Portable RN The All-In-One Nursing Reference

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Portable RN
The All-in-One Nursing Reference
F O U RT H E D I T I O N
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STAFF The clinical procedures described and recom-

mended in this publication are based on re-
Publisher search and consultation with medical and
Judith A. Schilling McCann, RN, MSN nursing authorities. To the best of our knowl-
edge, these procedures reflect currently ac-
Clinical Director cepted clinical practice; nevertheless, they
Joan Robinson, RN, MSN can’t be considered absolute and universal
recommendations. For individual application,
Art Director treatment recommendations must be con-
Elaine Kasmer sidered in light of the patient’s clinical condi-
tion and, before administration of new or in-
Product Manager frequently used drugs, in light of the latest
Diane Labus package-insert information. The authors and
the publisher disclaim responsibility for any
Clinical Project Manager adverse effects resulting directly or indirectly
Lorraine M. Hallowell, RN, BSN, RVS from the suggested procedures, from any un-
detected errors, or from the reader’s misun-
Clinical Editors derstanding of the text.
Pamela A. Kovach, RN, BSN ©2011 by Lippincott Williams & Wilkins. All
Joanne M. Bartelmo, RN, MSN rights reserved. This book is protected by
copyright. No part of it may be reproduced,
Editor stored in a retrieval system, or transmitted, in
Margaret Eckman any form or by any means — electronic, me-
chanical, photocopy, recording, or otherwise —
Copy Editor without prior written permission of the
Heather Ditch publisher, except for brief quotations embod-
ied in critical articles and reviews and testing
Associate Manufacturing and evaluation materials provided by publish-
Manager er to instructors whose schools have adopted
Beth J. Welsh its accompanying textbook. Printed in China.
For information, write Lippincott Williams &
Editorial Assistants Wilkins, 323 Norristown Road, Suite 200,
Ambler, PA 19002-2756.
Karen J. Kirk, Jeri O’Shea,
Linda K. Ruhf PRN4010210
Design Assistant
Kate Zulak
Library of Congress
Cataloging-in-Publication Data
Portable RN : the all-in-one nursing reference.
— 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60547-974-3 (alk. paper)
1. Nursing—Handbooks, manuals, etc.
I. Lippincott Williams & Wilkins.
[DNLM: 1. Nursing Process—Handbooks.
2. Nursing Care—methods—Handbooks.
WY 49 P839 2011]
RT51.P676 2011
610.7306⬘9—dc22 2009040212
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Contents
Contents
Contributors and consultants v
Assessment
1 Reviewing the techniques 1
Assessment findings
2 Distinguishing health from disease 62
ECGs
3 Interpreting them with ease and accuracy 103
Common laboratory tests

4 Giving care and interpreting results 145
Common disorders
5 Treating and preventing diseases 199
Common procedures
6 Performing them safely and accurately 263
Surgical patient care

7 Reviewing the techniques 402
Pain management
8 Assessing pain and using medications 435
Pressure ulcers and

9 traumatic wound care
Preventing, staging, and treating wounds 449
iii
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iv Contents
10 Precautions
Preventing the spread of infection 462
11 Troubleshooting
Spotting and correcting equipment problems 471
12 Drug administration
Reviewing the methods 507
13 Dosage calculation
Ensuring effective therapy 538
14 Drug hazards
Recognizing and responding to them 553
15 Complications
Spotting and correcting life-threatening conditions 633
16 End-of-life care
Caring for the dying patient and his family 654
17 Documentation systems
Completing forms fully and concisely 659
Appendices
Cultural considerations in patient care 676
Potential agents of bioterrorism 678
Web sites of selected organizations 680
Dangerous abbreviations 681
Selected references 682
Index 683
LWBK449-FM_pi-vi.qxd 11/15/09 9:20 AM Page v
Contributors
and consultants
Helen C. Ballestas, RN, PhD, CRRN Merita Konstantacos, RN, MSN

Assistant Professor Staff Nurse
Adelphi University Aultman Hospital
Garden City, N.Y. Canton, Ohio
Marie O. Brewer, RN, LNC Rexann G. Pickering, RN, BS, MS,
Clinical Consultant MSN, PhD, CIM, CIP
Hortense, Ga. Administrator, Human Protection
Methodist Healthcare
Marsha L. Conroy,
Memphis, Tenn.
RN, BA, MSN, APN
Faculty Ora V. Robinson, RN, PhD
Chamberlain College of Nursing Assistant Professor
Columbus, Ohio California State University
San Bernardino, Calif.
Laura M. Criddle, RN, PhD, FAEN
Clinical Nurse Dina N. Salvatore, RN
Oregon Health & Science University Surgical Services Nurse
Portland, Ore. Martha’s Vineyard Hospital—General
Surgery Clinic
Christine Greenidge, RN, MSN,
Oak Bluffs, Mass.
DHA, BC
Director of Nursing Professional Allison J. Terry, RN, MSN, PhD
Practice/Nursing Quality Officer Director, Center for Nursing
Montefiore Medical Center Alabama Board of Nursing
Bronx, N.Y. Montgomery, Ala.
Kathleen M. Hill, RN, MSN,
CCNS-CSC
Clinical Nurse Specialist, Surgical
Intensive Care Unit
Cleveland Clinic
Cleveland, Ohio
Christine Kennedy, RN, MSN
Hospital Clinical Instructor
VA Connecticut Healthcare Systems
Westhaven, Conn.
v
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1 Assessment
Reviewing the techniques
Reviewing assessment techniques 3

Performing a 10-minute assessment 3
Guidelines for an effective interview 4
Assessing overall health 5
Assessing activities of daily living 5
Performing palpation techniques 6
Performing percussion techniques 7
Identifying percussion sounds 8
Performing auscultation 8
Assessing the family 10
Assessing the cardiovascular system 11
Initial questions 11
Inspecting the precordium 11
Positioning the patient for cardiac auscultation 12
Auscultating heart sounds 12
Palpating arterial pulses 14
Evaluating edema 15
Palpating the thorax 16
Measuring blood pressure 16
Assessing the respiratory system 18
Inspecting the chest 18
Palpating for tactile fremitus 19
Percussing the thorax 19
Auscultating breath sounds 20
Assessing the neurologic system 21
Assessing neurologic vital signs 21
Comparing decerebrate and decorticate postures 23
Assessing cerebellar function 23
Comparing delirium, dementia, and depression 24
Assessing reflexes 25
Assessing the cranial nerves 29
Assessing the pupils 33
Using the Glasgow Coma Scale 34
1
2 Assessment
Assessing the GI system 34

Inspecting the abdomen 34
Auscultating bowel sounds 35
Percussing the abdomen 35
Palpating the abdomen 36
Eliciting abdominal pain 37
Percussing, palpating, and hooking the liver 38
Palpating for indirect inguinal hernia 39
Assessing the urinary system 39
Evaluating urine color 40
Inspecting the urethral meatus 40
Percussing the urinary organs 40
Palpating the urinary organs 41
Assessing the male reproductive system 42
Inspecting and palpating the male genitalia 42
Assessing the female reproductive system 44
Palpating the breasts and axillae 44
Inspecting the female genitalia 45
Palpating the uterus 46
Assessing the musculoskeletal system 46
Assessing range of motion 46
Testing muscle strength 51
Assessing the skin 53
Inspecting and palpating the skin 53
Assessing dark skin 54
Evaluating skin color variations 55
Assessing the eyes, ears, nose, and throat 56
Inspecting the conjunctivae 56
Testing the cardinal positions of gaze 57
Performing an ophthalmoscopic examination 58
Using the otoscope 59
Inspecting the nostrils 60
Inspecting and palpating the frontal and maxillary
sinuses 60
Inspecting and palpating the thyroid gland 61
tient’s current symptom is related to

Reviewing assessment his admitting diagnosis.
techniques When every minute counts, follow
these steps.
Performing a 10-minute
assessment Assess airway, breathing, and
circulation
You won’t always want or need to as- As your first priority, this assessment
sess a patient in 10 minutes. However, may consist of just a momentary obser-
rapid assessment is crucial when you vation. However, when a patient ap-
must intervene quickly — such as when pears to be unconscious or has difficul-
a hospitalized patient has a change in ty breathing, you’ll assess him more
his physical, mental, or emotional sta- thoroughly to detect the problem and
tus. allow immediate intervention.
You may also perform a rapid as-
sessment to confirm a diagnostic find- Make general observations
ing. For example, if arterial blood gas Note the patient’s mental status, gener-
analysis indicates a low oxygen con- al appearance, and level of conscious-
tent, you’ll quickly assess the patient ness (LOC) for clues about the nature
for other signs of oxygen deprivation, and severity of his condition.
such as increased respiratory rate and
cyanosis. Assess vital signs
Take the patient’s body temperature,
General guidelines pulse, respiratory rate, and blood pres-
Assess the patient quickly and system- sure. They provide a quick overview of
atically. To save time, cover some of his physiologic condition as well as
the assessment components simultane- valuable information about the heart,
ously. For example, make your general lungs, and blood vessels. The serious-
observations while checking the pa- ness of the patient’s chief complaint
tient’s vital signs or asking history and your general observations of his
questions. condition will determine how exten-
Be flexible. You won’t necessarily sively you measure vital signs. Chief
use the same sequence each time. Let complaint is further discussed in
the patient’s chief complaint and chapter 2.
your initial observations guide your Age alert A patient’s age, ac-
assessment. You may be unable to tivity level, and physical and
obtain a quick history and instead emotional condition may affect his vi-
will need to rely on your observa- tal signs. Compare with the patient’s
tions and the information on the baseline, if available.
patient’s chart.
Keep the patient calm and coopera- Conduct the health history
tive. If you don’t know him, first intro- Use pointed questions to explore the
duce yourself by name and title. Re- patient’s perception of his chief com-
main calm, and reassure him that you plaint. Find out what’s bothering him
can help. If your demeanor can reduce the most. Ask him to quantify the
his anxiety, he’ll be more likely to give problem. For instance, does he feel
you accurate information. worse today than he did yesterday?
Avoid drawing quick conclusions. In Such questions will help you to focus
particular, don’t assume that the pa- your assessment. If you’re in a hurry
4 Assessment
or if the patient can’t respond, obtain Create a pleasant interviewing

information from other sources, such atmosphere
as family members, admission forms, ◆ Select a quiet, well-lit, and relaxing
the medical history, and the patient’s setting. Keep in mind that extraneous
chart. noise and activity can interfere with
concentration, as can excessive or in-
Perform the physical examination sufficient light. A relaxing atmosphere
Begin by concentrating on areas related eases the patient’s anxiety, promotes
to the patient’s chief complaint — the comfort, and conveys your willingness
abdomen, for example, if the patient to listen.
complains of abdominal pain. Compare ◆ Ensure privacy. Some patients won’t
the results with baseline data, if avail- share personal information if they sus-
able. pect that others can overhear. You may,
You may have to perform a com- however, let friends or family members
plete head-to-toe or body systems remain if the patient requests it or if he
assessment — for instance, if a patient needs their help.
is unresponsive (yet has no breathing ◆ Make sure that the patient feels as
or circulatory problems) or is con- comfortable as possible. If the patient
fused and, thus, unreliable. However, is tired, short of breath, or frightened,
in most cases, the patient’s chief provide care and reschedule the history
complaint, your general observations, taking.
and your findings about the patient’s ◆ Take your time. If you appear
vital signs will guide your assess- rushed, you may distract the patient.
ment. Give him your undivided attention. If
you have little time, focus on specific
Guidelines for an effective areas of interest and return later in-
interview stead of hurrying through the entire
interview.
When you have time for a full assess-
ment, begin by interviewing the pa- Establish a good rapport
tient. Developing an effective inter- ◆ Sit and chat with the patient for a
viewing technique will help you to few minutes before the interview.
collect pertinent health history infor- Standing may suggest that you’re in a
mation efficiently. Use these guide- hurry, leading the patient to rush and
lines to enhance your interviewing omit important information.
skills. ◆ Explain the purpose of the inter-
view. Emphasize how the patient bene-
Be prepared fits when the health care team has the
◆ Before the interview, review all information needed to diagnose and
available information. Read the current treat a disorder.
clinical records and, if applicable, pre- ◆ Show your concern for the pa-
vious records. This will focus the inter- tient’s story. Maintain eye contact,
view, prevent the patient from tiring, and occasionally repeat what he tells
and save you time. you. If you seem preoccupied or unin-
◆ Review with the patient what terested, he may choose not to confide
you’ve learned to ensure that the infor- in you.
mation is correct. Keep in mind that ◆ Encourage the patient to help you
the patient’s current complaint may be to develop a realistic plan of care that
unrelated to his history. will serve his perceived needs.
Set the tone and focus Assessing overall health

◆ Encourage the patient to talk about
his chief complaint. This helps you to For a quick look at the patient’s overall
focus on his most troublesome signs health, ask these questions:
and symptoms and provides an oppor- ◆ Has your weight changed? Do your
tunity to assess the patient’s emotional clothes, rings, and shoes fit?
state and level of understanding. ◆ Do you have nonspecific signs and
◆ Keep the interview informal but symptoms, such as weakness, fatigue,
professional. Allow the patient time to night sweats, or fever?
answer questions fully and to add his ◆ Can you keep up with your normal
own perceptions. daily activities?
◆ Speak clearly and simply. Avoid us- ◆ Have you had any unusual symp-
ing medical terms. toms or problems recently?
Age alert Make sure the pa- ◆ How many colds or other minor ill-
tient hears and understands nesses have you had in the last year?
you, especially if he’s elderly. If you ◆ What prescription and over-the-
think he misunderstands, ask him to counter drugs and supplements do you
restate what you’ve discussed. take?
◆ Pay close attention to the patient’s
words and actions, interpreting not Assessing activities of daily living
only what he says but also what he
doesn’t say. For a comprehensive look at the pa-
Age alert If the patient is a tient’s health and health history, ask
child, direct as many questions these questions:
as possible to him. Rely on the par-
ents for information if the child is Diet and elimination
very young. ◆ How would you describe your ap-
petite?
Choose your words carefully ◆ What do you normally eat in a
◆ Ask open-ended questions to en- 24-hour period?
courage the patient to provide com- ◆ What foods do you like and dislike?
plete and pertinent information. Avoid Is your diet restricted at all?
yes-or-no questions. ◆ How much fluid do you drink dur-
◆ Listen carefully to the patient’s an- ing an average day?
swers. Use his words in your subse- ◆ Are you allergic to any food?
quent questions to encourage him to ◆ Do you prepare your meals, or does
elaborate on his signs, symptoms, and someone prepare them for you?
other problems. ◆ Do you go to the grocery store, or
does someone else shop for you?
Take notes ◆ Do you snack and, if so, on what?
◆ Avoid documenting everything dur- ◆ Do you eat a variety of foods?
ing the interview, but make sure to jot ◆ Do you have enough money to pur-
down important information, such as chase the groceries you need?
dates, times, and key words or phrases. ◆ When do you usually go to the bath-
Use these to help you recall the com- room? Has this pattern changed recently?
plete history for the medical record. ◆ Do you take any foods, fluids, or
◆ If you’re tape-recording the inter- drugs to maintain your normal elimina-
view, obtain written consent from the tion patterns?
patient. (Text continues on page 10.)
6 Assessment
Performing palpation techniques
Palpation uses pressure to assess struc-

ture size, placement, pulsation, and ten-
derness. Ballottement, a variation, in-
volves bouncing tissues against the hand
to assess rebound of floating structures.
Ballottement can be used to assess a
mass in a patient with ascites.
Light palpation
To perform light palpation, press gently
on the skin, indenting it 1⁄2⬙ to 3⁄4⬙ (1 to
2 cm). Use the lightest touch possible; too
much pressure blunts your sensitivity. Light ballottement
Close your eyes to concentrate on feeling. To perform light ballottement, apply light,
rapid pressure from quadrant to quadrant
of the patient’s abdomen. Keep your hand
on the surface of the skin to detect tissue
rebound.
Deep palpation
To perform deep palpation, indent the
skin about 11⁄2” (4 cm). Place your other Deep ballottement
hand on top of the palpating hand to To perform deep ballottement, apply
control and guide your movements. To abrupt, deep pressure; then release, but
perform a variation of deep palpation maintain contact.
that allows you to pinpoint an inflamed
area, push down slowly and deeply, then
lift your hand away quickly. If the patient
complains of increased pain as you re-
lease the pressure, you have identified re-
bound tenderness.
Use both hands (bimanual palpation)
to trap a deep, hard-to-palpate organ
(such as the kidney or spleen) or to fix or
stabilize an organ (such as the uterus)
while palpating with the other hand.
Performing percussion techniques
Percussion has two basic purposes: to

produce percussion sounds and to elicit
tenderness. It involves three types: indi-
rect, direct, and blunt percussion.
Indirect percussion
The most commonly used method, indi-
rect percussion, produces clear, crisp
sounds when performed correctly. To per-
form indirect percussion, use the second
finger of your nondominant hand as the
pleximeter (the mediating device used to
receive the taps) and the middle finger of
Blunt percussion
your dominant hand as the plexor (the
To perform blunt percussion, strike the ul-
device used to tap the pleximeter). Place
nar surface of your fist against the body
the pleximeter finger firmly against a
surface. Alternatively, you may use both
body surface, such as the upper back or
hands by placing the palm of one hand
abdomen. With your wrist flexed loosely,
over the area to be percussed and then
use the tip of your plexor finger to deliv-
making a fist with the other hand and us-
er a crisp blow just beneath the distal
ing it to strike the back of the first hand.
joint of the pleximeter. Make sure you
Both techniques aim to elicit tenderness —
hold the plexor perpendicular to the
not to create a sound — over organs such
pleximeter. Tap lightly and quickly, re-
as the kidneys. (Another blunt percussion
moving the plexor as soon as you have
method, used in the neurologic examina-
delivered each blow.
tion, involves tapping a rubber-tipped re-
flex hammer against a tendon to create a
reflexive muscle contraction.)
Direct percussion
To perform direct percussion, tap your
hand or fingertip directly against the
body surface as shown at the top of the
next column. This method helps assess an
adult’s sinuses for tenderness.
8 Assessment
Identifying percussion sounds
Percussion produces sounds that vary according to the tissue being percussed. This chart
shows important percussion sounds along with their characteristics and typical locations.
SOUND INTENSITY PITCH DURATION
Resonance Moderate to loud Low Moderate to long
Tympany Loud High Moderate
Dullness Soft to moderate High Long
Hyperresonance Very loud Very low Long
Flatness Soft High Short
Performing auscultation
Auscultation of body sounds — particularly those produced by the heart, lungs, blood ves-
sels, stomach, and intestines — detects both high-pitched and low-pitched sounds. Although
you can perform auscultation directly over a body area using only your ears, you’ll typically
perform it indirectly, using a stethoscope.
Assessing high-pitched sounds

To assess high-pitched sounds properly, such
as breath sounds and first and second heart
sounds, use the diaphragm of the stethoscope.
Make sure you place the entire surface of the
diaphragm firmly on the patient’s skin. If the
area is excessively hairy, you can improve dia-
phragm contact and reduce extraneous noise
by applying water or water-soluble jelly to the
skin before auscultating.
QUALITY SOURCE
Hollow Normal lung
Drumlike Gastric air bubble or intestinal air
Thudlike Liver, full bladder, pregnant uterus, or spleen
Booming Hyperinflated lung (as in emphysema)
Flat Muscle, bone, or tumor
Assessing low-pitched sounds

To assess low-pitched sounds, such as heart
murmurs and third and fourth heart sounds,
lightly place the bell of the stethoscope on
the appropriate area. Don’t exert pressure. If
you do, the patient’s chest will act as a di-
aphragm and you will miss low-pitched
sounds. If the patient is extremely thin or
emaciated, use a stethoscope with a pediatric
chest piece.
10 Assessment
Exercise and sleep ◆ Do you drink more when you’re un-

◆ Do you have a special exercise pro- der stress?
gram? What is it? How long have you ◆ Has drinking ever hampered your
been following it? How do you feel af- job performance or personal relation-
ter exercising? ships?
◆ How many hours do you sleep each ◆ Do you or does anyone in your fam-
day? When? Do you feel rested after- ily worry about your drinking?
ward? ◆ Do you feel dependent on alcohol?
◆ Do you fall asleep easily? ◆ Do you feel dependent on coffee,
◆ Do you take any drugs or do any- tea, or soft drinks? How much of these
thing special to help you to fall asleep? beverages do you drink in an average
◆ What do you do when you can’t day?
sleep? ◆ Do you use drugs that aren’t pre-
◆ Do you wake up during the night? scribed by a physician (marijuana, co-
◆ Do you have sleepy spells during caine, heroin, steroids, sleeping pills,
the day? When? tranquilizers)?
◆ Do you routinely take naps?
◆ Do you have any recurrent, disturb- Assessing the family
ing dreams?
◆ Have you ever been diagnosed with When assessing how and to what ex-
a sleep disorder, such as narcolepsy or tent the patient’s family fulfills its func-
sleep apnea? tions, remember to assess both the
family into which the patient was born
Recreation (family of origin) and, if different, the
◆ What do you do when you aren’t patient’s current family.
working? Because the following questions tar-
◆ What kind of unpaid work do you get a nuclear family — that is, mother,
do for enjoyment? father, and children — you may need to
◆ How much leisure time do you modify them somewhat for other types
have? of families, such as single-parent fami-
◆ Are you satisfied with what you can lies, families that include grandparents,
do in your leisure time? patients who live alone, or unrelated
◆ Do you and your family share individuals who live as a family. Re-
leisure time? member, you’re assessing the patient’s
◆ How do your weekends differ from perception of family function.
your weekdays?
Affective function
Tobacco, alcohol, and drugs To assess how family members regard
◆ Do you use tobacco? If so, what each other, ask these questions:
kind? How much do you use each day? ◆ How do the members of your family
Each week? When did you start using treat each other?
it? Have you ever tried to stop? ◆ How do they feel about each other?
◆ Do you drink alcoholic beverages? If ◆ How do they regard each other’s
so, what kind (beer, wine, whiskey)? needs and wants?
◆ How much alcohol do you drink ◆ How are feelings expressed in your
each day? Each week? What time of family?
day do you usually drink? ◆ Can family members safely express
◆ Do you usually drink alone or with both positive and negative feelings?
others?
◆ What happens when family mem- ◆ Do you have any friends whom you
bers disagree? consider family?
◆ How do family members deal with ◆ Does anyone other than your imme-
conflict? diate family (for example, grandpar-
◆ Do you feel safe in your environ- ents) live with you?
ment? ◆ Are you involved in community af-
fairs? Do you enjoy the activities?
Socialization and social placement
To assess the flexibility of family re- Economic function
sponsibilities, which aids discharge To explore money issues and their rela-
planning, ask these questions: tion to power roles within the family,
◆ How satisfied are you and your ask these questions:
partner with your roles as a couple? ◆ Does your family income meet the
◆ How did you decide to have (or not family’s basic needs?
to have) children? ◆ Who makes decisions about family
◆ Do you and your partner agree money allocation?
about how to bring up the children? If ◆ If you take prescription drugs, do you
not, how do you work out differences? have enough money to pay for them?
◆ Who is responsible for taking care
of the children? Is this arrangement
mutually satisfactory? Assessing the cardiovascular
◆ How well do you feel your children system
are growing up?
◆ Are family roles negotiable within
the limits of age and ability? Initial questions
◆ Do you share cultural values and
beliefs with your children? ◆ Ask the patient about cardiac prob-
lems, such as palpitations, tachycardia
Health care function or other irregular rhythms, chest pain,
To identify the family caregiver and dyspnea on exertion, paroxysmal noc-
thus facilitate discharge planning, ask turnal dyspnea, and cough.
these questions: ◆ Explore vascular problems. Does the
◆ Who takes care of family members patient experience pain, cyanosis, ede-
when they’re sick? Who makes physi- ma, ascites, intermittent claudication,
cian appointments? cold extremities, or phlebitis? Has he
◆ Are your children learning about ever had a stroke or symptoms of a
personal hygiene, healthful eating, and stroke?
the importance of adequate sleep and ◆ Ask about postural hypotension, hy-
rest? pertension, rheumatic fever, varicose
◆ How does your family adjust when veins, and peripheral vascular diseases.
a member is ill and unable to fulfill ex- ◆ Ask when, if ever, the patient had
pected roles? his last electrocardiogram.
Family and social structure Inspecting the precordium

To assess the value the patient places
on family and other social structures, ◆ First, place the patient in a supine
ask these questions: position, with his head flat or elevated
◆ How important is your family to for his respiratory comfort. If you’re
you? (Text continues on page 16.)
12 Assessment
Positioning the patient for cardiac auscultation
During auscultation, you will typically stand to the right of the patient, who is in a supine
position. The patient may lie flat or at a comfortable elevation.
If the heart sounds seem faint or undetectable, try repositioning the patient. Alternate
Forward-leaning position
The forward-leaning position is best for
hearing high-pitched sounds related to
semilunar valve problems, such as aortic
and pulmonic valve murmurs. Aortic re-
gurgitation is sometimes heard only in
the forward-leaning position. To auscul-
tate these sounds, help the patient into
the forward-leaning position and place
the diaphragm of the stethoscope over
the aortic and pulmonic areas in the right
and left second intercostal spaces.
Auscultating heart sounds
Using a stethoscope with 10⬙ to 12⬙ (25- to the mitral valve and left ventricular filling
30-cm) tubing, follow these steps to auscul- during diastole.
tate heart sounds: ◆ Begin auscultation in the aortic area,
◆ Locate the four different auscultation placing the stethoscope in the second inter-
sites, as illustrated at right. costal space along the right sternal border.
In the aortic area, blood moves from the ◆ Then move to the pulmonic area, located
left ventricle during systole, crossing the in the second intercostal space at the left
aortic valve and flowing through the aortic sternal border.
arch. In the pulmonic area, blood ejected ◆ Next, assess the tricuspid area, which
from the right ventricle during systole lies in the fifth intercostal space along the
crosses the pulmonic valve and flows left sternal border.
through the main pulmonary artery. In the ◆ Finally, listen in the mitral area, located
tricuspid area, sounds reflect the movement in the fifth intercostal space near the mid-
of blood from the right atrium across the clavicular line.
tricuspid valve, filling the right ventricle Note: If the patient’s heart is enlarged,
during diastole. In the mitral, or apical, the mitral area may be closer to the anteri-
area, sounds represent blood flow across or axillary line.
positioning may enhance the sounds or make them seem louder by bringing the heart closer
to the surface of the chest. Common alternate positions include the seated, forward-leaning
position and the left-lateral decubitus position.
Left-lateral decubitus position

The left-lateral decubitus position is best for
hearing low-pitched sounds related to atri-
oventricular valve problems, such as mitral
valve murmurs and extra heart sounds. A mi-
tral stenosis murmur is sometimes heard only
in the left-lateral position. A pericardial rub
can be heard in this position and is an abnor-
mal finding. To auscultate these sounds, help
the patient into the left-lateral decubitus posi-
tion and place the bell of the stethoscope
over the apical area. If these positions don’t
enhance the heart sounds, try auscultating
with the patient standing or squatting.
Sternoclavicular area
Aortic area Pulmonic area
Tricuspid (right
ventricular area)
Mitral area
Epigastric area
Midsternal line Midclavicular line

