSMENT

rIsK factors
● Possible inherited risk
● Older than 45 years of age, male sex
● More likely in African American clients
● Tobacco use
● Chronic pancreatitis
● Cirrhosis
● High intake of red meat (especially processed);

high‑fat diet
● Long‑term exposure to gasoline and pesticides
● Diabetes mellitus
● Family history of pancreatic cancer

eXPected fIndIngs
● Boring back and abdominal pain that radiates to the

back, that is sometimes relieved by sitting up and more
severe at night

● Fatigue
● Anorexia
● Pruritus

PHYSICAL ASSESSMENT FINDINGS
● Weight loss
● Palpable abdominal mass, enlarged
gallbladder and liver

● Hepatomegaly, splenomegaly
● Jaundice (late finding)
● Clay colored stools
● Dark, frothy urine
● Ascites
● Pruritus (buildup of bile salt)
● Early satiety or anorexia
● Glucose intolerance
● Gastrointestinal bleeding
● Flatulence

dIagnostIc Procedures
Biopsy (percutaneous or laparoscopic)

EXPECTED FINDINGS: Presence of cancer cells; holds
some risk of seeding (not always performed if imaging
shows tumor can be surgically removed)

Endoscopic retrograde
cholangiopancreatography (ERCP)

EXPECTED FINDINGS: Definitive diagnosis of tumor

CLIENT EDUCATION: A biliary drain or stent can be placed
during the procedure.

Abdominal paracentesis

EXPECTED FINDINGS: Presence of malignant cells in
abdominal fluid

CLIENT EDUCATION: Understand care of dressing at
puncture site and activity restrictions, as prescribed.

Imaging

EXPECTED FINDINGS: Ultrasound, MRI, or CT
visualization of the tumor during biopsy. Spiral (helical)
CT is the most used test for diagnosing and staging.

NURSING ACTIONS: Prepare client and explain
unexpected findings.

Tumor markers

CA 19‑9

Carcinoembryonic antigen (CEA)

EXPECTED FINDINGS: Positive (denotes non‑specific
malignancy)

CLIENT EDUCATION: CA 19‑9 or CEA can indicate many
types of cancer.

Other laboratory testing

EXPECTED FINDINGS: Amylase, lipase, alkaline
phosphatase, and bilirubin elevated

NURSING ACTIONS: Elevated liver enzymes, albumin, and
bilirubin can indicate primary or metastatic cancer.

92.5 Healthy stoma

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626 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

nursIng care
● Care of a client who has pancreatic cancer usually

focuses on palliation and not curative measures. Pain
management is the priority intervention. Advise
the client to ask for analgesics before the pain
becomes severe.

● Monitor blood glucose and administer insulin
as prescribed.

● A jejunostomy is often placed to provide enteral
feedings (prevents reflux, promotes absorption). Provide
nutritional support (enteral supplements, TPN).

NURSING ACTIONS: Increase feeding as tolerated,
monitoring frequency of diarrhea.

tHeraPeutIc Procedures

Chemotherapy, radiation

Used to shrink tumor size. Several medications are
given to improve the results. Administered instead of
surgery in some clients; otherwise before or after surgical
intervention.

Targeted therapy

Opioid medications

The client often reports extreme pain. High doses of
opioid medications are often required.

Surgical interventions

Can be open or laparoscopic.

Surgical interventions can be considered potentially
curative or palliative.

Partial pancreatectomy: Used to remove tumors less than
3 cm in diameter.

Total pancreatectomy: Removes the entire pancreas.

Whipple procedure (pancreaticoduodenectomy): Removal
of the head of the pancreas, duodenum, parts of the
jejunum and stomach, gallbladder, and possibly the spleen.
The pancreatic duct is connected to the common bile duct,
and the stomach is connected to the jejunum.

NURSING ACTIONS
● Monitor NG tube and surgical drains for color

and amount.
● Monitor for bloody or bile‑tinged drainage, which could

indicate anastomotic disruption.
● Place the client in semi‑Fowler’s position to facilitate

lung expansion and to prevent stress on the suture line.
● Monitor blood glucose and administer insulin as needed.

CLIENT EDUCATION: Understand the support measures for
pain, anorexia, weight loss, and community resources.

Palliative to relieve or prevent manifestations

Stent placement: A stent is placed to keep the bile duct
open and resists compression from the surrounding cancer.

Bypass surgery: Reroutes the flow of bile from the
common bile duct, bypassing the pancreas and into the
small intestines.

COMPLICATIONS
Clients who have an open Whipple procedure are at risk for
many complications (extensive blood loss, hypervolemia,
fluid and electrolyte imbalances, uncontrolled blood
glucose, kidney failure, third spacing of fluids, respiratory
distress, ileus, obstruction). Intensive care is usually
prescribed.

Fistulas

Breakdown of a site of anastomosis

NURSING ACTIONS: Report drainage that is not
serosanguineous from the drain, or drainage from the
wound to the provider immediately.

Peritonitis

Internal leakage of corrosive pancreatic fluid

NURSING ACTIONS
● Monitor for manifestations of peritonitis (elevated fever,

WBC, abdominal pain, abdominal tenderness/rebound
tenderness, alteration in bowel sounds, shoulder pain).

● Administer antibiotics as prescribed.

Thromboembolism

Due to hypercoagulable state caused by release of necrotic
products from the tumor, immobility postoperatively

NURSING ACTIONS
● Report findings of thromboembolism to the provider.
● Administer anticoagulants as prescribed.
● Maintain bed rest as indicated.

InterProfessIonaL care
● Case manager or social worker for continued care and

possible palliative interventions
● Counselors or spiritual support personnel to assist the

client and family with coping

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 627

Liver cancer
Cancers can be primary tumors originating in the liver
or metastatic cancers that spread from other organs
to the liver. Liver cancer most often is the result of
metastasis of other cancer types. Primary liver cancer is
infrequent.

Hepatocellular carcinoma (HCC) is the most frequently
occurring type of primary liver cancer. Primary
liver cancer can also originate in the bile duct or
liver vasculature.

Intrahepatic cholangiocarcinomas: Cancer that starts in
the cells that line the small bile ducts

Angiosarcoma/hemangioma: Rare cancer that starts in
cells lining the blood vessels of the liver

Hepatoblastoma: Rare cancer that develops in children,
typically younger than 4 years old

HEALTH PROMOTION AND
DISEASE PREVENTION

● Avoid excessive alcohol intake.
● Eat a low‑fat diet and maintain a BMI less than 30.
● Receive a hepatitis B vaccination.
● Take precautions against hepatitis B and C. (Recognize

that multiple sexual partners, IV drug use, and the
sharing of needles all increase risk.)

ASSESSMENT

rIsK factors
● Older age
● Cirrhosis

◯ Chronic hepatitis B or C infection
◯ Alcohol‑related liver disease
◯ Hemochromatosis (inability to breakdown iron)

● Male sex
● Tobacco use
● Mediterranean or Asian (particularly
Vietnamese) heritage

● African American or Hispanic clients

eXPected fIndIngs
● Right upper quadrant abdominal pain; epigastric

or back pain
● Loss of appetite
● Weakness and fatigue

PHYSICAL ASSESSMENT FINDINGS
● Edema
● Weight loss
● Enlarged liver upon palpation
● Jaundice
● Ascites
● Pruritus
● Encephalopathy
● Bleeding or bruising; anemia

dIagnostIc Procedures

Biopsy

Percutaneous or through the jugular to the hepatic veins
(via fluoroscopy)

EXPECTED FINDINGS: Presence of cancerous cells

NURSING ACTIONS
● Position the client to the right side for 1 to 2 hr to

ensure hemostasis.
● Monitor for hemorrhage (coagulation studies,

frank bleeding).

CLIENT EDUCATION: Biopsy through venous route reduces
the risk of hemorrhage.

Alpha‑fetoprotein (AFP)

EXPECTED FINDINGS: Elevated AFP: high probability of
cancer (false positive: cirrhosis, hepatitis); elevated CEA
along with elevated AFP can discriminate metastatic from
primary cancer.

CLIENT EDUCATION: False positives are possible.

Other laboratory testing

EXPECTED FINDINGS: Alkaline phosphatase (ALP),
serum aspartate aminotransferase (AST), albumin, and
bilirubin: elevated

CLIENT EDUCATION: Understand the other reasons liver
function tests might be elevated.

Imaging: contrast‑enhanced ultrasound or CT scan

EXPECTED FINDINGS: Visualization of tumor biopsy

NURSING ACTIONS: Monitor for bleeding if biopsy is
performed.

PATIENT‑CENTERED CARE

nursIng care
● Observe for potential bleeding complications (frank

bleeding, decreased hemoglobin and hematocrit, altered
coagulation findings).

● Administer blood products (packed red blood cells
and fresh frozen plasma) to replace blood volume and
clotting factors as prescribed by the provider.

● Encourage the client to consume small, frequent meals
that are high‑calorie, moderate fat.

● Replace vitamins due to the inability of the liver to store
them (vitamin pills or vitamin‑enriched supplements).

● Restrict fluids for clients who have ascites.
● Instruct the client on the benefits of avoiding alcohol

(prevents further damage, allows for healing and
regeneration of the liver, decreases risk of bleeding and
other life‑threatening complications).

● Measure abdominal girth daily (indicates
increased ascites).

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628 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

● Assess for adequate nutrition (fluid and electrolytes,
weight loss, anorexia).

● Monitor for worsening hepatic function (liver function
tests, jaundice).

● Assess and treat pain and abdominal discomfort.
● Provide medications as prescribed. Medications are

administered sparingly (especially opioids, sedatives,
and barbiturates) due to impaired liver function
(reduced ability to metabolize medications).

medIcatIons
Targeted therapy (sorafenib)

● A multi‑tyrosine kinase inhibitor taken orally and used
to treat advanced liver cancer.

● CLIENT EDUCATION: Report bleeding, heart palpitations,
or chest pain.

Hepatic arterial infusion
● The direct infusion of chemotherapy via a catheter into

the tumor. The client can go home with a catheter in
place if continuous infusion is desired. Systemic adverse
effects of chemotherapy are avoided through this
delivery method.

● CLIENT EDUCATION: Watch for evidence of infection
at the catheter site, hepatic toxicity (jaundice, liver
function tests), and immunosuppression (fatigue,
decreased WBC).

systemically delivered chemotherapy has
been found to be largely ineffective in treating
tumors of the liver or prolonging life. therefore,
more direct delivery methods are used.

tHeraPeutIc Procedures

Hepatic artery embolization

Using a catheter threaded through the femoral artery
and up to the liver, particles are injected into the arteries
that supply blood to the tumor to block blood flow. If
a chemotherapeutic drug is included, this procedure is
called chemoembolization. If radiation is included, this
procedure is called radioembolization.

NURSING ACTIONS: Monitor for bleeding.

Ablation procedures

Can be used to destroy cancerous cells.
● Radiofrequency ablation delivers an electric current

directly to the tumor via thin needles. This current is
converted into heat waves that kill the cancer cells.

● Percutaneous alcohol (ethanol) injections directly into
the tumor mass to cause cell death.

● Cryotherapy uses liquid nitrogen injected directly into
the tumor to destroy the tumor.

● Microwave thermotherapy uses microwaves transmitted
through a probe to heat and destroy the abnormal tissue

NURSING ACTIONS
● Monitor for hypothermia, bile leak, and hemorrhage.
● Monitor urine for myoglobinuria.

Tunneled abdominal drain

Can be placed and used at home to remove excess
ascetic fluid.

CLIENT EDUCATION
● Empty the drain and maintain the system.
● Do not remove more than 2,000 mL at one time to

prevent hypovolemia shock.

Chemotherapy

Useful for small, metastatic lesions

External radiation

Although liver cancer cells are sensitive to radiation, the
treatment cannot be used at very high doses because
normal liver tissue is also easily damaged.

Surgical Interventions

Surgical resection or liver transplantation is required for
long‑term survival.

Surgical resection: If liver cancer involves only one lobe
of the liver, surgical removal can be indicated. A liver‑lobe
resection can result in a survival rate of up to 5 years.
Most liver tumors are not resectable.

Liver transplantation: Can be an option for clients who
have small primary tumors. A resection of liver from a
living donor might be used, as it will grow to meet the
demands of the recipient.

● Immunosuppressants that are given after the transplant
can increase the risk for recurrence of cancer and for
development of secondary infection.

● For interprofessional care, see CHAPTER 91: CANCER

TREATMENT OPTIONS.

NURSING ACTIONS
● Inform the client about diagnostic tests that are done

to determine if the liver cancer has metastasized (chest
x‑ray, PET scan, MRI, laparoscopy).

● Monitor for altered blood glucose due to stress on the
liver caused by surgery.

● Monitor for bleeding, and replace fluids and blood
as necessary.

COMPLICATIONS
● Acute graft rejection following liver transplantation
● Liver failure or kidney failure (due to impaired blood

flow to the kidneys)

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 629

Kidney and renal
pelvis cancer

● Adenocarcinoma of the kidney, or renal cell cancer (RCC),
is the most common form of kidney cancer.

● Paraneoplastic syndromes (syndromes resulting from
cancer in the body) can occur with RCC. The tumor
can produce hormones or prevent hormone production,
causing imbalance in the body. Effects include:

◯ Anemia (reduced erythropoietin)
◯ Erythrocytosis (excess erythropoietin)
◯ Hypercalcemia (tumor production of

parathyroid hormone)
◯ Liver dysfunction
◯ Increased sedimentation rate
◯ Hypertension (increased renin)

● RCC can be discovered when imaging studies or
exploratory surgery are performed for other reasons.

● RCC that spreads to the inferior vena cava has a
poor prognosis.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Minimize exposure to chemicals (environmental).
● Stop use of tobacco products.

ASSESSMENT

rIsK factors
● Von Hippel‑Lindau syndrome
● Exposure to lead, cadmium, or phosphate
● Age (55 to 60 years: highest incidence)
● Family history of kidney, bladder, ureter, prostate gland,

uterus, ovary, or appendix cancer.
● Genetic and hereditary risk factors
● African American and American Indian clients
● Tobacco use

eXPected fIndIngs
● Smoky or cola‑colored urine
● Hematuria (late finding)
● Hormonal changes: darkening of nipples or

gynecomastia in men
● Inability to urinate or weak urine stream (urinary

tract obstruction)
● Abdominal or flank pain (often dull, aching)
● Palpable mass
● Renal bruit (possible)
● Weight loss
● Fever
● Hypertension

dIagnostIc Procedures

Hematologic studies

EXPECTED FINDINGS
● Hgb/Hct: decreased
● Ca: elevated
● ESR: elevated
● ACTH: elevated
● hCG: elevated
● BUN/creatinine: elevated
● LFTs: increases

NURSING ACTIONS: Inform client regarding
lab‑specific findings

Urinalysis

EXPECTED FINDINGS: Hematuria (possible)

CLIENT EDUCATION
● Understand the other reasons for hematuria.
● Remember the role of the kidneys in red blood

cell production.
● Understand the other reasons for elevated ESR.

Biopsy (percutaneous through the flank)

EXPECTED FINDINGS: Positive for cancer

NURSING ACTIONS
● Provide the client with diagnosis‑specific information.
● Maintain client activity restrictions as prescribed (bed

rest laying prone for at least 6 hr).

Nuclear imaging: IV urogram with nephrograms

EXPECTED FINDINGS
● Presence of tumor
● Increased (possible)

NURSING ACTIONS
● Prepare the client for the procedure (keep NPO, assess

for contrast dye allergy).
● Inform the client of other reasons for increased LFTs.

Imaging: CT, MRI, PET scans

EXPECTED FINDINGS: Identify tumor borders and presence
in surrounding tissue

NURSING ACTIONS: Prepare the client for imaging.

PATIENT‑CENTERED CARE

nursIng care
Monitor urine output and laboratory findings (BUN, serum
creatinine, urinalysis) to assess renal function of the
unaffected kidney.

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630 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

tHeraPeutIc Procedures

External beam radiation

External beam radiation uses radiation from a source
outside of the body to destroy cancer cells.

Targeted therapy (92.2)

Immunotherapy (biotherapy) (92.2)

Ablation therapy for kidney cancer
● Cryoablation uses a probe to deliver cold gases

to the tumor
● Radiofrequency ablation uses high‑energy radio waves

to heat and destroy the tumor
● Arterial embolization uses a catheter to deliver material

to block the artery that feeds the kidney with the tumor

Chemotherapy

Chemotherapy uses anti‑cancer drugs administered orally
or intravenously to destroy cancer cells. Kidney cancer
cells are usually resistant to chemotherapy. However,
chemotherapy can be used after targeted medication
or immunotherapy.

Surgical interventions

Clients undergoing surgery for RCC are at increased risk
for bleeding due to the highly vascular nature of RCC.

Nephrectomy is the standard of treatment for RCC.
● Ribs can be removed during surgery to allow better

access to the kidney or tumor.
● Surgical entry can be transthoracic, lumbar, or

abdominal. A wound drain can be placed.
● Adrenal glands are left intact, when possible.
● The unaffected kidney must be able to sustain adequate

renal function.

NURSING ACTIONS
● Perform routine postoperative monitoring, including

incision and drain care. Some clients require intensive
care monitoring for the first 48 hr.

◯ Monitor for evidence of bleeding (hypotension,
decreased urine output, altered level of consciousness).
Blood can pool under the client’s back.

◯ Monitor for adrenal insufficiency (nausea, vomiting,
diarrhea, hypoglycemia, hypotension).

◯ Monitor hemoglobin, hematocrit, and WBC every 6 to
12 hr for first 24 to 48 hr.

◯ Monitor urine output to evaluate remaining kidney
function (30 to 50 mL/hr).

CLIENT EDUCATION
● Avoid lifting more than 5 lb or engaging in

strenuous activity.
● Understand measures to protect the function of the

remaining kidney (control blood pressure, drink
adequate fluids, limit NSAID use, stop smoking).

COMPLICATIONS

Adrenal insufficiency

Manifestations of adrenal insufficiency are similar to
those of hemorrhage (hypotension, decreased urine output,
altered level of consciousness). This is a life‑threatening
emergency.

● Hypotension and decreased volume of urine output are
preceded by an increased volume of urine output.

● Other manifestations include hyperkalemia, abdominal
pain, and weakness.

NURSING ACTIONS
● Notify the provider of suspected adrenal insufficiency.
● Administer corticosteroids, as prescribed.
● Monitor ECG for dysrhythmia.
● Administer medications to remove excess potassium,

and avoid potassium‑sparing medications.
● Monitor capillary blood glucose hourly.
● Prevent and treat hypoglycemia (administer glucose,

glucagon, or IV fluids containing dextrose) as prescribed.
● Administer IV fluids to offset volume depletion.

Spinal cord decompression

Urinary bladder cancer
(urothelial cancer)

● Bladder cancer begins most often in the cells that line
the bladder called urothelium or transitional epithelium
layer. Although bladder cancer is the name commonly
used for urothelial cancers, the urothelial cells can
also be located in the kidney, renal pelvis, urethra,
and ureters.

● There are four layers of the bladder wall: transitional
epithelium (innermost layer), lamina propria,
muscularis propria, and fatty connective tissue. As
cancer advances, it grows through the next layer.

● Bladder cancer can be invasive (cancer cells grow
outside of the transitional epithelium) or noninvasive
(cancer cells remain in the transitional epithelium layer).
Bladder cancer is often described based on how far it
invades the bladder wall.

● Transitional cell carcinoma can be further classified as
papillary or flat based on how it grows.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Use personal protective equipment (PPE) when handling
chemicals, paints, fertilizers, gases, or items that
contain certain environmental chemicals.

● When working with chemicals is unavoidable, shower
and don clean clothing after task completion.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 631

ASSESSMENT

rIsK factors
● Frequent contact with rubber, paint, or electric cable
● Inhalation of gas, fumes, or chemical compounds
● Tobacco use
● Schistosoma haematobium (parasite) infection
● Long‑term cyclophosphamide use
● Male sex
● Chronic urinary tract inflammation
● Most common after 60 years of age

CAUSES OF CHRONIC BLADDER IRRITATION: UTI, kidney
and bladder stones, or chronic bladder catheters

eXPected fIndIngs
● Hematuria
● Dysuria, frequency, urgency (infection or

obstruction present)
● Weight loss
● Anorexia
● Abdominal asymmetry or bladder distention
● Pelvic, back, or abdominal pain

dIagnostIc Procedures

Biopsy (cystoscopic)

EXPECTED FINDINGS: Presence of cancer

NURSING ACTIONS: Prepare the client for cystoscopy.

Bladder wash

EXPECTED FINDINGS: Presence of cancerous cells in saline
“wash” solution (definitive diagnosis)

CLIENT EDUCATION: Saline will be instilled into the
bladder, then retrieved for microscopic examination.

Imaging: CT, MRI scan

EXPECTED FINDINGS
● CT scan: extent of tumor invasion
● MRI: depth and spread of tumor

NURSING ACTIONS: Prepare the client for imaging.

Nuclear imaging

IV (excretory) urography and pyelography

EXPECTED FINDINGS: Possible changes in structure or
function of the urinary tract

NURSING ACTIONS: Keep the client NPO prior to the
procedure, and check for allergy to contrast media.

Urinalysis

EXPECTED FINDINGS: Microscopic or gross hematuria

CLIENT EDUCATION: Understand the other possible
reasons for hematuria.

PATIENT‑CENTERED CARE

tHeraPeutIc Procedures

Intravesical treatments

Intravesical chemotherapy: Chemotherapy medications
are put directly into the bladder. Many of these same
medications are also administered systemically.

Intravesical immunotherapy (92.2)
● Interferon are substances infused into the bladder to

stimulate the immune system
● Bacillus Calmette‑Guérin (BCG)

◯ BCG is a live virus compound commonly used to
vaccinate high‑risk individuals against tuberculosis.

◯ BCG is infused into the bladder and retained for 2 hr
to prevent recurrence to superficial cancer cells.

NURSING ACTIONS
● After the 2 hr dwell time, the urinary catheter is

removed and the client is instructed to sit to void. This
position prevents urine splashing, reducing the risk
of contamination.

● Provide or assist in perineal cleansing.

CLIENT EDUCATION
● Restrict fluids for 4 hr prior to infusion therapy.
● Do not share a toilet with anyone for 24 hr after

treatment. At that time, disinfect the toilet by pouring a
10% bleach solution in the bowl, allowing it to sit 15 min,
then flushing and wiping off the toilet seat.

● If a private toilet is not possible, disinfect the toilet each
time following voiding.

● Urinate in a sitting position to avoid splashes.
● If only one toilet is in the home, allow the bleach

solution to sit for 15 min, then flush and clean it.
● Wash clothing and linen that comes in contact with

urine for 24 hr following infusion.
● Avoid sexual intercourse for 24 hr following the infusion.

Systemic chemotherapy

Can be used alone or in combination with radiation.
Chemotherapy can be given before surgery (neoadjuvant)
or after surgery (adjuvant).

External beam radiation (92.2)

This can cause radiation cystitis.

Surgical interventions
● Surface excision, transurethral resection of bladder

tumors, and partial cystectomy (removal of part of the
bladder) are used to treat small, confined tumors.

● Radical cystectomy with removal of surrounding tissue
or muscle is used for large, invasive, or recurrent
tumors. Intensive care can be required following
extensive bladder repair. Ureters are diverted to another
location. (92.6)

● Internal or external drains or catheters can be
placed intraoperatively.

● Clients who have neobladder surgery are at risk for
extreme weight loss.

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632 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

● Radical cystectomy with lymph node dissection includes
the removal of other pelvic structures.

◯ In males, the removal of the seminal vesicles and
prostate with possible urethrectomy and removal of
tissue surrounding these structures

◯ In females, the removal of the ovaries, fallopian tubes,
lower ureters, uterus, cervix, anterior vaginal wall,
and urethra

● Postoperatively, the client might have a Penrose drain,
catheter in the stoma, pouch around the stoma, or a
drainage tube in the nephrostomy.

NURSING ACTIONS
● Consult enterostomal therapy to assist with

management and client/family education related to
urinary diversion.

● Provide adequate nutrition, snacks, and supplements
to clients who have bladder reconstruction. Consult
nutrition services as needed.

● Monitor output from drains or catheters for expected
color and amount.

● Notify the provider if urine is decreased or absent in a
client who has an external pouch.

● Secure the client’s external drainage catheter. Notify
the provider if it becomes dislodged or removed.

● Monitor urinary output in the pouch or drains.
● Following sigmoidostomy surgery, inform all clients

that they will have to sit on the toilet to pass urine
through the rectum.

CLIENT EDUCATION
● Self‑catheterize and plan procedure at timed intervals

because there is no sensation of bladder fullness
(neobladder, continent pouch).

● Monitor peristomal skin for redness, excoriation, or
infection (ileal conduit, continent in pouch).

COMPLICATIONS

Hydronephrosis
● Inability to eliminate urine causes dilation of the

renal pelvis.
● A tumor that blocks the urinary tract can prevent

urinary elimination.

NURSING ACTIONS: Notify the provider if urine output is
decreased or absent.

InterProfessIonaL care
● Ostomy nurse referral for instruction on care of urinary

diversion or neobladder
● Referral to ostomy support group
● Nutrition consult for clients following neobladder surgery
● Ostomy nurse referral for instruction on care of colostomy
● Referral to ostomy support group
● Counseling for clients regarding body image or sexual

functioning

Breast cancer
● Breast cancer is the second‑leading cause of cancer

deaths in females in the U.S.
● Breast cancer in males is rare. Average onset age

68 years. Can present as a hard, painless mass.
Gynecomastia can be present.

● Breast cancer can be noninvasive (in situ) or invasive
(most common). Common sites of metastasis are bone,
lung, brain, and liver.

● Triple‑negative breast cancer is an aggressive form
of cancer in which cells lack receptors for estrogen,
progesterone, and HER2.

● Breast cancer rates are expected to increase over the
next 50 years due to the increase of the older adult
population.

Noninvasive breast cancers

Ductal carcinoma in situ (DCIS)
● Cancer cells are located in the duct and have not

invaded surrounding tissue.
● DCIS cells lack the biologic capacity to metastasize

Lobular carcinoma in situ (LCIS)
● Abnormal cell growth occurs in the

milk‑producing glands
● Can increase risk of developing a separate breast cancer

at a later time
● Managed with observation
● When other risk factors exist, prophylactic treatment

(tamoxifen, raloxifene, or mastectomy) can be
considered: cancer originates in the mammary ducts
and grows in the epithelial cells lining the ducts.

92.6 Urinary diversions

DIVERSION PORTAL OF EXIT URINARY ELIMINATION

Ureterostomy ureters skin continuous drainage into external pouch

Ileal conduit Ileum abdominal stoma continuous drainage into external pouch

Continent pouch (ileal
reservoir, Kock pouch)

Pouch created from
large intestine abdominal stoma

Penrose drain and catheter might be
present until sutures heal.
client performs intermittent urinary catheterization.

Bladder reconstruction
(neobladder)

Pouch created from
small intestine urethra client performs intermittent urinary catheterization.

Ureterosigmoidostomy Large intestine anus during bowel movement

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 633

Invasive breast cancers

Infiltrating ductal carcinoma
Can present as a lump, skin dimpling or edematous
thickening and pitting of breast skin (orange peel)

Inflammatory breast cancer (IBC)
● Can present as swelling, skin redness, and breast pain.
● Seldom presents as a lump and might not be present on

a mammogram

HEALTH PROMOTION AND
DISEASE PREVENTION

● Consume at least five servings of fruits and
vegetables daily.

● Obtain screening mammography.
● Maintain healthy weight.
● Engage in regular physical exercise.
● Minimize alcohol intake.
● Breast feeding for a year or more decreases breast

cancer risk.
● Avoid hormone replacement therapy.
● Avoid environmental estrogens.

ASSESSMENT

rIsK factors
● High genetic risk

◯ Inherited mutations of BRCA1 and BRCA2 (65%
lifetime risk for females, 7% for males)

● History of previous breast cancer
● Dense breast tissue
● Biopsy confirmed atypical hyperplasia
● Early age at diagnosis
● Female sex (less than 1% of males develop breast cancer)
● Age over 65
● First‑degree relative who has breast cancer
● Females

◯ Early menarche
◯ Late menopause
◯ Nulliparity or first pregnancy after age 30

● Males
◯ Testicular disorders

● Use of oral contraceptives
● High‑fat diet (possible risk)
● Low‑fiber diet (possible risk)
● Excessive alcohol intake (possibly related to folic

acid depletion)
● Cigarette smoking
● Exposure to low‑level radiation
● Hormone replacement therapy
● Obesity
● African American and Puerto Rican females are at

highest risk for triple‑negative breast cancer

eXPected fIndIngs
● Breast change (appearance, texture, presence of lumps)
● Breast pain or soreness

PHYSICAL ASSESSMENT FINDINGS
● Skin changes (peau d’orange) (92.7)
● Dimpling
● Breast tumors (usually small, irregularly shaped, firm,

nontender, and nonmobile)
● Increased vascularity, erythema
● Nipple discharge
● Nipple retraction or ulceration
● Enlarged lymph nodes
● Male clients often report a mass around the areola that

is hard and painless, nipple inversion, ulceration or
swelling of the chest. Lymphedema and gynecomastia
might be present.

dIagnostIc Procedures
Clients should focus on breast self‑awareness, being
aware of breast size, shape, and changes that occur as
hormones cycle. Awareness helps clients detect changes
earlier. Self‑breast examination is one tool that can be
used to promote breast self‑awareness.

MALES: Breast cancer in males is often diagnosed later,
with a poorer prognosis. Males at increased risk should
discuss a screening plan with the provider.

FEMALES who have breast changes or at high risk should
be screened earlier and more frequently. These clients
should also have an MRI performed.

Breast self‑examination (BSE),
clinical breast exam (CBE)

EXPECTED FINDINGS: Palpable tumors or lesions

CLIENT EDUCATION
● Have regular CBE (every 3 years age 20 to 39; yearly over
40 years of age).

● Perform BSE monthly as a part of breast self‑awareness.

Biopsy (open or fine‑needle)

EXPECTED FINDINGS: Definitive diagnosis of cancer
cell type. Sentinel lymph node biopsy can be performed
during surgery.

CLIENT EDUCATION: Provide diagnosis‑specific
information.

Stereotactic biopsy

Nonsurgical needle biopsy for breast tissue in which
affected tissue is visualized via client lying prone on
special table with mammogram machine underneath.

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634 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

Genetic testing

EXPECTED FINDINGS
● BRCA1 and BRCA2: presence of gene mutation increases

breast cancer risk
● HER2: presence of excess HER2 (normal gene

that causes cell replication) indicates the need for
targeted therapy.

CLIENT EDUCATION: Consider genetic testing for BRCA1
and BRCA2 if at risk (two first‑degree relatives diagnosed
with breast cancer prior to age 50 or family history of
breast and ovarian cancer).

Mammography, tomosynthesis (3D mammography)

EXPECTED FINDINGS: Visualization of the lesion

CLIENT EDUCATION: Consider additional
diagnostic testing.

MRI, ultrasound (US), CT scan, x‑ray

EXPECTED FINDINGS: Visualization of lesions.
Mammography is preferred over x‑ray; MRI and US can
provide better visualization of lesions for clients who have
dense breasts.

NURSING ACTIONS: Prepare client for imaging.

Nuclear imaging: breast‑specific gamma imaging

EXPECTED FINDINGS: Visualization of the lesion

CLIENT EDUCATION: Scanning will display the uptake of
the radioactive substance injected prior to the procedure.

Positron emission mammography (PEM)

Type of PET scan

EXPECTED FINDINGS: Visualization of the lesion

CLIENT EDUCATION: PEM provides consistent images
despite hormone fluctuations.

Serum testing

Liver enzymes, serum calcium, and alkaline phosphatase

EXPECTED FINDINGS: Metastatic disease

CLIENT EDUCATION: Provide diagnosis‑specific
information.

PATIENT‑CENTERED CARE

tHeraPeutIc Procedures
Adjuvant therapy follows surgery to decrease the risk of
reoccurrence.

Complementary and integrative therapies

Complementary and integrative therapies can help clients
who have breast cancer. These include biologically based
therapies (vitamins, cancer diets, herbal remedies), prayer,
guided imagery, aromatherapy, acupuncture, massage, and
journaling. Encourage clients to discuss these with the
provider and seek licensed practitioners to promote safety.

Hormone therapy

Most effective in cancer cells with estrogen or progesterone
receptors. This type of cancer has a better prognosis.

Ovarian ablation: Luteinizing releasing hormone (LH‑RH):
leuprolide or goserelin

● Inhibits estrogen synthesis.
● Can be used in premenopausal clients to stop or prevent

the growth of breast tumors.

Selective estrogen receptor modulators (SERMs):
toremifene (tamoxifen and raloxifene)

● Used in females who are at high risk for breast cancer or
who have advanced breast cancer.

● Suppress the growth of remaining cancer cells
postmastectomy or lumpectomy.

● Tamoxifen has been found to increase the risk of
endometrial cancer, deep‑vein thrombosis, and pulmonary
embolism. Raloxifene does not share these adverse effects.

92.7 Breast changes: Peau d’orange

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 635

Chemotherapy/radiation therapy
● Chemotherapy and/or radiation can augment or replace

a mastectomy, depending on several factors (client’s
age, hormone status related to menopause, genetic
predisposition, and staging of disease).

● Clients who undergo chemotherapy are usually given a
combination of several medications (cyclophosphamide,
doxorubicin, and fluorouracil).

● Radiation therapy is usually reserved for clients who
had a lumpectomy or breast‑conserving procedure.

◯ Whole or partial breast radiation can be prescribed.
Skin care is a priority concern due to radiation
damage and generalized fatigue.

◯ Brachytherapy with radioactive seeds can also be
an option.

◯ Intraoperative radiation therapy allows an intense dose
of radiation to be delivered directly to the surgical site.

● Target therapy is most effective in breast cancer
with HER2/neu gene. Trastuzumab, pertuzumab, and
ado‑trastuzumab emtansine (a) are signal transduction
inhibitors. They inhibit proteins that are signals for
cancer cells to grow.

● Clients who have metastatic cancer can receive a vascular
endothelial growth factor inhibitor, such as bevacizumab (v).
This medication reduces blood flow to the growing tumor.

Surgical interventions
● Surgical procedures include lumpectomy

(breast‑conserving), wide excision or partial mastectomy,
total mastectomy, modified radical mastectomy (lymph
nodes removed), radical mastectomy (lymph nodes and
muscle removed), and reconstructive surgery. (92.8)

● Clients often have breast conserving surgery through
the same day surgery unit.

NURSING ACTIONS
● Have the client sit with the head of the bed elevated 30°

when awake and support their arm on a pillow. Lying on
the unaffected side can relieve pain.

● Have the client wear a sling while ambulating (to
support arm).

● Avoid administering injections, taking blood pressure, or
obtaining blood from the client’s affected arm. Place a sign
above the client’s bed regarding these precautions.

● Emphasize the importance of a well‑fitted breast
prosthesis for a client who had a mastectomy.

● Provide emotional support to the client and family.
● Encourage the client to express feelings related to

perception of sexuality and body image.
● Monitor surgical drains, which can be used with

lumpectomy and modified radical mastectomy surgeries.

92.8 Total mastectomy with lymph node dissection

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636 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

CLIENT EDUCATION
● Care for the incision and drainage tubes. (Drains are

usually left in for 1 to 3 weeks.)
● Avoid placing the arm on the surgical side in a dependent

position. This position will interfere with wound healing.
● Perform early arm and hand exercises (squeezing a rubber

ball, elbow flexion and extension, and hand‑wall climbing)
to prevent lymphedema and to regain full range of motion.

● Do not to wear constrictive clothing and avoid cuts and
injuries to the affected arm.

● Conduct BSE.
● Report numbness, pain, heaviness, or impaired motor

function of the affected arm to the surgeon.
● Discuss breast reconstruction alternatives with

the surgeon.
◯ Reconstruction can begin during the original breast
removal procedure or after some healing has occurred.

◯ A tissue expander (a saline‑filled implant that has a
port through which additional saline can be injected,
gradually expanding the tissue prior to permanent
implant) is often placed during the original procedure.

◯ Saline or silicone implants are used for
permanent placement.

◯ Autologous flaps can also be used for reconstruction.
◯ Nipple reconstruction can be done using tissue from
the labia, abdomen, or inner thigh.

● Genetic counseling for clients who test positive for the
BRCA1/BRCA2 genetic mutation includes
recommendation of bilateral mastectomy and
oophorectomy to prevent cancer occurrence. Clients who
do not choose this option should have early, frequent,
thorough screening for breast and ovarian cancer.

● Community resources are available for emotional
support, particularly regarding changes in body image.

● Discuss concerns about sexuality or sexual functioning
following surgery. If sexual intimacy is desired,
planning to engage in sexual activity when feeling
less tired can be helpful, or using physical closeness to
promote intimacy during times of fatigue.

Other procedures

Stem cells (autologous or allogeneic) can be used to
treat clients who are at high risk of recurrence or have
advanced disease.

InterProfessIonaL care
● Reach for Recovery or other support programs can assist

with coping.
● Discuss options for prosthesis, dressing, and

breast reconstruction.

COMPLICATIONS
● Destruction of part of the chest wall and mastitis.
● Lymphedema can occur in the arm on the side of

surgery. Once it develops, it can be difficult to manage.

Ovarian cancer
● Ovarian cancers are epithelial tumors that grow on the

surface of the ovaries.
● The tumors grow quickly and are often bilateral.
● Metastases frequently occur before the primary ovarian

malignancy is diagnosed. There is a high recurrence
rate of ovarian cancer, after which it is treatable but
not curable.

● Ovarian cancer is the leading cause of death from
female reproductive cancers.

● The exact etiology of ovarian cancer is unknown.
However, the more times a woman ovulates in her
lifetime seems to be a risk factor because ovarian cancer
is more prevalent in females who have early menarche,
late‑onset menopause, nulliparity, and those who use
infertility agents.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Birth control pills and pregnancy can offer protection
against ovarian cancer (reduced estrogen exposure).

● Risk‑reducing or prophylactic bilateral
salpingo‑oophorectomy helps protect females who have
BRCA1 or BRCA2 mutations against ovarian cancer

● Although regular exams are recommended, it is difficult
to palpate ovarian tumors during a pelvic exam

ASSESSMENT

rIsK factors
● Age greater than 40 years; risk increases with age
● Nulliparity or first pregnancy after 30 years of age
● Family history of ovarian, breast, or genetic mutation

for hereditary nonpolyposis colon cancer (HNPCC)
● BRCA1 or BRCA2 gene mutations
● Diabetes mellitus
● Early menarche/late menopause
● Endometriosis
● High‑fat diet
● Infertility
● Older adult clients following surgery for cancer

eXPected fIndIngs
● Abdominal pain or swelling
● Abdominal discomfort (dyspepsia, indigestion, gas,

distention)
● Abdominal mass
● Urinary frequency
● Unexpected weight loss
● Vaginal bleeding
● Urinary frequency or incontinence

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 637

dIagnostIc Procedures
● There is no specific test for ovarian cancer.
● Staging of ovarian cancer is determined at the time of

the hysterectomy or exploratory laparotomy when the
tumor is removed and examined by the pathologist.

Physical assessment

EXPECTED FINDINGS: Enlarged ovary (possible if tumor is
at least 4 inches)

CLIENT EDUCATION: Understand the possible causes of an
enlarged ovary.

Biopsy

EXPECTED FINDINGS: Presence of cancer cells

CLIENT EDUCATION: Biopsy is usually performed during
surgery to remove the tumor.

Genetic testing

EXPECTED FINDINGS: BRCA1 and BRCA2: Presence of gene
mutation increases ovarian cancer risk.