14 Assessment
Palpating arterial pulses
To palpate the arterial pulses, you’ll ap- tient, palpate in the crease of the groin,
ply pressure with your index and middle halfway between the pubic bone and the
fingers positioned as shown here. hip bone.
Carotid pulse
Lightly place your fingers just medial to
the trachea and below the angle of the
jaw.
Popliteal pulse
Press firmly against the popliteal fossa at
the back of the knee.
Brachial pulse
Position your fingers medial to the biceps Posterior tibial pulse
tendon. Curve your fingers around the medial
malleolus, and feel the pulse in the
groove between the Achilles’ tendon and
the malleolus.
Radial pulse
Apply gentle pressure to the medial and
ventral side of the wrist, just below the
thumb. Dorsalis pedis pulse
Lightly touch the medial dorsum of the
foot while the patient points the toes
down. In this site, the pulse is difficult to
palpate and may seem to be absent in
some healthy patients.
Femoral pulse
Press relatively hard at a point inferior to
the inguinal ligament. For an obese pa-
Evaluating edema
To assess pitting edema, press firmly for 5 to 10 seconds over a bony surface, such as
the tibia, fibula, sacrum, or sternum. Then remove your finger and note how long the
depression remains. Document your observation on a scale of +1 (barely detectable de-
pression) to +4 (persistent pit as deep as 1⬙ [2.5 cm]).
In severe edema, tissue swells so much that fluid can’t be displaced, making pitting
impossible. The surface feels rock-hard, and subcutaneous tissue becomes fibrotic.
Brawny edema may develop eventually.
+1 pitting edema
+4 pitting edema
Brawny edema
16 Assessment
Palpating the thorax
Palpation of the anterior and posterior

thorax can detect structural and skin ab-
normalities, areas of pain, and chest
asymmetry. To perform this technique,
use the fingertips and palmar surfaces of
one or both hands to palpate systemati-
cally and in a circular motion. Alternate
palpation from one side of the thorax to
the other.
Anterior thorax
Begin palpation in the supraclavicular
area (#1 in the diagram at right). Then
palpate the anterior thorax in the follow-
ing sequence: infraclavicular, sternal,
xiphoid, rib, and axillary areas.
examining an obese patient or one Measuring blood pressure

with large breasts, have the patient sit
upright. This position will bring the When you assess the patient’s blood
heart closer to the anterior chest wall pressure, you’re measuring the fluctu-
and make pulsations more visible. If ating force that blood exerts against ar-
time allows, you can use tangential terial walls as the heart contracts and
lighting to cast shadows across the relaxes. To measure blood pressure ac-
chest. This makes it easier to see curately, follow these steps.
abnormalities.
◆ Standing to the patient’s right (un- Preparing the patient
less you’re left-handed), remove the Before beginning, make sure that the
clothing covering his chest wall. Quick- patient is relaxed and warm and hasn’t
ly identify the following anatomic sites, eaten, smoked, or exercised in the last
named for their underlying structures: 30 minutes. The patient can sit, stand,
sternoclavicular, pulmonary, aortic, or lie down during blood pressure mea-
right ventricular, epigastric, and left surement.
ventricular areas.
◆ Make a visual sweep of the chest Applying the cuff and stethoscope
wall, watching for movement, pulsa- ◆ To obtain a reading in an arm (the
tions, and exaggerated lifts or heaves most common measurement site), first
(strong outward thrusts seen at the choose an appropriately sized cuff.
sternal border or apex during systole). (The width of the cuff should be at
Posterior thorax
Begin palpation in the supraclavicular
area. Then move to the area between the
scapulae (interscapular), then the area
below the scapulae (infrascapular), and
finally down to the lateral walls of the
thorax.
least 20% greater than the diameter of porting it with your hand. Rest a re-
the upper arm.) Then wrap the sphyg- cumbent patient’s arm at his side.
momanometer cuff snugly around the Don’t use the patient’s muscle strength
upper arm, above the antecubital area. to hold up the arm; tension from mus-
Center the cuff bladder over the cle contraction can elevate systolic
brachial artery. pressure and distort the findings.
Age alert When measuring ◆ Palpate the brachial pulse, just be-
blood pressure in an infant or low and slightly medial to the antecu-
child, use an appropriate-sized cuff. bital area. Place the earpieces of the
Because blood pressure may be in- stethoscope in your ears, and position
audible in children younger than age the stethoscope head over the brachial
2, consider using an electronic stetho- artery, just distal to the cuff or slightly
scope or Doppler to obtain a more ac- beneath it.
curate measurement.
◆ Most cuffs have arrows that should
be placed over the brachial artery.
◆ Keep the mercury manometer at eye
level. If your sphygmomanometer has
an aneroid gauge, place it level with
the patient’s arm. Keep the patient’s
arm level with the heart by placing it
on a table or a chair arm or by sup-
18 Assessment
Generally, you’ll use the easy-to- minish or become muffled — phase IV

handle, flat diaphragm to auscultate (the fourth Korotkoff’s sound) — and
the pulse. However, if the patient has a the point at which they disappear —
diminished or hard-to-locate pulse, you phase V (the fifth Korotkoff’s sound).
may need to use the bell to detect the For children and highly active adults,
low-pitched sound of arterial blood many authorities consider phase IV the
flow more effectively. most accurate reflection of blood pres-
sure. For children younger than age 13,
Obtaining the blood pressure pregnant women, and highly active
reading adults, record phases I, IV, and V.
◆ Watch the manometer while you The American Heart Association
pump the bulb until the mercury col- and the World Health Organization rec-
umn or aneroid gauge reaches about 20 ommend documenting phases I and V
to 30 mm Hg above the point at which in most adults. To avoid confusion and
the pulse disappears. Slowly open the to make your measurements more use-
air valve and watch the mercury drop ful, follow this format for recording
or the gauge needle descend. Release blood pressure: systolic/disappearance
the pressure at a rate of about 3 mm Hg/ (for example, 120/76).
second, and listen for pulse sounds
(Korotkoff’s sounds). These sounds,
which determine the blood pressure Assessing the respiratory
measurement, are classified as follows: system
Phase I
A clear, faint tapping starts and in- Initial questions
creases in intensity to a thud or a loud-
er tap. ◆ Inquire about dyspnea or shortness
of breath. Does your patient have
Phase II breathing problems after physical exer-
The tapping changes to a soft swishing tion? Also ask him about pain, wheez-
sound. ing, paroxysmal nocturnal dyspnea,
and orthopnea (for example, number of
Phase III pillows used).
A clear, crisp tapping sound returns. ◆ Ask whether the patient has cough,
sputum production, hemoptysis, or
Phase IV (first diastolic sound) night sweats.
The sound becomes muffled and takes ◆ Find out if he has emphysema,
on a blowing quality. pleurisy, bronchitis, tuberculosis, pneu-
monia, asthma, or frequent respiratory
Phase V tract infections.
The sound disappears.
Inspecting the chest
◆ As soon as you hear blood begin to
pulse through the brachial artery, note Position the patient to allow access to
the reading on the aneroid dial or mer- his posterior and anterior chest. If his
cury column. This sound reflects phase condition permits, have him sit on the
I (the first Korotkoff’s sound) and coin- edge of a bed or examining table or on
cides with the patient’s systolic pres- a chair, leaning forward with his arms
sure. Continue to deflate the cuff, not- folded across his chest. If this isn’t
ing the point at which pulsations di- possible, place him in semi-Fowler’s
Assessing the respiratory system 19
position for the anterior chest examina- air, assessing for tactile fremitus —
tion. Then ask him to lean forward which involves palpating for voice vi-
slightly and use the side rails or mat- brations — provides valuable informa-
tress for support while you quickly ex- tion about the contents of the lungs.
amine his posterior chest. If he can’t Follow this procedure:
lean forward, place him in a lateral po- ◆ Place your open palm flat against
sition or ask another staff member to the patient’s chest without touching
help him to sit up. the chest with your fingers.
Systematically compare one side of
the chest with the other.
◆ First, inspect the patient’s chest for
obvious problems, such as draining,
open wounds, bruises, abrasions, scars,
and cuts. Also look for less obvious
problems, such as rib deformities, frac-
tures, lesions, or masses.
◆ Examine the shape of the patient’s
chest wall. Observe the anteroposterior
and transverse diameters.
◆ Note the patient’s respiratory pat-
tern, watching for characteristics such ◆ Ask the patient to repeat a reso-
as pursed-lip breathing. nant phrase, such as “ninety-nine” or
◆ Observe the movement of the chest “blue moon,” as you systematically
during respirations. The chest should move your hands over his chest from
move upward and outward symmetrical- the central airways to the lung periph-
ly on inspiration. Factors that may affect ery and back. Always proceed system-
movement include pain, poor position- atically from the top of the supra-
ing, and abdominal distention. Watch scapular area to the interscapular, in-
for paradoxical movement (possibly re- frascapular, and hypochondriac areas
sulting from fractured ribs or flail chest) (found at the levels of the fifth and
and asymmetrical expansion (atelectasis tenth intercostal spaces to the right
or underlying pulmonary disease). and left of the midline).
◆ Check for use of the accessory mus- ◆ Repeat this procedure on the poste-
cles and retraction of the intercostal rior thorax. You should feel vibrations
spaces during inspiration (possibly indi- of equal intensity on either side of the
cating respiratory distress). You may no- chest. Fremitus normally occurs in the
tice sudden, violent intercostal retraction upper chest, close to the bronchi, and
(airway obstruction or tension pneu- feels strongest at the second intercostal
mothorax); retraction of the abdominal space on either side of the sternum.
muscles during expiration (chronic ob- Little or no fremitus should occur in
structive pulmonary disease and other the lower chest. The intensity of the vi-
obstructive disorders); inspiratory inter- brations varies according to the thick-
costal bulging (cardiac enlargement or ness and structure of the patient’s
aneurysm); or localized expiratory chest wall as well as the intensity and
bulging (rib fracture or flail chest). pitch of his voice.
Palpating for tactile fremitus Percussing the thorax
Because sound travels more easily Percussion of the thorax helps to deter-
through solid structures than through mine the boundaries of the lungs and
20 Assessment
the amount of gas, liquid, or solid in bral column and the scapulae, as shown
the lungs. Percussion can effectively below. Posterior percussion should
assess structures as deep as 13⁄4⬙ to 3⬙ sound resonant to the level of T10.
(4.5 to 7.5 cm).
To percuss a patient’s thorax, al-
ways use indirect percussion, which in-
volves striking one finger with another.
Proceed systematically, percussing the
anterior, lateral, and posterior chest
over the intercostal spaces.
Avoid percussing over bones, such
as the manubrium, sternum, xiphoid,
clavicles, ribs, vertebrae, or scapulae.
Because of their denseness, bones pro-
duce a dull sound on percussion and,
therefore, yield no useful information.
Always follow the same sequence
when performing percussion, compar- Lateral thorax
ing variations in sound from one side Starting at the axilla, move down the
to the other. This helps to ensure con- side of the rib cage, percussing be-
sistency and prevents you from over- tween the ribs, as shown below. Per-
looking important findings. cussion of the lateral chest should pro-
duce resonance to the sixth or eighth
Anterior thorax intercostal space.
Place your hands over the lung apices
in the supraclavicular area. Then pro-
ceed downward, moving from side to
side at intervals of 11⁄2⬙ to 2⬙ (4 to
5 cm), as shown below. Anterior chest
percussion should produce resonance
from below the clavicle to the fifth in-
tercostal space on the right (where
dullness occurs close to the liver) and
to the third intercostal space on the left
(where dullness occurs near the heart).
Auscultating breath sounds
Auscultating breath sounds is an im-

portant step in physical assessment. It
helps you to detect abnormal accumu-
lation of fluid or mucus and obstructed
air passages.
To detect breath sounds, auscultate
the anterior, lateral, and posterior thorax,
Posterior thorax following the same sequence that you
Progress in a zigzag fashion from the used for percussion of the thorax. Begin
suprascapular to the interscapular to the at the upper lobes, and move from side
infrascapular areas, avoiding the verte- to side and down, comparing findings.
Age alert If the patient is a ty, and level of orientation to time,

child, begin just below the right place, and person.
clavicle, moving to the midsternum, LOC reflects brain stem function and
left clavicle, left nipple, and right nip- usually provides the first sign of central
ple. Assess one full breath (inspiration nervous system deterioration. Changes
and expiration) at each point. in pupillary activity may signal increased
Auscultate the lungs to detect normal, intracranial pressure (ICP). Level of ori-
abnormal, and absent breath sounds. entation evaluates higher cerebral func-
Classify breath sounds by their location, tions. Evaluating muscle strength and
intensity, pitch, and duration during the tone, reflexes, and posture may also help
inspiratory and expiratory phases. to identify nervous system damage. Fi-
nally, evaluating the respiratory rate and
pattern can help to locate brain lesions
Assessing the neurologic and determine their size.
system
Equipment
Penlight ◆ thermometer ◆ stethoscope
Initial questions ◆ sphygmomanometer ◆ pupil size
chart
◆ Ask the patient to state his full
name and the date, time, and place Implementation
where he is now. ◆ Explain the procedure to the pa-
◆ Investigate the character of any tient, even if he’s unresponsive.
headaches (frequency, intensity, loca- ◆ Assess the patient’s LOC.
tion, and duration). ◆ Ask the patient to state his full
◆ Determine whether your patient has name. If he responds appropriately, as-
vertigo or syncope. sess his orientation to time, place, and
◆ Ask if he has a history of seizures person. Assess the quality of his replies.
or use of anticonvulsants. ◆ Assess the patient’s ability to under-
◆ Explore cognitive disturbances, in- stand and follow one-step commands
cluding recent or remote memory loss, that require a motor response. For exam-
hallucinations, disorientation, speech ple, ask him to open and close his eyes.
and language dysfunction, or inability Note whether he can maintain his LOC.
to concentrate. ◆ If the patient doesn’t respond to
◆ Ask if the patient has a history of commands, squeeze the nail beds on
sensory disturbances, including tin- his fingers and toes with moderate
gling, numbness, and sensory loss. pressure and note his response. Alter-
◆ Explore motor problems, including nately, rub the upper portion of his
problems with gait, balance, coordina- sternum between the second and third
tion, tremor, spasm, or paralysis. intercostal spaces with your knuckles.
◆ Ask him if cognitive, sensory, or Check the motor responses bilaterally
motor symptoms have interfered with to rule out monoplegia and hemiplegia.
his activities of daily living.
Examine pupils and eye movement
Assessing neurologic vital signs ◆ Ask the patient to open his eyes. If
he’s unresponsive, lift his upper eye-
A supplement to routine measurement lids. Inspect the pupils for size and
of temperature, pulse, and respirations, shape, and compare them for equality.
neurologic vital signs are used to eval- To evaluate them more precisely, use a
uate the patient’s LOC, pupillary activi- chart showing the various pupil sizes.
22 Assessment
◆ Test the patient’s direct light re- Alert Never test this reflex if
sponse. First, darken the room. Hold you know or suspect that the
each eyelid open in turn, keeping the patient has a cervical spine injury.
other eye covered. Swing the penlight
from the patient’s ear toward the mid- Evaluate motor function
line of the face. Shine the light directly ◆ If the patient is conscious, test his
into the eye. Normally, the pupil con- grip strength in both hands at the same
stricts immediately when exposed to time. Extend your hands, ask the pa-
light and then dilates immediately tient to squeeze your fingers as hard as
when the light is removed. Wait 20 sec- he can, and compare the strength of
onds before testing the other pupil to each hand. Grip strength is usually
allow it to recover from reflex stimula- slightly stronger in the dominant hand.
tion. ◆ Test arm strength by having the pa-
◆ Test consensual light response. Hold tient close his eyes and hold his arms
both eyelids open, but shine the light straight out in front of him, with the
into one eye only. Watch for constric- palms up. See if either arm drifts
tion in the other pupil, which indicates downward or pronates, which indicates
proper nerve function. weakness.
◆ Brighten the room, and ask the con- ◆ Test leg strength by having the pa-
scious patient to open his eyes. Observe tient raise his legs, one at a time,
the eyelids for ptosis or drooping. Then against gentle downward pressure from
check the extraocular movements. Hold your hand.
up one finger and ask the patient to fol- ◆ If the patient is unconscious, exert
low it with his eyes as you move your pressure on each fingernail bed. If the
finger up, down, laterally, and oblique- patient withdraws, compare the
ly. See if the patient’s eyes track togeth- strength of each limb.
er to follow your finger (conjugate Alert If decorticate or decere-
gaze). Watch for involuntary jerking or brate posturing develops in re-
oscillating movements (nystagmus). sponse to painful stimuli, notify the
◆ Check accommodation. Hold up one physician immediately. (See Compar-
finger midline to the patient’s face and ing decerebrate and decorticate
several feet away. Ask the patient to fo- postures.)
cus on your finger as you move it toward ◆ Flex and extend the extremities on
his nose. His eyes should converge, and both sides to evaluate muscle tone.
his pupils should constrict equally. ◆ Test the plantar reflex in all patients.
◆ Test the corneal reflex with a wisp Stroke the lateral aspect of the sole of
of cotton. Have the patient look the patient’s foot with your thumbnail.
straight ahead. Bring the cotton wisp Normally, this elicits flexion of all toes.
in from the side to lightly touch the Watch for a positive Babinski’s sign —
cornea. Observe the patient for bilater- dorsiflexion of the great toe with fan-
al blinking. Tearing will occur in the ning of the other toes — which indicates
eye that’s touched. an upper motor neuron lesion.
◆ If the patient is unconscious, test ◆ Test for Brudzinski’s and Kernig’s
the oculocephalic (doll’s eye) reflex. signs in patients suspected of having
Hold the patient’s eyelids open. Quick- meningitis.
ly but gently turn the patient’s head to
one side and then to the other. If the Complete the neurologic
patient’s eyes move in the opposite di- examination
rection from the side to which you turn ◆ Take the patient’s temperature, pulse
the head, the reflex is intact. rate, respiration rate, and blood pressure.
Comparing decerebrate and decorticate postures
Decerebrate posture results from damage to the upper brain stem. In this posture, the
arms are adducted and extended, with the wrists pronated and the fingers flexed. The
teeth are clenched. The legs are stiffly extended, with plantar flexion of the feet.
Decorticate posture results from damage to one or both corticospinal tracts. In this
posture, the arms are adducted and flexed, with the wrists and fingers flexed on the
chest. The legs are stiffly extended and rotated internally, with plantar flexion of the
feet.
Especially check pulse pressure — the Romberg’s test

difference between systolic and diastolic To perform this test, ask the patient
pressure — because widening pulse to stand with his feet together, his
pressure can indicate increasing ICP. eyes open, and his arms at his side.
Hold your outstretched arms on ei-
Special considerations ther side of him so you can support
Alert If a patient’s status was him if he sways to one side or the
previously stable and he has a other. Observe his balance; then ask
sudden change in neurologic or rou- him to close his eyes. Note whether
tine vital signs, assess his condition he loses his balance or sways. If he
further and notify the physician im- falls to one side, Romberg’s test re-
mediately. sult is abnormal. Patients with cere-
bellar dysfunction have difficulty
Assessing cerebellar function maintaining their balance with their
eyes closed because they can’t use
To evaluate cerebellar function, you’ll the visual cues that orient them to
test the patient’s balance, whole-body the upright position.
coordination, and extremity coordination.
Finger-to-finger movements
Heel-to-toe walking To evaluate the patient’s extremity co-
To assess balance, ask the patient to ordination, test finger-to-finger move-
walk heel to toe. Although he may be ments. Have the patient sit about 2⬘
slightly unsteady, he should be able to (0.5 m) away from you. Hold your in-
walk and maintain his balance. dex finger up, and ask him to touch the
24 Assessment
tip of his index finger to the tip of Rapid skilled movements

yours and then to touch his nose. Next, To further evaluate the patient’s ex-
move your finger and ask him to repeat tremity coordination, test rapid skilled
the maneuver. Gradually, have him in- movements. Ask the patient to touch
crease his speed as you repeat the test. the thumb of his right hand to his right
Then test his other hand. Expect the index finger and then to each of his re-
patient to be more accurate with his maining fingers. Then instruct him to
dominant hand. A patient with cerebel- increase his speed. Observe his move-
lar dysfunction will overshoot his target ments for smoothness and accuracy.
and his movements will be jerky. Repeat the test on his left hand.
Comparing delirium, dementia, and depression
This table highlights the distinguishing characteristics of delirium, dementia, and

depression.
CLINICAL FEATURE DELIRIUM
Onset Acute, sudden
Course Short, with diurnal fluctuations in symptoms; symp-

toms worse at night, in darkness, and on awakening
Progression Abrupt
Duration Hours to less than 1 month; seldom longer
Awareness Reduced
Alertness Fluctuates; lethargic or hypervigilant
Attention Decreased
Orientation Generally impaired, but reversible
Memory Recent and immediate memory impaired
Thinking Disorganized, distorted, and fragmented; incoherent

speech, either slow or accelerated
Perception Distorted, with illusions, delusions, and hallucinations;

difficulty distinguishing between reality and misper-
ceptions
Assessing reflexes transmit messages to the muscles, and

the muscles respond to motor messages.
Assessment of the deep tendon and su- To evaluate the patient’s reflexes,
perficial reflexes provides information test deep tendon and superficial reflex-
about the intactness of the sensory re- es and observe the patient for primitive
ceptor organ. It also evaluates how well reflexes.
the afferent nerve relays the sensory
message to the spinal cord, the spinal Deep tendon reflexes
cord or brain stem segment mediates Before you test a deep tendon reflex,
the reflex, the lower motor neurons make sure that the limb is relaxed and
DEMENTIA DEPRESSION
Gradual Sudden or brief
Lifelong; symptoms progressive and Diurnal effects, with symptoms typically worse in
irreversible the morning; situational fluctuations, but less than
with acute confusion
Slow but uneven Variable, rapid, or slow, but even
Months to years At least 2 weeks, but can be several months to years

(Note: Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, specifies
duration of at least 2 weeks for diagnosis.)
Clear Clear
Generally normal Normal
Generally normal May decrease temporarily
May be impaired as disease pro- May be disoriented

gresses
Recent and remote memory impaired Selective or patchy impairment
Difficulty with abstraction; impover- Intact, with themes of hopelessness, helplessness, or

ished thoughts and impaired judg- self-deprecation
ment; words difficult to find
Misperceptions usually absent Intact, without delusions or hallucinations, except in

severe cases
(continued)
26 Assessment
Comparing delirium, dementia, and depression (continued)
CLINICAL FEATURE DELIRIUM
Speech Incoherent
Psychomotor behavior Variable; hypokinetic, hyperkinetic, and mixed
Sleep and wake cycle Altered
Affect Variable affective anxiety, restlessness, and irritability;

reversible
Findings on mental status testing Distracted from task; numerous errors
the joint is in midposition; for in- Biceps reflex

stance, the knee or elbow should be Position the patient’s arm so that his
flexed at a 45-degree angle. Then dis- elbow is flexed at a 45-degree angle
tract the patient by asking him to fo- and his arm is relaxed. Place your
cus on an object across the room. If thumb or index finger over the biceps
he focuses on his performance, the tendon and your remaining fingers
cerebral cortex may dampen his re- loosely over the triceps muscle. Strike
sponse. You can also distract the pa- your thumb or index finger with the
tient by using Jendrassik’s maneuver pointed tip of the reflex hammer, and
to enhance the biceps response. Sim- watch and feel for contraction of the
ply instruct him to clench his teeth or biceps muscle and flexion of the fore-
to squeeze his thigh. To enhance the arm.
patellar reflex, have the patient lock
his fingers together and pull. Docu-
ment which technique you used to
distract the patient.
Always move from head to toe in
testing deep tendon reflexes, and com-
pare contralateral reflexes. To elicit the
reflex, tap the tendon lightly but firmly
with the reflex hammer. Then grade
the briskness of the response: 0 (no re-
sponse), 1⫹ (diminished), 2⫹ (nor-
mal), 3⫹ (brisker than average), 4⫹
(hyperactive).
DEMENTIA DEPRESSION
Dysphasia as disease progresses; Normal, slow, or rapid

aphasia
Normal; may have apraxia Variable, with psychomotor retardation or agitation
Fragmented Insomnia or somnolence
Superficial, inappropriate, and labile; Depressed, dysphoric mood, with exaggerated and
attempts to conceal deficits in intel- detailed symptoms; preoccupied with personal
lect; may show personality changes, thoughts; insight present; verbal elaboration
aphasia, and agnosia; lacks insight
Failings highlighted by family; strug- Failings highlighted by patient; commonly responds

gles with test, with frequent “near “don’t know”; exerts little effort; commonly gives
miss” answers; exerts great effort to up; appears indifferent toward examination and
find an appropriate reply; commonly doesn’t care or attempt to find answer
requests feedback on performance
Triceps reflex partially flex his elbow. With the tip

Have the patient abduct his arm and of the hammer, strike the radius about
place his forearm across his chest. 2⬙ proximal to the radial styloid.
Strike the triceps tendon about 2⬙ Watch for supination of the hand and
(5 cm) above the olecranon process flexion of the forearm at the elbow.
on the extensor surface of the upper
arm. Watch for contraction of the tri-
ceps muscle and extension of the
forearm.
Patellar reflex
Have the patient sit on the side of the
bed with his legs dangling freely. If
he can’t sit up, flex his knee at a 45-
degree angle and place your nondomi-
Brachioradialis reflex nant hand behind it for support. Strike
Instruct the patient to rest the ulnar the patellar tendon just below the
surface of his hand on his knee and to patella, and look for contraction of the
28 Assessment
quadriceps muscle in the anterior thigh periphery toward the midline. After
and for extension of the leg. each stroke, watch for contraction of
the abdominal muscles and move-
ment of the umbilicus toward the
stimulus. If you’re evaluating an
obese patient, retract the umbilicus to
the side opposite the stimulus and
note whether it pulls toward the stim-
ulus. Aging and disease of the upper
and lower motor neurons can cause
an absent abdominal reflex.
Achilles reflex
Slightly flex the foot and support the
plantar surface. Using the pointed
end of the reflex hammer, strike the
Achilles tendon. Watch for plantar flex-
ion of the foot and ankle.
Cremasteric reflex
With a male patient, use an applicator
stick to lightly stimulate the inner
thigh. Watch for contraction of the cre-
master muscle in the scrotum and
prompt elevation of the testicle on the
side of the stimulus. This reflex may be
absent in patients with upper or lower
motor neuron disease.
Superficial reflexes Plantar reflex

Superficial reflexes include the abdomi- Using an applicator stick, a tongue
nal, cremasteric, and plantar reflexes. To blade, or a key, slowly stroke the later-
elicit these reflexes, stimulate the skin al side of the patient’s sole, from the
or mucous membranes. To document heel to the great toe and across the ball
your findings, use a plus sign (⫹) to in- of the foot, forming an upside-down
dicate that a reflex is present and a mi- “J.” The normal response is plantar
nus sign (⫺) to indicate that it’s absent. flexion of the toes. In an elderly pa-
tient, this normal response may be di-
Abdominal reflex minished because of arthritic deformi-
Place the patient in the supine posi- ties of the toe or foot.
tion, with his arms at his sides and In patients with disorders of the
his knees slightly flexed. Using the tip pyramidal tract (such as stroke), Babin-
of the reflex hammer, a key, or an ap- ski’s reflex, an abnormal response, is
plicator stick, briskly stroke both elicited. The patient responds to the
sides of the abdomen above and be- stimulus with dorsiflexion of his great
low the umbilicus, moving from the toe. You may also see a more
pronounced response in which the oth- age. Cerebral degenerative disease may
er toes extend and abduct. In some be the cause.
cases, you may even see dorsiflexion of
the ankle, knee, and hip. Sucking reflex
If the patient begins sucking while
you’re feeding him or suctioning his
mouth, you’ve elicited a reflex that in-
dicates cortical damage characteristic
of advanced dementia.
Grasp reflex
Apply gentle pressure to the patient’s
palm with your fingers. If he grasps
your fingers between his thumb and
index finger, he may have cortical (pre-
motor cortex) damage. This is the last
of the reflexes to appear.
Glabellar reflex
Primitive reflexes Repeatedly tap the bridge of the pa-
Although normal in infants, primitive tient’s nose. A persistent blinking re-
reflexes are pathologic in adults. sponse indicates diffuse cortical dys-
function.
Snout reflex
Tap lightly on the patient’s upper lip.
Lip pursing indicates frontal lobe dam- (Text continues on page 34.)
Assessing the cranial nerves
Assessment of the cranial nerves provides valuable information about the condition of
the central nervous system, particularly the brain stem. Because a disorder can affect
any cranial nerve, knowing how to test each nerve is important. The techniques vary
according to the nerve being tested.
CRANIAL NERVE AND ASSESSMENT NORMAL FINDINGS
TECHNIQUE
Olfactory (CN I)
Check the patency of the patient’s nostrils, and The patient should be able to detect
ask him to close both eyes. Occlude one nostril, the smell and identify it correctly. If
and hold a familiar, pungent substance — such as he says that he detects the smell
coffee, tobacco, soap, or peppermint — under the but can’t name it, offer a choice,
patient’s nose. Ask him to identify the sub- such as, “Do you smell lemon, cof-
stance. Repeat this technique with the other fee, or peppermint?”
nostril.
Optic (CN II)

To assess the optic nerve, check visual acuity, vi- Visual field intact.
sual fields, and the retinal structures.
(continued)
30 Assessment
Assessing the cranial nerves (continued)

TECHNIQUES
Oculomotor (CN III), trochlear

(CN IV), and abducens (CN VI)
To assess the oculomotor nerve, check pupil The pupils should be equal, round,
size, pupil shape, and pupillary response to and reactive to light. When assessing
light. To test the coordinated function of these pupil size, look for trends. For exam-
three nerves, assess them simultaneously by ple, watch for a gradual increase in
evaluating the patient’s extraocular eye move- the size of one pupil or the appear-
ment. ance of unequal pupils in a patient
whose pupils previously were equal.
The eyes should move smoothly and

in a coordinated manner through all
six directions of eye movement. Ob-
serve each eye for rapid oscillation
(nystagmus), movement not in uni-
son with that of the other eye, or in-
ability to move in certain directions
(ophthalmoplegia). Also note any
mention of double vision (diplopia).
Trigeminal (CN V)
To assess the sensory portion of the trigeminal A patient with a normal trigeminal
nerve, gently touch the right and then the left nerve should report feeling both
side of the patient’s forehead with a cotton ball light touch and sharp stimuli in all
while his eyes are closed. Instruct him to indi- three areas (forehead, cheek, and
cate when the cotton touches the area. Compare jaw) on both sides of his face.
the patient’s response on both sides. Repeat the
technique on the right and then the left cheek
and on the right and then the left jaw. Next, re-
peat the entire procedure using a sharp object.
The cap of a disposable ballpoint pen can be
used to test light touch (dull end) and sharp
stimuli (sharp end). (If you detect an abnormali-
ty, also test for temperature sensation by touch-
ing the patient’s skin with test tubes filled with
hot and cold water and asking him to differenti-
ate between them.)
To assess the motor portion of the trigeminal The jaws should clench symmetrical-
nerve, ask the patient to clench his jaws. Palpate ly and remain closed against resis-
the temporal and masseter muscles bilaterally, tance.
checking for symmetry. Try to open the patient’s
clenched jaws. Next, watch for symmetry as the
patient opens and closes his mouth.
Assess the corneal reflex. The lids of both eyes should close
when a wisp of cotton is lightly
stroked across a cornea.

TECHNIQUES
Facial (CN VII)

To test the motor portion of the facial nerve, ask the Normal facial movements and
patient to wrinkle his forehead, raise and lower his strength are symmetrical.
eyebrows, smile to show his teeth, and puff out his
cheeks. Also, with the patient’s eyes closed tightly,
attempt to open the eyelids. With each of these
movements, observe closely for symmetry.
To test the sensory portion of the facial nerve, which Normal taste sensations are
supplies taste sensation to the anterior two-thirds of symmetrical.
the tongue, first prepare four marked, closed con-
tainers: one containing salt; another, sugar; a third,
vinegar (or lemon); and a fourth, quinine (or bitters).
Then, with the patient’s eyes closed, place salt on the
anterior two-thirds of his tongue using a cotton-
tipped applicator or dropper. Ask him to identify the
taste as sweet, salty, sour, or bitter. Rinse the pa-
tient’s mouth with water. Repeat this procedure, al-
ternating flavors and sides of the tongue until all
four flavors have been tested on both sides. The
glossopharyngeal nerve (CN IX) supplies taste sensa-
tions to the posterior one-third of the tongue; these
are usually tested at the same time.
Acoustic (CN VIII)

To assess the acoustic portion of this nerve, test the The patient should be able to
patient’s hearing acuity. hear a whispered voice or the
ticking of a watch.
Romberg’s test is one way to test the vestibular The patient should display
nerve. Observing for nystagmus during extraocular normal eye movement and
movements is another test of the vestibular nerve. balance, with no dizziness or
vertigo.
(continued)
32 Assessment

TECHNIQUES
Glossopharyngeal (CN IX) and vagus

(CN X)
To assess these nerves, which have overlapping func- The patient’s voice should
tions, first listen to the patient’s voice for indications sound strong and clear. The
of a hoarse or nasal quality. Then watch the patient’s soft palate and uvula should
soft palate when he says “ah.” Next, test the gag re- rise when he says “ah,” and
flex after warning the patient. To evoke this reflex, the uvula should remain mid-
rough the posterior wall of the pharynx with a line. The palatine arches
cotton-tipped applicator or tongue blade. should remain symmetrical
during movement and at rest.
The gag reflex should be in-
tact. If it appears decreased or
if the pharynx moves asym-
metrically, evaluate each side
of the posterior wall of the
pharynx to confirm the integri-
ty of both cranial nerves.
Spinal accessory (CN XI)

To assess this nerve, press down on the patient’s Normally, both shoulders
shoulders as he attempts to shrug against this resis- should overcome resistance
tance. Note shoulder strength and symmetry while equally well. The neck should
inspecting and palpating his trapezius muscle. Then overcome resistance in both
apply resistance to his turned head while he attempts directions.
to return it to a midline position. Note neck strength
while inspecting and palpating the sternocleidomas-
toid muscle. Repeat for the opposite side.
Hypoglossal (CN XII)

To assess this nerve, observe the patient’s protruded Normally, the tongue should
tongue for deviation from midline, atrophy, or fascic- be midline and the patient
ulations (very fine muscle flickerings indicative of should be able to move it right
lower motor neuron disease). Next, ask him to move to left equally as well as up
his tongue rapidly from side to side with his mouth and down. The pressure that
open, then to curl his tongue up toward his nose, and the tongue exerts on the
then down toward his chin. Then use a tongue blade tongue blade should be equal
to apply resistance to his protruded tongue and ask on both sides. Speech should
him to try to push it to one side. Repeat on the other be clear.
side, and note tongue strength. Listen to the patient’s
speech for the sounds d, l, n, and t. If general speech
suggests a problem, ask the patient to repeat a
phrase or series of words containing these sounds.
Assessing the pupils
Pupillary changes can signal different conditions. Use these illustrations and lists of
causes to help you detect problems.
Bilaterally equal and reactive Bilateral, midsized (2 mm), fixed,

and nonreactive
◆ Normal
◆ Midbrain involvement caused by ede-
Unilateral, dilated (4 mm), fixed, ma, hemorrhage, infarction, laceration, or
and nonreactive contusion
Unilateral, small (1.5 mm),

and nonreactive
◆ Uncal herniation with oculomotor

nerve damage
◆ Brain stem compression by an ex-
panding lesion or an aneurysm ◆ Disruption of the sympathetic nerve
◆ Increased intracranial pressure supply to the head caused by a spinal
◆ Tentorial herniation cord lesion above T1
◆ Head trauma with subsequent subdur-
al or epidural hematoma Bilateral, pinpoint (less than
1 mm), and usually nonreactive
◆ Normal in some people
Bilateral, dilated (4 mm), fixed,

and nonreactive
◆ Lesion of the pons, usually after hem-

orrhage, leading to blocked sympathetic
◆ Severe midbrain damage impulses
◆ Cardiopulmonary arrest (hypoxia) ◆ Opiates such as morphine (Pupils may
◆ Anticholinergic poisoning be reactive.)
◆ Deep anesthesia ◆ Iritis
◆ Dilating drops ◆ Pilocarpine drugs
34 Assessment
Using the Glasgow Coma Scale phagia, nausea, vomiting, heartburn,

stomach or abdominal pain, frequent
The Glasgow Coma Scale provides an belching or flatulence, hematemesis,
objective way to evaluate a patient’s and jaundice. Has the patient had ul-
LOC and to detect changes from the cers?
baseline. To use this scale, evaluate and ◆ Determine whether the patient fre-
score your patient’s best eye-opening re- quently uses laxatives. Ask about hem-
sponse, verbal response, and motor re- orrhoids, rectal bleeding, character of
sponse. A total score of 15 indicates that stools (color, odor, and consistency),
he’s alert; oriented to time, place, and and changes in bowel habits. Does he
person; and can follow simple com- have a history of diarrhea, constipa-
mands. A comatose patient will score 7 tion, irritable bowel syndrome, Crohn’s
points or less. A score of 3 indicates a disease, colitis, diverticulitis, or cancer?
deep coma and a poor prognosis. ◆ Ask if he has had hernias, gallblad-
der disease, or liver disease, such as
Eye-opening response hepatitis or cirrhosis.
◆ Open spontaneously (Score: 4) ◆ Find out if he has had abdominal
◆ Open to verbal command (Score: 3) swelling or ascites.
◆ Open to pain (Score: 2) ◆ If the patient is older than age 50,
◆ No response (Score: 1) ask about the date and results of his
last Hemoccult test and screening
Verbal response colonoscopy.
◆ Oriented and converses (Score: 5)
◆ Disoriented and converses Inspecting the abdomen
(Score: 4)
◆ Uses inappropriate words (Score: 3) Place the patient in the supine posi-
◆ Makes incomprehensible sounds tion, with his arms at his sides and his
(Score: 2) head on a pillow to help relax the ab-
◆ No response (Score: 1) dominal muscles.
Mentally divide the abdomen into
Motor response quadrants or regions. Systematically in-
◆ Obeys verbal command (Score: 6) spect all areas, if time and the patient’s
◆ Localizes painful stimulus (Score: 5) condition permit, concluding with the
◆ Flexion, withdrawal (Score: 4) symptomatic area.
◆ Flexion, abnormal — decorticate Examine the patient’s entire ab-
rigidity (Score: 3) domen, observing the overall contour,
◆ Extension — decerebrate rigidity color, and skin integrity. Look for rash-
(Score: 2) es, scars, or incisions from past surg-
◆ No response (Score: 1) eries. Observe the umbilicus for protru-
sions or discoloration.
Note visible abdominal asymmetry,
masses, pulsations, or peristalsis. You
Assessing the GI system can detect masses — especially hepatic
and splenic masses — more easily by
Initial questions inspecting the areas while the patient
takes a deep breath and holds it. This
◆ Explore signs and symptoms, such forces the diaphragm downward, in-
as appetite and weight changes, dys- creasing intra-abdominal pressure and
reducing the size of the abdominal When describing bowel sounds, be

cavity. specific — for example, indicate whether
Finally, examine the rectal area for they’re quiet or loud gurgles, occasional
redness, irritation, or hemorrhoids. gurgles, fine tinkles, or loud tinkles.
Alert If the patient is preg- In a routine complete assessment,
nant, vary the position used auscultate for a full 5 minutes before
for assessment depending on the determining that bowel sounds are ab-
stage of pregnancy. For example, if sent. However, if you’re pressed for
the patient is in her final weeks, time, perform a rapid assessment. If
avoid the supine position because it you can’t hear bowel sounds within
may impair respiratory excursion 2 minutes, suspect a serious problem.
and blood flow. To enhance comfort, Even if subsequent palpation stimu-
have the patient lie on her side or lates peristalsis, report a long silence in
assume semi-Fowler’s position. Also, that quadrant.
during the assessment, remember Before you report absent bowel
the normal variations associated sounds, however, make sure that the
with pregnancy: increased pigmenta- patient’s bladder is empty. A full blad-
tion of the abdominal midline, pur- der may obscure the sounds. Gently
plish striae, and upward displace- pressing on the abdominal surface may
ment of the abdominal organs and initiate peristalsis and audible bowel
umbilicus. sounds, as will having the patient eat
or drink.
Auscultating bowel sounds Next, lightly apply the bell of the
stethoscope to each quadrant to aus-
Auscultate the abdomen to detect cultate for vascular sounds, such as
sounds that provide information about bruits and venous hums, and for fric-
bowel motility and the condition of the tion rubs. Normally, you shouldn’t
abdominal vessels and organs. hear vascular sounds.
To auscultate bowel sounds, which
result from the movement of air and Percussing the abdomen
fluid through the bowel, press the
diaphragm of the stethoscope against Abdominal percussion helps to deter-
the abdomen and listen carefully. mine the size and location of abdomi-
Auscultate the four quadrants system- nal organs and helps you identify areas
atically. of tenderness, gaseous distention, as-
The movement of air and fluid cites, or solid masses.
through the bowel by peristalsis nor- To perform this technique, percuss
mally creates soft, bubbling sounds in all four quadrants, moving clock-
with no regular pattern, commonly wise to the percussion sites in each
with soft clicks and gurgles inter- quadrant, as shown at the top of the
spersed. Loud, rapid, high-pitched, next page. Keep appropriate organ
gurgling bowel sounds are hyperactive locations in mind as you progress.
and may occur normally in a hungry However, if the patient has pain in a
patient. Sounds occurring at a rate of particular quadrant, adjust the percus-
one every minute or longer are hy- sion sequence to percuss that quadrant
poactive and normally occur after last. When tapping, move your right
bowel surgery or after the colon has finger away quickly to avoid inhibiting
filled with feces. vibrations.
36 Assessment
dominal wall; the size, condition, and

consistency of the abdominal organs;
Right Left the presence and nature of abdominal
upper upper masses; and the presence, degree, and
quadrant quadrant location of abdominal pain. For a rapid
assessment, palpate primarily to detect
areas of pain and tenderness, guarding,
rebound tenderness, and costovertebral
angle tenderness.
Right Left Age alert An abdominal mass
lower lower in a child may be a nephroblas-
quadrant quadrant
toma. Don’t palpate it to avoid
spreading tumor cells.
When assessing a tender abdomen, Light palpation

have the patient cough; then lightly Use light palpation to detect tender-
percuss the area where the cough pro- ness, areas of muscle spasm or rigidity,
duced the pain, helping to localize the and superficial masses. To palpate for
involved area. As you percuss, note ar- superficial masses in the abdominal
eas of dullness, tympany, and flatness wall, have the patient raise his head
as well as patient complaints of tender- and shoulders to tighten the abdominal
ness. muscles. Tension obscures a deep
Percussion sounds vary depending mass, but a wall mass remains palpa-
on the density of underlying struc- ble. Palpate using the finger pads or
tures; usually, you’ll detect dull notes palmar surface of three to four fingers.
over solids and tympanic notes over Depress 1⁄2⬙ to 1⬙ (1 to 2.5 cm) using
air. The predominant abdominal per- circular motions.
cussion sound is tympany, which is This technique may also help you
created by percussion over an air- to determine whether pain originates
filled stomach or intestine. Dull from the abdominal muscles or from
sounds normally occur over the liver deeper structures.
and spleen, a lower intestine filled If you detect tenderness, check for
with feces, and a bladder filled with involuntary guarding or abdominal
urine. Distinguishing abdominal per- rigidity. As the patient exhales, palpate
cussion notes may be difficult in the abdominal rectus muscles. Normal-
obese patients. ly, they soften and relax on exhalation;
Alert Abdominal percussion note abnormal muscle tension or in-
or palpation is contraindicated flexibility. Involuntary guarding points
in patients with abdominal organ to peritoneal irritation. In generalized
transplants or suspected leaking ab- peritonitis, rigidity is severe and dif-
dominal aortic aneurysm. It should be fuse, commonly described as a “board-
performed cautiously in patients with like” abdomen.
suspected appendicitis. A tense or ticklish patient may ex-
hibit voluntary guarding. Help him to
Palpating the abdomen relax with deep breathing. He should
inhale through his nose and exhale
Abdominal palpation provides useful through his mouth.
clues about the character of the ab-
If a patient has abdominal pain,

check for rebound tenderness. Because
this maneuver can be painful, perform
it near the end of the abdominal as-
sessment. Press your fingertips into the
site where the patient reports pain or
tenderness. As you quickly release the
pressure, the abdominal tissue will re-
bound. If the patient reports pain as
the tissue springs back, you’ve elicited
rebound tenderness.
Now release the pressure quickly in
Deep palpation a smooth motion. Pain on release — re-
If time permits, perform deep abdomi- bound tenderness — is a positive sign.
nal palpation to detect deep tenderness The pain may radiate to the umbilicus.
or masses and evaluate organ size. Caution: Don’t repeat this maneuver
Press 1⬙ to 3⬙ (2.5 to 8 cm), assessing to minimize the risk of rupturing an
for tenderness and masses. If you feel inflamed appendix.
a mass, note its size, shape, consisten-
cy, and location. If the patient has pain
or tenderness, note if the location is
generalized or localized. Note guarding
that the patient exhibits during deep
palpation. You may feel tensing of a
small or large area of abdominal mus-
culature directly below your fingers.
Eliciting abdominal pain
Rebound tenderness and the iliopsoas

and obturator signs can indicate condi-
tions consistent with an acute ab- Iliopsoas sign
domen. These include appendicitis, Place the patient in the supine position
cholecystitis, pancreatitis, diverticulitis, with the legs straight. Instruct the pa-
pelvic inflammatory disease, ruptured tient to raise his right leg upward as
cyst, ruptured ectopic pregnancy, and you exert slight downward pressure
peritoneal injury. with your hand.
Rebound tenderness
Place the patient in the supine position
with the knees flexed to relax the ab-
dominal muscles. Place your hands
gently on the right lower quadrant at
McBurney’s point, located about mid-
way between the umbilicus and the an-
terior superior iliac spine. Slowly and
deeply dip your fingers into the area.
38 Assessment
Repeat the maneuver with the left

leg. Increased abdominal pain with
testing on either leg is a positive result,
indicating irritation of the psoas
muscle.
Obturator sign
Place the patient in the supine position
with the right leg flexed 90 degrees at
the hip and knee. Hold the patient’s leg
just above the knee and at the ankle,
then rotate the leg laterally and medial-
ly. Increased pain is a positive sign,
indicating irritation of the obturator
muscle.
Percuss along the right midclavicu-

lar line, starting above the nipple.
Move downward until the percussion
notes change from normal lung reso-
nance to dullness, usually at the fifth
to seventh intercostal space. Again,
mark the point of change with a felt-tip
pen. Estimate the size of the liver by
measuring the distance between the
two marks.
Percussing, palpating, and hooking

the liver
You can estimate the size and position

of the liver through percussion and
palpation (or, in some cases, hooking).
The following illustrations show the
correct hand positions for these three
techniques.
Liver palpation
Liver percussion Place one hand on the patient’s back
Begin by percussing the abdomen at the approximate height of the liver.
along the right midclavicular line, start- Place your other hand below your
ing below the level of the umbilicus. mark of liver fullness on the right lat-
Move upward until the percussion eral abdomen. Point your fingers to-
notes change from tympany to dull- ward the right costal margin, and
ness, usually at or slightly below the press gently in and up as the patient
costal margin. Mark the point of inhales deeply. This maneuver may
change with a felt-tip pen. bring the liver edge down to a palpa-
ble position.
When you’ve inserted your finger as

far as possible, ask him to bear down
and cough. A hernia will feel like a
mass of tissue that withdraws when
met by the finger.
Inguinal ligament
Inguinal canal
Liver hooking
If liver palpation is unsuccessful, try
hooking the liver. Stand on the pa-
tient’s right side, below the area of liv-
er dullness, as shown below. As the
patient inhales deeply, press your fin-
gers inward and upward, attempting to
feel the liver with the fingertips of both
hands.
Assessing the urinary system

Initial questions
◆ Ask about urine color, oliguria, and

nocturia. (See Evaluating urine color.)
Does your patient experience inconti-
nence, dysuria, frequency, urgency, or
difficulty with the urinary stream (such
as reduced flow or dribbling)?
◆ Ask about pyuria, urine retention,
and passage of calculi.
Palpating for indirect inguinal ◆ Ask the patient if he has a history
hernia of bladder, kidney, or urinary tract in-
fections.
To check for an indirect inguinal her- Age alert If your patient is a
nia, examine the patient while he child, ask his parents if they’ve
stands. Then examine him in a supine had problems with his toilet training
position. Place your gloved index finger or bed-wetting.
on the neck of his scrotum and gently
push upward into the inguinal canal,
as shown in the next column. If you
meet resistance or if the patient com-
plains of pain, stop the examination.
40 Assessment
Evaluating urine color
For important clues about your patient’s health, ask about changes in urine color. Such
changes can result from fluid intake, medications, and dietary factors as well as from
various disorders.
APPEARANCE INDICATION
Amber or straw color Normal
Cloudy Infection, inflammation, glomerulonephritis, vegetarian

diet
Colorless or pale straw color Excess fluid intake, anxiety, chronic renal disease, dia-
(dilute urine) betes insipidus, diuretic therapy
Dark brown or black Acute glomerulonephritis, drugs (such as nitrofurantoin,

chlorpromazine, and antimalarials)
Dark yellow or amber Low fluid intake, acute febrile disease, vomiting or di-
(concentrated urine) arrhea causing fluid loss
Green-brown Bile duct obstruction
Orange-red to orange-brown Urobilinuria, drugs (such as phenazopyridine and ri-

fampin), obstructive jaundice (tea-colored urine)
Red or red-brown Porphyria, hemorrhage, drugs (such as doxorubicin)
Inspecting the urethral meatus Spread the labia and look for the
urethral meatus. It should be a pink,
Put on gloves before examining the irregular, slitlike opening located at
urethral meatus. the midline, just above the vagina.
To inspect a male patient’s urethral Check for swelling, discharge, signs
meatus, have him lie in the supine po- of urethral infection, cystocele, and
sition and drape him, exposing only ulcerations, which may signal an
his penis. Then compress the tip of STD.
the glans to open the urethral meatus,
which should be located in the center Percussing the urinary organs
of the glans. Check for swelling, dis-
charge, signs of urethral infection, and Percuss the kidneys to elicit pain or
ulcerations, which can signal a sexual- tenderness, and percuss the bladder to
ly transmitted disease (STD). elicit percussion sounds. Before you
To inspect a female patient’s ure- start, tell the patient what you’re going
thral meatus, help her into the dorsal to do. Otherwise, he may be startled
lithotomy position and drape her, ex- and you could mistake his reaction for
posing only the area to be assessed. a feeling of acute tenderness.
Kidney percussion
With the patient sitting upright, per-
cuss each costovertebral angle (the
angle over each kidney whose borders
are formed by the lateral and down-
ward curve of the lowest rib and the
spinal column). To perform direct per-
cussion, place your left palm over the
costovertebral angle and gently strike
it with your right fist, as shown be-
low. Use just enough force to cause a
painless but perceptible thud. To per-
form indirect percussion, gently strike Palpating the urinary organs
your fist over each costovertebral an-
gle. Make sure to percuss both sides Bimanual palpation of the kidneys and
of the body to assess both kidneys. A bladder may detect tenderness, lumps,
patient normally feels a thudding sen- and masses. In the normal adult, the
sation or pressure during percussion. kidneys usually can’t be palpated be-
Pain or tenderness suggests a kidney cause of their location deep within the
infection. abdomen. However, they may be pal-
pable in a thin patient or in a patient
with reduced abdominal muscle mass.
(The right kidney is slightly lower, so it
may be easier to palpate.) Both kidneys
descend with deep inhalation.
If palpable, the bladder normally feels
/ firm and relatively smooth. However, an
adult’s bladder may not be palpable.
Kidney palpation
Help the patient into the supine posi-
tion, and expose the abdomen from the
xiphoid process to the symphysis pu-
bis. Standing at the patient’s right side,
place your left hand under the back,
midway between the lower costal mar-
Bladder percussion gin and the iliac crest, as shown at the
Before you percuss the bladder, have top of the next page.
the patient urinate. Then ask the pa- Next, place your right hand on the
tient to lie in the supine position. Next, patient’s abdomen, directly above your
directly percuss the area over the blad- left hand. Angle your right hand slight-
der, beginning 2⬙ (5 cm) above the ly toward the costal margin. To palpate
symphysis pubis, as shown in the next the right lower edge of the right kid-
column. To detect differences in sound, ney, press your right fingertips about
percuss toward the base of the bladder. 11⁄2⬙ (4 cm) above the right iliac crest
Percussion normally produces a tym- at the midinguinal line; press your left
panic sound. Over a urine-filled blad- fingertips upward into the right costo-
der, it produces a dull sound. vertebral angle, as shown on the next
page.
42 Assessment
As you palpate the bladder, note its

size and location and check for lumps,
masses, and tenderness. The bladder
normally feels firm and relatively
smooth. (Keep in mind that an adult’s
bladder may not be palpable.) During
deep palpation, the patient may report
the urge to urinate — a normal re-
sponse.
Instruct the patient to inhale deeply

so that the lower portion of the right
kidney can move down between your
Assessing the male
hands. If it does, note the shape and reproductive system
size of the kidney. Normally, it feels
smooth, solid, and firm, yet elastic. Initial questions
Ask the patient if palpation causes ten-
derness. ◆ Ask the patient about penile dis-
Alert Avoid using excessive charge or lesions and testicular pain or
pressure to palpate the kidney lumps.
because this may cause intense pain. ◆ Ask if the patient performs testicu-
To assess the left kidney, move to lar self-examinations. Has he had a va-
the patient’s left side and position your sectomy?
hands as described earlier, but with ◆ Ask about the patient’s sexual histo-
this change: Place your right hand 2⬙ ry, including sexual orientation, type of
(5 cm) above the left iliac crest. Then activity, frequency, number of partners,
apply pressure with both hands as the safe sex practices, and condom use.
patient inhales. If the left kidney can ◆ Ask about STDs and other infec-
be palpated, compare it with the right tions. Assess the patient’s knowledge
kidney; it should be the same size. of how to prevent STDs, including ac-
quired immunodeficiency syndrome.
Bladder palpation ◆ Find out if the patient has a history
Before you palpate the bladder, make of prostate problems.
sure that the patient has voided. Then ◆ Ask if he’s satisfied with his sexual
locate the edge of the bladder by press- function. Does he have any concerns
ing deeply in the midline about 1⬙ to 2⬙ about erectile dysfunction or sterility?
(2.5 to 5 cm) above the symphysis pu- Also inquire about his contraceptive
bis, as shown below. practices.
Inspecting and palpating the male

genitalia
First, ask the patient to disrobe from

the waist down and to cover himself
with a drape. Then put on gloves and
examine his penis, scrotum, and testi-
cles, inguinal and femoral areas, and
prostate gland.
Assessing the male reproductive system 43
Penis a flashlight against the scrotum, behind