CLIENT EDUCATION: Genetic testing can be used to
determine risk of developing ovarian cancer, but it is
not used to diagnose or monitor treatment. Some clients
who have these genetic mutations elect to have bilateral
salpingo‑oophorectomy to prevent ovarian cancer.

Tumor markers

EXPECTED FINDINGS
● Germ cell tumors: Human chorionic gonadotropin (hCG),

alpha‑fetoprotein (AFP), and lactate dehydrogenase
(LDH) elevated

● Epithelial tumor: Cancer antigen‑125 (CA‑125) elevated
(greater than 35 units/mL)

CLIENT EDUCATION
● Unexpectedly high hCG levels can occur in germ cell

ovarian cancer.
● Unexpected AFP findings indicate probability of cancer

(false positive: cirrhosis, hepatitis).
● Unexpected CA‑125 findings indicate possible cancer

(false positive: endometriosis, pregnancy, fibroids, and
menses). More testing or surgery will likely be required.

Transvaginal ultrasound, MRI,
chest x‑ray, CT or PET scan

EXPECTED FINDINGS: Metastatic disease

CLIENT EDUCATION: Understand the implications of
metastatic disease and offer emotional support.

PATIENT‑CENTERED CARE

tHeraPeutIc Procedures

Chemotherapy (traditional or intraperitoneal)
● Cisplatin and carboplatin are the most common

chemotherapeutic medications used for ovarian cancer.
● Intraperitoneal therapy with dwell time, a form of

intracavitary chemotherapy, can be used.

Surgical interventions

Exploratory laparotomy can be performed to diagnose,
treat, and stage ovarian tumors. Debulking (cytoreduction)
of very large tumors can be done laparoscopically.

A total abdominal hysterectomy (TAH) with bilateral
salpingectomy and oophorectomy (BSO) is the usual
treatment for ovarian cancer. TAH with BSO also helps
determine the extent of the disease as well as local and
distant metastases. Staging of the cancer is done at
this time.

NURSING ACTIONS
● Observe for urinary retention and difficulty voiding.
● Assess bowel sounds. Paralytic ileus can occur due to

manipulation of the bowel during surgery.
● Discuss sexuality, surgically induced menopause, and

other self‑image issues with the client.

CLIENT EDUCATION
● Avoid straining, driving, lifting more than 5 lb,

douching, and participating in sexual intercourse until
the provider gives release.

● Immediately report evidence of infection, as well as
vaginal discharge that is excessive or has a foul odor.

COMPLICATIONS
Abdominal ascites and intestinal obstruction

Uterine (endometrial) cancer
● Endometrial cancer is the most common

gynecological cancer.
● Endometrial cancer is more common in older adult

females (related to prolonged exposure to estrogen).
● Estrogen therapy in postmenopausal clients who have a

uterus should include progesterone to decrease the risk
of endometrial cancer.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Avoid the use of unopposed estrogen when considering
postmenopausal hormone replacement therapy.

● Avoid smoking.

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638 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

ASSESSMENT

rIsK factors
● Family history of endometrial or colorectal cancer
● Personal history of breast or ovarian cancer
● Diabetes
● Genetic mutation for HNPCC
● Obesity (due to fat cell production of estrogen)
● Unopposed estrogen hormone replacement therapy
● Nulliparity
● Use of tamoxifen to prevent or treat breast cancer
● Late menopause (longer‑term exposure to significant

estrogen levels)
● Smoking
● Uterine polyps

eXPected fIndIngs
● Irregular and/or postmenopausal bleeding
● Low‑back, abdominal, or low pelvic pain

dIagnostIc Procedures

Biopsy

EXPECTED FINDINGS: Endometrial biopsy: presence
of carcinoma

CLIENT EDUCATION: Biopsy is usually performed through
transvaginal ultrasound.

Pathology testing for staging

EXPECTED FINDINGS: Extent, size of tumor,
and metastasis

CLIENT EDUCATION: This occurs after exploratory
laparotomy or hysterectomy following tumor removal.

Genetic testing

EXPECTED FINDINGS: HNPCC testing: presence of the gene

CLIENT EDUCATION: The presence of HNPCC increases the
risk of carcinoma.

Tumor markers

EXPECTED FINDINGS
● Alpha‑fetoprotein (AFP): elevated
● Cancer antigen‑125 (CA‑125): positive

CLIENT EDUCATION: Results indicate some type of
carcinoma.

Transvaginal ultrasound and endometrial biopsy

Endometrial thickness and presence of carcinoma. This is
the standard test for diagnosis.

Other assessments to determine metastatic cancer

Chest x‑ray, intravenous pyelography, abdominal
ultrasound, CT of the pelvis, MRI of the abdomen/pelvis,
and liver and bone scans

PATIENT‑CENTERED CARE

tHeraPeutIc Procedures

Radiation therapy
● Given as adjuvant therapy, usually after a hysterectomy.
● Brachytherapy and external radiation therapy can be

options for cancer that is no longer limited to the uterus.

Brachytherapy: delivered inside the body
● An applicator is placed in the vagina, then the

radioactive isotope is placed in the applicator for several
minutes. This can occur two to 10 times a week. The
client must remain in bed during the treatment.

● CLIENT EDUCATION
◯ Report vaginal bleeding, urethral burning, hematuria,
fatigue, diarrhea, fever or abdominal pain

◯ Understand that there is no radioactivity between
treatments and there are no restrictions on
interactions with others.

External beam radiation therapy (EBRT): delivered
outside the body

● Can be used in combination with surgery, brachytherapy,
and/or chemotherapy

● Often given for 4 to 6 weeks on an outpatient basis

Chemotherapy

Often given as a palliative therapy for when cancer has
recurred, or involves distant metastasis.

Surgical interventions

Total hysterectomy with bilateral salpingectomy/
oophorectomy is the standard treatment. The vagina is
spared, allowing for sexual intercourse to continue.

● An open, laparoscopic, or vaginal approach can be used.
● Peritoneal fluid sampling during this procedure allows

for testing of metastasis to the peritoneal cavity.
A radical hysterectomy might be required. This includes
removal of the pelvic lymph nodes and upper third of
the vagina.

NURSING ACTIONS
● Observe for urinary retention and difficulty voiding due

to proximity to the urethra (more common after vaginal
hysterectomy).

● Monitor bowel sounds for paralytic ileus (more common
due to manipulation of the bowel during surgery).

● Discuss sexuality, surgically‑induced menopause, and
other self‑image issues with the client.

CLIENT EDUCATION
● Avoid straining, driving, lifting more than 5 lb,

douching, and sexual intercourse until the provider
gives release.

● Immediately report evidence of infection, excess vaginal
discharge, or foul‑smelling drainage.

● If premenopausal, consider hormone replacement
therapy options.

● Explore complementary and integrative therapies, such
as mind‑body and biologic therapies, healing touch,
herbs, vitamins, and nutrition.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 639

Cervical cancer
Cervical cancer is a slow‑growing cancer. With proper
screening, it can be detected early and treated with
good results.

Early cervical cancer is often undetected. Manifestations
do not occur until the cancer has become invasive.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Vaccination series with HPV vaccine between 9 and
26 years of age before first sexual contact

● Pap and pelvic exams for cervical cancer screening
● HPV screening (co‑testing) every 5 years for females

aged 30 to 65 years
● Limit the number of sexual partners.
● Use condoms during sexual intercourse.
● Avoid smoking.

ASSESSMENT

rIsK factors
● Infection with high‑risk HPV types (strains 16 and 18),

which is associated in 90% of cases
● Chronic cervical inflammation/infections
● Infection with HIV or other immunosuppressive disorder
● History of sexually transmitted infections
● Early sexual activity (before 18 years of age)
● Client or male partner who had multiple sexual partners
● Male partner who had a female partner with

cervical cancer
● Low economic status
● Family history of cervical cancer
● African American descent
● Cigarette smoking

eXPected fIndIngs
● Painless vaginal bleeding between menses
● Dysuria, hematuria
● Watery, blood‑tinged vaginal discharge (early finding);

dark, foul‑smelling discharge (late finding)
● Unexplained weight loss
● Pelvic pain
● Pain during and after vaginal sexual intercourse
● Rectal bleeding
● Chest pain, coughing
● Leg pain or edema (late finding)

dIagnostIc Procedures
Simultaneous PAP test and HPV testing improves the
accuracy of the reading.

Papanicolaou (Pap) test

EXPECTED FINDINGS: Abnormal cells

CLIENT EDUCATION
● Begin Pap screening by 21 years of age (or 3 years

following first sexual intercourse). Frequency of
screening depends on many factors (age, results,
presence of a cervix).

● The Pap is a screening tool and not diagnostic. An
abnormal Pap requires additional testing.

Colposcopy with biopsy

EXPECTED FINDINGS: Abnormal cells (follow‑up
to Pap test)

HPV typing: DNA test

EXPECTED FINDINGS: Presence of HPV on cervical cells

CLIENT EDUCATION: HPV increases the risk of
cervical cancer.

Chest x‑ray, MRI, CT, PET

EXPECTED FINDINGS: Metastatic/advanced disease

PATIENT‑CENTERED CARE

nursIng care
Administer antibiotics for pelvic, vaginal, or urinary
tract infections.

tHeraPeutIc Procedures

Removal of the lesion
● By conization, cryotherapy, laser ablation, hysterectomy,

or a loop electrosurgical excision procedure.
● Conization can be used as either a diagnostic procedure

or treatment in early cancer.

CLIENT EDUCATION
● Report heavy vaginal bleeding, foul‑smelling drainage,

or fever to the provider.
● Vaginal discharge is normal.
● Take showers rather than tub baths.
● Avoid heavy lifting, vaginal penetration, douches, and

tampons for the prescribed time (typically 3 weeks).

Radiation

Brachytherapy and external radiation therapy can
be options for cancer that is no longer limited to
local invasion.

NURSING ACTIONS
● Monitor for skin damage, especially in the perineal area.
● Chemotherapy can be used along with radiation.

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640 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

Surgical interventions

Hysterectomy: Clients who have early stage cervical
cancer can require a simple hysterectomy (removes the
uterus and cervix) or a radical hysterectomy (removes the
uterus, upper third of the vagina, uterosacral uterovesical
ligaments, and pelvic nodes). The choice to have a
hysterectomy is guided by the client’s condition and desire
for future childbearing. Radical hysterectomy with lymph
node resection can be as effective as radiation. Care of
a client following hysterectomy is found in CHAPTER 62:

DIAGNOSTIC AND THERAPEUTIC PROCEDURES FOR FEMALE

REPRODUCTIVE DISORDERS.

Exenteration: Clients who have extensive cancer can
require this more extensive pelvic surgery. Pelvic
exenteration can include removal of all pelvic organ and
lymph nodes, which requires construction of a urinary
and bowel diversion, as well as a vagina.

NURSING ACTIONS
● Manage drains as well as urinary and bowel diversions.
● Assess for body image disturbance and encourage the

client to speak openly about it.
● Teach the client about findings of wound infection and

how to care for drains that can remain after discharge.
● Instruct the client about how to care for urinary and

bowel diversion.
● Instruct the client about how to care for perineal

wounds and expectations regarding discharge.

CLIENT EDUCATION: Monitor vaginal bleeding. An
expected finding is one saturated perineal pad every 4 hr.

COMPLICATIONS
● Fistula development can occur after pelvic exenteration.
● Kidney infections are also common secondary to the

urinary diversion.

Prostate cancer
● Second most common type of cancer in men
● Prostate cancer is a slow‑growing cancer. Conservative

treatment can be the treatment of choice for a client, based
on how fast the cancer is growing, if the cancer has spread,
and the client’s age and life expectancy. Treatment can be
delayed up to 10 years following diagnosis.

● The posterior lobe or outer gland epithelium are
sites of origin for most prostate cancer. It is usually
slow‑growing in response to androgen (testosterone
and dihydrotestosterone).

● Manifestations are often similar to those of benign
prostatic hyperplasia.

HEALTH PROMOTION AND
DISEASE PREVENTION

● Consume a diet low in animal fat and include omega‑3
fatty acids (fish), fruits, and vegetables.

● Engage in regular exercise.
● Discuss PSA screening with a provider at age 50 years.

Clients at higher risk might need to consider starting at
age 40 years.

ASSESSMENT

rIsK factors
● History of vasectomy
● Age greater than 65 years (risk increases with age)
● Family history
● African‑American heritage
● High‑fat, complex carbohydrates or low‑fiber diet
● Hereditary prostate cancer 1 (HPC1), BRCA1, or

BRCA2 mutation
● Rapid growth of the prostate (benign high‑grade

prostatic intraepithelial neoplasia)
● Exposure to environmental toxins such as arsenic

eXPected fIndIngs
● Urinary manifestations: hesitancy, weak stream,

urgency, frequency, nocturia
● Recurrent bladder infections
● Urinary retention
● Blood in urine and semen (late manifestation)
● Painful ejaculation
● Pain, particularly bone (pelvis, spine, hips, ribs)
● Unexplained weight loss
● Loss of sexual desire or function
● Penile discharge or scrotal pain/swelling
● Significant residual urine after voiding a small

amount of urine
● Swollen lymph nodes, especially in the groin

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 641

dIagnostIc Procedures

Digital rectal examination (DRE)

EXPECTED FINDINGS: Hard prostate with palpable
irregularities

CLIENT EDUCATION: Discuss prostate screening after
age 50 with a provider.

Biopsy

EXPECTED FINDINGS
● Presence of cancer
● Staging is based on biopsy result.

◯ Gleason score of 7 or higher: moderately differentiated
◯ Gleason score 8 to 10: poorly differentiated

CLIENT EDUCATION
● PSA, age, race, and family history are used to determine

if biopsy is needed.
● Understand the diagnosis‑specific information.

Genetic testing

EXPECTED FINDINGS: Hereditary prostate cancer 1 (HPC1),
BRCA1, or BRCA2 positive

CLIENT EDUCATION: The presence of the gene increases
cancer risk.

Prostate specific antigen (PSA)

EXPECTED FINDINGS: Elevation (greater than
4 ng/mL) indicates possible prostate disease (not specific
to carcinoma).

CLIENT EDUCATION
● Discuss prostate screening after age 50.
● Have the PSA assessed prior to DRE to promote accuracy

of results.

Early prostate cancer antigen (EPCA‑2)

EXPECTED FINDINGS: Positive (possible serum maker for
prostate cancer)

CLIENT EDUCATION: Positive results are highly indicative
for prostate cancer and eliminate the need for biopsy.

Transrectal ultrasonography (TRUS)

EXPECTED FINDINGS: Visualization of lesions

CLIENT EDUCATION
● Understand the possible complications and

postprocedure care (extra fluids, no strenuous exercise,
manifestations to report).

● An enema will be administered prior to procedure.

Urinalysis

EXPECTED FINDINGS: Hematuria, bacteriuria

CLIENT EDUCATION: Understand the causes of hematuria
and bacteriuria.

Bone scan, MRI CT, x‑ray
Determines metastasis

PATIENT‑CENTERED CARE
Active surveillance can be used to monitor the client who
has prostate cancer but desires to postpone treatment.
Older adult clients or clients who have less than 5 years
life expectancy might opt to do this. The client’s condition
is monitored regularly and treatment started if the client
notices a worsening of manifestations.

medIcatIons

Sipuleucel‑T

A vaccine against cancer. Destroys existing cells and
prevents future cancer development.

Hormone therapy

Leuprolide, goserelin, triptorelin: luteinizing
hormone‑releasing hormone (LH‑RH) agonists

● Used in advanced prostate cancer to produce
chemical castration.

● CLIENT EDUCATION
◯ Be aware that hot flashes are an adverse effect.
◯ Impotence and decreased libido can also be
adverse effects.

◯ Monitor for osteoporosis, which can occur due to
testosterone suppression.

Flutamide, bicalutamide, nilutamide: androgen receptor
blocker

● Used alone or in conjunction with a LH‑RH agonist.
● CLIENT EDUCATION

◯ Gynecomastia is a possible adverse medication effect.
◯ Have liver function tests monitored frequently.

If primary medications are not successful,
high‑dose ketoconazole, an antifungal that
blocks androgen production, or estrogen
(diethylstilbestrol) can be given.

Chemotherapy

Can be used on clients whose cancer has spread or who
have had minimal improvement with other therapies.

CLIENT EDUCATION: Have routine blood tests performed
to monitor for neutropenia, leukopenia, thrombocytopenia,
and anemia.

tHeraPeutIc Procedures

Radiation

Internal (brachytherapy) or external beam (EBRT)
● External comes from a source of radiation outside the body.
● Intensity‑modulated radiation uses thousands of

beams and angles of varying intensity that are even
more controlled to target the cancer tissues and reduce
exposure of radiation to healthy tissue.

● Used as a palliative treatment or to treat cancer that
has recurred.

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642 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

CLIENT EDUCATION: Proctitis can occur following
radiation treatment. Report rectal cramping, passing
mucus or blood in the stool, or rectal urgency. Proctitis
should resolve 6 weeks following surgery.

Surgical interventions

PSA levels should reduce within a few days postoperatively.

Radical prostatectomy is the treatment of choice.
● Not likely to be beneficial if the cancer has spread

to the lymph nodes, bones, or other organs. See
CHAPTER 66: BENIGN PROSTATIC HYPERTROPHY for care
following prostatectomy.

● Involves the removal of the prostate gland, along with
the seminal vesicles, the cuff at the bladder neck, and
the regional lymph nodes.

● Open or laparoscopic surgery can be done using a
suprapubic, perineal, or retropubic approach.

● Laparoscopic can be used if PSA is less than 10 ng/mL,
no previous hormone therapy or abdominal surgery.

● Perineal nerves are seldom disrupted, so the client
should not experience sexual dysfunction. However, dry
climax can occur. Removal of tissue at the bladder neck
allows seminal fluid to travel upward rather than down
the urethral tract, resulting in retrograde ejaculation.

NURSING ACTIONS
● Provide catheter care and administer bladder

antispasmodics as prescribed.
● If the suprapubic approach was used, monitor

suprapubic catheter output. Catheter is usually removed
when residual urine measurements are less than 75 mL.

● Provide information regarding availability of a sex
therapist or intimacy counselor if needed.

CLIENT EDUCATION
● Bilateral orchiectomy might be performed as a

palliative surgery to slow cancer growth by minimizing
testosterone production.

● Discuss concerns about body image or sexuality.

InterProfessIonaL care
● Case management to facilitate provider appointments

and home care
● Support groups for client and family

COMPLICATIONS
Urinary incontinence

Erectile dysfunction

Testicular cancer
● Testicular cancer is rare and most common in clients

between the ages of 15 and 34 years.
● With early detection, testicular cancer has a 95%

cure rate.
● Testicular self‑examination is best performed during or

after a bath or shower when the scrotum is relaxed.
● Move the penis to the side, and examine one testicle

at a time.
● Hold the testicle between the thumb and fingers of both

hands, and roll it gently between the fingers.
● Look and feel for any hard lumps; smooth rounded

bumps; or change in size, shape, or consistency of
the testicle.

● It is normal for one testicle to be larger or hang lower
than the other.

● Palpation of the epididymis can feel like a lump.
● Noncancerous conditions (hydrocele, varicocele) cause

testicular lumps or swelling.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 92 cancer dIsorders 643

Active Learning Scenario

a nurse is teaching a client who has a new diagnosis
of prostate cancer. What information should the nurse
include in the teaching? use the active Learning
template: system disorder to complete this item.

MEDICATIONS: describe at least four
medications and their uses.

THERAPEUTIC PROCEDURES: describe a prostatectomy.

NURSING CARE: describe at least three nursing actions.

Application Exercises

1. a nurse is reviewing the plan of care for a client who has
leukemia and has developed thrombocytopenia. Which
of the following actions should the nurse take first?

a. Instruct the client to take rest
periods throughout the day.

B. encourage the client to reposition in bed every 2 hr.

c. check temperature every 4 hr.

d. monitor platelet counts.