Observe the penis. Its size will depend the lump. The testicle will appear as
on the patient’s age and overall devel- an opaque shadow, as will lumps,
opment. The penile skin should be masses, warts, or blood-filled areas.
slightly wrinkled and pink to light Transilluminate the other testicle to
brown in a white patient, and light compare your findings.
brown to dark brown in a black pa- Next, palpate the epididymis, which
tient. Check the penile shaft and glans is normally located in the posterolater-
for lesions, nodules, inflammation, and al area of the testicle. It should be
swelling. Also check the glans for smooth, discrete, nontender, and free
smegma, a cheesy secretion. Gently from swelling or induration.
compress the glans and inspect the Finally, palpate each spermatic
urethral meatus for discharge, inflam- cord, located above each testicle. Begin
mation, and lesions, specifically genital palpating at the base of the epididymis,
warts. If you note a discharge, obtain a and continue to the inguinal canal. The
culture specimen for gonorrhea and vas deferens is a smooth, movable cord
chlamydia. inside the spermatic cord. If you feel
Using your thumb and forefinger, swelling, irregularity, or nodules, tran-
palpate the entire penile shaft. It silluminate the problem area, as de-
should be somewhat firm, and the skin scribed earlier. If serous fluid is pre-
should be smooth and movable. Note sent, you’ll see a red glow; if tissue
swelling, nodules, or indurations. and blood are present, you won’t see
this glow.
Scrotum and testicles
Have the patient hold his penis away Prostate gland
from his scrotum so that you can ob- Usually, a physician performs prostate
serve the general size and appearance palpation as part of a rectal examina-
of the scrotum. The skin will be darker tion. However, if the patient hasn’t
than the rest of the body. Spread the scheduled a separate rectal examina-
surface of the scrotum, and examine tion, you may palpate the prostate dur-
the skin for swelling, nodules, redness, ing the reproductive system assess-
ulceration, and distended veins. You’ll ment. Because palpation of the
probably see some sebaceous cysts — prostate usually is uncomfortable and
firm, white-to-yellow, nontender cuta- may embarrass the patient, begin by
neous lesions. Also check for pitting explaining the procedure and reassur-
edema, a sign of cardiovascular dis- ing the patient that the procedure
ease. Spread the pubic hair and check shouldn’t be painful.
the skin for lesions and parasites. Have the patient urinate to empty
Gently palpate both testicles be- the bladder and reduce discomfort dur-
tween your thumb and first two fin- ing the examination. Then ask him to
gers. Assess their size, shape, and re- stand at the end of the examination
sponse to pressure (typically, deep vis- table, with his elbows flexed and his
ceral pain). The testicles should be upper body resting on the table. If he
equal in size. They should feel firm, can’t assume this position because he’s
smooth, and rubbery, and they should unable to stand, have him lie on his
move freely in the scrotal sac. If you left side with his right knee and hip
note hard, irregular areas or lumps, flexed or with both knees drawn up to-
transilluminate the testicle by darken- ward his chest.
ing the room and pressing the head of
44 Assessment
Inspect the skin of the perineal, ◆ Has she experienced sexual assault
anal, and posterior scrotal surfaces. or abuse?
The skin should appear smooth and ◆ Find out what birth control method
unbroken, with no protruding masses. she uses.
Apply water-soluble lubricant to ◆ Determine the dates of her last gy-
your gloved index finger. Then intro- necologic examination and Papanico-
duce the finger, pad down, into the pa- laou (Pap) test.
tient’s rectum. Instruct the patient to ◆ Ask about STDs and other infec-
relax to ease passage of the finger tions. Assess her knowledge of how to
through the anal sphincter. prevent STDs, including acquired im-
Using the pad of your index finger, munodeficiency syndrome.
gently palpate the prostate on the ante- ◆ Ask the patient about her satisfac-
rior rectal wall, located just past the tion with her sexual function.
anorectal ring. The prostate should feel
smooth and rubbery. Normal size Palpating the breasts and axillae
varies, but usually is about that of a
walnut. The prostate shouldn’t pro- Have the patient put on a gown. As-
trude into the rectum lumen. Identify sess the patient’s breast history, includ-
the two lateral lobes and the median ing tumors, cancer, cysts, trauma,
sulcus. surgery, galactorrhea, and implants.
Ask about mammograms. Ask about
lumps, pain, breast changes, and dis-
Assessing the female charge.
reproductive system Begin the breast examination with
the patient sitting with her arms at her
sides. Inspect the breasts with the pa-
Initial questions tient’s arms over her head and then
when she’s leaning forward with her
◆ Ask your patient about her age at hands pressed into her hips. Visually
menarche and the character of her note any abnormalities. Palpate each
menses (frequency, regularity, and du- breast using the pads of your fingers.
ration). What was the date of her last Use a specific pattern, such as spiral-
period? Does she have a history of ing outward, a circular motion, or
menorrhagia, metrorrhagia, or amenor- moving vertically across the breast. In-
rhea? If she’s postmenopausal, find out clude the tail of Spence and axilla.
the date of menopause. Then examine the breast with the pa-
◆ Ask if she has irregular or painful tient supine. Place a pillow under the
vaginal bleeding, dyspareunia, or fre- side you are examining, and have the
quent vaginal infections. patient raise her arm above her head
◆ Ask about her type of sexual prac- and place her hand behind her head.
tices, frequency, number of partners, Proceed to palpate each breast as de-
safe sex practices, and condom use. scribed earlier.
◆ Ask about her obstetric history, in- Note the consistency of the breast
cluding the total number of pregnan- tissue. Check for nodules or unusual
cies (G), number of births (P), number tenderness. Nodularity may increase
of premature births, number of abor- before menstruation, and tenderness
tions, and number of living children. may result from premenstrual fullness,
Has she had any problems with cysts, or cancer. Any lump or mass that
fertility? feels different from the rest of the
Assessing the female reproductive system 45
breast may represent a pathologic discharge. Next, inspect the urethral

change. opening. It should be slitlike and the
Palpate the areola and nipple, and same color as the mucous membranes.
gently compress the nipple between Look for erythema, polyps, and dis-
your thumb and index finger to detect charge.
discharge. If you see discharge, note
the color, consistency, and quantity. Inspecting the internal genitalia
With the patient seated, palpate the First, select a speculum that’s appropri-
axillae. Palpate the right axilla with the ate for the patient. In most cases,
middle three fingers of one hand while you’ll use a Graves speculum. Howev-
supporting the patient’s arm with your er, if the patient is a virgin or nulli-
other hand. You can usually palpate parous or has a contracted introitus as
one or more soft, small, nontender a result of menopause, you should use
central nodes. If the nodes feel large or a Pedersen speculum.
hard or are tender, or if the patient has Hold the blades of the speculum
a suspicious-looking lesion, palpate the under warm running water. This
other groups of lymph nodes. warms the blades and helps to lubri-
cate them, making insertion easier and
Inspecting the female genitalia more comfortable for the patient. Don’t
use commercial lubricants — they’re
Before you begin the examination, ask bacteriostatic and will distort cells on
the patient to urinate. Next, help her Pap tests. Sit or stand at the foot of the
into the dorsal lithotomy position and examination table. Tell the patient that
drape her. After putting on gloves, ex- she’ll feel some pressure, and then in-
amine the patient’s external and inter- sert the speculum.
nal genitalia, as appropriate. Separate the labia with the fingers
and gently pull down on the posterior
Inspecting the external genitalia aspect to open the introitus. With the
Observe the skin and hair distribution speculum closed, insert the blades so
of the mons pubis. Spread the hair that the width is almost vertical. Gen-
with your fingers to check for lesions tly push downward and rotate the
and parasites. blade width to horizontal. Follow the
Next, inspect the skin of the labia canal to the cervix. Open the blades,
majora, spreading the hair to examine and position them with the cervix in
for lesions, parasites, and genital warts. view.
The skin should be slightly darker than While inserting and withdrawing
the rest of the body, and the labia ma- the speculum, note the color, texture,
jora should be round and full. Examine and mucosal integrity of the vagina
the labia minora, which should be dark and vaginal secretions. A thin, white,
pink and moist. In nulliparous women, odorless discharge is normal.
the labia majora and minora are close With the speculum in place, exam-
together; in women who have experi- ine the cervix for color, position, size,
enced vaginal deliveries, they may shape, mucosal integrity, and dis-
gape open. charge. The cervix should be smooth,
Closely observe each vulvar struc- round, rosy pink, and free from ulcera-
ture for syphilitic chancres and cancer- tions and nodules. A clear, watery dis-
ous lesions. Examine the area of Bar- charge is normal during ovulation; a
tholin’s and Skene’s glands and ducts slightly bloody discharge is normal just
for swelling, erythema, enlargement, or before menstruation. Obtain a culture
46 Assessment
specimen of any other discharge. After

you inspect the cervix, obtain a speci-
Assessing the musculoskeletal
men for a Pap test. system
When you’ve completed your exam-
ination, unlock the speculum blades Initial questions
and close them slowly while you begin
to withdraw the instrument. Close the ◆ Ask if the patient has muscle pain,
blades completely before they reach joint pain, swelling, tenderness, or dif-
the introitus, and withdraw the specu- ficulty with balance or gait. Does he
lum from the vagina. have joint stiffness? If so, find out
when it occurs and how long it lasts.
Palpating the uterus ◆ Ask whether the patient has noticed
noise with joint movement.
To palpate the uterus bimanually, in- ◆ Find out if he has arthritis or gout.
sert the index and middle fingers of ◆ Ask about a history of fractures, in-
one gloved hand into the patient’s juries, back problems, or deformities.
vagina, and place your other hand on Also ask about weakness and paralysis.
the abdomen between the umbilicus ◆ Explore limitations on walking, run-
and symphysis pubis. Press the ab- ning, or participation in sports. Do
domen in and down while you elevate muscle or joint problems interfere with
the cervix and uterus with your two activities of daily living?
fingers, as shown below. Try to grasp Age alert If the patient is an
the uterus between your hands. Note infant or a toddler, ask the par-
cervical motion tenderness. Palpate ents if the patient has achieved devel-
over the right and left ovaries. These opmental milestones — such as sitting
will be small and almond-shaped. up, crawling, and walking.
Assessing range of motion
Assess the patient’s posture, gait, and

stance. Assessment of joint range of
motion (ROM) tests joint function. To
assess joint ROM, ask the patient to
move specific joints through the nor-
mal ROM. If he can’t do so, move the
joints through passive ROM.
The following pages show each
joint and illustrate the tests for ROM,
including the expected degree of mo-
tion for each joint.
Slide your fingers farther into the

anterior fornix and palpate the body of
the uterus between your hands. Note
its size, shape, surface characteristics,
consistency, and mobility. Note tender-
ness of the uterine body and fundus.
Also note fundal position.
Shoulders
90°
To assess forward flexion and back-
ward extension, have the patient bring External
his straightened arm forward and up rotation
and then behind him.
Forward motion 180°

Internal
rotation 90°
Backward
Elbows
extension
Assess flexion by having the patient
bend his arm and attempt to touch his
shoulder. Assess extension by having
50° to 60° him straighten his arm.
Assess abduction and adduction by

asking the patient to bring his straight-
ened arm to the side and up and then Flexion 180°
in front of him.
180°
Abduction
Extension 0°
To assess pronation and supination,

hold the patient’s elbow in a flexed po-
Adduction sition, and ask him to rotate his arm
45° to 50° until his palm faces the floor. Then ro-
tate his hand back until his palm faces
upward.
To assess external and internal rota-
tion, have the patient abduct his arm
with his elbow bent. Then ask him to
place his hand first behind his head
and then behind the small of his back.
Supination Pronation
90° 90°
48 Assessment
Wrists To assess extension and flexion, ask

To assess flexion, ask the patient to the patient first to straighten his fingers
bend his wrist downward; assess ex- and then to make a fist with his thumb
tension by having him straighten his remaining straight.
wrist. To assess hyperextension, ask
him to bend his wrist upward.
Extension
Hyperextension (dorsiflexion)
0°
70°
0°
80°
Flexion
Flexion
0°
Assess radial and ulnar deviation by
asking the patient to move his hand
first toward the radial side and then to-
ward the ulnar side. 90°
Radial deviation 20° Thumbs

Assess extension by having the patient
straighten his thumb. To assess flexion,
0° have him bend his thumb at the top
joint and then at the bottom.
Ulnar deviation 30° to 50° Extension 90°
Fingers
To assess abduction and adduction, 0°
have the patient first spread his fingers
and then bring them together. In ab-
duction, there should be 20 degrees be-
tween the fingers; in adduction, the
fingers should touch.
Abduction Flexion
20°
0°
Assess adduction by having the patient

extend his hand, bringing his thumb
first to the index finger and then to the
little finger.
Adduction
Hips Hyperextension
Assess flexion by asking the patient to
bend his knee to his chest while keep-
ing his back straight. If he has under- 30°
gone total hip replacement, don’t per-
form this movement without the sur- 0°
geon’s permission; motion can
dislocate the prosthesis.
To assess abduction, have the pa-
tient move his straightened leg away
from the midline.
To assess adduction, instruct the pa-
tient to move his straightened leg from
the midline toward the opposite leg.
Flexion 120°
Abduction
20° to 30°
45° to 50°
Adduction
0°
Assess extension by having the pa-

tient straighten his knee. To assess hy- To assess internal and external rota-
perextension, ask him to extend his leg tion, ask the patient to bend his knee
straight back. This motion can be per- and turn his leg inward. Then have
formed with the patient in the prone or him turn his leg outward.
standing position.
50 Assessment
Toes
Internal rotation 40° Assess extension and flexion by asking
the patient to straighten and then curl
his toes. Then check hyperextension by
asking him to straighten his toes and
point them upward.
0° 40°
0°
45° External rotation
40°
Ankles and feet

Have the patient show plantar flexion
by bending his foot downward. Ask
him to show hyperextension by bend-
ing his foot upward.
0°
Knees 20°
Ask the patient to straighten his leg at
the knee to show extension; ask him to
bend his knee and bring his foot up to
45° to 50°
touch his buttock to show flexion.
Plantar flexion
0°
To assess eversion and inversion,

ask the patient to point his toes. Have
him turn his foot inward and then out-
ward.
120° to 130°
Flexion
5° 5°
0° 0°
0° Eversion Inversion
To assess forefoot adduction and ab- sition against your resistance; as he

duction, stabilize the patient’s heel does, palpate for deltoid contraction.
while he turns his foot first inward and
then outward.
20°
10°
0°
Abduction Adduction
Testing muscle strength

Biceps
Assess motor function by testing the pa- With your hand on the patient’s fist,
tient’s strength in the affected limb. Be- have him flex his forearm against your
fore you begin the muscle strength tests, resistance; observe for biceps contrac-
find out whether the patient is right- or tion.
left-handed. The dominant arm is usual-
ly stronger. Have him attempt normal
ROM movements against your resis-
tance. Note the strength that the patient
exerts. If the muscle group is weak,
lessen your resistance to permit an ac-
curate assessment. If necessary, position
the patient so that his limb doesn’t have
to resist gravity, and repeat the test.
To minimize subjective interpreta-
tions of the test findings, rate muscle
strength on a scale of 0 to 5, as follows: Triceps
0 = No visible or palpable contraction Have the patient abduct and hold his
felt; paralysis arm midway between flexion and ex-
1 = Slight palpable contraction felt tension. Hold and support his arm at
2 = Passive ROM maneuvers when the wrist, and ask him to extend it
gravity is removed against your resistance. Observe for tri-
3 = Active ROM against gravity ceps contraction.
4 = Active ROM against gravity and
light resistance
5 = Active ROM against full resistance;
normal strength
Deltoid
With your patient’s arm fully extended,
place one hand over his deltoid muscle
and the other hand on his wrist. Have
him abduct his arm to a horizontal po-
52 Assessment
Dorsal interosseous your resistance; as he’s doing so, pal-

Have the patient extend and spread pate for quadriceps contraction.
his fingers and resist your attempt to
squeeze them together.
Forearm and hand (grip) Gastrocnemius

Have the patient grasp your middle With the patient in the prone position,
and index fingers and squeeze them as support his foot and ask him to plan-
hard as he can. tarflex his ankle against your resis-
tance. Palpate for gastrocnemius con-
traction.
Psoas
Support the patient’s leg and have him
raise his knee and flex his hip against
your resistance (as shown below). Ob- Anterior tibialis
serve for psoas contraction. With the patient sitting on the side of
the examination table with his legs
dangling, place your hand on his foot
and ask him to dorsiflex his ankle
against your resistance.
Quadriceps
Have the patient bend his knee slightly
while you support his lower leg. Then
ask him to extend his knee against
Extensor hallucis longus Inspecting and palpating the skin

With your fingers on the patient’s great
toe, have him dorsiflex the toe against Before you begin your examination,
your resistance. Palpate for extensor make sure that the lighting is adequate
hallucis contraction. for inspection. Put on a pair of gloves.
To examine the patient’s skin, you’ll
use both inspection and palpation —
sometimes simultaneously. During your
examination, focus on such skin tissue
characteristics as color, texture, turgor,
moisture, and temperature. Evaluate
skin lesions, edema, hair distribution,
and fingernails and toenails.
Color
Begin by systematically inspecting the
skin’s overall appearance. Remember,
skin color reflects the patient’s nutri-
tional, hematologic, cardiovascular,
and pulmonary status.
Observe the patient’s general color-
ing and pigmentation, keeping in mind
Assessing the skin racial differences as well as normal
variations from one part of the body to
Initial questions another. Examine all exposed areas of
the skin, including the face, ears, back
◆ Determine if your patient has any of the neck, axillae, and backs of the
known skin disease, such as psoriasis, hands and arms.
eczema, or hives. Note the location of any bruising,
◆ Ask him to describe any changes in discoloration, or erythema. Look for
skin pigmentation, temperature, mois- pallor, a dusky appearance, jaundice,
ture, or hair distribution. and cyanosis. Ask the patient if he’s
◆ Examine the skin for itching, rashes, noticed any changes in skin color any-
or scaling. Is his skin excessively dry where on his body.
or oily?
◆ Find out if the skin reacts to hot or Texture
cold weather. If so, how? Inspect and palpate the texture of the
◆ Ask the patient about skin care, sun skin, noting thickness and mobility.
exposure, use of SPF products and SPF Does the skin feel rough, smooth,
number used, and use of protective thick, fragile, or thin? Changes can in-
clothing. dicate local irritation or trauma, or
◆ Ask if your patient has noticed easy they may be a result of problems in
bruising or bleeding, changes in warts other body systems. For example,
or moles, or lumps. Ask about the rough, dry skin is common in hypothy-
presence and location of scars, sores, roidism; soft, smooth skin is common
and ulcers. in hyperthyroidism. To determine if the
skin over a joint is supple or taut, have
the patient bend the joint as you pal-
pate.
54 Assessment
Turgor Make sure to distinguish between

Assessing the turgor, or elasticity, of generalized and localized warmth or
the patient’s skin helps you to evaluate coolness. Generalized warmth, or
hydration. To assess turgor, gently hyperthermia, is associated with fever
squeeze the skin on the forearm. If it stemming from a systemic infection or
quickly returns to its original shape, viral illness. Localized warmth occurs
the patient has normal turgor. If it re- with a burn or localized infection. Gen-
sumes its original shape slowly or eralized coolness occurs with hypother-
maintains a tented shape, the skin has mia; localized coolness, with arterio-
poor turgor. sclerosis.
Age alert Decreased turgor oc-
curs with dehydration as well Skin lesions
as with aging. Increased turgor is as- During your inspection, you may
sociated with progressive systemic note vascular changes in the form of
sclerosis. red, pigmented lesions. Among the
To accurately assess skin turgor in most common lesions are heman-
an elderly patient, try squeezing the giomas, telangiectases, petechiae,
skin of the sternum or forehead instead purpura, and ecchymoses. These le-
of the forearm. In an elderly patient, sions may indicate disease. For in-
the skin of the forearm tends to be stance, you’ll see telangiectases in
paper-thin, dry, and wrinkled, so it pregnant patients and in those with
doesn’t accurately represent the pa- hepatic cirrhosis.
tient’s hydration status.
Assessing dark skin
Moisture
Observe the skin for excessive dry- Be prepared for certain color variations
ness or moisture. If the patient’s skin when assessing dark-skinned patients.
is too dry, you may see reddened or For example, some dark-skinned pa-
flaking areas. Elderly patients com- tients have a pigmented line, called
monly have dry, itchy skin. Moisture Futcher’s line, extending diagonally
that appears shiny may result from and symmetrically from the shoulder to
oiliness. the elbow on the lateral edge of the bi-
If the patient is overhydrated, the cep muscle. This line is normal. Also
skin may be edematous and spongy. normal are deeply pigmented ridges in
Localized edema can occur in response the palms.
to trauma or skin abnormalities such To detect color variations in dark-
as ulcers. When you palpate local ede- skinned and black patients, examine
ma, document associated discoloration the sclerae, conjunctivae, buccal mu-
or lesions. cosa, tongue, lips, nail beds, palms,
and soles. A yellow-brown color in
Temperature dark-skinned patients or an ash-gray
To assess skin temperature, touch the color in black patients indicates pallor,
surface with the back of your hand. In- which results from a lack of the under-
flamed skin will feel warm because of lying pink and red tones normally pre-
increased blood flow. Cool skin results sent in dark skin.
from vasoconstriction. With hypovole- Among dark-skinned black patients,
mic shock, for instance, the skin feels yellowish pigmentation isn’t necessari-
cool and clammy. ly an indication of jaundice. To detect
jaundice in these patients, examine the fected area may have decreased color
hard palate and the sclerae. because fluid expands the distance be-
Look for petechiae by examining ar- tween the pigmented layers and the ex-
eas with lighter pigmentation, such as ternal epithelium. When you palpate
the abdomen, gluteal areas, and the the affected area, it may feel tight.
volar aspect of the forearm. To distin- Cyanosis can be difficult to identify
guish petechiae and ecchymoses from in both white and black patients. Be-
erythema in dark-skinned patients, ap- cause certain factors, such as cold, af-
ply pressure to the area. Erythematous fect the lips and nail beds, make sure
areas will blanch, but petechiae or ec- to assess the conjunctivae, palms,
chymoses won’t, because erythema is soles, buccal mucosa, and tongue as
commonly associated with increased well.
skin warmth. To detect rashes in black or dark-
When you assess edema in dark- skinned patients, palpate the area to
skinned patients, remember that the af- identify changes in skin texture.
Evaluating skin color variations

COLOR DISTRIBUTION POSSIBLE CAUSE
Absent Small, circumscribed areas Vitiligo
Generalized Albinism
Blue Around lips (circumoral Cyanosis (Note: In black patients, bluish

pallor) or generalized gingivae are normal.)
Deep red Generalized Polycythemia vera (increased red blood

cell count)
Pink Local or generalized Erythema (superficial capillary dilation

and congestion)
Tan to brown Facial patches Chloasma of pregnancy or butterfly

rash of lupus erythematosus
Tan to brown- Generalized (not related to Addison’s disease

bronze sun exposure)
Yellow Sclera or generalized Jaundice from liver dysfunction (Note:

In black patients, yellow-brown pig-
mentation of the sclera is normal.)
Yellow-orange Palms, soles, and face; not Carotenemia (carotene in the blood)
sclera
56 Assessment
Nose
Assessing the eyes, ears, nose, ◆ Ask about nasal problems, includ-
and throat ing allergies, sinusitis, discharge, colds,
coryza (more than four times a year),
Initial questions rhinitis, trauma, and frequent sneezing.
◆ Determine whether your patient has
Eyes an obstruction, breathing problems, or
◆ Ask the patient about vision prob- an inability to smell. Has he had nose-
lems, such as myopia, hyperopia, bleeds? Has he had a change in ap-
blurred vision, or double vision. Does petite or the sense of smell? Has he
he wear corrective lenses? used nasal sprays?
◆ Find out when he had his last eye ◆ Ask if he has had surgery on his
examination. nose or sinuses. If so, ask when, why,
◆ Ask if he has noticed any visual dis- and what type.
turbances, such as rainbows around
lights, blind spots, flashing lights, or Mouth and throat
loss of vision. ◆ Investigate whether your patient
◆ Ask if he has excessive tearing, dry has sores in the mouth or on the
eyes, itching, burning, pain, inflamma- tongue. Does he have a history of oral
tion, swelling, color blindness, or pho- herpes infection?
tophobia. ◆ Find out if he has toothaches,
◆ Elicit any history of eye infections, bleeding gums, loss of taste, voice
eye trauma, glaucoma, cataracts, de- changes, dry mouth, or frequent sore
tached retina, or other eye disorders. throats.
◆ If he’s older than age 50 or has a ◆ If the patient has frequent sore
family history of glaucoma, ask about throats, ask when they occur. Are they
the date and results of his last test for associated with fever or difficulty swal-
glaucoma. lowing? How have the sore throats
been treated medically?
Ears ◆ Ask if the patient has ever had a
◆ Find out if the patient has hearing problem swallowing. If so, does he
problems, such as deafness, poor hear- have trouble swallowing solids or liq-
ing, tinnitus, or vertigo. Is he abnor- uids? Is the problem constant or inter-
mally sensitive to noise? Has he no- mittent? What precipitates the difficul-
ticed recent changes in his hearing? ty? What makes it go away?
◆ Ask about ear discharge, pain, or ◆ Determine whether he has dental
tenderness behind the ears. caries or tooth loss. Ask if he wears
◆ Ask about frequent or recent ear in- dentures or bridges.
fections or ear surgery. ◆ Ask about the date and result of his
◆ Ask the date and result of his last last dental examination.
hearing test. ◆ Ask about his dental hygiene prac-
◆ Ask if he uses a hearing aid. tices, including the use of fluoride
◆ Determine his ear-care habits, in- toothpaste.
cluding the use of cotton-tipped appli-
cators to remove ear wax. Inspecting the conjunctivae
◆ Ask about exposure to loud noise,
including the use of protective earplugs Inferior palpebral conjunctiva
or headphones. While wearing gloves, gently evert the
patient’s lower eyelid with the thumb
and index finger, as shown below. Ask Testing the cardinal positions
the patient to look up, down, to the of gaze
left, and to the right as you examine
the palpebral conjunctiva. It should be The pupillary response to light should
clear and shiny. be tested before the cardinal positions
of gaze. Shine a bright light in the eye,
and bring the light in from the side.
Watch the response of the pupil to
light in that eye and also in the oppo-
site eye. Repeat the test on the other
eye, and then proceed to assessing the
cardinal positions of gaze.
This test of coordinated eye move-
ments evaluates the oculomotor, tri-
geminal, and abducens nerves as well
as the extraocular muscles. To perform
Superior palpebral conjunctiva the test, sit directly in front of the pa-
Check the superior palpebral conjuncti- tient and ask him to remain still. Hold
va only if you suspect a foreign body a small object, such as a pencil, direct-
or if the patient has eyelid pain. To ly in front of his nose at a distance of
perform this examination, ask the pa- about 18⬙ (46 cm). Ask him to follow
tient to look down while you gently the object with his eyes without mov-
pull the medial eyelashes forward and ing his head.
upward with your thumb and index Then move the object to each of the
finger. six cardinal positions, returning it to
While holding the eyelashes, press the midpoint after each movement.
on the tarsal border with a cotton- The patient’s eyes should remain paral-
tipped applicator to evert the eyelid, as lel as they move. Note abnormal find-
shown below. Hold the lashes against ings, such as nystagmus or the failure
the brow and examine the conjunctiva, of one eye to follow the object.
which should be pink, with no Test each of the six cardinal posi-
swelling. tions of gaze: left superior, left lateral,
left inferior, right inferior, right lateral,
and right superior. The following illus-
trations show testing of the three left
positions.
Left superior
To return the eyelid to its normal

position, release the eyelashes and ask
the patient to look upward. If this
doesn’t invert the eyelid, grasp the eye-
lashes and gently pull them forward.
58 Assessment
Left lateral front of and about 15 degrees to the

right of the patient’s line of vision in
the right eye. Hold the ophthalmoscope
in your right hand with the viewing
aperture as close to your right eye as
possible. Place your left thumb on the
patient’s right eyebrow to keep from
hitting him with the ophthalmoscope
as you move in close. Keep your right
index finger on the lens selector to ad-
just the lens as necessary, as shown
below. To examine the left eye, perform
these steps on the patient’s left side.
Use your left eye to examine the left
eye.
Left inferior
◆ Instruct the patient to look straight

ahead at a fixed point on the wall.
Next, approaching from an oblique an-
gle about 15⬙ (38 cm) out and with the
diopter set at 0, focus a small circle of
light on the pupil, as shown below.
Performing an ophthalmoscopic
examination
To use an ophthalmoscope to identify

abnormalities of the inner eye, follow
these steps.
◆ Place the patient in a darkened or
semidarkened room, with neither you
nor the patient wearing glasses unless
you’re very myopic or astigmatic. How- Look for the orange-red glow of the
ever, either of you may wear contact red reflex, which should be sharp and
lenses. distinct through the pupil. The red re-
◆ Sit or stand in front of the patient flex indicates that the lens is free from
with your head about 18⬙ (46 cm) in opacity and clouding.
◆ Move closer to the patient, changing darker than the rest of the retinal back-
the lens selector with your forefinger to ground, is free from vessels and locat-
keep the retinal structures in focus, as ed temporally to the optic disk. The
shown below. fovea centralis retina is a slight depres-
sion in the center of the macula.
Using the otoscope
Perform an otoscopic examination to as-

sess the external auditory canal, tym-
panic membrane, and malleus. Before
you insert the speculum into the pa-
tient’s ear, check the canal opening for
foreign particles or discharge. Palpate
the tragus and pull up the auricle. If this
area is tender, don’t insert the speculum;
the patient may have external otitis, and
◆ Change the lens selector to a posi- inserting the speculum could be painful.
tive diopter to view the vitreous hu- If the ear canal is clear, straighten
mor, observing for opacity. the canal by grasping the auricle and
◆ View the retina with a strong nega- pulling it up and back, as shown be-
tive lens setting. Look for a retinal low. Then insert the speculum.
blood vessel, and follow that vessel to-
ward the patient’s nose, rotating the
lens selector to keep the vessel in fo-
cus. Carefully examine all of the retinal
structures, including the retinal vessels,
optic disk, retinal background, macula,
and fovea centralis retinae.
◆ Examine the vessels for color, size
ratio of arterioles to veins, arteriole light
reflex, and arteriovenous (AV) crossing.
The crossing points should be smooth,
without nicks or narrowing. The vessels Age alert For an infant or a
should be free from exudate, bleeding, toddler, grasp the auricle and
and narrowing. Retinal vessels normally pull it down and back.
have an AV ratio of 2:3 or 4:5. Hold the otoscope as shown below,
◆ Evaluate the color of the retinal struc- with your hands parallel to the pa-
tures. The retina should be light yellow tient’s head. Avoid hitting the ear canal
to orange, and the background should be with the speculum.
free from hemorrhages, aneurysms, and
exudates. The optic disk, located on the
nasal side of the retina, should be
orange-red with distinct margins. Note
the size, shape, clarity, and color of the
disk margins. The physiologic cup is nor-
mally yellow-white and readily visible.
◆ Examine the macula last, and as
briefly as possible, because it’s very
light-sensitive. The macula, which is
60 Assessment
Inspecting the nostrils You should see the choana (posteri-

or air passage), cilia, and the middle
To perform direct inspection of the nos- and inferior turbinates. Below each
trils, you’ll need a nasal speculum and turbinate is a groove, or meatus, where
a small flashlight or penlight. the paranasal sinuses drain.
Have the patient sit in front of you When you’ve completed your in-
and tilt his head back. Insert the tip of spection of one nostril, close the specu-
the closed speculum into one of the lum and remove it. Then inspect the
nostrils until you reach the point other nostril.
where the blade widens. Slowly open
the speculum as wide as you can with- Inspecting and palpating
out causing discomfort. Shine the the frontal and maxillary sinuses
flashlight into the nostril to illuminate
the area. The illustration below shows During an inspection, you’ll be able to
proper placement of the nasal specu- examine the frontal and maxillary si-
lum. The inset shows the structures nuses, but not the ethmoidal and sphe-
that should be visible during examina- noidal sinuses. However, if the frontal
tion of the left nostril. and maxillary sinuses are infected, you
can assume that the ethmoidal and
sphenoidal are infected as well.
Begin by checking for swelling
around the eyes, especially over the si-
nus area. Then palpate the frontal and
maxillary sinuses for tenderness and
warmth.
To palpate the frontal sinuses, place
your thumb above the patient’s eyes,
just under the bony ridges of the upper
orbits, and press up. Place your finger-
tips on his forehead and apply gentle
pressure.
Nasal septum
To palpate the maxillary sinuses,
place your thumbs as shown below.
Nasal airway Then apply gentle pressure by pressing
your thumbs (or index and middle fin-
Middle turbinate
gers) up and in on each side of the
Middle meatus nose, just below the zygomatic bone
Inferior meatus (cheekbone).
Inferior turbinate
Note the color and patency of the

nostril and the presence of exudate.
The mucosa should be moist, pink to
red, and free from lesions and polyps.
Normally, you wouldn’t see drainage,
edema, or inflammation of the nasal
mucosa, although some tissue enlarge-
ment is normal in a pregnant patient.
Inspecting and palpating An enlarged thyroid may feel well-

the thyroid gland defined and finely lobulated. Thyroid
nodules feel like a knot, protuberance,
To locate the thyroid gland, observe the or swelling. A firm, fixed nodule may
lower third of the patient’s anterior be a tumor. Don’t confuse thick neck
neck. With the patient’s neck extended muscles with an enlarged thyroid or
slightly, look for masses or asymmetry goiter.
in the gland. Ask him to sip water,
with his neck still slightly extended.
Watch the thyroid rise and fall with the
trachea. You should see slight, symmet-
rical movement. A fixed thyroid lobe
may indicate a mass.
Palpate the thyroid gland while
standing in front of the patient. Locate
the cricoid cartilage first, and then
move one hand to each side to palpate
the thyroid lobes. The lobes can be dif-
ficult to feel because of their location
and the presence of overlying tissues.
Another way to test the thyroid is to
stand behind the patient and place the
fingers of both hands on the neck, just
below the cricoid cartilage. Have the
patient swallow, and feel the rise of the
thyroid isthmus. Move your fingers
down and to the sides to feel the later-
al lobes.
To evaluate the size and texture of
the thyroid gland, ask the patient to tilt
his head to the right. Gently displace
the thyroid toward the right. Have the
patient swallow as you palpate the lat-
eral lobes of the thyroid, as shown be-
low. Displace the thyroid toward the
left to examine the left side.
2 Assessment findings
Distinguishing health from disease
Normal findings 63
Head and neck 63
Eyes 63
Ears 64
Nose and mouth 64
Lungs 65
Heart 65
Abdomen 66
Arms and legs 67
Exploring the most common chief complaints 67
Anxiety 67
Cough (nonproductive) 69
Cough (productive) 70
Diarrhea 71
Dizziness 73
Dysphagia 74
Dyspnea 75
Eye pain 77
Fatigue 79
Fever 80
Headache 81
Heartburn 83
Hematuria 84
Hemoptysis 85
Hoarseness 87
Nausea 87
Pain (abdominal) 88
Pain (back) 90
Pain (chest) 92
Palpitations 93
Paresthesia 94
Rash (papular) 95
Rash (pustular) 96
Rash (vesicular) 97
Vision loss 98
Visual floaters 99
Weight gain 99
Weight loss 101
62
Normal findings 63
◆ A palpable, symmetrical, lesion-free

Normal findings thyroid with no tenderness
◆ Midline location of the trachea and
To distinguish between health and dis- absence of tracheal tenderness
ease, you must be able to recognize nor- ◆ No crepitus, tenderness, or lesions
mal assessment findings in each part of in the cervical spine
the body. When you perform a physical ◆ Symmetrical muscle strength in the
examination, use this head-to-toe roster neck
of normal findings as a reference. It’s
designed to help you quickly zero in on Auscultation
physical abnormalities and evaluate Head
your patient’s overall condition. ◆ Auscultate the temporal artery
Head and neck Neck

◆ Auscultate for carotid bruits
Inspection
Head Eyes
◆ A symmetrical, lesion-free skull
◆ Symmetrical facial structures with Inspection
normal variations in skin texture and ◆ No edema, scaling, or lesions on
pigmentation eyelids
◆ An ability to shrug the shoulders, a ◆ Eyelids completely covering corneas
sign of an adequately functioning cra- when closed
nial nerve XI (accessory nerve) ◆ Eyelid color the same as surround-
ing skin color
Neck ◆ Palpebral fissures of equal height
◆ Unrestricted range of motion in the ◆ Margin of the upper lid falling be-
neck tween the superior pupil margin and
◆ No bulging of the thyroid the superior limbus
◆ Symmetrical lymph nodes with no ◆ Symmetrical, lesion-free upper eye-
swelling lids that don’t sag or droop when the
◆ Flat jugular veins patient opens his eyes
◆ Evenly distributed eyelashes that
Palpation curve outward
Head ◆ Globe of the eye neither protruding
◆ No lumps or tenderness on the from nor sunken into the orbit
head ◆ Eyebrows with equal size, color,
◆ Symmetrical strength in the facial and distribution
muscles, a sign of adequately function- ◆ Absence of nystagmus
ing cranial nerves V and VII (trigemi- ◆ Clear conjunctiva with visible small
nal and facial nerves) blood vessels and no signs of drainage
◆ Symmetrical sensation when you ◆ White sclera visible through the
stroke a wisp of cotton on each cheek conjunctiva
◆ A transparent anterior chamber that
Neck contains no visible material when you
◆ Mobile, soft lymph nodes less than shine a penlight into the side of the eye
1
⁄2 (1 cm) with no tenderness ◆ Transparent, smooth, and bright
◆ Symmetrical pulses in the carotid cornea with no visible irregularities or
arteries lesions
◆ Closing of the lids of both eyes when tion or drainage, seen on otoscopic ex-
you stroke each cornea with a wisp of amination
cotton, a test of cranial nerve V (trigem-
inal nerve) Palpation
◆ Round, equal-sized pupils that react ◆ No masses or tenderness on the au-
to light and accommodation ricle
◆ Constriction of both pupils when ◆ No tenderness on the auricle or tra-
you shine a light on one gus during manipulation
◆ Lacrimal structures free from exu- ◆ Either small, nonpalpable lymph
date, swelling, and excessive tearing nodes on the auricle or discrete, mobile
◆ Proper eye alignment lymph nodes with no signs of tenderness
◆ Parallel eye movement in each of ◆ Well-defined, bony edges on the mas-
the six cardinal fields of gaze toid process with no signs of tenderness
Palpation Nose and mouth

◆ No eyelid swelling or tenderness
◆ Globes that feel equally firm, but Inspection
not overly hard or spongy Nose
◆ Lacrimal sacs that don’t regurgitate ◆ Symmetrical, lesion-free nose with
fluid no deviation of the septum or dis-
charge
Ears ◆ Little or no nasal flaring
◆ Nonedematous frontal and maxil-
Inspection lary sinuses
◆ Bilaterally symmetrical, proportion- ◆ Ability to identify familiar odors
ately sized auricles with a vertical mea- ◆ Pink-red nasal mucosa with no visi-
surement of 11⁄2 to 4 (4 to 10 cm) ble lesions and no purulent drainage
◆ Tip of ear crossing eye–occiput line ◆ No evidence of foreign bodies or
(an imaginary line extending from the dried blood in the nose
lateral aspect of the eye to the occipital
protuberance) Mouth
◆ Long axis of the ear perpendicular ◆ Pink lips with no dryness, cracking,
to (or no more than 10 degrees from lesions, or cyanosis
perpendicular to) the eye–occiput line ◆ Symmetrical facial structures
◆ Color match between the ears and ◆ Ability to purse the lips and puff
facial skin out the cheeks, a sign of an adequately
◆ No signs of inflammation, lesions, functioning cranial nerve VII (facial
or nodules nerve)
◆ No cracking, thickening, scaling, or ◆ Ability to open and close the mouth
lesions behind the ear when you bend easily
the auricle forward ◆ Light pink, moist oral mucosa with
◆ No visible discharge from the audi- no ulcers or lesions
tory canal ◆ Visible salivary ducts with no in-
◆ A patent external meatus flammation
◆ Skin color on the mastoid process ◆ White, hard palate
that matches the skin color of the sur- ◆ Pink, soft palate
rounding area ◆ Pink gums with no tartar, inflamma-
◆ No redness or swelling tion, hemorrhage, or leukoplakia
◆ Normal drum landmarks and a ◆ All teeth intact, with no signs of oc-
bright reflex, with no canal inflamma- clusion, caries, or breakage
Normal findings 65
◆ Pink tongue that protrudes symmet- ◆ Quiet, unlabored respirations with

rically and has no swelling, coating, no use of accessory neck, shoulder, or
ulcers, or lesions abdominal muscles. You should also
◆ Ability to move the tongue easily see no intercostal, substernal, or supra-
and without tremor, a sign of a proper- clavicular retractions.
ly functioning cranial nerve XII (hypo- ◆ Symmetrically expanding chest wall
glossal nerve) during respirations
◆ No swelling or inflammation on the ◆ Normal adult respiratory rate of 12 to
anterior and posterior arches 20 breaths/minute, with some variation
◆ No lesions or inflammation on the depending on the patient’s age
posterior pharynx ◆ Regular respiratory rhythm, with ex-
◆ Lesion-free tonsils that are the ap- piration taking about twice as long as
propriate size for the patient’s age inspiration. Men and children breathe
◆ A uvula that moves upward when diaphragmatically, whereas women
the patient says “ah” and a gag reflex breathe thoracically.
that occurs when a tongue blade ◆ Skin color that matches the rest of
touches the posterior pharynx. These the body’s complexion
are signs of properly functioning cra-
nial nerves IX and X. Palpation
◆ Warm, dry skin
Palpation ◆ No tender spots or bulges in the
Nose chest
◆ No structural deviation, tenderness, ◆ No asymmetrical expansion, fre-
or swelling on the external nose mitus, or subcutaneous crepitation
◆ No tenderness or edema on the
frontal and maxillary sinuses Percussion
◆ Resonant percussion sounds over
Mouth the lungs
◆ Lips free from pain and induration
◆ No tenderness on the posterior and Auscultation
lateral surfaces of the tongue ◆ Loud, high-pitched bronchial breath
◆ No tenderness or nodules on the sounds over the trachea
floor of the mouth ◆ Intense, medium-pitched broncho-
vesicular breath sounds over the main-
Lungs stem bronchi, between the scapulae,
and below the clavicles
Inspection ◆ Soft, breezy, low-pitched vesicular
◆ Symmetrical side-to-side configura- breath sounds over most of the periph-
tion of the chest eral lung fields
◆ Anteroposterior diameter less than
the transverse diameter, with a 1:2 ra- Heart
tio in an adult
◆ Normal chest shape, with no defor- Inspection
mities, such as a barrel chest, kypho- ◆ No visible pulsations, except at the
sis, retraction, sternal protrusion, or point of maximum impulse (PMI)
depressed sternum ◆ No lifts (heaves) or retractions in
◆ Costal angle less than 90 degrees, the four valve areas of the chest wall
with the ribs joining the spine at a 45-
degree angle
Palpation Abdomen
◆ No detectable vibrations or thrills
◆ No lifts (heaves) Inspection
◆ No pulsations, except at the PMI ◆ Skin free from vascular lesions,
and epigastric area. At the PMI, a lo- jaundice, surgical scars, and rashes
calized (less than 1⁄2 [1 cm] in diame- ◆ Faint venous patterns (except in
ter) tapping pulse may be felt at the thin patients)
start of systole. In the epigastric area, ◆ Flat, round, or scaphoid abdominal
pulsation from the abdominal aorta contour
may be palpable. ◆ Symmetrical abdomen
◆ Umbilicus positioned midway be-
Auscultation tween the xiphoid process and the
◆ A first heart sound (S1) — the lub symphysis pubis, with a flat or concave
sound heard best with the diaphragm hemisphere
of the stethoscope over the mitral area ◆ No variations in skin color
when the patient is in a left lateral po- ◆ No apparent bulges
sition. It sounds longer, lower, and ◆ Abdominal movement apparent
louder there than second heart sounds with respirations
(S2). S1 splitting may be audible in the ◆ Pink or silver-white striae from
tricuspid area. pregnancy or weight loss
◆ An S2 sound — the dub sound heard
best with the diaphragm of the stetho- Auscultation
scope in the aortic area while the pa- ◆ High-pitched, gurgling bowel
tient sits and leans forward. It sounds sounds, heard every 5 to 15 seconds
shorter, sharper, higher, and louder through the diaphragm of the stetho-
there than S1 sounds. Normal S2 split- scope in all four quadrants of the ab-
ting may be audible in the pulmonic domen
area on inspiration. ◆ Vascular sounds heard through the
◆ A third heart sound (S3). This bell of the stethoscope
sound is normal in children and slen- ◆ Venous hum over the inferior vena
der, young adults with no cardiovas- cava
cular disease. It usually disappears ◆ No bruits, murmurs, friction rubs,
when adults reach ages 25 to 35. or other venous hums
However, in an older adult, it may sig-
nify ventricular failure. S3 may be Percussion
heard best with the bell of the stetho- ◆ Tympany predominantly over hol-
scope over the mitral area with the low organs, including the stomach, in-
patient in a supine position and exhal- testines, bladder, abdominal aorta, and
ing. It sounds short, dull, soft, and gallbladder
low. ◆ Dullness over solid masses, includ-
◆ A murmur, which may be functioning the liver, spleen, pancreas, kidneys,
al in children and young adults, but is uterus, and a full bladder
abnormal in older adults. Innocent
murmurs are soft and short, and they Palpation
vary with respirations and patient posi- ◆ No tenderness or masses
tion. They occur in early systole and ◆ Abdominal musculature free from
are heard best in the pulmonic or mi- tenderness and rigidity
tral area with the patient in a supine ◆ No guarding, rebound tenderness,
position. distention, or ascites
◆ Unpalpable liver except in children questions about the patient’s health

(If palpable, the liver edge is regular, history, conduct a physical examination
sharp, and nontender and is felt no based on the history data you collect,
more than 3⁄4 [2 cm] below the right and analyze possible causes of the
costal margin.) problem.
◆ Unpalpable spleen The following list examines the
◆ Unpalpable kidneys except in thin most common chief complaints en-
patients or those with a flaccid abdom- countered in nursing practice. For each
inal wall (The right kidney is felt more one, you’ll find a concise description,
commonly than the left.) detailed questions to ask during the
history, areas to focus on during the
Arms and legs physical examination, and common
causes to consider.
Inspection
◆ No gross deformities Anxiety
◆ Symmetrical body parts
◆ Good body alignment A subjective reaction to a real or imag-
◆ No involuntary movements ined threat, anxiety is a nonspecific
◆ Smooth gait feeling of uneasiness or dread. It may
◆ Full range of motion in all muscles be mild to moderate or severe. Mild to
and joints moderate anxiety may cause slight
◆ No pain with full range of motion physical or psychological discomfort.
◆ No visible swelling or inflammation Severe anxiety may be incapacitating
of joints or muscles or even life-threatening.
◆ Equal bilateral limb length and sym- Anxiety is a normal response to ac-
metrical muscle mass tual danger, prompting the body
(through stimulation of the sympathet-
Palpation ic nervous system) to purposeful ac-
◆ Normal shape with no swelling or tion. It’s also a normal response to
tenderness physical and emotional stress, which
◆ Equal bilateral muscle tone, texture, virtually any illness can produce. Anxi-
and strength ety may also be precipitated or exacer-
◆ No involuntary contractions or bated by many nonpathologic factors,
twitching including lack of sleep, poor diet, and
◆ Equally strong bilateral pulses excessive intake of caffeine or other
stimulants. However, excessive, unwar-
ranted anxiety may indicate an under-
Exploring the most common lying psychological problem.
chief complaints
Health history
◆ What are you anxious about? When
A patient’s chief complaint is the start- did the anxiety first occur? What were
ing point for almost every initial as- the circumstances? What do you think
sessment. You may be the patient’s caused it?
first contact, so you must recognize the ◆ Is the anxiety constant or sporadic?
condition and determine the need for Do you notice any precipitating factors?
medical or nursing intervention. To ◆ How intense is the anxiety on a
thoroughly evaluate the patient’s chief scale of 0 to 10, with 10 being the
complaint, you must ask the right worst? What decreases it?
◆ Do you smoke? Do you use caf- is a midsystolic click followed by an

feine? Alcohol? Drugs? What medica- apical systolic murmur.
tions do you take?
Mood disorder
Physical examination In the depressive form of mood disor-
Perform a complete physical examina- der, chronic anxiety occurs with vary-
tion, focusing on complaints that the ing severity. The hallmark is depres-
anxiety may trigger or aggravate. sion on awakening that abates during
the day. Associated findings include
Causes dysphoria; anger; insomnia or hyper-
Asthma somnia; decreased libido, interest, en-
In allergic asthma attacks, acute ergy, and concentration; appetite dis-
anxiety occurs with dyspnea, wheez- turbance; multiple somatic complaints;
ing, productive cough, accessory mus- and suicidal thoughts.
cle use, hyperresonant lung fields,
diminished breath sounds, coarse Obsessive-compulsive disorder
crackles, cyanosis, tachycardia, and Chronic anxiety occurs in obsessive-
diaphoresis. compulsive disorder, along with recur-
rent, unshakable thoughts or impulses
Conversion disorder to perform ritualistic acts. The patient
Chronic anxiety is characteristic of con- recognizes these acts as irrational, but
version disorder, along with one or two can’t control them. Anxiety builds if he
somatic complaints that have no physi- can’t perform these acts and diminish-
ologic basis. Common complaints are es after he does.
dizziness, chest pain, palpitations, a
lump in the throat, and choking. Phobias
In phobias, chronic anxiety occurs
Hyperthyroidism along with persistent fear of an object,
Acute anxiety may be an early sign of activity, or situation that results in a
hyperthyroidism. Classic signs include compelling desire to avoid it. The pa-
heat intolerance, weight loss despite in- tient recognizes the fear as irrational,
creased appetite, nervousness, tremor, but can’t suppress it.
palpitations, sweating, an enlarged thy-
roid, and diarrhea. Exophthalmos may Postconcussion syndrome
occur as well. Postconcussion syndrome may produce
chronic anxiety or periodic attacks of
Hyperventilation syndrome acute anxiety. Associated symptoms in-
Hyperventilation syndrome produces clude irritability, insomnia, dizziness,
acute anxiety, pallor, circumoral and and mild headache. The anxiety is usu-
peripheral paresthesia and, occasional- ally most pronounced in situations that
ly, carpopedal spasms. demand attention, judgment, or com-
prehension.
Mitral valve prolapse
Panic may occur in patients with mitral Posttraumatic stress disorder
valve prolapse, which is referred to as Posttraumatic stress disorder produces
the click-murmur syndrome. The disor- chronic anxiety of varying severity and
der may also cause paroxysmal palpita- is accompanied by intrusive, vivid
tions accompanied by sharp, stabbing, memories and thoughts of the traumatic
or aching precordial pain. Its hallmark event. The patient also relives the event
in dreams and nightmares. Insomnia, tivity relieve or exacerbate it? Does it

depression, and feelings of numbness get better or worse at certain times of
and detachment are common. the day? How does the cough sound?
Does it occur often? Is it paroxysmal?
Somatoform disorder ◆ Does pain accompany the cough?
Most common in adolescents and ◆ Have you noticed any recent
young adults, somatoform disorder is changes in your appetite, energy level,
characterized by chronic anxiety and exercise tolerance, or weight? Have you
various somatic complaints that have had surgery recently? Do you have any
no physiologic basis. Anxiety and de- allergies? Do you smoke? Have you
pression may be prominent or hidden been exposed recently to fumes or
by dramatic, flamboyant, or seductive chemicals?
behavior. ◆ What medications are you taking?
Other causes Physical examination