2. a nurse is reviewing the medical record of a client
who has suspected ovarian cancer. Which of the
following findings should the nurse identify as a risk
factor for ovarian cancer? (select all that apply.)

a. Previous treatment for endometriosis

B. family history of colon cancer

c. first pregnancy at age 24

d. report of first period at age 14

e. use of oral contraceptives for 10 years

3. a nurse is caring for a client 24 hr following a liver
lobectomy for hepatocellular carcinoma. Which of the
following laboratory reports should the nurse monitor?

a. urine specific gravity

B. Blood glucose

c. serum amylase

d. d‑dimer

4. a nurse is providing teaching about colon
cancer to a group of females 45 to 65 years
of age. Which of the following statements
should the nurse include in the teaching?

a. “colonoscopies for individuals with no family
history of cancer should begin at age 40.”

B. “a sigmoidoscopy is recommended
every 5 years beginning at age 60.”

c. “fecal occult blood tests should be done
annually beginning at age 50.”

d. “an mrI provides a definitive
diagnosis of colon cancer.”

5. a nurse is caring for a client who has multiple
types of skin lesions. Which of the following
skin lesions are indicative of a malignant
melanoma? (select all that apply.)

a. diffuse vesicles

B. uniformly colored papule

c. area with asymmetric borders

d. rough, scaly patch

e. Irregular colored mole

6. a nurse is reviewing testicular self‑examination
with a client. Which of the following client
statements indicates understanding?

a. “It is best to examine the testicles before bathing.”

B. “It is not necessary to report small
lumps, unless they are painful.”

c. “I will examine one testicle at a time.”

d. “I will use my palms to feel for abnormalities.”

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644 CHAPTER 92 cancer dIsorders CONTENT MASTERY SERIES

Application Exercises Key

1. a. offer the client rest periods throughout the day to prevent
fatigue. However, another action is the priority.

B. encourage the client to reposition in bed every 2 hr to prevent
skin breakdown. However, another action is the priority.

c. check the client’s temperature every 4 hr to
monitor for indicators of infection. However,
another action is the priority.

d. CORRECT: the greatest risk to the client who has
thrombocytopenia is injury due to bleeding. the priority
action for the nurse to take is to monitor the client’s
platelet level to ensure it does not reach critical level.
the nurse should institute bleeding precautions.

NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission‑Based Precautions/Surgical Asepsis

2. a. CORRECT: endometriosis is a risk factor
for ovarian cancer.

B. CORRECT: a family history of breast, ovarian, or
colon cancer is a risk factor for ovarian cancer.

c. a first pregnancy after 30 years of age or
nulliparity is a risk factor for ovarian cancer.

d. early menarche is a risk factor for ovarian cancer.
e. Birth control pills offer protection against ovarian cancer.

NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention

3. a. alterations in urine specific gravity following a
liver lobectomy are not expected.

B. CORRECT: Blood glucose should be monitored during the
first 24 to 48 hr following a liver lobectomy due to decreased
gluconeogenesis and stress to the liver from surgery.

c. alterations in serum amylase following a
liver lobectomy are not expected.

d. alterations in the d‑dimer following a liver
lobectomy are not expected.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

4. a. a colonoscopy is recommended every 10 years beginning at
age 50 for a client who has no family history of cancer.

B. a sigmoidoscopy is recommended every
5 years beginning at age 50.

c. CORRECT: fecal occult blood tests should be done
annually by clients ages starting at age 50 years.

d. a biopsy performed during an endoscopic
procedure confirms this diagnosis.

NCLEX® Connection: Health Promotion and Maintenance,
Aging Process

5. a. diffuse vesicles are consistent with an allergic reaction.
B. a uniformly colored papule is consistent

with a birthmark or skin injury.
c. CORRECT: a lesion with asymmetric borders is

considered suspicious for a melanoma.
d. a rough, scaly patch is consistent with

skin irritation due to friction.
e. CORRECT: a lack of uniformity of pigmentation of a

mole is considered suspicious for a melanoma.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

6. a. examining the testicles after showering or bathing ensures the
scrotum is relaxed, and examination is more accurate.

B. the client should report any lump or swelling
to the provider as soon as possible.

c. CORRECT: the client should examine one testicle at a
time to ensure that an abnormality is not missed.

d. the client should use the thumb and fingers to
examine the testes to better detect small changes
because the fingertips are more sensitive.

NCLEX® Connection:

Active Learning Scenario Key

Using the Active Learning Template: System Disorder

MEDICATIONS
● Hormone therapy: luteinizing hormone‑releasing
hormone agonists: leuprolide acetate

● androgen receptor blocker: flutamide
● chemotherapy: docetaxel
● antifungal: ketoconazole
● estrogen: diethylstilbestrol

THERAPEUTIC PROCEDURES: Prostatectomy is the surgical
removal of the prostate gland, seminal vesicles, bladder
cuff, and regional lymph nodes. It can be done by an open
surgery or laparoscopic approach in the suprapubic, perineal,
or retropubic area. Perineal nerves are usually not disrupted,
so the client should not experience sexual dysfunction.

NURSING INTERVENTIONS
● ask if the client has concerns about body image or sexuality.
● offer to refer the client to a therapist or
intimacy counselor, if desired.

● Provide catheter care (suprapubic or urethral).
administer bladder antispasmodics.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 93 PaIn management for cLIents WHo HaVe cancer 645

UNIT 13 IMMUNE SYSTEM AND CONNECTIVE
TISSUE DISORDERS
SECTION: CANCER‑RELATED DISORDERS

CHAPTER 93 Pain Management
for Clients Who
Have Cancer

management of cancer pain is necessary
to optimize quality of life for a client who
has cancer. not all clients who have cancer
have pain.

either the tumor or the treatment can cause
cancer pain. tumor pressure or cell invasion
can cause direct tissue, bone, and nerve pain.
surgery, radiation, chemotherapy, and inactivity
can also cause cancer pain.

PAIN
● Pain is subjective and can indicate tissue injury or

impending tissue injury.
● Pain can have physical and emotional components.
● The reaction to pain varies from person to person. Age,

sex, and culture can influence it.
● Pain can be acute or chronic.

◯ Acute pain occurs suddenly and is short‑term. Acute
cancer pain can be the result of surgery.

◯ Chronic pain can result from nerve changes and lasts
longer than 3 months. Tumor growth and the effects
on surrounding tissue (destruction or pressure) cause
chronic cancer pain.

tYPes of PaIn
Neuropathic

● Due to nerve damage
● Numb, tingling, shooting, burning, or radiating

Visceral/Deep
● Occurs in internal organs
● Can be difficult to identify
● Deep, sharp pain

Somatic
● Occurs in bone or connective tissues
● Localized, sharp, dull, or throbbing

ASSESSMENT
● The most reliable indicator of pain is the client’s verbal

expression of pain.
● Use standard pain measures (location, quality, intensity,

timing, setting, associated manifestations, aggravating
or relieving factors) to assess pain.

● Pain assessment also involves observing
and documenting nonverbal indicators and
physiological changes.

NONVERBAL INDICATORS OF ACUTE PAIN
● Agitation, grimacing
● Elevated heart rate, respiratory rate, blood pressure
● Diaphoresis, pupil dilation
● Splinting of an area

NONVERBAL INDICATORS OF CHRONIC PAIN
● Depression
● Lethargy
● Anger
● Weakness

BARRIERS TO EFFECTIVE PAIN MANAGEMENT
● Inadequate pain assessment
● Inadequate education of the client about analgesic use
● Health care professionals’ lack of knowledge regarding

pharmacological pain management
● Reluctance by the client to report pain
● Fear of addiction leading to nonadherence
● Inadequate dosing

MANAGEMENT
An interprofessional team (providers, nurses, pain
management and treatment specialists) can provide
optimal pain control.

● Palliative cancer pain management provides comfort
and reduce pains rather than curing the cancer.

● The goal of palliative pain management is to reduce
pain to improve quality of life while maintaining
dignity and mental clarity.

METHODS OF PAIN MANAGEMENT: Surgery,
chemotherapy, and radiation therapy can reduce pain by
removing the tumor or reducing its size, which can alter
pressure on adjacent tissues or organs.

NURSING ACTIONS
● Nursing care is specific to each surgery or procedure.
● Include information regarding the specific procedure

or treatment.

CLIENT AND FAMILY EDUCATION
● Include the family in care and management.
● Consider joining support groups and professional

organizations (the American Cancer Society).
● Radiation: Perform specific skin care and avoid

sun exposure.
● Chemotherapy: Avoid infection, and manage other

adverse effects.

CHAPTER 93

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646 CHAPTER 93 PaIn management for cLIents WHo HaVe cancer CONTENT MASTERY SERIES

MEDICATIONS
Pharmacological management of pain includes NSAIDs,
opioids, antidepressants, anticonvulsants, corticosteroids,
and local anesthetics. Some clients who have cancer
pain require a multimodal approach to pain control, in
which two or more classes of analgesics are prescribed to
relieve pain.

Non‑opioid medications and NSAIDs
● Acetaminophen
● Ketorolac
● Aspirin (acetylsalicylic acid)
● Ibuprofen
● Celecoxib

THERAPEUTIC INTENT: For mild to moderate pain

NURSING ACTIONS
● Monitor for gastrointestinal (GI) bleeding (bloody stools,

coffee‑ground emesis).
● Monitor for bruising and bleeding.
● Do not administer acetaminophen to clients who have

liver disease. Clients who have a healthy liver should
take no more than 4 g/day. For long‑term treatment,
adults should take no more than 3 g/day.

● Monitor for tinnitus and hearing loss with NSAIDs.
● NSAIDs can cause cardiovascular adverse effects (heart

failure, dysrhythmias).

CLIENT EDUCATION
● Take with food to prevent GI upset.
● Be alert to GI or other bleeding and bruising.
● Do not crush or chew enteric‑coated products.
● Drink adequate fluids when taking NSAIDs to prevent

acute renal failure due to the effect of prostaglandins on
renal function.

Opioids
● Morphine
● Meperidine
● Hydromorphone
● Oxycodone
● Fentanyl (available for transdermal use as well as a

lozenge/sucker, buccal film and tablets, and nasal and
sublingual spray)

● Combinations, such hydrocodone with acetaminophen,
for breakthrough pain

THERAPEUTIC INTENT
● Moderate to severe pain
● Breakthrough pain

NURSING ACTIONS
● Use with caution for older adult clients.
● Manage acute severe pain with short‑term (24 to 48 hr),

around‑the‑clock administration of opioids rather than
following a PRN schedule.

● The parenteral route is best for immediate, short‑term
relief of acute pain. The oral route is better for chronic,
nonfluctuating pain.

● Monitor and intervene for adverse effects of opioid use:
constipation, orthostatic hypotension, urinary retention,
nausea, vomiting, and sedation.

● Monitor for respiratory depression.
● Have naloxone available to reverse effects.
● Administer stimulant laxatives to prevent

opioid‑induced constipation.

CLIENT EDUCATION
● Avoid driving and using hazardous equipment until the

effects of the opioid are known.
● Do not take medications with alcohol.
● Prevent constipation with diet changes and

stool softeners.
● Nausea can subside after a few days.
● Reduce the risk of orthostatic hypotension by rising

slowly from a lying or sitting position.

Antidepressants

Tricyclic antidepressants (TCAs)
● Amitriptyline
● Desipramine
● Imipramine
● Nortriptyline

Selective norepinephrine reuptake inhibitors (SNRIs)
● Venlafaxine
● Duloxetine
● Nortriptyline

THERAPEUTIC INTENT
● Reduce depression
● Promote sleep
● Increase serotonin and norepinephrine levels to improve

feelings of well‑being
● Decrease neuropathic pain

NURSING ACTIONS
● Use with caution for older adult clients.
● Use with caution for young adult clients and those who

are at risk for suicide, because antidepressants can
increase suicide risk.

● TCAs
◯ Do not administer to clients who have seizure
disorders or a history of cardiac problems.

◯ Adverse effects include dry mouth, dizziness,
mental clouding, weight gain, constipation, and
orthostatic hypotension.

● SNRIs: Adverse effects include nausea, headache,
sedation, insomnia, weight gain, impaired memory,
sweating, and tremors.

CLIENT EDUCATION
● Notify the provider if depression increases or if thoughts

of suicide occur.
● Therapeutic effects can take 2 to 3 weeks.
● Take TCAs in the evening.

Anticonvulsants
● Gabapentin
● Phenytoin
● Pregabalin
● Carbamazepine

THERAPEUTIC INTENT: Neuralgia and neuropathic pain

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 93 PaIn management for cLIents WHo HaVe cancer 647

NURSING ACTIONS
● Monitor electrolytes.
● Monitor liver function.
● Monitor blood cell counts.
● Monitor medication levels.
● Monitor for tremors.
● Monitor for rash (life‑threatening).

CLIENT EDUCATION
● Medication can cause sleepiness and dizziness.
● Avoid alcohol.
● Do not drive at the start of therapy.
● Notify the provider if rash or tremors occur.

Corticosteroids
● Prednisolone (syrup)
● Dexamethasone

THERAPEUTIC INTENT: Reduce pain by reducing swelling

NURSING ACTIONS
● Reduce dosage gradually.
● Monitor for muscle weakness, joint pain, or fever.
● Monitor glucose levels.
● Monitor for changes in behavior or confusion.

CLIENT EDUCATION
● Do not discontinue the medication suddenly.
● Take the medication with food.
● The medication weakens the immune system.
● Report any indications of infection.

Adjunctive agents: Sympatholytic agents

Clonidine

THERAPEUTIC INTENT
● Neuropathic pain
● Administered with bupivacaine in epidural or other

local infusions

NURSING ACTIONS: Monitor for hypotension.

CLIENT EDUCATION: Change positions slowly, because
these medications can cause orthostatic hypotension.

Adjunctive agents: Skeletal muscle relaxants

Baclofen

THERAPEUTIC INTENT: With other pain medications for
muscle spasms accompanying cancer pain

NURSING ACTIONS: Monitor for seizure activity.

CLIENT EDUCATION
● Take the medication with food.
● Use caution when driving or operating machinery.
● These medications can cause drowsiness and dizziness.

Systemic local anesthetics
● Lidocaine
● Bupivacaine
● Ropivacaine

THERAPEUTIC INTENT: Administered via an infusion pump
directly into the area of pain (intrathecal, intra‑articular,
intrapleural) to provide pain relief

NURSING ACTIONS
● Monitor for hypotension.
● Monitor for infection at the catheter insertion site.
● Evaluate pain status.
● Monitor for motor impairment and level of sedation.
● Administer with an opioid or another medication

(clonidine).

CLIENT EDUCATION
● Observe the infusion site for indications of infection

(redness and swelling).
● Watch for fever.
● Notify the provider of increased pain or decreased

movement that can indicate a motor block.
● Care for and protect the external part of the catheter.

Topical local anesthetics

Lidocaine (patch)

THERAPEUTIC INTENT: Block generation and conduction of
nerve impulses that transmit pain

NURSING ACTIONS: Monitor for pain relief and local skin
reactions.

CLIENT EDUCATION: Use the medication only on
intact skin.

admInIstratIon metHods

Oral
● First choice for administration
● Short‑ and long‑acting formulations available

Transdermal

Fentanyl
● Easy to administer
● Slow onset, consistent dosing
● Long duration (48 to 72 hr)

Rectal

Low WBC and platelet counts are contraindications.

Subcutaneous infusion

Morphine or hydromorphone
● Slow infusion rate (2 to 4 mL/hr)
● Requires nursing support
● Risk of infiltration
● Rapid onset

Intravenous
● Requires nursing support
● Risk of infiltration
● Rapid onset

Epidural or intrathecal
● Risk of infection, pruritus, and urinary retention
● Requires nursing care to monitor, especially with

increases in dosage
● More effective than IV analgesia during the immediate

postoperative period

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648 CHAPTER 93 PaIn management for cLIents WHo HaVe cancer CONTENT MASTERY SERIES

Sublingual/buccal
● Place sublingual forms under the tongue for absorption.
● Place buccal forms between the gum and cheek.
● Forms include tablets, films, and sprays.
● The client should refrain from drinking, eating, or

smoking when taking the medication.

Topical/local
● Place patches directly over or adjacent to the

painful area.
● Medication produces minimal systemic absorption and

adverse effects.
● Lidocaine patch remains on for 12 hr, off for 12 hr
● Monitor for local skin reactions.

ANESTHETIC INTERVENTIONS

Regional nerve blocks

Involves injecting an anesthetic agent (bupivacaine)
and/or a corticosteroid directly into a nerve root to provide
pain relief

● For identifying or treating an isolated area of pain;
for example, an intercostal nerve block treats chest or
abdominal wall pain.

● The procedure can take from 15 min to 1 hr, depending
on the area receiving the block.

NURSING ACTIONS
● Measure baseline vital signs. Monitor blood pressure

and vital signs during the procedure and for at least 1 hr
following the procedure (follow established guidelines).

● Establish IV access before the procedure.
● Monitor for manifestations of systemic infusion

(metallic taste, ringing in ears, perioral
numbness, seizures).

● Assess the insertion site for redness and swelling.
● Assess the level of nerve block and pain.
● Protect the area of numbness from injury.

CLIENT EDUCATION
● Observe the injection site for swelling, redness,

or drainage.
● Protect the area of numbness from injury and notify

the provider of increased pain or manifestations of
systemic infusion.

Epidural or intrathecal catheters
● Involves injecting a local anesthetic or analgesic into

the epidural space (the area outside the dura mater of
the spinal cord) or intrathecal space (the subarachnoid
area within the spinal cord sheath that contains
cerebrospinal fluid)

● Involves surgically placing an external catheter under
the skin with an external port for long‑term use.

◯ For chronic pain management
◯ Allows administration of a continuous infusion or
injection PRN

◯ For upper abdominal pain, thoracic pain, and pain
below the umbilicus

NURSING ACTIONS
● Monitor during and for at least 1 hr following insertion

or injection for hypotension, anaphylaxis, muscle
weakness, seizures, and dura puncture.

● Monitor for respiratory depression and sedation.
● Monitor the insertion site for hematoma, infection, and

leakage of cerebral spinal fluid.
● Assess the level of sensory block.
● Evaluate leg strength prior to ambulating.
● Local anesthetics block the sympathetic nervous system,

causing peripheral vasodilation and hypotension. This
can cause reduced stroke volume, cardiac output, and
peripheral resistance. Increase the rate of IV fluid
infusion to compensate for the sympathetic blocking
effects of regional anesthetics.

CLIENT EDUCATION
● Notify the provider of manifestations of infection (fever,

swelling, redness; increase in pain or severe headache;
sudden weakness of the lower extremities; decreases in
bowel or bladder control).

● Notify the provider of manifestations of
systemic infusion.

OTHER INVASIVE TECHNIQUES

Neurolytic ablation

Involves interrupting the nerve pathway or destroying
the nerve roots that are causing pain; usually involves
a CT‑guided probe and injection of chemicals (phenol
or ethanol)

● For example, celiac plexus nerve ablation can be
effective for pancreatic, stomach, abdominal, small
bowel, and proximal colon pain.

● The procedure is irreversible.
● Nerve ablation can provide relief for several months

until nerve fibers regenerate.
● Nerve ablation can cause loss of sensory, motor, and

autonomic function.
● Use only when noninvasive methods are ineffective.

Radiofrequency ablation

Electrical current creates heat on a probe that the provider
guides to the tumor or nerves to destroy cancer cells or
ablate nerve endings (for lung and bone tumors).

ALTERNATIVE APPROACHES
Use alternative approaches to pain management in
addition to pain medications or other techniques. Many of
these provide some pain reduction with minimal
adverse effects.

Transcutaneous electrical nerve stimulation (TENS)

Skin electrodes near or over the area of pain transmit
low‑voltage electrical impulses. The client regulates the
voltage to achieve the perception of pins and needles
(sensory perception) rather than pain.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 93 PaIn management for cLIents WHo HaVe cancer 649

NURSING ACTIONS
● Monitor electrode sites for burns and rash.
● Offer other pain medications.
● Do not use for clients who have pacemakers or

cardiac dysrhythmias.
● Remove hair before applying the electrodes.