Angina pectoris, chronic obstructive Note whether the patient appears agi-
pulmonary disease, heart failure, hypo- tated, anxious, confused, diaphoretic,
chondrial neurosis, hypoglycemia, myo- flushed, lethargic, nervous, pale, or
cardial infarction (MI), pheochromocy- restless. Is his skin cold or warm,
toma, pneumothorax, and pulmonary clammy or dry?
embolism can cause anxiety. Certain Observe the rate and depth of his
drugs cause anxiety, especially sympa- respirations, noting abnormal patterns.
thomimetics and central nervous sys- Then examine his chest configuration
tem stimulants. Also, many antidepres- and chest wall motion.
sants can cause paradoxical anxiety. Check the patient’s nose and mouth
for congestion, drainage, inflammation,
Cough (nonproductive) and signs of infection. Then inspect his
neck for jugular vein distention and
A nonproductive cough is a noisy, tracheal deviation.
forceful expulsion of air from the lungs As you palpate the patient’s neck,
that doesn’t yield sputum or blood. note enlarged lymph nodes or masses.
One of the most common signs of a Next, percuss his chest while listening
respiratory disorder, a nonproductive for dullness, flatness, and tympany. Fi-
cough can be ineffective and cause nally, auscultate his lungs for crackles,
damage, such as airway collapse, rup- decreased or absent breath sounds,
ture of the alveoli, or blebs. pleural friction rubs, rhonchi, and
A nonproductive cough that later wheezes.
becomes productive is a classic sign of
a progressive respiratory disease. An Causes
acute nonproductive cough has a sud- Asthma
den onset and may be self-limiting. A Typically, an asthma attack occurs at
nonproductive cough that persists be- night, starting with a nonproductive
yond 1 month is considered chronic; cough and mild wheezing. Then it pro-
this type of cough commonly results gresses to audible wheezing, chest
from cigarette smoking. tightness, a cough that produces thick
mucus, and severe dyspnea. Other
Health history signs include accessory muscle use,
◆ When did the cough begin? Does a cyanosis, diaphoresis, flaring nostrils,
certain body position or a specific ac- flushing, intercostal and supraclavicular
retractions on inspiration, prolonged ex- time of day, meals, activities, or the en-
pirations, tachycardia, and tachypnea. vironment? Has it increased since cough-
ing began? What are the color, odor, and
Interstitial lung disease consistency of the sputum? How does
With interstitial lung disease, the pa- the cough sound and feel? Have you
tient has a nonproductive cough and ever had a productive cough before?
progressive dyspnea. He may also be ◆ Have you noticed recent changes in
cyanotic and fatigued and have fine your appetite or weight?
crackles, finger clubbing, chest pain, ◆ Do you have a history of recent
and recent weight loss. surgery or allergies? Do you smoke or
drink alcohol? If so, how much? Do
Other causes you work around chemicals or respira-
A nonproductive cough may stem from tory irritants?
airway occlusion, atelectasis, the com- ◆ What medications are you taking?
mon cold, hypersensitivity pneumoni- ◆ Do you currently or have you in the
tis, pericardial effusion, pleural effu- past lived with anyone diagnosed with
sion, pulmonary embolism, Hantavirus tuberculosis?
infection, and sinusitis. Also, incentive
spirometry, intermittent positive-pres- Physical examination
sure breathing, and suctioning can in- As you examine the patient’s mouth
duce a nonproductive cough. and nose for congestion, drainage, and
Age alert Acute otitis media, inflammation, note his breath odor.
which commonly occurs in in- Then inspect his neck for jugular vein
fants and young children because of distention. As he breathes, observe the
their short eustachian tubes, also pro- chest for accessory muscle use, inter-
duces nonproductive coughing. costal and supraclavicular retractions,
and uneven expansion.
Cough (productive) Palpate his neck for enlarged lymph
nodes, masses, and tenderness. Next,
With productive coughing, the airway percuss his chest, listening for dull-
passages are cleared of accumulated ness, flatness, and tympany. Finally,
secretions that normal mucociliary ac- auscultate for abnormal breath sounds,
tion doesn’t remove. The sudden, crackles, pleural friction rubs, rhonchi,
forceful, noisy expulsion contains spu- and wheezes.
tum, blood, or both.
Usually caused by a cardiopulmo- Causes
nary disorder, productive coughing typ- Bacterial pneumonia
ically stems from an acute or chronic With bacterial pneumonia, an initially
infection that causes inflammation, dry cough becomes productive. Rust-
edema, and increased production of colored sputum appears in pneumococ-
mucus in the airways. Such coughing cal pneumonia; brick-red or currant-
can also result from inhaling antigenic jelly sputum, in Klebsiella pneumonia;
or irritating substances. The most com- salmon-colored sputum, in staphylo-
mon cause is cigarette smoking. coccal pneumonia; and mucopurulent
sputum, in streptococcal pneumonia.
Health history
◆ When did the cough begin? How Lung abscess
much sputum do you cough up daily? Is The cardinal sign of a ruptured lung
sputum production associated with the abscess is coughing that produces
copious amounts of purulent, foul- ◆ Do you have any known food aller-
smelling and, possibly, blood-tinged gies?
sputum. A ruptured abscess can also ◆ Have you been experiencing any
cause anorexia, diaphoresis, dyspnea, unusual stress?
fatigue, fever with chills, halitosis,
headache, inspiratory crackles, pleuritic Physical examination
chest pain, tubular or amphoric breath If the patient isn’t in shock, proceed
sounds, and weight loss. with a brief physical examination.
Evaluate hydration, check skin turgor
Other causes and the mucous membranes, and take
A productive cough can result from blood pressure with the patient lying,
acute bronchiolitis, aspiration and sitting, and standing. Inspect the ab-
chemical pneumonitis, bronchiectasis, domen for distention and palpate for
the common cold, cystic fibrosis, lung tenderness. Auscultate bowel sounds.
cancer, pertussis, pulmonary em- Check for tympany over the abdomen.
bolism, pulmonary edema, and tra- Take the patient’s temperature and
cheobronchitis. Also, expectorants, in- note chills or rash. Conduct a rectal ex-
centive spirometry, and intermittent amination and a pelvic examination if
positive-pressure breathing can cause a indicated.
productive cough.
Causes
Diarrhea Anthrax, GI
GI anthrax manifests after the patient
Usually a chief sign of an intestinal has eaten contaminated meat from an
disorder, diarrhea is an increase in the animal infected with Bacillus anthracis.
volume of stools compared with the Early signs and symptoms include de-
patient’s normal bowel habits. It creased appetite, nausea, vomiting, and
varies in severity and may be acute or fever. Later signs and symptoms in-
chronic. Acute diarrhea may result clude severe bloody diarrhea, abdomi-
from acute infection, stress, fecal im- nal pain, and hematemesis.
paction, or the effect of a drug.
Chronic diarrhea may result from Carcinoid syndrome
chronic infection, obstructive and in- With carcinoid syndrome, severe diar-
flammatory bowel disease, malabsorp- rhea occurs with flushing — usually of
tion syndrome, an endocrine disorder, the head and neck — that’s commonly
or GI surgery. Periodic diarrhea may caused by emotional stimuli or the in-
result from food intolerance or from gestion of food, hot water, or alcohol.
ingestion of caffeine or spicy or high- Associated signs and symptoms include
fiber foods. abdominal cramps, dyspnea, weight
loss, anorexia, weakness, palpitations,
Health history valvular heart disease, and depression.
◆ Do you have abdominal pain and
cramps? Cholera
◆ Do you have difficulty breathing? After ingesting water or food contami-
◆ Are you weak or fatigued? nated by the bacterium Vibrio cholerae,
◆ What medications do you take? the patient experiences abrupt watery
◆ Have you had GI surgery or radia- diarrhea and vomiting. Other signs and
tion therapy recently? symptoms include thirst (caused by
◆ Describe your diet. severe water and electrolyte loss),
weakness, muscle cramps, decreased distress, vomiting, weight loss and,

skin turgor, oliguria, tachycardia, and possibly, passage of blood and
hypotension. Without treatment, death mucus.
can occur within hours.
Intestinal obstruction
Clostridium difficile infection Partial intestinal obstruction increases
The patient may be asymptomatic or intestinal motility, resulting in diarrhea,
may have soft, unformed stools or wa- abdominal pain with tenderness and
tery diarrhea that may be foul-smelling guarding, nausea and, possibly, disten-
or grossly bloody; abdominal pain, tion.
cramping, and tenderness; fever; and a
white blood cell count as high as Irritable bowel syndrome
20,000/µl. In severe cases, the patient Diarrhea alternates with constipation
may have toxic megacolon, colonic or normal bowel function. The patient
perforation, or peritonitis. may have abdominal pain, tender-
ness, and distention; dyspepsia; and
Crohn’s disease nausea.
Crohn’s disease is a recurring inflam-
matory disorder that produces diarrhea Ischemic bowel disease
accompanied by abdominal pain with Ischemic bowel disease is a life-threat-
guarding, tenderness, and nausea. The ening disorder that causes bloody diar-
patient may also have fever, chills, rhea with abdominal pain. If severe,
weakness, anorexia, and weight loss. shock may occur, requiring surgery.
Escherichia coli 0157:H7 Lactose intolerance

With E. coli infection, the patient has With lactose intolerance, diarrhea oc-
watery or bloody diarrhea, nausea, curs within several hours of ingesting
vomiting, fever, and abdominal cramps milk or milk products. It’s accompa-
after eating undercooked beef or other nied by cramps, abdominal pain, bor-
foods contaminated with this strain of borygmi, bloating, nausea, and flatus.
bacteria. Hemolytic uremic syndrome,
which causes red blood cell destruction Large-bowel cancer
and eventually acute renal failure, is a With large-bowel cancer, bloody diar-
complication of E. coli 0157:H7 infec- rhea is seen with partial obstruction.
tion in children age 5 and younger and Other signs and symptoms include ab-
in elderly people. dominal pain, anorexia, weight loss,
weakness, fatigue, exertional dyspnea,
Infections and depression.
Acute viral, bacterial, and protozoal
infections (such as cryptosporidiosis) Ulcerative colitis
cause the sudden onset of watery di- The hallmark of ulcerative colitis is re-
arrhea as well as abdominal pain, current bloody diarrhea with pus or
cramps, nausea, vomiting, and fever. mucus. Other signs and symptoms in-
Significant fluid and electrolyte loss clude tenesmus, hyperactive bowel
may cause signs of dehydration and sounds, cramping lower abdominal
shock. Chronic tuberculosis and fun- pain, low-grade fever, anorexia and, at
gal and parasitic infections may pro- times, nausea and vomiting. Weight
duce less severe but more persistent loss, anemia, and weakness are late
diarrhea, accompanied by epigastric findings.
Other causes ders, such as hypertension and verte-

Many antibiotics — such as ampicillin, brobasilar artery insufficiency.
cephalosporins, tetracyclines, and clin-
damycin — cause diarrhea. Other drugs Health history
that may cause diarrhea include mag- ◆ When did the dizziness start? How
nesium-containing antacids, colchicine, severe is it? How often does it occur,
guanethidine, lactulose, dantrolene, and how long does each episode last?
ethacrynic acid, mefenamic acid, Does the dizziness abate spontaneous-
methotrexate, metyrosine and, in high ly? Is it triggered by standing up sud-
doses, cardiac glycosides and quini- denly or bending over?
dine. Laxative abuse can cause acute ◆ Do you have blurred vision, chest
or chronic diarrhea. Foods that contain pain, a chronic cough, diaphoresis, a
certain oils may inhibit absorption of headache, or shortness of breath?
food, causing acute, uncontrollable di- ◆ Have you ever had hypertension or
arrhea and rectal leakage. Gastrectomy, another cardiovascular disorder? What
gastroenterostomy, and pyloroplasty about diabetes mellitus, anemia, respi-
may produce diarrhea. High-dose radi- ratory or anxiety disorders, or head in-
ation therapy may produce enteritis jury?
and diarrhea. ◆ What medications and supplements
Age alert Diarrhea in children are you taking?
commonly results from infec- Age alert Many children have
tion, although chronic diarrhea may difficulty describing dizziness
result from malabsorption syndrome, and instead complain of tiredness,
an anatomic defect, or allergies. Be- stomachache, and feeling sick.
cause dehydration and electrolyte im-
balance occur rapidly in children, di- Physical examination
arrhea can be life-threatening. Dili- Assess the patient’s LOC, respirations,
gently monitor all episodes of and body temperature. As you observe
diarrhea, and immediately replace his breathing, look for accessory mus-
lost fluids. cle use or barrel chest. Look also for
finger clubbing, cyanosis, dry mucous
Dizziness membranes, and poor skin turgor. Eval-
uate the patient’s motor and sensory
A common symptom, dizziness is a functions and reflexes.
sensation of imbalance or faintness Palpate the extremities for peripher-
that’s sometimes associated with al edema and capillary refill. Auscul-
blurred or double vision, confusion, tate the patient’s heart rate and rhythm
and weakness. Dizziness may be mild and his breath sounds. Take his blood
or severe and may be aggravated by pressure while he’s lying down, sitting,
standing up quickly and alleviated by and standing. If the diastolic pressure
lying down. Onset may be abrupt or exceeds 100 mm Hg, notify the physi-
gradual. Episodes are usually brief. cian immediately and instruct the pa-
Dizziness typically results from in- tient to lie down.
adequate blood flow and oxygen sup-
ply to the cerebrum and spinal cord. It Causes
may occur with anxiety, respiratory Cardiac arrhythmias
and cardiovascular disorders, and post- With cardiac arrhythmias, dizziness
concussion syndrome. Dizziness is also lasts for several minutes or longer and
a key symptom of certain serious disor- may precede fainting. Other signs and
symptoms include blurred vision, con- Health history

fusion, hypotension, palpitations, ◆ When did your difficulty swallow-
paresthesia, weakness, and an irregu- ing start? Is swallowing painful? If so,
lar, rapid, or thready pulse. is the pain constant or intermittent?
Can you point to the spot where you
Hypertension have the most trouble swallowing?
With hypertension, dizziness may pre- Does eating alleviate or aggravate the
cede fainting, but may be relieved by problem? Do you have more trouble
rest. Other findings include blurred swallowing solids or liquids? Does the
vision, elevated blood pressure, head- problem disappear after you try to
ache, and retinal changes, such as he- swallow a few times? Is swallowing
morrhage and papilledema. easier if you change position?
◆ Have you or has anyone in your
Transient ischemic attack family ever had an esophageal,
Dizziness of varying severity occurs oropharyngeal, respiratory, or neuro-
during a transient ischemic attack. logic disorder? Have you recently had
Lasting from a few seconds to 24 a tracheotomy or been exposed to a
hours, an attack may be triggered by toxin?
turning the head to the side and may
signal an impending stroke. During an Physical examination
attack, the patient may experience Evaluate the patient’s swallowing and
blindness or visual field deficits, his cough and gag reflexes. As you lis-
diplopia, hearing loss, numbness, pare- ten to his speech, note signs of muscle,
sis, ptosis, and tinnitus. tongue, or facial weakness; aphasia; or
dysarthria. Is his voice nasal or hoarse?
Other causes Check his mouth for dry mucous mem-
Dizziness may result from anemia, branes and thick secretions.
generalized anxiety disorder, orthostat-
ic hypotension, panic disorder, or post- Causes
concussion syndrome. Also, dizziness Airway obstruction
may be an adverse reaction to certain A life-threatening condition, upper-
drugs, such as anxiolytics, central ner- airway obstruction is marked by mild
vous system depressants, narcotic anal- to severe wheezing and respiratory dis-
gesics, decongestants, antihistamines, tress. Dysphagia occurs along with gag-
antihypertensives, or vasodilators. ging and dysphonia.
Some herbal medications, such as
St. John’s wort, can cause dizziness. Esophageal carcinoma
In the patient with esophageal carcino-
Dysphagia ma, painless dysphagia typically ac-
companies rapid weight loss. As the
Difficulty swallowing, or dysphagia, is carcinoma advances, dysphagia be-
the most common — and sometimes the comes painful and constant. The pa-
only — symptom of an esophageal disor- tient has a cough with hemoptysis,
der. This symptom may also result from hoarseness, sore throat, and steady
oropharyngeal, respiratory, and neuro- chest pain.
logic disorders, or from exposure to tox- Age alert For patients older
ins. Patients with dysphagia have an in- than age 50 with head or neck
creased risk of aspiration and choking cancer, dysphagia is commonly the
and of malnutrition and dehydration. initial chief complaint.
Esophagitis ◆ Have you recently had an upper res-

A patient with corrosive esophagitis piratory tract infection or experienced
has dysphagia accompanied by exces- trauma? Do you smoke? If so, how
sive salivation, fever, hematemesis, in- much and for how long? Have you
tense pain in the mouth and anterior been exposed to any allergens? Do you
chest, and tachypnea. Candida esoph- have any known allergies?
agitis produces dysphagia and sore ◆ What medications and supplements
throat. In reflux esophagitis, dysphagia are you taking?
is a late symptom that usually accom-
panies stricture. Physical examination
Observe the patient’s respirations, not-
Hiatal hernia ing their rate and depth as well as
The patient with a hiatal hernia may breathing difficulties or abnormal respi-
complain of belching, dysphagia, dys- ratory patterns. Check for flaring nos-
pepsia, flatulence, heartburn, regurgita- trils, grunting respirations, inspiratory
tion, and retrosternal or substernal stridor, intercostal retractions during
chest pain that’s aggravated by lying inspirations, and pursed-lip expirations.
down or bending over. Examine the patient for barrel
chest, diaphoresis, jugular vein disten-
Other causes tion, finger clubbing, and peripheral
Dysphagia results from botulism, edema. Note the color, consistency,
esophageal diverticula or stricture, ex- and odor of sputum.
ternal esophageal compression, Palpate his chest for asymmetrical
hypocalcemia, laryngeal nerve damage, expansion, decreased diaphragmatic
and Parkinson’s disease. Radiation excursion, tactile fremitus, and subcu-
therapy and tracheotomy may also taneous crepitation. Also check the
cause dysphagia. rate, rhythm, and intensity of his pe-
ripheral pulses.
Dyspnea As you percuss the lung fields, note
dull, hyperresonant, or tympanic per-
Patients typically describe dyspnea as cussion sounds. Auscultate the lungs
shortness of breath, but this symptom for bronchophony, crackles, decreased
also refers to difficult or uncomfortable or absent unilateral breath sounds,
breathing. Its severity varies greatly and egophony, pleural friction rubs, rhon-
is generally unrelated to the seriousness chi, whispered pectoriloquy, and
of the underlying cause. Dyspnea may wheezing. Auscultate the heart for ab-
arise suddenly or slowly and may sub- normal sounds or rhythms, such as
side rapidly or persist for years. ventricular or atrial gallop, and for
pericardial friction rubs and tachycar-
Health history dia. Also monitor the patient’s blood
◆ When did the dyspnea first occur? pressure and pulse pressure.
Did it begin suddenly or gradually? Is it
constant or intermittent? Does it occur Causes
during activity or while you’re resting? Acute respiratory distress syndrome
Does anything seem to trigger, worsen, In acute respiratory distress syndrome
or relieve it? Have you ever had dysp- (ARDS), acute dyspnea is followed by
nea before? accessory muscle use, crackles, grunt-
◆ Do you have chest pain or a pro- ing respirations, progressive respiratory
ductive or nonproductive cough? distress, rhonchi, and wheezes. In the
late stages, anxiety, cyanosis, decreased Myocardial infarction

mental acuity, and tachycardia occur. Sudden dyspnea occurs with crushing
Severe ARDS can produce signs of substernal chest pain that may radiate
shock, such as cool, clammy skin and to the back, neck, jaw, and arms. The
hypotension. The typical patient has patient’s history may include heart dis-
no history of underlying cardiac or pul- ease, hypertension, hypercholesterol-
monary disease, but has had a recent emia, or use of a drug — such as co-
pulmonary or systemic insult. caine, dextrothyroxine sodium (Cholox-
in), estramustine phosphate sodium
Airway obstruction (partial) (Emcyt), or aldesleukin (Proleukin) —
Inspiratory stridor and acute dyspnea that can precipitate an MI.
occur as the patient tries to overcome
the obstruction. Related findings in- Pneumonia
clude accessory muscle use, anxiety, Dyspnea occurs suddenly and is usual-
asymmetrical chest expansion, ly accompanied by fever, pleuritic chest
cyanosis, decreased or absent breath pain that worsens with deep inspira-
sounds, diaphoresis, hypotension, and tion, and shaking chills. The patient
tachypnea. The patient may have as- also has a dry or productive cough, de-
pirated vomitus or a foreign body or pending on the stage and type of pneu-
may have been exposed to an monia. Sputum may be discolored and
allergen. foul-smelling. Crackles, decreased
breath sounds, dullness on percussion,
Asthma and rhonchi may also be present. The
Acute dyspneic attacks occur along history may include exposure to a con-
with accessory muscle use, apprehen- tagious organism, hazardous fumes, or
sion, dry cough, flushing or cyanosis, air pollution.
intercostal retractions, tachypnea, and
tachycardia. On palpation, you’ll detect Pulmonary edema
decreased tactile fremitus. Hyperreso- In pulmonary edema, severe dyspnea is
nance occurs on chest percussion. On commonly preceded by signs of heart
auscultation, you’ll note wheezing and failure, such as crackles in both lung
rhonchi or, during a severe episode, de- fields, cyanosis, tachycardia, tachy-
creased breath sounds. pnea, and marked anxiety. The patient
may have a dry cough or one that pro-
Heart failure duces copious amounts of pink, frothy
Dyspnea usually develops gradually sputum. The history may show cardio-
or occurs as chronic paroxysmal noc- vascular disease, cyanosis, fatigue, and
turnal dyspnea. In ventricular failure, pallor.
dyspnea occurs with basilar crackles,
dependent peripheral edema, distend- Pulmonary embolism
ed jugular veins, fatigue, orthopnea, Severe dyspnea occurs with intense
tachycardia, ventricular or atrial gal- angina-like or pleuritic pain that’s ag-
lop, and weight gain. The patient may gravated by deep breathing and tho-
have a history of cardiovascular dis- racic movement. Other findings include
ease, or he may be taking a drug — crackles, cyanosis, diffuse wheezing,
such as amiodarone (Cordarone), a dull percussion sounds, low-grade
beta-adrenergic blocker, or a cortico- fever, nonproductive cough, pleural
steroid — that can precipitate heart friction rubs, restlessness, tachypnea,
failure. and tachycardia. The patient’s history
may include acute MI, heart failure, a ptosis or exophthalmos. Finally, test vi-
hip or leg fracture, recent abdominal sual acuity with and without correc-
surgery, hormonal contraceptive use, tion, and assess extraocular move-
pregnancy, thrombophlebitis, immobi- ments. Characterize any discharge.
lity, or thrombophilias.
Causes
Other causes Acute angle-closure glaucoma
Dyspnea may also result from anemia, Blurred vision and sudden, excruciat-
anxiety, cardiac arrhythmias, cor pul- ing pain in and around the eye charac-
monale, inhalation injury, lung cancer, terize acute angle-closure glaucoma.
pleural effusion, and sepsis. The pain may be so severe that it caus-
es nausea, vomiting, and abdominal
Eye pain pain. Other findings include halo vi-
sion, rapidly decreasing visual acuity,
Eye pain, also known as ophthalmal- and a fixed, nonreactive, moderately
gia, may be described as a burning, dilated pupil.
throbbing, aching, or stabbing sensa-
tion in or around the eye. It may also Blepharitis
be characterized as a foreign-body sen- Blepharitis is a burning pain in both
sation. This sign varies from mild to eyelids that’s accompanied by itching,
severe; its duration and exact location a sticky discharge, and conjunctival
provide clues to the cause. injection. Related findings include
Eye pain usually results from foreign-body sensation, lid ulcerations,
corneal abrasion, but it may also be and loss of eyelashes.
caused by glaucoma or other eye disor-
ders, trauma, and neurologic or sys- Burns
temic disorders. Any of these may With chemical burns, sudden and se-
stimulate nerve endings in the cornea vere eye pain may occur with erythema
or external eye, producing pain. and blistering of the face and lids, pho-
tophobia, miosis, conjunctival injec-
Health history tion, blurring, and inability to keep the
◆ Can you describe your pain? Is it an eyelids open. With ultraviolet radiation
ache or a sharp pain? How long does it burns, moderate to severe pain occurs
last? Is it accompanied by burning, about 12 hours after exposure along
itching, or discharge? When did the with photophobia and vision changes.
pain begin? Is it worse in the morning
or in the evening? Chalazion
◆ Have you had any recent trauma or A chalazion causes localized tender-
surgery? ness and swelling on the upper or low-
◆ Do you have headaches? If yes, how er eyelid. Eversion of the lid shows
often and at what time of day do they conjunctival injection and a small red
occur? lump.
Physical examination Conjunctivitis

During the physical examination, don’t Some degree of eye pain and excessive
manipulate the eye if you suspect trau- tearing occurs with four types of
ma. Carefully assess the lids and con- conjunctivitis. Allergic conjunctivitis
junctiva for redness, inflammation, and causes bilateral mild burning pain
swelling. Then examine the eyes for accompanied by itching, conjunctival
injection, and a characteristic ropy dis- body sensation, a dark speck on the
charge. cornea, and dramatic conjunctival in-
Bacterial conjunctivitis causes pain jection.
only when it affects the cornea. Other-
wise, it produces burning and a Glaucoma
foreign-body sensation. A purulent dis- Open-angle glaucoma may cause mild
charge and conjunctival injection are aching in the eyes as well as loss of pe-
also typical. ripheral vision, halo vision, and re-
If the cornea is affected, fungal con- duced visual acuity that isn’t corrected
junctivitis may cause pain and photo- by glasses. Angle-closure glaucoma
phobia. Even without corneal involve- may cause pain and pressure over the
ment, it causes itching, burning eyes; a eye, blurred vision, halo vision, de-
thick, purulent discharge; and conjunc- creased visual acuity, and nausea and
tival injection. vomiting.
Viral conjunctivitis produces itch-
ing, redness, a foreign-body sensation, Iritis (acute)
visible conjunctival follicles, and eyelid Acute iritis causes moderate to severe
edema. eye pain with severe photophobia, dra-
matic conjunctival injection, and
Corneal abrasions blurred vision. The constricted pupil
With corneal abrasions, eye pain is may respond poorly to light.
characterized by a foreign-body sensa-
tion. Excessive tearing, photophobia, Migraine headache
conjunctival injection, and an inability Migraines can produce pain so severe
to keep the eyelid open are also com- that the eyes also ache. Additionally,
mon. the patient may have nausea, vomiting,
blurred vision, and sensitivity to light
Corneal ulcers and noise.
Both bacterial and fungal corneal ul-
cers cause severe eye pain. They may Ocular laceration and intraocular foreign
also cause a purulent eye discharge, bodies
sticky eyelids, photophobia, and im- Penetrating eye injuries usually cause
paired visual acuity. Bacterial corneal mild to severe unilateral eye pain and
ulcers also produce a gray-white, irreg- impaired visual acuity. Eyelid edema,
ularly shaped ulcer on the cornea; uni- conjunctival injection, and an abnor-
lateral pupil constriction; and conjunc- mal pupillary response may also occur.
tival injection. Fungal corneal ulcers
produce conjunctival injection, eyelid Optic neuritis
edema and erythema, and a dense, With optic neuritis, the patient may
cloudy, central ulcer surrounded by have pain in and around the eye. Se-
progressively clearer rings. vere vision loss and tunnel vision de-
velop, but improve in 2 to 3 weeks.
Foreign bodies in the cornea and Pupils respond sluggishly to direct
conjunctiva light, but normally to consensual
Sudden, severe pain is common with light.
foreign bodies in the cornea and con-
junctiva, but vision usually remains in- Other causes
tact. Other findings include excessive Contact lenses may cause eye pain and
tearing, photophobia, miosis, a foreign- a foreign-body sensation. Ocular
surgery may also produce eye pain that Age alert Always ask older
ranges from a mild ache to a severe patients about fatigue because
pounding or stabbing sensation. this symptom may be insidious and
Age alert Glaucoma, which mask a more serious underlying con-
can cause eye pain, is usually a dition.
disease of older patients, becoming
clinically significant after age 40. It Physical examination
usually occurs bilaterally and leads to Observe the patient’s general appear-
slowly progressive vision loss, espe- ance for signs of depression or organic
cially in the peripheral visual fields. illness. Is he unkempt? Expressionless?
Tired or unhealthy looking? Is he
Fatigue slumped over? Assess his mental sta-
tus, noting especially agitation, atten-
A common symptom, fatigue is a feel- tion deficits, mental clouding, or psy-
ing of excessive tiredness, lack of ener- chomotor impairment.
gy, or exhaustion, accompanied by a
strong desire to rest or sleep. Fatigue Causes
differs from weakness, which involves Anemia
the muscles and may occur with fa- Fatigue after mild activity is generally
tigue. the first symptom of anemia. Other
Fatigue is a normal response to signs and symptoms typically include
physical overexertion, emotional stress, dyspnea, pallor, and tachycardia.
and sleep deprivation. It can also result
from psychological and physiologic dis- Cancer
orders, especially viral infections and Unexplained fatigue is commonly the
endocrine, cardiovascular, or neurolog- earliest indication of cancer. Related
ic disorders. signs and symptoms reflect the type,
location, and stage of the tumor. They
Health history usually include abnormal bleeding,
◆ When did the fatigue begin? Is it anorexia, nausea, pain, a palpable
constant or intermittent? If it’s inter- mass, vomiting, and weight loss.
mittent, when does it occur? Does the
fatigue worsen with activity and im- Chronic infection
prove with rest, or vice versa? (The for- In a patient with a chronic infection,
mer usually signals a physiologic disor- fatigue is usually the most prominent
der; the latter, a psychological disor- symptom — and sometimes the only
der.) one.
◆ Have you experienced any recent
stressful changes at home or at work? Depression
◆ Have you changed your eating Chronic depression is usually accompa-
habits? Have you recently lost or nied by persistent fatigue unrelated to
gained weight? exertion. The patient may also have
◆ Have you or has anyone in your anorexia, constipation, headache, and
family been diagnosed with any cardio- sexual dysfunction.
vascular, endocrine, or neurologic dis-
orders? What about viral infections or Diabetes mellitus
psychological disorders? The most common symptom of dia-
◆ What medications and supplements betes mellitus is fatigue, which may
are you taking? begin insidiously or abruptly. Related
findings include polydipsia, polypha- 104 F [40 C]). Fever above 108 F
gia, polyuria, and weight loss. (42.2 C) causes unconsciousness and,
if prolonged, brain damage.
Heart failure Age alert Infants and young
Persistent fatigue and lethargy are children experience higher and
characteristic symptoms of heart fail- more prolonged fevers, more rapid
ure. Left-sided heart failure produces temperature increases, and greater
exertional and paroxysmal nocturnal temperature fluctuations than do old-
dyspnea, orthopnea, and tachycardia. er children or adults.
Right-sided heart failure causes jugular
vein distention and, sometimes, a Health history
slight but persistent nonproductive ◆ When did the fever begin? How
cough. high did it reach? Is the fever constant,
or does it disappear and then reappear
Hypothyroidism later?
Fatigue occurs early in the course of ◆ Do you also have chills, fatigue, or
hypothyroidism, along with forgetful- pain?
ness, cold intolerance, weight gain, ◆ Have you had any immunodeficien-
metrorrhagia, and constipation. cy disorders, infections, recent trauma
or surgery, or diagnostic tests? Have
Myasthenia gravis you traveled recently?
The cardinal symptoms of myasthenia ◆ What medications and supplements
gravis are easy fatigability and muscle are you taking? Have you recently had
weakness that worsen with exertion anesthesia?
and abate with rest. These symptoms
are related to the specific muscle Causes
groups affected. Infectious and inflammatory disorders
Fever may be low, as in Crohn’s dis-
Other causes ease and ulcerative colitis, or extremely
Anxiety, MI, rheumatoid arthritis, sys- high, as in bacterial pneumonia. It may
temic lupus erythematosus, and malnu- be remittent, as in infectious mononu-
trition can cause fatigue, as can certain cleosis; sustained, as in meningitis; or
drugs — notably antihypertensives and relapsing, as in malaria. Fever may
sedatives — and most types of surgery. arise abruptly, as in Rocky Mountain
spotted fever, or insidiously, as in my-
Fever coplasmal pneumonia. Typically, it ac-
companies a self-limiting disorder such
An abnormal elevation of body temper- as the common cold.
ature above 98.6 F (37 C), fever (or
pyrexia) is a common sign arising from Medications
disorders that affect virtually every Fever and rash commonly result from
body system. As a result, fever alone hypersensitivity to such medications as
has little diagnostic value. However, quinidine, methyldopa (Aldomet), pro-
persistently high fever is a medical cainamide, phenytoin (Dilantin), anti-
emergency. infectives, barbiturates, iodides, and
Fever can be classified as low (oral some antitoxins. Fever can also result
reading of 99 to 100.4 F [37.2 to from the use of chemotherapeutic
38 C]), moderate (100.5 to 104 F agents and medications that decrease
[38 to 40 C]), or high (greater than sweating such as anticholinergics. Toxic
doses of salicylates, amphetamines, fever, muscle twitching, nausea, photo-

and antidepressants can cause fever. phobia, seizures, difficulty speaking or
walking, neck stiffness, visual distur-
Other causes bances, vomiting, or weakness?
Fever may also result from an injection ◆ Have you been under unusual stress
of contrast media used in diagnostic at home or at work? For family mem-
tests or from surgery. Other causes in- bers: Have you noticed any changes in
clude blood transfusion reactions, exer- the patient’s behavior or personality?
cise, heat stroke, malignant hypother- ◆ Do you have a history of blood
mia, or neuroleptic malignant syn- dyscrasia, cardiovascular disease, glau-
drome. coma, hemorrhagic disorders, hyper-
tension, poor vision, seizures, migraine
Headache headaches, or smoking? Have you had
a recent traumatic injury, dental work,
Headache is the most common neuro- or a sinus, ear, or systemic infection?
logic symptom. A headache may be ◆ What medications and supplements
mild to severe, localized or general- are you taking?
ized, and constant or intermittent.
About 90% of all headaches are benign Physical examination
and can be described as vascular, mus- Observe the rate and depth of the pa-
cle contracting, or a combination of tient’s respirations, noting breathing
both. difficulty or abnormal patterns. Inspect
Occasionally, this symptom indi- his head for bruising, swelling, and si-
cates a severe neurologic disorder. A nus bleeding. Check also for Battle’s
generalized, pathologic headache may sign, neck stiffness, otorrhea, and rhin-
result from disorders associated with orrhea.
intracranial inflammation, increased in- Assess the patient’s LOC. Is he
tracranial pressure (ICP), meningeal ir- drowsy, lethargic, or comatose? Exam-
ritation, or vascular disturbance. A ine his eyes, noting pupil size, equality,
headache may also result from disor- and response to light. With the patient
ders of the eye or sinus and from the both at rest and active, note tremors.
effects of drugs, tests, and treatments. Gently palpate the skull and sinuses
for tenderness. Unless head trauma has
Health history occurred, slowly move the neck to
◆ When did the headache first occur? check for nuchal rigidity or pain. Then
Describe your pain on a scale of 0 to assess the patient’s motor strength. Pal-
10, with 10 being the worst. Is the pain pate his peripheral pulses, noting their
mild, moderate, or severe? Is it local- rate, rhythm, and intensity.
ized or generalized? If it’s localized, Check for Babinski’s reflex. As you
where does it occur? Is it constant or percuss for other reflexes, note hyper-
intermittent? If it’s intermittent, what’s reflexia. Then auscultate over the tem-
the duration? How would you describe poral artery, listening for bruits. Also
the pain; for example, is it stabbing, monitor the patient’s blood pressure
dull, throbbing, or viselike? Does any- and pulse pressure.
thing seem to trigger it, exacerbate it,
or relieve it? Have you had this kind of Causes
headache before? Brain abscess
◆ Have you also experienced confu- Headache caused by a brain abscess
sion, dizziness, drowsiness, eye pain, typically intensifies over a few days. It
localizes to a particular spot and is ag- encephalitis, such as mumps or herpes

gravated by straining. The headache simplex.
may be accompanied by a decreased
LOC (drowsiness to deep stupor), focal Epidural hemorrhage (acute)
or generalized seizures, nausea, and With acute epidural hemorrhage, a pro-
vomiting. Depending on the abscess gressively severe headache immediate-
site, the patient may also have aphasia, ly follows a brief loss of consciousness.
ataxia, impaired visual acuity, hemi- Then the patient’s LOC declines rapidly
paresis, personality changes, or trem- and steadily. Accompanying signs and
ors. Signs of infection may or may not symptoms include increasing ICP, ipsi-
appear. The patient may have a history lateral pupil dilation, nausea, and vom-
of systemic, chronic middle ear, mas- iting. The patient’s history usually
toid, or sinus infection; osteomyelitis of shows head trauma within the last
the skull or a compound fracture; or a 24 hours.
penetrating head wound.
Glaucoma (acute angle-closure)
Brain tumor Glaucoma is an ophthalmic emergency
Headache caused by a brain tumor that may cause an excruciating head-
develops near the tumor site and ache. Other signs and symptoms in-
becomes generalized as the tumor clude blurred vision, a cloudy cornea,
grows. Pain is usually intermittent, halo vision, a moderately dilated and
deep-seated, dull, and most intense in fixed pupil, photophobia, nausea, and
the morning. It’s aggravated by cough- vomiting.
ing, stooping, Valsalva’s maneuver, and
changes in head position. Hypertension
Patients with hypertension may have a
Cerebral aneurysm (ruptured) slightly throbbing occipital headache
Headache caused by a cerebral on awakening. During the day, the
aneurysm is sudden and excruciating. severity may decrease. However, if the
It may be unilateral and usually peaks patient’s diastolic blood pressure ex-
within minutes of the rupture. The ceeds 120 mm Hg and the headache re-
headache may be accompanied by nau- mains constant, this situation is con-
sea, vomiting, and signs of meningeal sidered a medical emergency because
irritation, and the patient may lose of the potential for stroke.
consciousness. His history may include
hypertension or other cardiovascular Meningitis
disorders, a stressful lifestyle, or With meningitis, the patient has a se-
smoking. vere constant, generalized headache
that starts suddenly and worsens with
Encephalitis movement. He may also have chills,
Headache caused by encephalitis is se- fever, hyperreflexia, nuchal rigidity,
vere and generalized and is accompa- and positive Kernig’s and Brudzinski’s
nied by a deteriorating LOC over a signs. His history may include recent
48-hour period. Fever, focal neurologic systemic or sinus infection, dental
deficits, irritability, nausea, nuchal work, or exposure to bacteria or virus-
rigidity, photophobia, seizures, and es that commonly cause meningitis,
vomiting may also develop. The patient such as Haemophilus influenzae, Strep-
may have a history of exposure to the tococcus pneumoniae, enteroviruses,
viruses that commonly cause and mumps.
Migraine (Lanoxin), nitroglycerin (Nitrostat),

A severe, throbbing headache, a mi- isosorbide (Isordil), or another vaso-
graine may follow a 5- to 15-minute dilator can cause headaches. Also, the
prodrome of dizziness; tingling of the use of certain herbal medicines — such
face, lips, or hands; unsteady gait; and as St. John’s wort, ginseng, and
visual disturbances. Other signs and ephedra — can cause headaches.
symptoms include anorexia, nausea,
photophobia, and vomiting. Heartburn
Sinusitis (acute) A substernal burning sensation that ris-

Patients with sinusitis have a dull, peri- es in the chest and may radiate to the
orbital headache that’s typically aggra- neck or throat, heartburn (also known
vated by bending over or touching the as pyrosis) results from the reflux of
face. They may also have fever, ma- gastric contents into the esophagus.
laise, nasal discharge, nasal turbinate Usually, it’s accompanied by regurgita-
edema, sinus tenderness, and sore tion. Because increased intra-abdomi-
throat. Sinus drainage relieves the nal pressure contributes to reflux,
sinusitis. heartburn commonly occurs with preg-
nancy, ascites, or obesity, but it may
Subarachnoid hemorrhage also be caused by GI disorders, connec-
The hallmarks of subarachnoid hemor- tive tissue disease, and certain drugs.
rhage are a sudden, violent headache In most cases, heartburn develops
and dizziness, hypertension, ipsilateral after meals or occurs when a person
pupil dilation, nausea, nuchal rigidity, lies down, bends over, lifts heavy ob-
seizures, vomiting, and an altered LOC jects, or exercises vigorously. It usually
that may progress rapidly to coma. The worsens with swallowing and improves
patient’s history may include congenital when the person sits upright or takes
vascular defects, arteriovenous malfor- antacids. Some patients confuse heart-
mation, cardiovascular disease, smok- burn with an MI, but a patient who is
ing, hypertension, or excessive stress. having an MI typically has other symp-
toms besides a burning sensation.
Subdural hematoma
A severe, localized headache usually Health history
follows head trauma that causes an im- ◆ When did the heartburn start? Do
mediate loss of consciousness, a latent certain foods or beverages seem to trig-
period of drowsiness, confusion or per- ger it? Does stress or fatigue seem to
sonality changes, and agitation. Later, aggravate it? Do movement, certain
signs of increased ICP may develop. If body positions, or very hot or cold liq-
the head trauma occurred within 3 days uids worsen or relieve it? Where exact-
of the onset of signs and symptoms, ly is the burning sensation? Does it ra-
the hematoma is acute. If it occurred diate to other areas? Does it cause you
within 3 weeks, subacute; after more to regurgitate sour or bitter fluids?
than 3 weeks, chronic. Have you ever had heartburn before? If
so, what relieved it?
Other causes ◆ Do you have a history of GI prob-
Cervical traction, lumbar puncture, lems or connective tissue disease? For
myelography, withdrawal from a vaso- women of childbearing age: Are you
pressor or a sympathomimetic, or the pregnant?
use of indomethacin (Indocin), digoxin ◆ What medications are you taking?
Physical examination weight loss. Other GI effects include ab-

Auscultate the heart and lungs to rule dominal distention, constipation or di-
out a heart or lung disorder. Palpate arrhea, and malodorous, floating stools.
the abdomen for abdominal pain.
Other causes
Causes Heartburn may also be caused by
Esophageal cancer esophageal diverticula, obesity, and the
Heartburn may indicate esophageal use of certain drugs, including aspirin,
cancer. The first symptom is usually nonsteroidal anti-inflammatory drugs,
painless dysphagia that progressively anticholinergics, inhaled corticosteroids,
worsens. Eventually, partial obstruction inhaled beta-adrenergic blockers, and
and rapid weight loss occur. The pa- drugs that have anticholinergic effects.
tient may have a feeling of substernal
fullness, hoarseness, nausea, sore Hematuria
throat, steady pain in the posterior and
anterior chest, and vomiting. A cardinal sign of renal and urinary
tract disorders, hematuria is blood in
Gastroesophageal reflux the urine. Hematuria may be evident or
Severe, chronic heartburn is the most may be confirmed by a urine test for
common symptom of gastroesophageal occult blood.
reflux. Heartburn usually occurs within Bleeding may be continuous or in-
1 hour after eating and may be trig- termittent, is commonly accompanied
gered by certain foods or beverages. It by pain, and may be aggravated by
worsens when the person lies down or prolonged standing or walking. Dark
bends over and abates when he sits, or brownish blood indicates renal or
stands, or ingests antacids. Other find- upper urinary tract bleeding; bright red
ings include dull retrosternal pain that blood, lower urinary tract bleeding.
may radiate, hypersalivation, odyno-
phagia, dysphagia, flatulent dyspepsia, Health history
and postural regurgitation. ◆ When did you first notice blood in
your urine? Does it occur every time
Peptic ulcer you urinate? Are you passing any clots?
Heartburn and indigestion usually sig- Have you ever had this problem before?
nal the onset of a peptic ulcer attack. ◆ Do you have any pain? If so, does
Most patients have a gnawing, burning the pain occur only when you urinate,
pain in the left epigastrium, although or is it continuous? On a scale of 0 to
some report sharp pain. The pain typi- 10 with 10 being the worst pain imag-
cally occurs when the stomach is emp- inable, rate the pain.
ty and is generally relieved by taking ◆ Do you have bleeding hemorrhoids?
antacids. The pain may also occur after Have you had any recent trauma or
the patient drinks coffee or alcohol or performed any strenuous exercise? Do
takes aspirin. you have a history of renal, urinary,
prostatic, or coagulation disorders? For
Scleroderma female patients: Are you menstruating?
A connective tissue disease, scleroder- ◆ What medications are you taking?
ma may cause esophageal dysfunction
resulting in heartburn, bloating after Physical examination
meals, odynophagia, the sensation of Check the urinary meatus for bleeding
food sticking behind the sternum, and or abnormalities. Palpate the abdomen
and flanks, noting pain or tenderness. pain, high fever, and signs and symp-
Finally, percuss the abdomen and toms of a urinary tract infection.
flanks, especially the costovertebral an-
gle, to elicit tenderness. Renal infarction
Patients with renal infarction usually
Causes have gross hematuria. Other symptoms
Bladder cancer include anorexia, costovertebral angle
A primary cause of gross hematuria in tenderness, and constant, severe flank
men, bladder cancer may produce pain and upper abdominal pain.
in the bladder, rectum, pelvis, flank,
back, or legs. You may also note signs Other causes
of urinary tract infection. Hematuria may result from benign
prostatic hyperplasia, bladder trauma,
Calculi obstructive nephropathy, polycystic
Both bladder and renal calculi produce kidney disease, renal trauma, and ure-
hematuria that may be accompanied thral trauma. It may result from a di-
by signs and symptoms of urinary tract agnostic test, such as cystoscopy or
infection. Bladder calculi usually pro- renal biopsy. It may also result from
duce gross hematuria, pain referred to the use of a drug, such as an antico-
the penile or vulvar areas and, in some agulant; a chemotherapeutic agent,
patients, bladder distention. Renal cal- such as cyclophosphamide, bacillus
culi may produce either microscopic or Calmette-Guérin intravesical (Thera-
gross hematuria. Cys), or leuprolide (Lupron); or thi-
abendazole (Mintezol). Also, certain
Glomerulonephritis herbal medicines, such as garlic and
Usually, acute glomerulonephritis be- gingko biloba, may cause hematuria
gins with gross hematuria. It may also when taken with an anticoagulant.
produce anuria or oliguria, flank and
abdominal pain, and increased blood Hemoptysis
pressure. Chronic glomerulonephritis
typically causes microscopic hematuria The expectoration of blood or bloody
accompanied by generalized edema, in- sputum from the lungs or tracheo-
creased blood pressure, and protein- bronchial tree is known as hemoptysis.
uria. Usually caused by an abnormality of
the tracheobronchial tree, hemoptysis
Nephritis is associated with inflammatory condi-
Acute nephritis causes fever, a macu- tions or lesions that cause erosion and
lopapular rash, and microscopic hema- necrosis of the bronchial tissues and
turia. In chronic interstitial nephritis, blood vessels.
the patient may have dilute, almost Hemoptysis is sometimes confused
colorless urine along with polyuria. with bleeding from the mouth, throat,
nasopharynx, or GI tract. Severe he-
Pyelonephritis (acute) moptysis requires emergency endotra-
A typical sign of pyelonephritis is mi- cheal intubation and suctioning.
croscopic or gross hematuria that pro-
gresses to grossly bloody hematuria. Health history
After the infection resolves, microscop- ◆ When did you begin expectorating
ic hematuria may persist for a few blood? How much blood or sputum are
months. Other findings include flank you expectorating? How often?
◆ Did you recently have a flulike syn- Lung abscess

drome? Have you had any recent inva- A patient with a lung abscess expecto-
sive pulmonary procedures or chest rates copious amounts of bloody, puru-
trauma? lent, foul-smelling sputum. He also has
◆ Do you smoke? Did you ever anorexia, chills, diaphoresis, fever,
smoke? If so, how much? Have you headache, and pleuritic or dull chest
ever been diagnosed with a cardiac, pain. Lung auscultation may show
respiratory, or bleeding disorder? tubular breath sounds or crackles. Per-
◆ What medications are you taking? cussion shows dullness on the affected
Are you taking an anticoagulant? side. The patient may have a history of
a recent pulmonary infection or evi-
Physical examination dence of poor oral hygiene, with dental
After assessing the patient’s LOC, ex- or gingival disease.
amine his nose, mouth, and pharynx
for sources of bleeding. Observe the Lung cancer
rate and depth of his respirations, not- Ulceration of the bronchus commonly
ing breathing difficulty or abnormal causes recurring hemoptysis (an early
breathing patterns. Also, look for ab- sign), which can vary from blood-
normal chest movement, accessory streaked sputum to blood. Related find-
muscle use, and retractions. Inspect ings include anorexia, chest pain, dys-
the skin for central and peripheral pnea, fever, a productive cough, weight
cyanosis, diaphoresis, lesions, and pal- loss, and wheezing.
lor.
Palpate the rate, rhythm, and inten- Pulmonary edema
sity of the peripheral pulses. Then feel A patient with pulmonary edema may
the chest, noting abnormal pulsations, expectorate copious amounts of frothy,
diaphragmatic tenderness, and fremi- blood-tinged, pink sputum. He may
tus. Check for respiratory excursion. If also have dyspnea and orthopnea. On
the patient has a history of trauma, examination, you may detect diffuse
carefully check the position of the tra- crackles in both lung fields and a ven-
chea and note edema. tricular gallop (S3).
As you percuss over the lung fields,
note dullness, flatness, hyperreso- Tracheal trauma
nance, or tympany. Auscultate the With tracheal trauma, the bleeding ap-
lungs for crackles, rhonchi, and pears to come from the back of the
wheezes and the heart for bruits, gal- throat. Accompanying signs and symp-
lops, murmurs, and pleural friction toms include airway occlusion, dyspha-
rubs. Also, monitor the patient’s blood gia, hoarseness, neck pain, and respira-
pressure and pulse pressure. tory distress.
Causes Other causes

Bronchitis (chronic) Hemoptysis may also result from
The patient with chronic bronchitis bronchiectasis, coagulation disorders,
usually has a productive cough that cystic fibrosis, lung or airway injuries
lasts at least 3 months and leads to ex- from diagnostic procedures, and prima-
pectoration of blood-streaked sputum. ry pulmonary hypertension.
Other respiratory signs include dysp-
nea, prolonged expiration, scattered
rhonchi, and wheezing.
Hoarseness crackles, rhonchi, tubular sounds, or

wheezes. To detect bradycardia, aus-
A rough or harsh-sounding voice, cultate the heart.
hoarseness can be acute or chronic. It
may result from infections or inflam- Causes
matory lesions or exudates in the lar- Inhalation injury
ynx, from laryngeal edema, from com- Exposure to a fire or an explosion can
pression or disruption of the vocal cause an inhalation injury that pro-
cords or recurrent laryngeal nerve duces coughing, hoarseness, orofacial
damage, or from irritating polyps on burns, singed nasal hair, and soot-
the vocal cords. Hoarseness can also stained sputum. Subsequent signs and
occur with aging because the laryngeal symptoms include crackles, rhonchi,
muscles and mucosa atrophy, leading wheezes, and respiratory distress.
to diminished control of the vocal
cords. Hoarseness may be exacerbated Laryngitis
by excessive alcohol intake, smoking, Persistent hoarseness may be the only
inhalation of noxious fumes, excessive sign of chronic laryngitis. In acute
talking, and shouting. laryngitis, hoarseness or complete loss
of the voice develops suddenly. Related
Health history findings include cough, fever, pain (es-
◆ When did the hoarseness start? Is it pecially during swallowing or speak-
constant or intermittent? Does anything ing), profuse diaphoresis, rhinorrhea,
relieve or exacerbate it? Have you been and sore throat.
overusing your voice?
◆ Have you also had a cough, a dry Vocal cord polyps
mouth, difficulty swallowing dry food, A patient with vocal cord polyps has
shortness of breath, or a sore throat? raspy hoarseness and may also have a
◆ Have you ever had cancer or other chronic cough and a crackling voice.
disorders? Do you regularly drink alco-
hol or smoke? If so, how much? Other causes
Hoarseness may result from hypothy-
Physical examination roidism, pulmonary tuberculosis,
Inspect the patient’s mouth and throat rheumatoid arthritis, and laryngeal
for redness or exudate, possibly indi- cancer (most common in men ages 50
cating an upper respiratory tract infec- to 70). Prolonged intubation, surgical
tion. Ask him to stick out his tongue: If severing of the recurrent laryngeal
he can’t, the hypoglossal nerve (cranial nerve, and a tracheostomy may also
nerve XII) may be impaired. produce hoarseness.
As the patient breathes, observe Age alert In infants and
him for asymmetrical chest expansion, young children, hoarseness
intercostal retractions, nasal flaring, commonly stems from acute laryn-
stridor, and other signs of respiratory gotracheobronchitis (croup).
distress.
Palpate the patient’s neck for masses Nausea
and the cervical lymph nodes and thy-
roid gland for enlargement. Then pal- A profound feeling of revulsion to food
pate the trachea to check for deviation. or a signal of impending vomiting,
As you percuss the chest wall, note nausea is usually accompanied by
dullness. Auscultate the lungs for anorexia, diaphoresis, hypersalivation,
pallor, tachycardia, tachypnea, and Causes

vomiting. A common symptom of GI Appendicitis
disorders, nausea may also result from A patient with appendicitis will feel
electrolyte imbalances; infections; nauseated and may vomit. He’ll also
metabolic, endocrine, and cardiac dis- have vague epigastric or periumbilical
orders; early pregnancy; drug therapy; discomfort that localizes to the right
surgery; and radiation therapy. Also, lower quadrant.
severe pain, anxiety, alcohol intoxica-
tion, overeating, and ingestion of Cholecystitis (acute)
something distasteful can trigger nau- In acute cholecystitis, nausea common-
sea. ly follows severe right upper quadrant
pain that may radiate to the back or
Health history shoulders. Associated findings include
◆ When did the nausea begin? Is it in- abdominal tenderness, vomiting and,
termittent or constant? How severe is possibly, abdominal rigidity and disten-
it? tion, diaphoresis, and fever with chills.
◆ Do you have any other signs and
symptoms, such as abdominal pain, Gastritis
loss of appetite, changes in bowel Patients with gastritis commonly expe-
habits, excessive belching or gas, rience nausea, especially after inges-
weight loss or vomiting? tion of alcohol, aspirin, spicy foods, or
◆ For female patients: Are you preg- caffeine. Belching, epigastric pain,
nant or could you be? Have you ever fever, malaise, and vomiting of mucus
had a GI, endocrine, or metabolic dis- or blood may also occur.
order? Have you had any recent infec-
tions? Have you ever had cancer, radia- Other causes
tion therapy, or chemotherapy? Nausea may result from cirrhosis, an
◆ What medications and supplements electrolyte imbalance, labyrinthitis,
are you taking? Do you drink alcohol metabolic acidosis, MI, a renal or uro-
and, if so, how much? logic disorder, or ulcerative colitis. Use
of an anesthetic, an antibiotic, an anti-
Physical examination neoplastic, ferrous sulfate, oral potassi-
Examine the patient’s skin for bruises, um, or quinidine, or an overdose of a
jaundice, poor turgor, and spider an- cardiac glycoside or theophylline may
giomas. Inspect his abdomen for dis- also trigger nausea, as may radiation
tention. therapy or surgery — especially abdom-
Because palpation and percussion inal surgery. Certain herbal medicines,
can affect the frequency and intensity such as gingko biloba and St. John’s
of bowel sounds, you should auscultate wort, may also cause nausea.
the abdomen first. Listen for bowel
sounds in each quadrant. Then, using Pain (abdominal)
the bell of the stethoscope, listen for
abdominal bruits. Usually, abdominal pain results from
As you palpate the abdomen, note GI disorders, but it can also stem from
rigidity, tenderness, or rebound tender- reproductive, genitourinary, musculo-
ness. Next, palpate the size of the liver. skeletal, or vascular disorders; from
Then percuss the abdomen and liver drug use; or from the effect of toxins.
for abnormalities. Abdominal pain may originate in the
abdominopelvic viscera, the parietal
peritoneum, or the capsules of the liv- trauma. Obtain and record a baseline
er, kidneys, or spleen. The pain may be measurement of abdominal girth at the
acute or chronic and diffuse or local- umbilicus.
ized. After inspecting for jugular vein dis-
tention, observe the rate and depth of
Health history respirations, noting abnormal patterns.
◆ When did the pain begin? What Observe the color and odor of the pa-
does it feel like? How long does it last? tient’s urine.
Where exactly is it? Does it radiate to Because palpation and percussion
other areas, such as the chest or back? can affect the frequency and intensity
Does it get better or worse when you of bowel sounds, you should auscultate
change position, move, exert yourself, the abdomen first. Listen for bowel
cough, eat, or have a bowel move- sounds in each quadrant, noting
ment? whether the sounds are high-pitched
◆ Does fever occur during episodes of and tinkling, hyperactive, or absent.
pain? Do you have appetite changes, Listen to the patient’s heart and
constipation, diarrhea, nausea, pain breath sounds for abnormalities. Also,
with urination, pink or cloudy urine, monitor his blood pressure and pulse
vomiting, or urinary frequency or ur- pressure.
gency? As you systematically palpate the
◆ Do you have a history of adrenal abdominal, pelvic, flank, and epigastric
disease, heart disease, recent infection, areas, note enlarged organs, masses,
or recent blunt trauma to the abdo- rigidity, tenderness, rebound tender-
men, flank, or chest? Have you had ness, or tenderness with guarding.
any condition that could predispose Check the patient’s peripheral pulses
you to emboli or that could narrow an for rate, rhythm, and intensity.
arterial lumen? Have you recently had Percuss each abdominal quadrant,
a urinary tract procedure or surgery? noting tenderness, increased pain,
Have you traveled to a foreign country and percussion sounds. Dull percus-
recently? sion sounds indicate free fluid; hollow
◆ For women of childbearing age: sounds, air.
What was the date of your last
menses? Has your menstrual pattern Causes
changed? Could you be pregnant? Abdominal aortic aneurysm (dissecting)
◆ Have you ever used I.V. drugs? Do Constant, dull upper abdominal pain
you drink alcohol? If so, how much radiating to the lower back typically
and how often? What medications and accompanies rapid enlargement of the
supplements do you take? aneurysm and may indicate a rupture.
Palpation may show an epigastric mass
Physical examination that pulsates before rupture. On aus-
After assessing the patient’s LOC, ob- cultation, you may detect a systolic
serve his skin for diaphoresis, jaundice, bruit over the aneurysm. You may also
and turgor. Then check for coolness, note abdominal rigidity, increasing ab-
discoloration, and edema of the arms dominal girth, and signs of hypovole-
and legs. Inspect the abdomen and mic shock.
chest for signs of trauma: A bluish dis-
coloration around the umbilicus Abdominal trauma
(Cullen’s sign) and around the flank The patient may have generalized or
area (Turner’s sign) can indicate blunt localized abdominal pain along with
abdominal ecchymosis, abdominal ten- pain. These episodes alternate with