CLIENT EDUCATION
● Place the electrodes on clean, hairless, intact skin.
● Inspect the skin under the electrodes for burns

or irritation.
● Do not use if pregnant.
● Do not use near the head or over the heart.

Spinal cord stimulation

Invasive technique reserved for those unresponsive to
other methods. Requires a surgical procedure to place
electrodes in the epidural space; the electrodes connect to
an implanted or external programmed generator.

NURSING ACTIONS: Care is the same as for clients
undergoing epidural anesthesia.

CLIENT EDUCATION: Program the device for
maximal comfort.

Relaxation techniques and imagery

Useful during a procedure or a period of increased pain
● Relaxation techniques include deep breathing,

progressive relaxation, and meditation.
● Positive imagery involves visualizing a peaceful image

with or without audio recordings.
● Relaxation and imagery can reduce anxiety, stress,

and pain, and they can assist the client to feel more in
control of the pain.

Distraction

Music, television, exercise, and family and friends can
be effective distractions from pain and stress. Other
distractions include repetitive actions or movements,
focused breathing, or use of a visual focal point. A change
of scenery can offer a distraction from pain.

Heat or cold, pressure, massage, or vibration
● Heat increases blood flow, relaxes muscles, and reduces

joint stiffness.
● Cold decreases inflammation and causes local analgesia.
● Do not use heat or cold directly on skin that has

radiation damage.
● Massage and vibration can cause relaxation, distraction,

and increased surface circulation.

Acupuncture

Acupuncture uses vibration or electrical stimulation by
inserting small needles into the skin and subcutaneous
tissues at different depths to stimulate and alter nerve
pathways. It can also increase the client’s pain threshold.

Hypnosis

Hypnosis involves using an altered state of awareness to
redirect the perception of pain. It can help induce positive
imagery, reduce anxiety, and improve coping.

Peer group support

A support group helps provide emotional support for the
client and family. Other benefits include the presence of
a social network, availability of information, and help in
strengthening coping skills.

Application Exercises

1. a nurse is caring for a client who has chronic cancer
pain and has a permanent epidural catheter for
administration of a fentanyl/bupivacaine solution.
the nurse should monitor the client for which of
the following findings? (select all that apply.)

a. respiratory depression

B. Hypotension

c. sedation

d. muscle spasticity

e. sensory blockage

2. a nurse is caring for a client who will undergo
a neurolytic ablation. the client asks the nurse
the reason for this procedure. Which of the
following responses should the nurse make?

a. “It should provide permanent pain relief.”

B. “It reduces the adverse effects
of your pain medication.”

c. “It increases your ability to fight infections.”

d. “It increases cells that stop bleeding.”

3. a nurse is caring for a client who has cancer and has
a prescription for transcutaneous electrical nerve
stimulation (tens) for pain management. Which
of the following actions should the nurse take?

a. remove hair before applying the electrodes
from the tens unit on the skin.

B. apply alcohol to the client’s skin before
attaching the electrodes from the tens unit.

c. attach the electrodes from the tens unit
over painful incisions or skin damage.

d. avoid other pain medications
when using the tens unit.

4. a nurse is caring for a client who has a prescription
for gabapentin for neuropathic pain. the nurse
should monitor the client for which of the
following adverse effects of this medication?

a. constipation

B. urinary retention

c. Insomnia

d. dizziness

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650 CHAPTER 93 PaIn management for cLIents WHo HaVe cancer CONTENT MASTERY SERIES

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT

transcutaneous electrical nerve stimulation (tens)
● monitor electrode sites for burns or rash.
● offer pain medications.
● do not use on clients who have pacemakers or dysrhythmias.
● Place electrodes on clean, hairless, intact skin. Inspect
skin under the electrodes for burns or irritation.

● do not use if the client is pregnant.
● do not use near the head or over the heart.

relaxation and imagery
● use during a procedure or during a period of increased
pain. encourage deep breathing, progressive relaxation,
meditation, or a focus on a peaceful image.

● use with or without audio recordings.
● reduces stress, anxiety, and pain, and promotes
a feeling of control of the pain.

application of heat or cold, pressure, massage, or vibration
● apply heat to increase blood flow, relax
muscles, and reduce joint stiffness.

● apply cold to decrease inflammation and produce local analgesia.
● massage can cause relaxation, distraction,
and increased surface circulation.

● do not apply heat or cold directly to skin that has radiation damage.
● avoid further skin irritation with excessive massage or vibration.

distraction
● offer music.
● encourage watching television, exercising,
and activities with family and friends.

● use repetitive actions or movements, focused breathing,
a visual focal point, and a change of scenery.

acupuncture
● Inform the client acupuncture can increase the client’s pain threshold.
● make referrals to community resources.
● Involves inserting small needles into the skin at different depths to
stimulate and alter nerve pathways. this affects the pain threshold.

Hypnosis
● Inform the client that hypnosis redirects
the client’s perception of pain.

● make referrals to community resources.
● use to induce positive imagery, reduce anxiety, and improve coping.

Peer group
● make referrals to community resources.
● encourage family participation.
● groups provide emotional support for family members and clients.
● groups offer the presence of a social network, availability
of information, and strengthening of coping skills.

NCLEX® Connection: Basic Care and Comfort,
Non‑Pharmacological Comfort Interventions

Application Exercises Key

1. a. CORRECT: respiratory depression is an adverse
effect of epidural analgesics. other adverse effects
include seizures and dura puncture.

B. CORRECT: Hypotension is an adverse effect of epidural
analgesics that can be corrected by administration of fluids.
other adverse effects include hematoma and infection.

c. CORRECT: sedation is an adverse effect of
epidural analgesics. other adverse effects
include anaphylaxis and severe headache.

d. muscle weakness, not spasticity, is an adverse
effect of epidural analgesics.

e. CORRECT: sensory blockage is an adverse effect of
epidural analgesics. other adverse effects include
decreases in bowel and bladder control.

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management

2. a. CORRECT: Inform the client that neurolytic ablation
causes permanent destruction of the nerves that
transmit pain from a specific area and is a last resort
after other methods have been unsuccessful.

B. neurolytic ablation should reduce the need for
analgesics. However, it does not reduce the
adverse effects of pain medication.

c. neurolytic ablation does not treat myelosuppression (which
reduces immunity) or increase the ability to fight infections.

d. neurolytic ablation does not treat thrombocytopenia.
the procedure can cause complications, such as
disruption of bladder and bowel function, but
it does not affect clotting mechanisms.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. CORRECT: remove the client’s hair before applying
the electrodes from the tens unit to the skin.

B. the skin should be clean and intact before
applying the electrodes, but the skin does
not have to be cleansed with alcohol.

c. apply the electrodes over intact skin that is over or near the
site of pain, but not over incisions or areas of damage.

d. administer pain medication while the
client is using the tens unit.

NCLEX® Connection: Basic Care and Comfort,
Non‑Pharmacological Comfort Interventions

4. a. monitor a client who is taking an opioid analgesic
for constipation. However, constipation is not
an adverse effect of gabapentin.

B. monitor a client who is taking an opioid analgesic
for urinary retention. However, urinary retention
is not an adverse effect of gabapentin.

c. monitor the client for sedation, rather than insomnia.
d. CORRECT: monitor the client for dizziness. Instruct the client

to avoid driving until medication effects are known.

NCLEX® Connection: Reduction of Risk Potential,
Potential for Alterations in Body Systems

Active Learning Scenario

an nurse manager is leading a discussion with a group of
nurses on the oncology unit about alternative approaches
to pain management. What information should the nurse
manager include in the discussion? use the atI active
Learning template: Basic concept to complete this item.

RELATED CONTENT
● describe four approaches.
● describe two nursing interventions for each approach.
● describe one teaching point for each approach.

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RN ADULT MEDICAL SURGICAL NURSING ncLeX® connectIons 651

NCLEX® Connections

When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:

Reduction of Risk Potential
POTENTIAL FOR ALTERATIONS IN BODY SYSTEMS:
Apply knowledge of pathophysiology to monitoring for complications.

POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC
TESTS/TREATMENTS/PROCEDURES: Position client to
prevent complications following tests/treatments/procedure.

THERAPEUTIC PROCEDURES
Provide preoperative and postoperative education.

Provide preoperative care.

Manage the client during and following a
procedure with moderate sedation.

Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS: Provide postoperative care.

UNEXPECTED RESPONSE TO THERAPIES: Promote recovery
of the client from unexpected response to therapy.

MEDICAL EMERGENCIES: Apply knowledge of pathophysiology
when caring for a client experiencing a medical emergency; Recognize
signs and symptoms of client complications and intervene.

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652 ncLeX® connectIons CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 94 anestHesIa and moderate sedatIon 653

UNIT 14 NURSING CARE OF PERIOPERATIVE CLIENTS

CHAPTER 94 Anesthesia and
Moderate Sedation

an anesthetic is a chemical agent that clients
receive prior to a surgical procedure to induce
loss of consciousness, amnesia, and analgesia.
there are different types of anesthesia for use
in the surgical setting, and the nurse should be
familiar with their adverse effects.

moderate sedation is a type of anesthesia.
a client does not lose consciousness, but still
receives induction of amnesia and analgesia.

Anesthesia
Anesthesia is a state of depressed central nervous system
(CNS) activity, with depression of consciousness, loss of
responsiveness to stimulation, and muscle relaxation.
Anesthesia is general, regional, or local.

General anesthesia causes loss of sensation, consciousness,
reflexes, and memory of the surgery. It is used for major
surgery, or one that requires complete muscle relaxation.

Regional anesthesia (local conduction or field block,
epidural, spinal or nerve block) causes reduction of
sensation in selected parts of the body due to blockage of
peripheral nerves, or the spinal cord.

Local anesthesia involves topical application of an
anesthetic agent to the skin or mucous membranes. The
term can be used to refer to any anesthesia that is not
general (monitored).

ASSESSMENT
RISK FACTORS

● General anesthesia
◯ Family history of malignant hyperthermia
◯ Respiratory disease (hypoventilation)
◯ Cardiac disease (dysrhythmias, altered cardiac output)
◯ Gastric contents (aspiration)
◯ Alcohol or substance use disorder

● Local anesthesia
◯ Allergy to ester‑type anesthetics
◯ Alterations in peripheral circulation

● Older adult clients are more susceptible than any other
population to anesthetic agents.

◯ Careful titration of medications helps control the
incidence of unwanted effects.

◯ Airway patency is the main priority in all situations,
but cardiac problems can arise much more quickly in
older adult clients.

◯ Pay specific attention when an older adult is
undergoing a procedure, because the client’s condition
can deteriorate quickly.

General anesthesia
Anesthetics for general anesthesia are either injectable or
for inhalation. Anesthetics for inhalation are volatile gases
or liquids in combination with oxygen. Anesthetists give
injectable anesthetics IV.

● Inhalation anesthetic agents include halothane,
isoflurane, and nitrous oxide in combination
with oxygen.

● IV anesthetic agents include benzodiazepines, etomidate,
propofol, ketamine, and short‑acting barbiturates
(methohexital).

◯ Propofol is the most common anesthetic agent.
◯ Clients receive propofol during mechanical ventilation,
radiation therapy, and diagnostic procedures.

◯ Allergies to eggs and soybean oil are contraindications
for receiving propofol.

● Exhalation eliminates inhalation anesthetics. The rate
of elimination depends on pulmonary ventilation and
blood flow to the lungs. Postoperative administration of
oxygen and encouraging the client to take deep breaths
are important interventions.

PHases of generaL anestHesIa
Induction: Initiation of IV access, administration of
preoperative medications given, securing of airway patency

Maintenance: Performance of surgery, airway
maintenance

Emergence: Completion of surgery, removal of assistive
airway devices

stages of generaL anestHesIa
Anesthetic effects follow four stages.

Stage I: Beginning analgesia and relaxation. The client
feels dizzy and detached with reduced sensation to pain.
Clients are sometimes sensitive to noise and stimuli.

Stage II: The client might feel delirious, act excited, and
can be loud or crying. This stage can be bypassed if
medications are given quickly enough. Pupils dilate but
still respond to light.

Stage III: Operative or surgical anesthesia. The client
has relaxed muscles and eventually loses reflexes. Vital
functions begin to reduce, sensation is lost, and the client
cannot hear. Pupils are small but reactive.

Stage IV: Dangerous level of anesthesia. Vital organ function
is depressed to the point of respiratory failure and cardiac
arrest. Pupils are fixed and death can occur. Anesthesia must
be stopped immediately. The client might receive stimulant
medications and narcotic agonists (to reverse opioids).

CHAPTER 94

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654 CHAPTER 94 anestHesIa and moderate sedatIon CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

medIcatIons
During administration of anesthetics, clients also receive
adjunct medications to achieve further reactions.

Opioids
● Fentanyl
● Sufentanil
● Alfentanil

USES
● Sedation
● Analgesics to relieve preoperative and postoperative pain

ADVERSE EFFECTS
● Depresses the CNS, resulting in respiratory depression

or distress
● Delays awakening following surgery or a procedure
● Can result in postoperative constipation and

urinary retention
● Can trigger nausea and vomiting

Benzodiazepines
● Diazepam
● Midazolam

USES
● Reduce anxiety preoperative
● Promote amnesia
● Produce mild sedation (unconsciousness) with little‑to‑

moderate respiratory depression with careful titration

ADVERSE EFFECTS: Can result in cardiac and respiratory
arrest with rapid administration or without waiting for
the full effect to develop

Antiemetics
● Ondansetron
● Metoclopramide
● Promethazine

USES
● Decrease postanesthesia nausea and vomiting
● Enhances gastric emptying (metoclopramide)
● Induces sedation (promethazine)
● Decrease the risk for aspiration

ADVERSE EFFECTS
● Dry mouth
● Dizziness
● Extrapyramidal manifestations and tardive dyskinesia

(metoclopramide)
● Respiratory depression and apnea (promethazine)

Anticholinergics
● Atropine
● Glycopyrrolate

USES
● Decrease the risk of bradycardia during surgery due to

the parasympathetic response to surgical manipulation
● Block the muscarinic response to acetylcholine by

decreasing salivation, perspiration, bowel motility, and
GI secretions

● Decrease the risk for aspiration

ADVERSE EFFECTS
● Urinary retention, difficulty starting urination
● Tachycardia
● Dry mouth

CONTRAINDICATION: Glaucoma

Sedatives
● Pentobarbital
● Secobarbital

USES
● Sedative effect for preanesthesia sedation or amnesia
● Induction of general anesthesia

ADVERSE EFFECTS: Respiratory depression

! avoid giving within 14 days of
starting or stopping an maoI.

Neuromuscular blocking agents
● Succinylcholine
● Vecuronium

USES
● Skeletal muscle relaxation for surgery
● Airway placement
● In conjunction with IV anesthetic agents (propofol,

opioids, benzodiazepines)

ADVERSE EFFECTS
● Total flaccid paralysis
● Requires mechanical ventilation because it blocks

contraction of all muscles, including the diaphragm and
respiratory system

CONSIDERATIONS
● Ensure that the client has signed a consent form,

because an adult who has received sedation cannot give
legal consent.

● Have the client urinate before receiving medication so
they will not need to get out of bed.

● Ensure that the bed is in the low position and that the
side rails are up for safety.

● Monitor airway and oxygen saturation.
● Monitor and report laboratory values (ABGs,

CBC, electrolytes).
● Monitor cardiac status (rhythm, heart rate, blood pressure).
● Monitor temperature.
● Once client is positioned on the surgical table, apply

safety belts.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 94 anestHesIa and moderate sedatIon 655

● Monitor drains, tubes, catheters, and IV access
throughout anesthesia and surgery.

● Assess level of sedation and anesthetic effects (level of
consciousness, vital signs).

● If hypotension occurs as an adverse effect of medication
or dehydration, lower the head of bed, administer an
IV fluid bolus, and monitor.

● Notify the surgeon and anesthesiologist of abnormalities.

COMPLICATIONS

Malignant hyperthermia

MANIFESTATIONS
● Acute life‑threatening medical emergency
● Inherited muscle disorder that anesthesia induces

chemically
● Hypermetabolic condition causing an alteration in

calcium activity in muscle cells (muscle rigidity,
hyperthermia, and damage to the CNS)

● Triggering agents including inhalation anesthetic
agents and succinylcholine

● Increased carbon dioxide level, decreased oxygen
saturation level, and tachycardia occur first, followed by
dysrhythmias, muscle rigidity, hypotension, tachypnea,
skin mottling, cyanosis, and muscle‑cell protein in the
urine (myoglobinuria)

● Extremely elevated temperature a late manifestation:
increasing as high as 44° C (111.2° F)

NURSING ACTIONS
● Assist with the termination of surgery.
● Administer IV dantrolene, a muscle relaxant.
● Administer 100% oxygen.
● Obtain specimens for ABGs to monitor for metabolic

acidosis and blood tests to check for hyperkalemia.
● Infuse iced IV 0.9% sodium chloride.
● Apply a cooling blanket; ice to axillae, groin, neck, and

head; and iced lavage.
● Insert an indwelling urinary catheter to monitor output

and for hematuria.
● Monitor cardiac rhythm and treat dysrhythmias.
● Transfer client to intensive care.

Anesthetic toxicity

MANIFESTATIONS
● Anesthetics and other medications can cause

complications and interactions.
● Risk of toxicity is increased for older adult clients. Other

risk factors include poor liver or kidney function.

Unrecognized hypoventilation

MANIFESTATIONS: Cardiac arrest, hypoxia, brain damage,
and death can result from failure to oxygenate and
exchange gases during surgery.

NURSING ACTIONS
● Monitor end‑tidal carbon dioxide levels.
● For equipment malfunction, manually ventilate the client.

Intubation problems

Risk factors for oral injury include small mouth, inability
to open the mouth fully, and oral tumors.

MANIFESTATIONS
● Injury to teeth, lips, and vocal cord
● Neck injury from improper neck extension during

intubation
● Sore throat

Anesthesia awareness
● The client is unexpectedly aware of what is occurring

during surgery and able to remember details after the
procedure. The client might not be able to alert the
operative team that they are awake depending on the
medications administered for sedation and muscle
relaxation.

● Prevent the occurrence by premedicating the client with
an amnesic agent and avoid the use of muscle paralytics.

MANIFESTATIONS
● Increased blood pressure, tachycardia, movement
● Medications (paralytic medications, calcium channel

blockers, beta‑blockers) can mask manifestations.

Regional anesthesia
● Used when prevention of postoperative pain is also a

desired effect (total joint replacement).
● Beneficial in emergency surgery when the client has not

been NPO for sufficient time.

metHods of admInIstratIon
Spinal: Anesthetic injection into the cerebrospinal fluid
(CSF) in the subarachnoid space to provide autonomic,
sensory, and motor blockade below the level of innervation

COMPLICATIONS
● Headache, nausea, vomiting, and pain.
● Cardiac arrest (rare). Treat unexplained bradycardia

with epinephrine to prevent cardiac arrest.

Epidural: Anesthetic injection into the epidural space in
the thoracic or lumbar areas of the spine to block sensory
pathways, but leave motor function intact

COMPLICATIONS
● High spinal anesthesia

◯ A possible complication of epidural anesthesia if the
dura is punctured.

◯ Leads to depressed respirations, respiratory arrest,
and severe hypotension.

◯ Treatment includes IV fluids, vasopressors, and
airway support.

● Headache
◯ With spinal anesthesia; the re

Nerve block: Injection of anesthetic around or into an
area of nerves to block sensation often for surgery on an
extremity or for chronic pain

Field block: Injection of anesthetic around the operative
field for procedures of the chest, plastic surgery, dental,
and hernia repairs

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656 CHAPTER 94 anestHesIa and moderate sedatIon CONTENT MASTERY SERIES

CONSIDERATIONS
● The client will be awake during the procedure.
● Staff should provide a peaceful environment and ensure

that nothing is said that the client does not need to hear.

Local anesthesia
● Examples of local anesthetic agents are procaine

and lidocaine.
● Concurrent administration of a vasoconstrictor, usually

epinephrine, prolongs effects and decreases the risk of
systemic toxicity.

metHods of admInIstratIon
Topical: Apply directly to the skin or mucous membranes.

Local infiltration: Inject directly into tissues through
which the surgeon will make an incision.

CONSIDERATIONS
● Local anesthesia cannot be used if the incision is large

and the amount of medication required to numb the
tissue would be toxic to the client.

● A rapid‑acting analgesic may be administered
simultaneously to minimize pain with injection.

● Local anesthesia is usually combined with a regional block.

comPLIcatIons
● Edema and inflammation of the injection site (early);

risk for gangrene, necrosis, and tissue abscess.
● Systemic toxicity

◯ Findings include restlessness, altered speech, blurred
vision, metallic taste, tremors, tachycardia. Can lead
to hypotension, cardiac arrest, apnea and death.

◯ Treatment includes airway support and
administration of a rapid‑acting barbiturate.

Moderate sedation
Moderate sedation is the administration of sedatives
and/or hypnotics and opioids to the point where the
client relaxes enough that the surgeon can perform minor
procedures without discomfort for the client, yet the client
can respond to verbal stimuli, retains protective reflexes
(gag reflex), is easily arousable, and—most importantly—
independently maintains a patent airway.

● Only a qualified provider can administer moderate
sedation: anesthesiologists, certified registered
nurse anesthetists, attending providers, or RNs with
certification in advanced cardiac life support (ACLS) and
are under the supervision of a qualified provider.

● Continuously monitor a client who is undergoing moderate
sedation. During the procedure, an RN who has no other
responsibilities at that time must be present to monitor the
client. This nurse must remain with the client at all times
before, during, and immediately after the procedure.

Procedures
Minor surgical procedures: dental, podiatric, cosmetic,
ophthalmic procedures

Diagnostic procedures: various types of endoscopy, bone
marrow aspiration, lumbar puncture

Cardioversion

Wound care: suturing, dressing changes, incision and
drainage of abscesses, burn debridement

Reduction and immobilization of fractures

Placement and removal of implanted devices, catheters,
and tubes

ASSESSMENT
RISK FACTORS: Older adult clients are at an increased risk
for adverse reactions to sedation because of decreased liver
and kidney function.

CONSIDERATIONS

PreProcedure
● Obtain a full history, including allergies, medication

usage, and preexisting medical conditions (pulmonary
disease). Report any previous experiences with sedation
or anesthesia, especially any adverse reactions. Note the
last dose of each medication, especially if it could alter
the client’s response (diuretic, antihypertensive, opioid).

● Perform a full assessment, including baseline vital
signs, cardiac rhythm, and level of consciousness.

● Instruct the client to adhere to the instructions to
remain NPO, or the surgeon might cancel the procedure.

● Establish IV access and administer fluids.
● Verify that the client signed the informed consent.
● Attach monitoring equipment.
● Remove dentures in case intubation becomes necessary.

IntraProcedure
● Remain with the client at all times. Allow other staff to

assist the provider with the procedure.
● Continually assess and monitor level of consciousness

(Glasgow coma scale score), cardiac rhythm, respiratory
status, and vital signs.

● Maintain a safe environment for the older adult client
due to sensory limitations.

● Pay careful attention to cardiac and respiratory status
for older adult clients, as problems can arise faster.

● Ensure the following equipment is within immediate
reach for routine monitoring and in case deep sedation
with respiratory depression occurs.

◯ Emergency cart with emergency medications, airway
and ventilatory equipment, defibrillator, and IV supplies

◯ A 100% oxygen source and administration
supplies, airways, manual resuscitation bag, and
suction equipment

◯ ECG monitor and display, noninvasive blood pressure
monitor, pulse oximeter, capnography, thermometer,
and stethoscope

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 94 anestHesIa and moderate sedatIon 657

PostProcedure
Monitor and document vital signs and level of
consciousness until the client is fully awake and all
assessment criteria return to presedation levels.

TYPICAL DISCHARGE CRITERIA
● Level of consciousness as on admission
● Vital signs stable for 30 to 90 min
● Able to cough and breathe deeply
● Able to tolerate oral fluids
● Able to urinate
● No nausea, vomiting, shortness of breath, or dizziness
● No obvious bleeding
● Capnography indicates adequate respiratory status

PATIENT‑CENTERED CARE

medIcatIons
Opioids: Morphine, fentanyl, alfentanil
Anesthetics: Etomidate, propofol
Benzodiazepines: Midazolam, diazepam

Dosages required for light sedation are highly individual
and require careful titration.

When a client receives moderate sedation, use naloxone
to reverse the adverse effects of the opioid. Administer
flumazenil to reverse the adverse effects of benzodiazepines.

CONSIDERATIONS
Before, during, and after the procedure, keep emergency
equipment at the client’s bedside.

Most hospitals and facilities require that for moderate
sedation, an RN has certification in ACLS or pediatric
advanced life support (PALS) in case of an emergency. For
complications, stop or reverse sedation and provide care to
alleviate the problem.

COMPLICATIONS

Airway obstruction, cardiac dysrhythmias,
hypotension, anaphylaxis

NURSING ACTIONS: Insert an oral airway and suction.

Respiratory depression

NURSING ACTIONS
● Administer oxygen and reversal agents (naloxone and

flumazenil).
● Insert an oral airway and suction.

Cardiac arrhythmias
NURSING ACTIONS: Obtain a 12‑lead ECG and provide
antidysrhythmics and fluids.

Hypotension
NURSING ACTIONS: Provide fluids and vasopressors.

Anaphylaxis
NURSING ACTIONS: Administer epinephrine.

Application Exercises

1. a nurse administered midazolam IV bolus
to a client before a procedure. the client’s
blood pressure is 86/40 mm Hg, and the heart
rate is 134/min. Which of the following IV
medications should the nurse administer?

a. naloxone

B. morphine

c. flumazenil

d. atropine

2. a nurse is assisting an anesthesiologist who is
delivering nitrous oxide by face mask to a client
during the induction of anesthesia. Which of
the following is the priority nursing action?

a. assess oxygen saturation.

B. measure blood pressure.

c. Palpate pulse rate.

d. check temperature.

3. a nurse is caring for a client who develops malignant
hyperthermia. Which of the following actions
should the nurse take? (select all that apply.)

a. Infuse iced IV fluids.

B. Provide 100% oxygen.

c. Place a cooling blanket on the client.

d. treat the complication while the
surgeon continues surgery.

e. administer IV dantrolene.

4. a nurse is caring for a client who develops a systemic
toxic reaction following a regional block. Which
of the following actions should the nurse take?

a. monitor blood creatinine levels.

B. Provide airway support.

c. turn the client to the right side.

d. administer a diuretic.

5. a nurse is caring for a client who reports a headache
following an epidural regional nerve block. Which
of the following actions should the nurse take?

a. decrease the client’s fluid intake.

B. apply pressure to the puncture site.

c. Place the head of the bed flat.

d. Instruct the client to lie prone.

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658 CHAPTER 94 anestHesIa and moderate sedatIon CONTENT MASTERY SERIES

Application Exercises Key

1. a. naloxone reverses respiratory depression
resulting from an opioid medication.

B. morphine relieves pain and can cause
hypotension and respiratory depression.

c. CORRECT: midazolam is a benzodiazepine.
administer flumazenil to reverse its effects.

d. atropine sulfate treats bradycardia.

NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies

2. a. CORRECT: the greatest risk for the client is injury from
hypoxia. therefore, this is the priority finding.

B. measuring blood pressure is important for
assessing the client’s cardiovascular status.
However, another finding is the priority.

c. Palpating pulse rate is important for assessing
the client’s cardiovascular status. However,
another finding is the priority.

d. checking temperature at the time of induction
is important for identifying hypothermia.
However, another finding is the priority.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. CORRECT: Infusing iced IV fluids should help lower
the client’s rapidly rising temperature.

B. CORRECT: Providing 100% oxygen will help
prevent hypoxia due to muscle tremors and
rigidity from increased lactic acid.

c. CORRECT: Placing a cooling blanket on the client
will help lower the rapidly rising temperature.

d. terminating surgery should occur as soon as the
surgical team suspects malignant hyperthermia.

e. CORRECT: dantrolene IV is a muscle relaxant
that treats malignant hyperthermia.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

4. a. monitor aBgs, cBc, and electrolytes for a client who
has a systemic toxic reaction to a regional block.

B. CORRECT: a systemic toxic reaction results in
cns depression. In this event, it is important to
support the client’s airway with maintaining patency
and administering supplemental oxygen.

c. turning the client to the right side will not help with
a systemic toxic reaction to a regional block.

d. Hypertension is an early finding of systemic toxicity, but it
can progress to hypotension. administering a diuretic could
worsen the condition; a barbiturate medication is required.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

5. a. Increase fluid intake to keep the client well‑hydrated
and to help replace cerebrospinal fluid.

B. applying pressure to the puncture site will not relieve
the headache from cerebrospinal fluid leakage.

c. CORRECT: Placing the head of the bed flat will
decrease the intensity of the headache.

d. Instructing the client to lie prone could worsen or
not improve the client’s headache pain.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT
● fentanyl (opioid)
● Propofol (anesthetic)
● midazolam (benzodiazepine)

UNDERLYING PRINCIPLES: the purpose of moderate
sedation is to relax the client to a point where they do not
feel discomfort, yet they are able to respond to verbal stimuli,
retain reflexes (gag reflex), and are easily arousable.

NURSING INTERVENTIONS

Preprocedure
● attach monitoring equipment.
● Initiate IV access.
● Verify informed consent.
● Have an emergency cart and equipment available in the room.
● Have oxygen and suction equipment ready and available.

Intraprocedure
● assess the level of consciousness.
● monitor cardiac and respiratory status.

Postprocedure
● continue to monitor vital signs and consciousness.
● determine the ability to cough, breathe deeply, and swallow.
● assess for nausea, vomiting, shortness of
breath, and dizziness before discharge.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario

a nurse is preparing to administer moderate sedation to
a client who will undergo a colonoscopy. What actions
should the nurse plan for the client? use the atI active
Learning template: Basic concept to complete this item.

RELATED CONTENT: List three medications for
and classifications of moderate sedation.

UNDERLYING PRINCIPLES: state the
purpose of moderate sedation.

NURSING INTERVENTIONS: List two nursing actions for
each: preprocedure, intraprocedure, and postprocedure.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 95 PreoPeratIVe nursIng care 659

UNIT 14 NURSING CARE OF PERIOPERATIVE CLIENTS

CHAPTER 95 Preoperative
Nursing Care

surgery can take on many forms, including
curative, palliative, cosmetic, functional,
diagnostic, and transplant. there are three
categories of inpatient surgical procedures
based on acuity: emergent, urgent, or elective.
outpatient or ambulatory surgery generally is
an elective surgery that is not considered acute
(cataract removal, hernia repair).

Preoperative care takes place from the time
a client is scheduled for surgery until care is
transferred to the operating suite. assessment
of risk factors is one of the major aspects of
preoperative care. Preoperative care includes
a thorough assessment of the client’s physical,
emotional, and psychosocial status prior to surgery.

rIsK factors
FOR SURGICAL COMPLICATIONS

● Obstructive sleep apnea: Airway obstruction,
oxygen desaturation

● Pregnancy: Fetal risk with anesthesia
● Respiratory disease: COPD, pneumonia, asthma
● Cardiovascular disease: Heart failure,

myocardial infarction, hypertension, dysrhythmias
● Diabetes mellitus: Decreased intestinal motility,

altered blood glucose levels, delayed healing, infection
● Liver disease: Altered medication metabolism and

increased risk for bleeding
● Kidney disease: Altered elimination and

medication excretion
● Endocrine disorders: Hypo/hyperthyroidism,
Addison’s disease, Cushing’s syndrome

● Immune system disorders: Immunocompromised
● Coagulation defect: Increased risk of bleeding
● Malnutrition: Delayed healing
● Obesity: Pulmonary complications due to

hypoventilation, effect on anesthesia, elimination, and
wound healing

● Some medications: Antihypertensives, anticoagulants,
NSAIDs, tricyclic antidepressants, herbal medications,
over‑the‑counter medications

● Substance use: Tobacco, alcohol
● Family history: Malignant hyperthermia
● Allergies: Latex, anesthetic agents
● Inability to cope, lack of support system
● Disease processes involving multiple body systems

● Older adult clients: Possible age‑related changes include
the following.

◯ Decreased hepatic and renal function that alters
clearance of anesthetic agents and opioids

◯ Co‑morbidities (chronic disease processes, use of
multiple medications)

◯ Greater risk of adverse reactions to preoperative
medications

◯ Less physiologic reserve than younger clients, which
can cause decreased immune system response and
decreased wound healing

◯ Reduction of muscle mass and amount of body water,
which places older adult clients at risk for dehydration

◯ Sensory decline (decreased eyesight, hearing loss)
◯ Oral alterations (dentures, bridges, loose teeth) that

pose problems during intubation
◯ Perspire less, which leads to dry, itchy skin that

becomes fragile and easily abraded
◯ Decreased subcutaneous fat, which makes them more
susceptible to temperature changes

PreoPeratIVe assessment
Detailed history: Medical history, surgical history,
tolerance of anesthesia, medication use, complementary
or alternative practices (herbals), psychosocial history,
cultural considerations, substance use (including tobacco),
social support systems, occupation, and perceptions and
knowledge about surgery

Allergies: Medications, latex, contrast agents, and
food products

● Allergies to banana or kiwi can indicate the client is at
risk for a reaction to latex.

● Allergy to eggs or soybean oil is a contraindication to
the use of propofol for anesthesia.

● Allergies to shellfish can result in a reaction to
povidone‑iodine.

Anxiety level: Regarding the procedure, support systems,
and coping mechanisms

Baseline data: Head‑to‑toe assessment, vital signs, and
oxygen saturations

Venous thromboembolism risk: Evaluation based on
surgical procedure, client history, and anticipated time the
client will be immobilized following surgery

dIagnostIc Procedures
Urinalysis: Renal function, rule out infection
Blood type and cross match: Transfusion readiness
CBC: Fluid status, anemia, infection/immune status
Pregnancy test: Fetal risk of anesthesia
Clotting studies: PT, INR, aPTT, platelet count
Blood electrolyte levels: Electrolyte imbalances
Blood creatinine and BUN: Renal status
ABGs: Oxygenation status
Chest x‑ray: Heart and lung status
12‑lead ECG: Baseline heart rhythm, dysrhythmias, history of
cardiac disease; performed on all clients older than 40 years

CHAPTER 95

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660 CHAPTER 95 PreoPeratIVe nursIng care CONTENT MASTERY SERIES

PATIENT‑CENTERED CARE

nursIng care
● Verify that the informed consent is accurately

completed, signed, and witnessed.
● Administer enemas and/or laxatives the night

before and/or the morning of the surgery for clients
undergoing bowel surgery.

● Regularly check scheduled medication prescriptions.
Some medications (antihypertensives, anticoagulants,
antidepressants) can be withheld until after the procedure.

● Determine whether autologous blood or direct blood
donation from family is available if needed.

● Ensure that the client remains NPO for at least 6 hr for
solid foods and 2 hr for clear liquids before surgery with
general anesthesia to avoid aspiration. Note on the chart
the last time the client ate or drank.

● Perform skin preparation, which can include cleansing
with antimicrobial soap. If absolutely necessary, use
electric clippers or chemical depilatories to remove hair
in areas that will be involved in the surgery.

● Ensure that jewelry, dentures, prosthetics, makeup, nail
polish, and glasses are removed. These items can be
given to the family or stored safely.

● Cover the client with a lightweight cotton blanket
heated in a warmer to prevent hypothermia.
Hypothermia increases the chance for surgical wound
infections, alters metabolism of medication, and causes
coagulation problems and cardiac dysrhythmias.

● Establish IV access using a large‑bore (18‑gauge)
catheter for easier infusing of IV fluids or blood products.

● Administer preoperative medications (prophylactic
antimicrobials, antiemetics, sedatives) as prescribed.

◯ Prophylactic antibiotics are administered within 1 hr
of surgical incision.

◯ If the client previously took a beta‑blocker,
administer a beta‑blocker prior to surgery to prevent
a cardiac event and mortality.

◯ Have the client void prior to administration.
◯ Monitor response to medications.
◯ Raise side rails following administration to

prevent injury.
● Ensure that the preoperative checklist is complete. (95.1)
● Confirm and verify the correct surgical site with the

client and all health care team members before clearly
marking the surgical site.

● Minimize client anxiety while waiting to go to surgery
by using distraction techniques (watching TV, reading,
listening to music).

● For clients encountering severe anxiety and panic,
reassurance will be necessary and sedation medications
can be given. Nonpharmacological interventions
(distraction, imagery, and music therapy) can
be initiated.

● Ensure that measures are taken to prevent postoperative
deep‑vein thromboembolism by continuing
anticoagulation therapy and/or anti‑embolism
stockings, pneumatic compression devices, and
range‑of‑motion exercises.

Informed consent
● Once surgery has been discussed as treatment with the

client and significant other, family member, or friend,
it is the responsibility of the provider to obtain consent
after discussing the risks and benefits of the procedure.
The nurse is not to obtain the consent for the provider
in any circumstance.

● The nurse can clarify any information that remains
unclear after the provider’s explanation of the procedure.
The nurse cannot provide any new or additional
information not previously given by the provider.

● The nurse’s role is to witness the client’s signing
of the consent form after the client acknowledges
understanding of the procedure.

● The nurse should determine if the client is legally
capable of providing consent.

◯ 18 years of age or emancipated.
◯ Mentally capable of understanding the risks, reason,
and options for surgery and anesthesia.

◯ Free from the influence of medication that
affects decision‑making or judgment (opioids,
benzodiazepines, sedatives).

● A legal guardian or health care surrogate can sign if the
client is not capable of providing consent or if there is
no family.

● Two witnesses can be required if the client is able
to only sign with an “X,” has vision or hearing
impairments, or if there is a language barrier.

● Informed consent is required for surgical procedures,
invasive procedures (biopsy, paracentesis, scopes),
and any procedure requiring sedation or anesthesia,
involving radiation, or that places the client at increased
risk for complications.

PROVIDER RESPONSIBILITIES
● Obtain informed consent.
● To obtain informed consent, the provider must explain

the following.
◯ Complete description of the treatment/procedure
◯ Description of the professionals who will be

performing and participating in the treatment
◯ Information on the risks of anesthesia
◯ Description of the anticipated benefits of the
treatment/procedure

◯ Description of the potential harm, pain, and/or
discomfort that can occur

◯ Options for other treatments
◯ The right to refuse treatment

CLIENT RESPONSIBILITIES
● Give informed consent.
● To give informed consent, do the following.

◯ Give it voluntarily (no coercion involved).
◯ Receive enough information to make a decision based
on an understanding of what is expected.

◯ Be competent and of legal age or be an emancipated
minor. When the client is unable to provide consent,
another authorized person must give consent.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 95 PreoPeratIVe nursIng care 661

NURSE RESPONSIBILITIES
● Witnesses informed consent.
● To witness informed consent, do the following.

◯ Ensure that the provider gave the client the
necessary information.

◯ Ensure that the client understood the information and
is competent to give informed consent.

◯ Notify the provider if the client has more questions
or appears to not understand any of the information
provided. (The provider is then responsible for
giving clarification.)

◯ Have the client sign the informed consent document.
◯ Document questions the client has and notify the

provider. Also document any additional reinforcement
of teaching.

◯ Provide a trained medical interpreter (not a family
member or friend) and record the use of an interpreter
in the medical record.

cLIent educatIon
● Understand the purpose and effects of preoperative

medications that will be administered.
● Be aware of postoperative pain control techniques

(medications, immobilization, patient‑controlled
analgesia pumps, splinting)

● Perform splinting, coughing, and deep breathing.
● Perform range‑of‑motion exercises and early ambulation

for prevention of thrombi and respiratory complications.

● Use antiembolism stockings and pneumatic compression
devices to prevent deep‑vein thrombosis.

● Perform bowel and skin preparations as prescribed
(cleansing enema, preoperative shower with
medicated soap).

● Understand the purpose of invasive lines used in
surgery and after (drains, catheters, IV lines).

● Adhere to the postoperative diet.
● Perform incentive spirometry to promote oxygenation.
● Adhere to preoperative instructions regarding medications.

◯ If taking acetylsalicylic acid, stop taking it for
1 week before an elective surgery to decrease the risk
of bleeding.

◯ Ask the provider before taking any herbal or over‑the‑
counter medications. Some medications can increase
the risk of bleeding or adverse effects from anesthesia.

◯ Medications for cardiovascular disease, pulmonary
disease, seizures, diabetes mellitus, some
antihypertensive medications, and eye drops for
glaucoma are usually allowed prior to surgery or
a procedure.

● Use a pain scale to rate pain level.
● Understand the care and restrictions relative to the

surgical procedure performed.
● Avoid smoking, alcohol, or illicit drug use, which can

interfere with surgical medications and increase the risk
for surgical complications.

95.1 Preoperative checklist

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662 CHAPTER 95 PreoPeratIVe nursIng care CONTENT MASTERY SERIES

COMPLICATIONS
Complications during the postoperative period usually are
related to the medications given preoperatively.

● Other postoperative complication include inadequate
wound healing, infection and sepsis; anemia;
hypovolemia and possible circulatory shock; and
electrolyte imbalance.

● Be alert for any allergic reactions the client has
to medications.

Sedatives (benzodiazepines, barbiturates)
● Respiratory depression, drowsiness, dizziness
● NURSING ACTIONS

◯ Monitor respiratory rate and oxygen saturation.
◯ Administer oxygen.
◯ Administer a reversal agent, flumazenil.

Opioids
● Respiratory depression, drowsiness, dizziness,

constipation, urinary retention
● NURSING ACTIONS

◯ Monitor respiratory rate and oxygen saturation.
◯ Administer oxygen.
◯ Administer a reversal agent, naloxone.
◯ Perform prescribed intermittent catheterization.

IV infusions (0.9% NaCl, lactated Ringer’s)
● Fluid overload, hypernatremia
● NURSING ACTIONS

◯ Monitor I&O closely.
◯ Slow the IV fluid rate of infusion.
◯ Administer prescribed diuretic.

Gastrointestinal medications (antiemetics, antacids, H2
receptor blockers)

● Alkalosis, cardiac abnormalities (some H2 receptor
blockers), drowsiness

● NURSING ACTIONS
◯ Obtain preoperative cardiac history.
◯ Monitor for electrolyte abnormalities.

Active Learning Scenario

a nurse is planning care for a client scheduled for
a surgical procedure. What potential complications
should the nurse consider? use the atI active Learning
template: Basic concept to complete this item.

RELATED CONTENT: List at least three possible
complications the nurse should prevent, explain the related
cause, and include one intervention for each complication.

Application Exercises

1. a nurse is assessing a client’s laboratory values before
surgery. Which of the following results should the
nurse report to the provider? (select all that apply.)

a. Potassium 3.9 meq/L

B. sodium 145 meq/L

c. creatinine 2.8 mg/dL

d. Blood glucose 235 mg/dL

e. WBc 17,850/mm3

2. a nurse is providing preoperative teaching
to a client who is to have abdominal surgery.
Which of the following statements should
the nurse make? (select all that apply.)

a. “take your heart medication with a
sip of water before surgery.”

B. “splint the abdominal incision with a pillow
when coughing and deep breathing.”

c. “Bed rest is recommended for the first 48 hours.”

d. “anti‑embolism stockings are
applied before surgery.”

e. “You can eat solid foods up to
4 hours before surgery.”

3. a nurse is verifying informed consent for a client
who is having a paracentesis. Which of the following
actions should the nurse take? (select all that apply.)

a. explain to the client the purpose
of having the procedure.

B. Inform the client of risks to having the procedure.

c. ensure the client understands
information about the procedure.

d. Witness the client signing the
informed consent form.

e. determine if the client is capable of
understanding the reason for the procedure.

4. a nurse is caring for a client who is scheduled
for an exploratory laparotomy. the client’s
temperature is 39° c (102.2° f) orally. Which of
the following actions should the nurse take?

a. Inform the surgeon of the elevated temperature.

B. transfer the client to the preoperative unit.

c. apply ice packs to the groin.

d. encourage the client to increase
intake of clear liquids.

5. a preoperative nurse is caring for a client
who is having a colon resection. Which of the
following actions should the nurse take?

a. encourage the client to void after
preoperative medication administration.

B. administer antibiotics 2 hr prior to surgical incision.

c. remove hair using a manual razor.

d. remove nail polish on fingers and toes.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 95 PreoPeratIVe nursIng care 663

Application Exercises Key

1. a. the potassium level is within the
expected reference range.

B. the sodium level is within the expected reference range.
c. CORRECT: report an elevated creatinine level,

which can indicate impaired renal function.
d. CORRECT: report an elevated blood glucose,

which needs treatment prior to surgery.
e. CORRECT: report an elevated WBc count, which

indicates a need for antibiotic therapy before surgery.

NCLEX® Connection: Reduction of Risk Potential,
Laboratory Values

2. a. CORRECT: teach the client to take certain
cardiac and other medications as prescribed
with a sip of water before surgery.

B. CORRECT: teach the client how to splint with
a pillow to support the incision when coughing
and deep breathing postoperatively.

c. teach the client the importance of early ambulation
following abdominal surgery to prevent complications.

d. CORRECT: Inform the client of the application of
antiembolism stockings to prevent deep‑vein thrombosis.

e. Inform the client to stop eating solid food
for 6 hr or more before surgery.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

3. a. the provider should explain the purpose
of the procedure.

B. the provider should inform the client of
risks to having the procedure.

c. CORRECT: ensure the client understands the
information about the procedure.

d. CORRECT: Witness the client sign the informed consent.
e. CORRECT: determine if the client is capable of

understanding the reason for the procedure.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

4. a. CORRECT: Immediately notify the surgeon of the elevated
temperature to determine if canceling the surgery is
necessary due to an underlying infection.

B. transferring the client to the preoperative unit
is not an appropriate nursing action when there
is a possible underlying infection.

c. applying ice packs to the client’s groin is not an appropriate
action for a temperature of 39° c (102.2° f).

d. Increasing intake of clear liquids is not an
appropriate action because the client should
be nPo for at least 2 hr before surgery.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

5. a. the client should void before administration of medication
for relaxation or sedation to prevent the risk for falls.

B. administer antibiotics within 1 hr prior to the surgical
incision as a prophylactic measure to prevent infection.

c. remove hair at the surgical site with electric clippers
or use a chemical depilatory to prevent traumatizing
the skin and increasing the risk for infection.

d. CORRECT: ensure the nail beds are visible for color and
circulation by removing nail polish before surgery.

NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT

Prevent respiratory depression.
● caused by overmedication with benzodiazepines,
barbiturates, or opioids.

● administer a prescribed reversal agent, and monitor closely.

Prevent fluid overload.
● caused by too much IV fluids and inability
to readily excrete the fluids.

● obtain a preoperative cardiac and pulmonary history, monitor I&o
closely, slow the rate of IV fluids, and administer a prescribed diuretic.

Prevent deep‑vein thrombosis.
● caused by blood stasis in lower extremities
due to absent muscle contractility.

● apply antiembolism stockings and/or pneumatic
compression devices, administer prescribed anticoagulants,
and teach range‑of‑motion exercises.

Prevent infection.
● caused by micro‑organisms contaminating the surgical wound.
● administer a prescribed prophylactic antibiotic within
1 hr before the surgical incision is made.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications from Surgical Procedures and Health Alterations

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664 CHAPTER 95 PreoPeratIVe nursIng care CONTENT MASTERY SERIES

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 96 PostoPeratIVe nursIng care 665

UNIT 14 NURSING CARE OF PERIOPERATIVE CLIENTS

CHAPTER 96 Postoperative
Nursing Care

transferring a client who is postoperative from
the operating suite to the postanesthesia care
unit (Pacu) is the responsibility of the anesthesia
provider, who is an anesthesiologist or certified
registered nurse anesthetist. the circulating
nurse will give the verbal hand‑off report to the
Pacu nurse.

Postoperative care is usually provided initially
in the Pacu, where skilled nurses who are
certified in advanced cardiac life support can
monitor a client’s recovery from anesthesia. In
some instances, a client is transferred from the
operating suite directly to the intensive care unit.

Initial postoperative care involves making
assessments, administering medications,
managing pain, preventing complications,
and determining when a client is ready to be
discharged from the Pacu. during the immediate
postoperative stage, maintaining airway patency
and ventilation and monitoring circulatory
status are the priorities for care. Postoperative
clients who receive general anesthesia require
frequent assessment of their respiratory status.
Postoperative clients who receive epidural or
spinal anesthesia require ongoing assessment of
motor and sensory function.

a client who is stable and able to breathe
spontaneously is discharged to a postsurgical
unit or home if an outpatient surgical procedure
was performed. a client discharged home must
demonstrate ability to swallow and safely ambulate
to the bathroom and wheelchair with assistance.
a client who had an outpatient surgery should be
accompanied by a significant other, family member,
or other caregiver who can receive discharge
instructions and transport the client home.

rIsK factors for comPLIcatIons
Immobility: Respiratory compromise, thrombophlebitis,
pressure injury

Anemia: Blood loss, inadequate/decreased oxygenation,
impaired healing factors

Hypovolemia: Tissue perfusion

Hypothermia: Risk of surgical wound infection,
altered absorption of medication, coagulopathy, and
cardiac dysrhythmia

Cardiovascular diseases: Fluid overload,
deep‑vein thrombosis, arrhythmia

Respiratory disease: Respiratory compromise

Immune disorder: Risk for infection, delayed healing

Diabetes mellitus: Gastroparesis, delayed wound healing

Coagulation defect: Increased risk of bleeding

Malnutrition: Delayed healing

Obesity: Respiratory compromise, postoperative nausea
and vomiting, wound healing, dehiscence, evisceration

Age‑related: Respiratory, cardiovascular, and renal
changes necessitate specific attention to the postoperative
recovery of older adults.

● Older adult clients are more susceptible to cold
temperatures, so additional warm blankets in the PACU
can be required.

● Responses to medications and anesthetics can delay
return of orientation postoperatively.

● Age‑related physiologic changes (decreased liver and
kidney function) can affect response to and elimination
of postoperative medications. Monitor for appropriate
response and possible adverse effects.

◯ Older adults perspire less, which leads to dry, itchy
skin that becomes fragile and easily abraded. The use
of paper tape for wound dressings can be appropriate,
as well as lifting precautions.

◯ Older adults can be at risk for delayed wound healing
because of possible compromised nutrition.

dIagnostIc Procedures
CBC: WBC (infection/immune status), Hgb and Hct (fluid
status, anemia)

Metabolic profile: Blood electrolytes (electrolyte
imbalances), BUN, and creatinine (renal function)

ABGs: Oxygenation status

Additional laboratory tests: Blood glucose,
prothrombin time, INR based on procedure and associated
health problems

CHAPTER 96

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666 CHAPTER 96 PostoPeratIVe nursIng care CONTENT MASTERY SERIES

PACU ASSESSMENT
Upon receiving a client from the operating suite,
immediately perform a full body assessment with priority
given to airway, breathing, and circulation.

monItorIng and management

Airway and breathing
● An artificial airway (endotracheal tube, nasal trumpet,

or oral airway) is left in place until a client can
maintain an open airway without support. Assess for
symmetry of breath sounds and chest wall movement.

◯ Absent breath sounds on the left can indicate the
endotracheal tube has migrated down the right
mainstem bronchus or that there is a pneumothorax.

● Monitor breath sounds. Snoring or stridor (a
high‑pitched crowing type sound) can indicate poor
oxygen exchange.

● Assess blood oxygen saturation levels continuously
(should be greater than 95% or at preoperative status).

● Assess respiratory pattern, rate, and depth to determine
adequacy of oxygen exchange.

● Auscultate lung sounds.
● Administer humidified oxygen.
● Suction accumulated secretions if the client is unable

to cough. Use an oral suction device for thick oral
secretions or a large French suction catheter for
nasopharyngeal or nasotracheal secretions.

◯ Retained neuromuscular blocking agents can hinder
the client’s ability to cough and eliminate secretions.

● Extubation of the endotracheal tube is based on the
client’s response to commands, ability to elevate head,
and use of thoracic breathing.

● As soon as the client follows commands, encourage
coughing, deep breathing, and use of the
incentive spirometer.

Circulation
● Observe for internal bleeding (abdominal distention,

visible hematoma under/near the surgical site,
tachycardia, hypotension, restlessness, increased pain)
and external bleeding.

● Assess for hypervolemia and hypovolemia.
● Assess skin color, temperature, sensation, and

capillary refill.
● Check mucous membranes, lips, and nail beds

for cyanosis.
● Assess and compare peripheral pulses for impaired

circulation and deep‑vein thrombosis (DVT).
◯ Monitor for indication of DVT (pain, edema,
erythema, warmth).

◯ Continue preventative measures: sequential
compression devices, anti‑embolism stockings, and
prescribed anticoagulants or antiplatelet medications.

● Monitor ECG readings and compare apical and
peripheral pulses to check for a pulse deficit, which can
indicate a dysrhythmia.

● Monitor fluid and electrolyte balance.

Vital signs
● Per agency protocol, obtain vital signs until stable

(every 15 min) and assess for trends.
● Evaluate and treat the presence of hypotension and

potential causes (anesthesia or other medications,
cardiac depression, blood loss, pooling of blood in
extremities, position changes).

● Report a blood pressure difference of 25% from
baseline, a drop of 15 to 20 mm Hg in diastolic or
systolic pressures, or a trending decrease in diastolic
or systolic pressures by 5 mm Hg at each 15‑min vital
sign assessment.

● Evaluate and treat hypertension and potential causes
(pain, hypoxia, bladder distention).

● Provide heated blankets when the client arrives after
a temperature is obtained and reapply if the client is
hypothermic. Causes of hypothermia include decreased
body fat, age‑related changes in the hypothalamus
that regulates body temperature, and decreased
environmental temperature in the surgical suite.

Positioning
● If the client responds to verbal stimuli, gradually

elevate the head of the bed to semi‑Fowler’s position, if
not contraindicated, to facilitate chest expansion.

● Maintain lateral position (right or left side) if the client
is unresponsive or unconscious (risk of aspiration).

● Avoid placing a pillow under the knees or engaging
the knee gatch of the bed, which can decrease
venous return.

● Elevate legs and lower the head of the bed if
hypotension or shock develops.

Response to anesthesia (sedation, nausea, vomiting)
● Monitor level of consciousness (weakness,

restlessness, agitation, somnolence, irritability, change
in orientation).

● Assess for movement of and sensation in extremities.
Sensory function and voluntary movement of the
extremities following a regional block should occur
before transfer to another unit.

● Administer an antiemetic for nausea and vomiting after
checking bowel sounds.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 96 PostoPeratIVe nursIng care 667

Input and output
● Monitor fluid and electrolyte balance following surgery.

◯ Review postoperative laboratory findings
(potassium, sodium, creatinine and BUN, hemoglobin
and hematocrit).

◯ Assess skin turgor and monitor for diaphoresis.
◯ Review I&O during surgery and in PACU: emesis,
drains, nasogastric (NG) tube, urine, estimated blood
losses, IV fluids, and blood products.

◯ Administer isotonic IV fluids (0.9% sodium chloride,
lactated Ringer’s, dextrose 5% in lactated Ringer’s) to
maintain adequate cardiac output and fluid and
electrolyte balance.

◯ Administer prescribed blood products to treat
hypovolemia (autologous blood, intraoperative blood
salvage using a cell saver device, packed cells, fresh
frozen plasma, albumin, platelets).

● Palpate bladder for distention.
● Monitor output from drainage devices (nasogastric tube,

surgical drains).
● Observe color, consistency, odor, and amount of urine.

Urine output less than 30 mL/hr can indicate hypovolemia.

Surgical wound, incision site, dressing
● Observe drainage tubes for patency and proper function.
● Check dressings for excessive drainage and reinforce as

needed. Report excess drainage to the surgeon.
● Outline drainage spots with a pen, noting date and time.

Report increasing drainage to the surgeon.

Pain
● Administer pain medication as appropriate, secondary to

recovery status.
● Observe for adverse effects of analgesia, such as

respiratory depression and decreased oxygen saturation.
● Incorporate nonpharmacological approaches to pain

management based on client needs and preferences.
These can include massage, relaxation techniques,
meditation, diversion (listening to music), and
noise reduction.

Mentation
● Monitor level of consciousness and mental status.
● Determine level of stimulation needed for arousal (pain,

touch, verbal).
● Determine level of orientation compared to baseline.
● Older adult clients can experience acute confusion or

delirium related to anesthesia or other medications,
dehydration, hypoxia, blood loss, or electrolyte
imbalance. Episodes of postoperative delirium can last
2 days or more in older adult clients.

● Clients who are oversedated or have respiratory
depression from moderate sedation can need
a reversal agent (flumazenil), which is a
benzodiazepine antagonist.

aLdrete scorIng
Monitor recovery from anesthesia by using the Aldrete
scoring system. Each of five factors is given a score based
upon observations of the client. The scores are totaled to
determine the Aldrete score.

96.1 Modified Aldrete Scoring System
ASSESSMENT/OBSERVATION SCORE

Activity

able to move four extremities 2
able to move two extremities 1
able to move no extremities 0

Consciousness

fully awake 2
arousable 1
unarousable 0

Respiration

Breathe deeply and cough 2
dyspnea, hypoventilation 1
apneic 0

O2 saturation

o2 saturation maintained at
92% (minimum) on room air 2

Inhaled oxygen is necessary
to maintain o2 saturation
greater that 90%

1

o2 saturation level is less than
90% even though inhaled
oxygen is being given

0

Circulation

Blood pressure is within 20%
of preanesthesia level 2

Blood pressure is 21% to
49% of preanesthesia level 1

Blood pressure is within 50%
of preanesthesia level 0

crIterIa for dIscHarge from Pacu
The anesthesiologist must discharge or agree to
dismiss the client before transfer to another unit or
discharge to home.

● Aldrete score of 8 to 10
● Stable vital signs
● No evidence of bleeding
● Return of reflexes (gag, cough, swallow)
● Minimal to absent nausea and vomiting
● Wound drainage that is minimal to moderate
● Urine output at least 30 mL/hr

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668 CHAPTER 96 PostoPeratIVe nursIng care CONTENT MASTERY SERIES

UNIT ASSESSMENT
Upon receiving the client from the PACU, immediately
perform a full body assessment with priority given to
airway, breathing, and circulation. This assessment serves
as a baseline to identify changes in postoperative status.

monItorIng and management

Airway and breathing
● Monitor oxygen saturation using a pulse oximeter.
● Assist with coughing and deep breathing at least every
1 hr while awake, and provide a pillow or folded blanket
so the client can splint as necessary for abdominal or
chest incision.

● Contraindications to coughing include cosmetic, eye, or
intracranial surgeries.

● Assist with the use of an incentive spirometer at least
every 1 to 2 hr while awake to encourage expansion of
the lungs and prevent atelectasis.

Positioning
● Reposition every 2 hr, and ambulate early and regularly.
● Do not put pillows under knees or elevate the knee

gatch on the bed (decreases venous return).
● Encourage early ambulation with adequate rest

periods to prevent cardiovascular disorders,
deep‑vein thrombosis, and pulmonary complications.

Fluid status and oral comfort
● A client who returns to the medical‑surgical unit

is given a prescription IV solution based on needs
(hydration, electrolytes).

● Encourage ice chips and fluids as prescribed/tolerated.
● Provide frequent oral hygiene.

Pain
● If prescribed, provide continuous pain relief through the

use of a patient‑controlled analgesia pump. Epidural
and intrathecal infusions are also used postoperatively.

● A preventative approach using around‑the‑clock
scheduling is more effective than PRN medication
delivery during the first 24 to 48 hr postoperatively.

● Assess pain level frequently, using a standardized
pain scale.

● Encourage the client to ask for pain medication before
pain gets severe.

● Assess for manifestations of pain (an increased pulse,
respirations, or blood pressure; restlessness; and
wincing or moaning during movement).

● Monitor for adverse effects of opioids (respiratory
depression, nausea [encourage the client to change
positions slowly], urinary retention, and constipation).

● Provide analgesia 30 min before ambulation or
painful procedures.

● In the event of overmedication with an opioid,
administer a reversal agent such as naloxone (an
opioid antagonist).

● Assess for effectiveness of pain medication
after administration.

● Incorporate nonpharmacological approaches to pain
management based on client needs and preferences. These
can include massage, relaxation techniques, meditation,
diversion (listening to music), and noise reduction.

Kidney function
● Output should equal intake.
● Monitor and report urinary output less than 30 mL/hr.
● Palpate bladder following voiding to assess for distention.
● Consider using a bladder scan to assess suspected

retention of urine.

Bowel function
● Maintain the client NPO until return of gag reflex (risk

of aspiration) and peristalsis (risk of paralytic ileus).
● Irrigate NG suction tubes with saline as needed to

maintain patency. Do not move NG tubes in clients
who are postoperative following gastric surgery as
prescribed (risk to incision).

● Monitor bowel sounds in all four quadrants as well as
ability to pass flatus.

● Advance diet as prescribed and tolerated (clear liquids
to regular).

● Encourage gum chewing as a low‑cost method to
stimulate gastric secretions and promote the return of
intestinal peristalsis.

Thromboembolism
● Apply pneumatic compression devices and/or

anti‑embolism stockings.
● Reposition every 2 hr, and ambulate early and regularly.
● Administer prescribed anticoagulants or

antiplatelet medications.
● Monitor extremities for calf pain, warmth, erythema,

and edema.

Incisions and drain sites
● Monitor drainage (should progress from sanguineous to

serosanguineous to serous).
● Monitor the incision site. Expected findings include

pink wound edges, slight swelling under sutures/staples,
and slight crusting of drainage. Report any evidence of
infection, including redness, excessive tenderness, and
purulent drainage.

● Monitor wound drains with each vital sign assessment.
Empty closed‑suction drainage collection devices as
needed to maintain compression. Report increases in
drainage (possible hemorrhage).

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 96 PostoPeratIVe nursIng care 669

● In most instances, the surgeon will perform the first
dressing change. Subsequent dressing changes can be
performed by the nurse using surgical aseptic technique.

● Use an abdominal binder as prescribed for clients who
are obese or debilitated.

● Encourage splinting with position changes, coughing,
and deep breathing.

● Administer prophylactic antibiotics as prescribed.
● Remove sutures or staples in 5 to 10 days as prescribed.
● If incision is secured with wound closure tape, instruct the

client to keep in place until strips fall off on their own.

Wound healing
● Encourage the client to consume a diet high in calories,

protein, and vitamin C.
● If the client has diabetes mellitus, maintain appropriate

glycemic control.

Discharge teaching
● Teach the client the purpose, administration guidelines,

and adverse effects of medications.
● Reinforce activity restrictions (driving, stairs, limits on

weight lifting, sexual activity) with the client.
● Provide dietary guidelines, if applicable.
● Inform the client about treatment instructions (wound

care, catheter care, use of assistive devices).
● Inform the client of emergency contact information.
● Advise the client to inform the surgeon if pain is

unrelieved by current medication.
● Teach the client to monitor and report any indications

of infection at the surgical site to the surgeon.

96.3 Penrose drain

96.2 Jackson‑Pratt drain

96.4 Hemovac drain

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670 CHAPTER 96 PostoPeratIVe nursIng care CONTENT MASTERY SERIES

COMPLICATIONS

Airway obstruction

Swelling or spasm of the larynx or trachea, mucus in the
airway, or relaxation of the tongue into the nasopharynx
can cause airway obstruction, often manifesting as stridor
or snoring.

NURSING ACTIONS
● Monitor for choking; noisy, irregular respirations;

decreased oxygen saturation values; and cyanosis.
Intervene accordingly.

● Implement a head‑tilt/chin‑lift maneuver to pull the
tongue forward and open the airway.

● Keep emergency equipment at the bedside in the PACU
(resuscitation bag, suction equipment, airways).

● Notify the anesthesiologist, elevate head of bed if not
contraindicated, provide humidified oxygen, and plan
for reintubation with endotracheal tube.

Hypoxia

Hypoxia is evidenced by a decrease in oxygen saturation.

NURSING ACTIONS
● Monitor oxygenation status, and administer oxygen

as prescribed.
● Encourage coughing and deep breathing to

prevent atelectasis.
● Position client with head of bed elevated, and turn every
2 hr to facilitate chest expansion.

Hypovolemic shock

Postoperative shock can result from a massive loss of
circulating blood volume.

NURSING ACTIONS
● Monitor for decreased blood pressure and urinary

output, increased heart and respiratory rates, narrowing
of pulse pressure, and slow capillary refill.

● Administer oxygen.
● Place the client in a supine position with legs elevated.
● Administer IV fluids and vasopressors as prescribed.

Paralytic ileus

Can occur due to the absence of GI peristaltic activity
caused by abdominal surgery or other physical trauma

NURSING ACTIONS
● Monitor bowel sounds.
● Encourage ambulation.
● Advance the diet as tolerated when bowel sounds or

flatus are present.
● Administer prokinetic agents (metoclopramide),

as prescribed.
● The client can have an NG tube inserted to empty

stomach contents.

Wound dehiscence or evisceration
● Caused by spontaneous opening of the incisional wound

(dehiscence)
● Can progress to the protrusion of the internal organs

through the incision (evisceration)

NURSING ACTIONS
● Monitor risk factors (obesity, coughing, moving without

splinting, poor nutritional status, diabetes mellitus,
infection, hematoma, steroid use).

● If wound dehiscence or evisceration occurs, call for
help, stay with the client, cover the wound with a
sterile towel or dressing that is moistened with sterile
saline, do not attempt to reinsert organs, place in a
low‑Fowler’s position with hips and knees bent, monitor
for shock, and notify the provider immediately.

Deep‑vein thrombosis

Caused by dehydration, stress response that leads to
hypercoagulability of the blood, immobility, obesity,
trauma, malignancy, history of thrombosis, hormones,
and use of indwelling venous catheter

NURSING ACTIONS
● Prophylactic measures include administration of

low‑molecular‑weight heparin, low‑dose heparin,
or low‑dose warfarin; anti‑embolism stockings;
pneumatic compression devices; range‑of‑motion
exercises; and early ambulation.

● Avoid any form of pressure behind the knee with a
pillow or blanket, which can cause constriction of blood
vessels and decreased venous return.

● Avoid dangling the client’s legs for long periods of time.
● Provide adequate hydration by administering IV fluids or

encouraging increased oral fluid intake.

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RN ADULT MEDICAL SURGICAL NURSING CHAPTER 96 PostoPeratIVe nursIng care 671

Application Exercises

1. a nurse is reviewing the medical records of several
clients in the postanesthesia care unit (Pacu) to
identify risk factors that can lead to postoperative
complications. Which of the following clients are
at risk for complications? (select all that apply.)

a. a client who has a WBc of 22,500/uL

B. a client who uses an insulin pump

c. a client who takes warfarin daily

d. a client who has heart failure

e. a client who has a BmI of 26

2. a nurse is caring for a client who manifests
indications of hypovolemia while in the Pacu.
Which of the following findings requires action
by the nurse? (select all that apply.)

a. urine output less than 25 mL/hr

B. Hematocrit 53%

c. Bun 24 mg/dL

d. tenting of skin over the sternum

e. apical pulse rate 62/min

3. a nurse is caring for a client who arrived in the
Pacu following a total hip arthroplasty. the client
is not responding to verbal stimuli. Which of the
following actions should the nurse perform first?

a. compare and contrast the peripheral pulses.

B. apply a warm blanket.

c. assess dressings.

d. Place the client in a lateral position.

4. a nurse is planning care for a client to prevent
postoperative atelectasis. Which of the following
interventions should the nurse include in
the plan of care? (select all that apply.)

a. encourage use of the incentive
spirometer every 2 hr.

B. Instruct the client to splint the incision
when coughing and deep breathing.

c. reposition the client every 2 hr.

d. administer antibiotic therapy.

e. assist with early ambulation.

5. a nurse is caring for a client who reports
nausea and vomiting 2 days postoperative
following hysterectomy. Which of the following
actions should the nurse perform first?

a. assess bowel sounds.

B. administer antiemetic medication.

c. restart prescribed IV fluids.

d. Insert a prescribed nasogastric tube.

Active Learning Scenario

a nurse is reviewing the health records of several clients
to identify postoperative complications. What information
should the nurse expect to find? use the atI active
Learning template: Basic concept to complete this item.

RELATED CONTENT: List three possible
complications. describe one cause and one
intervention for each complication.

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672 CHAPTER 96 PostoPeratIVe nursIng care CONTENT MASTERY SERIES

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT

Paralytic ileus
● caused by abdominal surgery or other physical trauma
and absent gastrointestinal peristaltic activity

● monitor bowel sounds, encourage ambulation, and
insert nasogastric tube to empty stomach contents.

Wound evisceration
● Protrusion of the abdominal contents through the incisional wound
of the abdominal cavity, caused by failure to splint when moving
or coughing, delayed healing due to obesity or diabetes mellitus

● call for help, cover the wound with sterile saline
soaked dressings or towel, and position the client in
semi‑fowler’s position with hips and knees bent.

airway obstruction
● swelling or spasm of the larynx or trachea, mucus in the airway,
or relaxation of the tongue into the nasopharynx can cause
airway obstruction, often manifesting as stridor or snoring.

● notify the anesthesiologist, provide humidified oxygen,
elevate the head of the bed if not contraindicated, perform
a head‑tilt/chin‑lift maneuver to open the airway, and
plan for reintubation of the endotracheal tube.

Hypovolemic shock
● caused by blood loss
● monitor for decreased blood pressure and urinary
output, increased heart and respiratory rates, narrowing
of the pulse pressure, and slow capillary refill.

● administer oxygen.
● Place the client in a supine position with the legs elevated.
● administer IV fluids and vasopressors as indicated.

NCLEX® Connection: Physiological Adaptation, Medical
Emergencies

Application Exercises Key

1. a. CORRECT: an increased WBc indicates an
underlying infection and places the client at risk
for postoperative complications.

B. CORRECT: an insulin pump indicates the client has
diabetes mellitus and places the client at risk of
postoperative complications (delayed wound healing).

c. CORRECT: a client who takes warfarin daily is at risk for
bleeding and postoperative complications (hemorrhage).

d. CORRECT: a client who has a history of heart failure is at
risk for complications (fluid overload, dysrhythmias).

e. BmI 26 is within the expected reference range and does not
place the client at risk for postoperative complications.

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

2. a. CORRECT: urine output less than 25 mL/hr is
a manifestation of hypovolemia and requires
intervention by IV fluid therapy.

B. CORRECT: Hematocrit 53% indicates concentrated
blood volume and is a manifestation of hypovolemia,
requiring intervention by IV fluid therapy.

c. CORRECT: Bun 24 mg/dL indicates decreased kidney
function and can be a manifestation of hypovolemia,
requiring intervention with IV fluid therapy.

d. CORRECT: tenting of skin indicates decreased or
absent skin turgor due to dehydration, requiring
intervention with IV fluid therapy.

e. an apical pulse rate of 62/min is not a
manifestation of hypovolemia.

NCLEX® Connection: Physiological Adaptation,
Medical Emergencies

3. a. comparing and contrasting peripheral pulses
is important to ensure adequate circulation,
but it is not the first nursing action.

B. applying warm blankets to prevent hypothermia is
important, but it is not the first nursing action.

c. assessing dressings for drainage is important
to monitor the amount of drainage present,
but it is not the first nursing action.

d. CORRECT: the greatest risk to the client who is unresponsive
or unconscious is injury from aspiration. turning the client
to the side will help keep the airway clear of secretions

NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures

4. a. CORRECT: use of the incentive spirometer every 2 hr
expands the lungs and prevents atelectasis.

B. CORRECT: Incisional splinting with a pillow or
blanket supports the incision during coughing and
deep breathing, which prevents atelectasis.

c. CORRECT: repositioning the client every 2 hr will
mobilize secretions and allow the client to deep breathe
and expand the lungs to prevent atelectasis.

d. antibiotic therapy is used to prophylactically prevent or
treat infection and does not prevent atelectasis.

e. CORRECT: early ambulation expands the lungs
through deep breathing and prevents atelectasis.

NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems

5. a. CORRECT: using the nursing process, the first step is
to assess the client. this enables the nurse to check for
peristalsis and will guide further interventions.

B. administering an antiemetic medication can alleviate nausea
and vomiting, but it is not the first nursing action.

c. restarting prescribed IV fluids will prevent
dehydration, but it is not the first nursing action.

d. Inserting a prescribed nasogastric tube can alleviate nausea
and vomiting, but it is not the first nursing action.

NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

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RN ADULT MEDICAL SURGICAL NURSING references 673

References
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier &
Erb’s fundamentals of nursing: Concepts, process, and practice
(10th ed.). Upper Saddle River, NJ: Prentice‑Hall.

Burchum, J. R., & Rosenthal, L. D. (2019). Lehne’s
pharmacology for nursing care (10th ed). St. Louis, MO.

deWit, S. C., Stromberg, H. K., & Dallred, C. V. (2017). Medical‑
Surgical nursing: Concepts and practice (3rd ed.). St. Louis: Saunders

Ford, S. M., & Roach, S. S. (2018). Roach’s introductory clinical
pharmacology (11th ed.). Philadelphia: Wolters Kluwer.

Grodner, M., Escott‑Stump, S., & Dorner, S. (2016).
Nutritional foundations and clinical applications of nutrition: A
nursing approach (6th ed.). St. Louis, MO: Mosby.

Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook
of medical‑surgical nursing (14th ed.). Philadelphia: Wolters Kluwer.

Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018).
Medical‑Surgical nursing: Concepts for Interprofessional
collaborative care (9th Ed). St. Louis, MO.

Lilley, L. L., Rainforth‑Collins, S., & Snyder, J. S. (2017). Pharmacology
and the nursing process (8th ed.). St. Louis, MO: Elsevier.

Lowdermilk, D. L., Perry, S. E., Cashion, M. C., & Aldean, K. R. (2016).
Maternity & women’s health care (11th ed.). St. Louis, MO: Elsevier.

National Cancer Institute. (2018). Examples of cancer
health disparities. Retrieved from https://www.cancer.
gov/about‑cancer/diagnosis‑staging/symptoms

National Cancer Institute. (2018). Symptoms of cancer. Retrieved from
https://www.cancer.gov/about‑cancer/diagnosis‑staging/symptoms

Pagana, K. D., & Pagana, T. J. (2018). Mosby’s manual of
diagnostic and laboratory tests (6th ed.). St. Louis: Elsevier.

Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2017).
Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier.

United States Department of Agriculture (USDA). Food composition
databases. Retrieved from http://ndb.nal.usda.gov/ndb/search/list

Vallerand, A. H., Sanoski, C. A. & Deglin, J. H. (2017).
Davis’s drug guide for nurses (15 ed.). Philadelphia.

Vallerand, A. H., Sanoski, C. A. & Deglin, J. H. (2019).
Davis’s drug guide for nurses (16 ed.) Philadelphia.

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ACTIVE LEARNING TEMPLATES BasIc concePt A1

Basic Concept
STUDENT NAME _____________________________________

CONCEPT ______________________________________________________________________________ REVIEW MODULE CHAPTER ___________

Related Content
(E.G., DELEGATION,
LEVELS OF PREVENTION,
ADVANCE DIRECTIVES)

Underlying Principles Nursing Interventions
WHO? WHEN? WHY? HOW?

ACTIVE LEARNING TEMPLATE:

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A2 BasIc concePt CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES dIagnostIc Procedure A3

Diagnostic Procedure
STUDENT NAME _____________________________________

PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________

Description of Procedure

Indications

Interpretation of Findings

CONSIDERATIONS

Nursing Interventions (pre, intra, post)

Potential Complications

Client Education

Nursing Interventions

ACTIVE LEARNING TEMPLATE:

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A4 dIagnostIc Procedure CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES groWtH and deVeLoPment A5

EXPECTED GROWTH AND DEVELOPMENT

Growth and Development
STUDENT NAME _____________________________________

DEVELOPMENTAL STAGE _______________________________________________________________ REVIEW MODULE CHAPTER ___________

Health Promotion

Physical
Development

Immunizations

Cognitive
Development

Health Screening

Psychosocial
Development

Nutrition

Age‑Appropriate
Activities

Injury Prevention

ACTIVE LEARNING TEMPLATE:

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A6 groWtH and deVeLoPment CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES medIcatIon A7

Medication
STUDENT NAME _____________________________________

MEDICATION __________________________________________________________________________ REVIEW MODULE CHAPTER ___________

CATEGORY CLASS ______________________________________________________________________

PURPOSE OF MEDICATION

Expected Pharmacological Action

Complications

Contraindications/Precautions

Interactions

Medication Administration

Evaluation of Medication Effectiveness

Therapeutic Use

Nursing Interventions

Client Education

ACTIVE LEARNING TEMPLATE:

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A8 medIcatIon CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES nursIng sKILL A9

Nursing Skill
STUDENT NAME _____________________________________

SKILL NAME ____________________________________________________________________________ REVIEW MODULE CHAPTER ___________

Description of Skill

Indications

Outcomes/Evaluation

CONSIDERATIONS

Nursing Interventions (pre, intra, post)

Potential Complications

Client Education

Nursing Interventions

ACTIVE LEARNING TEMPLATE:

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A10 nursIng sKILL CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES sYstem dIsorder A11

System Disorder
STUDENT NAME _____________________________________

DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________

ASSESSMENT SAFETY
CONSIDERATIONS

PATIENT-CENTERED CARE

Alterations in
Health (Diagnosis)

Pathophysiology Related
to Client Problem

Health Promotion and
Disease Prevention

Risk Factors Expected Findings

Laboratory Tests Diagnostic Procedures

Complications

Therapeutic Procedures Interprofessional Care

Nursing Care Client EducationMedications

ACTIVE LEARNING TEMPLATE:

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A12 sYstem dIsorder CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES tHeraPeutIc Procedure A13

Therapeutic Procedure
STUDENT NAME _____________________________________

PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________

Description of Procedure

Indications

Outcomes/Evaluation

CONSIDERATIONS

Nursing Interventions (pre, intra, post)

Potential Complications

Client Education

Nursing Interventions

ACTIVE LEARNING TEMPLATE:

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A14 tHeraPeutIc Procedure CONTENT MASTERY SERIES

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ACTIVE LEARNING TEMPLATES concePt anaLYsIs A15

Concept Analysis
STUDENT NAME _____________________________________

CONCEPT ANALYSIS ____________________________________________________________________

Defining Characteristics

Antecedents
(WHAT MUST OCCUR/BE IN PLACE FOR
CONCEPT TO EXIST/FUNCTION PROPERLY)

Negative Consequences
(RESULTS FROM IMPAIRED ANTECEDENT —
COMPLETE WITH FACULTY ASSISTANCE)

Related Concepts
(REVIEW LIST OF CONCEPTS AND IDENTIFY, WHICH
CAN BE AFFECTED BY THE STATUS OF THIS CONCEPT
— COMPLETE WITH FACULTY ASSISTANCE)

Exemplars

ACTIVE LEARNING TEMPLATE:

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A16 concePt anaLYsIs CONTENT MASTERY SERIES