derness, or vomiting. If he’s hemor- pain-free periods.
rhaging into the peritoneal cavity, you
may note abdominal rigidity, dullness Pancreatitis
on percussion, and increasing abdomi- The characteristic symptom of pancre-
nal girth. You may hear hollow bowel atitis is fulminating, continuous upper
sounds if an abdominal organ has been abdominal pain that may radiate to
perforated, or bowel sounds may be both flanks and to the back.
absent. Bowel sounds heard in the
chest cavity usually signal a diaphrag- Renal calculi
matic tear. Depending on the location of the cal-
culi, the patient may have severe ab-
Appendicitis dominal or back pain. However, the
The patient with appendicitis may have classic symptom of renal calculi is col-
sudden pain in the epigastric or umbili- icky pain that travels from the cos-
cal region that increases over a few tovertebral angle to the flank, the
hours or days, along with flulike symp- suprapubic region, and the external
toms. Anorexia, constipation or diar- genitalia.
rhea, nausea, and vomiting precede the
pain, which may be dull or severe. Other causes
Pain localizes at McBurney’s point in Abdominal pain may result from adren-
the right lower quadrant. Abdominal al crisis, cholecystitis, heart failure, dia-
rigidity and rebound tenderness may betic ketoacidosis, diverticulitis, hepat-
also occur. ic abscess, mesenteric artery ischemia,
MI, an ovarian cyst, a perforated ulcer,
Ectopic pregnancy peritonitis, pneumonia, pneumothorax,
With ectopic pregnancy, lower abdomi- pyelonephritis, renal infarction, or
nal pain may be sharp, dull, or cramp- splenic infarction. Other causes include
ing, and either constant or intermittent. the use of salicylates and nonsteroidal
The pain may be accompanied by anti-inflammatory drugs.
breast tenderness, nausea, vaginal
bleeding, vomiting, and urinary fre- Pain (back)
quency. The patient typically has a
1- to 2-month history of amenorrhea. Back pain may be acute, chronic, con-
Rupture of the fallopian tube produces stant, or intermittent. It may also re-
sharp lower abdominal pain that may main localized in the back or may radi-
radiate to the shoulders and neck and ate along the spine or down one or
become extreme on cervical or adnexal both legs. Pain may be exacerbated by
palpation. activity (most commonly, stooping or
lifting) and alleviated by rest or may be
Hepatitis unaffected by either.
Liver enlargement from any type of Intrinsic back pain results from
hepatitis causes discomfort or dull pain muscle spasm, nerve root irritation,
and tenderness in the right upper fracture, or a combination of these
quadrant. causes. It usually occurs in the lower
back or lumbosacral area. Back pain
Intestinal obstruction may also be referred from the ab-
Intestinal obstruction causes short domen, possibly signaling a life-threat-
episodes of intense, colicky, cramping ening disorder.
Health history Finally, percuss each abdominal

◆ When did the pain first occur? quadrant. Note abnormal sounds, in-
What does it feel like? Is it mild, mod- creased pain, and tenderness.
erate, or severe? Is it constant or inter-
mittent? Where exactly is it? Is it asso- Causes
ciated with activity? What relieves or Abdominal aortic aneurysm (dissecting)
exacerbates it? For women of child- Lower back pain and dull upper ab-
bearing age: Does the pain occur be- dominal pain commonly accompany a
fore or during your menses? rapidly enlarging aneurysm and may
◆ Have you had recent episodes of ab- indicate the early stages of rupture. On
dominal tenderness or rigidity, fever, palpation, you may detect tenderness
nausea, or vomiting? Do you feel un- over the area of the aneurysm as well
usual sensations in your legs? Have as a pulsating epigastric mass. Other
you had urinary frequency or urgency signs include absent femoral and pedal
or painful urination? pulses, mottling of the skin below the
◆ Do you have a history of trauma, waist, and signs of hypovolemic shock.
back surgery, or urinary tract surgery,
procedures, obstructions, or infections? Pancreatitis
◆ What medications and supplements Fulminating, continuous abdominal
are you taking? pain that may radiate to the back and
both flanks characterizes pancreatitis.
Physical examination You may also note abdominal tender-
Observe the rate and depth of respira- ness, rigidity, and distention; fever; hy-
tions, noting breathing difficulty or ab- poactive bowel sounds; pallor; tachy-
normal breathing patterns. Check the cardia; and vomiting. The history may
skin for diaphoresis, discoloration, ede- include alcohol abuse, use of a thiazide
ma, mottling, and pallor. Then inspect diuretic, gallbladder disease, or trauma.
the back, legs, and abdomen for signs
of trauma. After you check for abdomi- Pyelonephritis (acute)
nal distention, take a baseline abdomi- The patient with acute pyelonephritis
nal girth measurement. has progressive back pain or flank ten-
Because palpation and percussion derness accompanied by costovertebral
can affect the frequency and intensity angle pain and abdominal pain in one
of bowel sounds, you should auscultate or two quadrants. Associated signs and
the abdomen first. Listen for bowel symptoms include dysuria, high fever,
sounds in each quadrant. Then listen hematuria, nocturia, shaking chills,
over the abdominal aorta for bruits and vomiting, and urinary frequency and
over the lungs for crackles. Also moni- urgency. The history may show a re-
tor the patient’s blood pressure and cent urinary tract procedure, urinary
pulse pressure. tract infection or obstruction, compro-
Palpate the abdominal, epigastric, mised renal function, or a neurogenic
and pelvic areas for abdominal rigidity, bladder.
enlarged organs, masses, and tender-
ness. If you feel pulsations, don’t pal- Other causes
pate deeply. Check the peripheral puls- Back pain may also result from appen-
es for rate, rhythm, and intensity. Gen- dicitis, cholecystitis, a herniated disk,
tly palpate the painful area, noting lumbosacral sprain, osteoporosis, a
contractions, excessive muscle tone, or perforated ulcer, renal calculi, a tumor,
spasm. or vertebral osteomyelitis.
Pain (chest) time. Look for facial edema, jugular

vein distention, and tracheal deviation.
Patients describe chest pain in many Note signs of altered LOC, anxiety,
ways. They may report a dull ache, a dizziness, or restlessness.
sensation of heaviness or fullness, a Observe the rate and depth of the
feeling of indigestion, or a sharp, patient’s respirations, noting abnormal
shooting pain. The pain may be con- patterns or breathing difficulty. If the pa-
stant or intermittent, may radiate to tient has a productive cough, examine
other body parts, and may arise sud- the sputum.
denly or gradually. Patients may say Palpate the patient’s neck, chest,
that stress, anxiety, exertion, deep and abdomen. Note asymmetrical chest
breathing, or certain foods seem to expansion, masses, subcutaneous crep-
trigger the pain. itation, tender areas, tracheal devia-
Chest pain may indicate several tion, or tactile fremitus. Also palpate
acute and life-threatening cardiopul- his peripheral pulses, and record their
monary and GI conditions. It can also rate, rhythm, and intensity.
result from musculoskeletal and hema- As you percuss over an affected
tologic disorders, anxiety, and the use lung, note dullness. Auscultate the
of certain drugs. lungs to identify crackles, diminished
or absent breath sounds, pleural fric-
Health history tion rubs, rhonchi, or wheezes. Auscul-
◆ When did the chest pain begin? Did tate the heart for clicks, gallops, mur-
it develop suddenly or gradually? Is the murs, and a pericardial friction rub. To
pain localized or diffuse? Does it radi- check for abdominal bruits, apply the
ate to the neck, jaw, arms, or back? Is bell of the stethoscope over the abdom-
the pain sharp and stabbing or dull inal aorta. Also, monitor the patient’s
and aching? Is it constant or intermit- blood pressure closely.
tent? Does breathing, changing posi-
tions, or eating certain foods worsen or Causes
relieve the pain? Angina
◆ Do you have other signs and symp- Angina usually begins gradually, builds
toms, such as coughing, shortness of to a peak, and subsides slowly. The
breath, headache, nausea, palpitations, pain can last from 2 to 10 minutes. It
vomiting, or weakness? occurs in the retrosternal region and
◆ Have you ever had cardiac or respi- radiates to the neck, jaw, and arms.
ratory disease, cardiac surgery, chest Associated signs and symptoms include
trauma, or intestinal disease? Do you diaphoresis, dyspnea, nausea, vomit-
have a family history of cardiac dis- ing, palpitations, and tachycardia. On
ease? auscultation, you may detect an atrial
◆ Do you drink alcohol or use illicit gallop (or fourth heart sound [S4]) or a
drugs? What medications and supple- murmur. Attacks may occur at rest or
ments are you taking? may be provoked by exertion, emotion-
al stress, or a heavy meal.
Physical examination
Assess the patient’s skin temperature, Aortic aneurysm (dissecting)
color, and general appearance, noting A patient with a dissecting aortic
coolness, cyanosis, diaphoresis, mot- aneurysm has sudden, excruciating,
tling below the waist, pallor, peripheral tearing pain in the chest and neck, ra-
edema, and prolonged capillary refill diating to the upper back, lower back,
and abdomen. Other signs and symp- and subcutaneous crepitation. Other
toms include abdominal tenderness, signs and symptoms include accessory
heart murmurs, jugular vein distention, muscle use, anxiety, asymmetrical
systolic bruits, tachycardia, syncope, chest expansion, nonproductive cough,
and dyspnea. tachycardia, and tachypnea. The histo-
ry may include chronic obstructive pul-
Cholecystitis monary disease, lung cancer, diagnostic
The patient with cholecystitis has sud- or therapeutic procedures involving the
den epigastric or right upper quadrant thorax, or thoracic trauma.
pain. The pain may be steady or inter-
mittent, may radiate to the back, and Pulmonary embolism
may be sharp or intense. Other signs Typically, the patient with pulmonary
and symptoms include chills, diaphore- embolism has sudden dyspnea with in-
sis, nausea, and vomiting. Palpation of tense anginalike or pleuritic ischemic
the right upper quadrant may show pain that’s aggravated by deep breath-
distention, rigidity, tenderness, and a ing and thoracic movement. Other find-
mass. ings include anxiety, cough with blood-
tinged sputum, dull percussion sounds,
Myocardial infarction crackles, restlessness, and tachycardia.
With MI, the patient has severe, crush- If the embolism is large, the cardiovas-
ing substernal pain that radiates to the cular, pulmonary, and neurologic sys-
left arm, jaw, or neck. The pain may tems may be compromised. The pa-
be accompanied by anxiety, clammy tient’s history may include throm-
skin, diaphoresis, dyspnea, a feeling of bophlebitis, hip or leg injury,
impending doom, nausea, vomiting, abdominal surgery, acute MI, heart fail-
pallor, and restlessness. The patient ure, pregnancy, the use of hormonal
may have an atrial gallop (or an S4), contraceptives, or immobility.
crackles, hypotension or hypertension,
murmurs, and a pericardial friction Other causes
rub. A history of heart disease, hyper- Chest pain may also result from abrupt
tension, hypercholesterolemia, or co- withdrawal of beta-adrenergic blockers,
caine abuse is common. acute bronchitis, anxiety, esophageal
spasm, esophageal reflux, lung ab-
Peptic ulcer scess, muscle strain, pancreatitis, pneu-
A sharp, burning pain arising in the monia, a rib fracture, or tuberculosis.
epigastric region, usually hours after
eating, characterizes a peptic ulcer. Palpitations
Other signs and symptoms include epi-
gastric tenderness, nausea, and vomit- Defined as a person’s conscious aware-
ing. Food or antacids usually relieve ness of his own heartbeat, palpitations
the pain. are usually felt over the precordium or
in the throat or neck. The patient may
Pneumothorax describe his heart as pounding, jump-
In pneumothorax, a collapsed lung pro- ing, turning, fluttering, flopping, or
duces sudden, sharp, severe chest pain missing or skipping beats. Palpitations
that’s commonly unilateral and increas- may be regular or irregular, fast or
es with chest movement. You may de- slow, and paroxysmal or sustained. Be-
tect decreased breath sounds, hyperres- sides cardiac causes, palpitations may
onant or tympanic percussion sounds, stem from anxiety, drug reactions,
hypertension, thyroid hormone defi- breath sounds. Also monitor blood

ciency, and several other problems. pressure and pulse pressure.
Health history Causes

◆ When did the palpitations start? Acute anxiety attack
Where do you feel them? How would During an acute anxiety attack, palpa-
you describe them? What were you do- tions may be accompanied by di-
ing when they started? How long did aphoresis, facial flushing, and trem-
they last? Have you ever had palpita- bling. The patient usually hyperventi-
tions before? lates, which may lead to dizziness,
◆ Do you have chest pain, dizziness, or syncope, and weakness.
weakness along with the palpitations?
◆ Are you under unusual stress at Cardiac arrhythmias
home or at work? Have you recently With cardiac arrhythmias, paroxysmal
had multiple blood transfusions or an or sustained palpitations may occur
infusion of phosphate? with dizziness, fatigue, and weakness.
◆ Have you ever had thyroid disease, Other signs and symptoms include
calcium or vitamin D deficiency, malab- chest pain, confusion, decreased blood
sorption syndrome, bone cancer, renal pressure, diaphoresis, pallor, and an ir-
disease, hypoglycemia, or cardiovascu- regular, rapid, or slow pulse rate. The
lar or pulmonary disorders that may patient may be taking a drug that can
produce arrhythmias or hypertension? cause cardiac arrhythmias — for in-
◆ What medications and supplements stance, an antihypertensive, a sympath-
are you taking? Are you taking an over- omimetic, a ganglionic blocker, an anti-
the-counter drug that contains caffeine cholinergic, or a methylxanthine.
or a sympathomimetic, such as a
cough, cold, or allergy preparation? Do Thyrotoxicosis
you smoke or drink alcohol? If so, how In patients with thyrotoxicosis, sustained
much? palpitations may accompany diaphore-
sis, diarrhea, dyspnea, heat intolerance,
Physical examination nervousness, tachycardia, tremors, and
Assess the patient’s LOC, noting anxiety, weight loss despite increased appetite.
confusion, or irrational behavior. Check Exophthalmos and an enlarged thyroid
his skin for pallor and diaphoresis, and gland may also develop.
observe the eyes for exophthalmos.
Note the rate and depth of his respi- Other causes
rations, checking for abnormal patterns Palpitations may also arise from ane-
and breathing difficulty. Also inspect mia, aortic insufficiency, hypocalcemia,
the fingertips for capillary nail bed pul- hypertension, hypoglycemia, mitral
sations. valve stenosis or prolapse, and
To check for thyroid gland enlarge- pheochromocytoma. Also, certain
ment, gently palpate the patient’s neck. herbal medicines, such as ginseng and
Then palpate his muscles for weakness ephedra, may cause palpitations.
and twitching. Evaluate his peripheral
pulses, noting the rate, rhythm, and in- Paresthesia
tensity. Assess his reflexes for hyper-
reflexia. Paresthesia is an abnormal sensation,
Auscultate the heart for gallops and commonly described as numbness,
murmurs and the lungs for abnormal prickling, or tingling, that’s felt along
the peripheral nerve pathways. It may Brain tumor

develop suddenly or gradually and may Tumors that affect the parietal lobe
be transient or permanent. A common may cause progressive contralateral
symptom of many neurologic disorders, paresthesia accompanied by agnosia,
paresthesia may also occur in certain anomia, agraphia, apraxia, homony-
systemic disorders and with the use of mous hemianopsia, and loss of propri-
certain drugs. oception.
Health history Herniated disk

◆ When did the paresthesia begin? Herniation of a lumbar or cervical disk
What does it feel like? Where does it may cause acute or gradual paresthesia
occur? Is it transient or constant? along the distribution pathways of the
◆ Have you had recent trauma, affected spinal nerves. Other neuro-
surgery, or an invasive procedure that muscular effects include muscle
may have injured the peripheral spasms, severe pain, and weakness.
nerves? Have you been exposed to in-
dustrial solvents or heavy metals? Have Herpes zoster
you had long-term radiation therapy? Paresthesia, an early symptom of her-
Do you have neurologic, cardiovascu- pes zoster, occurs in the dermatome
lar, metabolic, renal, or chronic inflam- supplied by the affected spinal nerve.
matory disorders, such as arthritis or Within several days, this dermatome is
lupus erythematosus? marked by a pruritic, erythematous,
◆ What medications and supplements vesicular rash accompanied by sharp,
are you taking? shooting pain.
Physical examination Spinal cord injury

Focus on the patient’s neurologic sta- Paresthesia may occur after spinal
tus, assessing his LOC and cranial shock resolves in a patient with partial
nerve function. Also note his skin color spinal cord transection. The paresthe-
and temperature. sia may be unilateral or bilateral and
Test muscle strength and deep ten- may occur at or below in the level of
don reflexes in the extremities that are the lesion.
affected by paresthesia. Systematically
evaluate light touch, pain, temperature, Other disorders
vibration, and position sensation. Then Paresthesia may result from arthritis,
palpate the pulses. stroke, migraine headache, multiple
sclerosis, peripheral neuropathies, vita-
Causes min B12 deficiency, hypocalcemia, and
Acute lower extremity, arterial occlusion heavy metal or solvent poisoning. Also,
A patient with an arterial embolus may long-term radiation therapy, parenteral
have sudden paresthesia and coldness gold therapy, and certain drugs — such
in one or both legs. Severe pain at rest, as chemotherapeutic agents, paclitaxel
intermittent claudication, and paresis (Taxol), interferons, and isoniazid
are also characteristic. The leg be- (Laniazid) — may cause paresthesia.
comes cyanotic, and a line of tempera-
ture and color demarcation develops at Rash (papular)
the level of the occlusion. Pulses are
absent below the occlusion, and capil- Consisting of small, raised, circum-
lary refill time is prolonged. scribed and, possibly, discolored lesions,
a papular rash can erupt anywhere on toes — may cause an allergic reaction
the body and in various configurations. that produces a papular, macular, or
A characteristic sign of many cutaneous petechial rash. Associated findings in-
disorders, a papular rash may also re- clude fever, headache, lymphadenopa-
sult from allergies or from infectious, thy, myalgia, nausea, and vomiting.
neoplastic, or systemic disorders.
Age alert In bedridden elderly Kaposi’s sarcoma
patients, the first sign of a pres- Kaposi’s sarcoma is a neoplastic disor-
sure ulcer is commonly an erythema- der that’s most commonly found in pa-
tous area, sometimes with firm tients with acquired immunodeficiency
papules. syndrome. Kaposi’s sarcoma produces
purple or blue papules or macules on
Health history the extremities, ears, and nose. Firm
◆ When and where did the rash pressure causes these lesions to de-
erupt? What did it look like? Has it crease in size, but they return to their
spread or changed in any way? If so, original size within 10 to 15 seconds.
when and how did it spread? The lesions may become scaly, ulcer-
◆ Does the rash itch or burn? Is it ate, and bleed.
painful or tender?
◆ Have you had a fever, GI distress, or Psoriasis
a headache? Do you have any aller- Psoriasis causes small, erythematous,
gies? Have you had any previous skin pruritic papules on the scalp, chest, el-
disorders, infections, sexually transmit- bows, knees, back, buttocks, and geni-
ted diseases, or tumors? What child- talia. The papules may be painful.
hood diseases have you had? They enlarge and coalesce, forming
◆ Have you recently been bitten by an red, elevated plaques covered by silver
insect or a rodent or exposed to any- scales, except in moist areas, such as
one with an infectious disease? the genitalia. The scales may flake off
◆ What medications and supplements easily or may thicken, covering the
are you taking? Have you applied any plaque. Other common findings include
topical agents to the rash and, if so, pitted fingernails and arthralgia.
when was the last application?
Other causes
Physical examination Infectious mononucleosis or sarcoido-
Observe the color, configuration, and sis may produce a papular rash. This
location of the rash. type of rash may also be caused by
nonsteroidal anti-inflammatory drugs,
Causes succimer (Chemet), and interferons.
Acne vulgaris
In acne vulgaris, the rupture of en- Rash (pustular)
larged comedones produces inflamed
and, possibly, painful and pruritic Crops of pustules (small, elevated, cir-
papules, pustules, nodules, or cysts. cumscribed lesions), vesicles (small
They may appear on the face, shoul- blisters), and bullae (large blisters)
ders, chest, or back. filled with purulent exudate make up a
pustular rash. The lesions vary in size
Insect bites and shape and may be generalized or
Venom from insect bites — especially localized (limited to the hair follicles or
those of ticks, lice, flies, and mosqui- sweat glands).
Pustules may result from skin disor- sites include the wrists, elbows, axil-
ders, systemic disorders, ingestion of lae, and waist.
certain drugs, and exposure to skin irri-
tants. Although many pustular lesions Other causes
are sterile, a pustular rash usually indi- A pustular rash may result from acne
cates infection. vulgaris, blastomycosis, furunculosis,
and pustular psoriasis. Also, certain
Health history drugs — such as bromides, iodides, cor-
◆ When and where did the rash ticotropin, corticosteroids, lithium (Es-
erupt? Did another type of skin lesion kalith), phenytoin (Dilantin), pheno-
precede the pustules? barbital (Luminal), isoniazid (Lani-
◆ What does the rash look like? Has it azid), and hormonal contraceptives —
spread or changed in any way? If so, can cause a pustular rash.
how and where did it spread?
◆ Have you or has a family member Rash (vesicular)
ever had a skin disorder or allergies?
◆ What medications are you taking? The lesions in a vesicular rash are scat-
Have you applied topical medication to tered or linear vesicles that are sharply
the rash and, if so, when did you last circumscribed and are usually less than
apply it? 0.5 cm in diameter. They may be filled
with clear, cloudy, or bloody fluid. Le-
Physical examination sions larger than 0.5 cm in diameter
Examine the entire skin surface, noting are called bullae. A vesicular rash may
if it’s dry, oily, moist, or greasy. Record be mild or severe and may be transient
the exact location, distribution, color, or permanent.
shape, and size of the lesions.
Health history
Causes ◆ When and where did the rash
Folliculitis erupt? Did other skin lesions precede
A bacterial infection of the hair folli- the vesicles?
cles, folliculitis produces individual ◆ What does the rash look like? Has it
pustules, each pierced by a hair. The spread or changed in any way? If so,
patient may also have pruritus. Hot-tub how and where did it spread?
folliculitis is characterized by pustules ◆ Do you or does anyone in your fam-
on the areas normally covered by a ily have a history of allergies or skin
bathing suit. disorders?
◆ Have you recently had an infection
Scabies or been bitten by an insect?
Threadlike channels or burrows un-
der the skin characterize scabies, a Physical examination
disorder that can also produce pus- Examine the patient’s skin and note
tules, vesicles, and excoriations. The the location, general distribution, color,
lesions are 1 to 10 cm long, with a shape, and size of the lesions. Check
swollen nodule or red papule con- for crusts, macules, papules, scales,
taining the itch mite. In men, crusted scars, and wheals. Note whether the
lesions commonly develop on the outer layer of epidermis separates easi-
glans and shaft of the penis and on ly from the basal layer.
the scrotum. In women, lesions may Palpate the vesicles or bullae to de-
form on the nipples. Other common termine whether they’re flaccid or tense.
Causes ◆ Have you ever had a cardiovascular

Burns or endocrine disorder, an infection, or
Thermal burns that affect the epider- allergies? Does anyone in your family
mis and part of the dermis commonly have a history of vision loss or other
cause vesicles and bullae, along with eye problems?
erythema, moistness, pain, and ◆ What medications and supplements
swelling. are you taking?
Herpes zoster Physical examination

In herpes zoster, fever and malaise oc- Observe the patient’s eyes for conjunc-
cur first. Then the vesicular rash ap- tival or scleral redness, drainage, ede-
pears along a dermatome. This rash is ma, foreign bodies, and signs of trau-
accompanied by pruritus, deep pain, ma. With a flashlight, examine the
and paresthesia or hyperesthesia, usu- cornea and iris. Observe the size,
ally of the trunk and sometimes of the shape, and color of the pupils. Then
arms and legs. The vesicles erupt, dry test direct and consensual light reflexes
up, and form scabs in about 10 days. and visual accommodation, extraocular
Occasionally, herpes zoster involves muscle function, and visual acuity.
the cranial nerves; such involvement Gently palpate each eye, noting hard-
produces dizziness, eye pain, facial ness. Auscultate over the neck and
palsy, hearing loss, impaired vision, temple for carotid bruits.
and loss of taste.
Causes
Other causes Glaucoma
Other causes of vesicular rashes in- Acute angle-closure glaucoma may
clude dermatitis, herpes simplex, insect cause rapid blindness. Findings in-
bites, pemphigus, scabies, tinea pedis, clude halo vision, nonreactive pupil-
and toxic epidermal necrolysis. lary response, photophobia, rapid on-
set of unilateral inflammation and
Vision loss pain, and reduced visual acuity. In
contrast, chronic open-angle glaucoma
Vision loss can occur suddenly or grad- progresses slowly. Usually bilateral, it
ually, may be temporary or permanent, causes aching eyes, halo vision, pe-
and may range from a slight impair- ripheral vision loss, and reduced visu-
ment to total blindness. It may result al acuity.
from eye, neurologic, and systemic dis-
orders as well as from trauma and re- Eye trauma
actions to certain drugs. Sudden unilateral or bilateral vision
loss may occur after eye injury. The
Health history loss may be total or partial and perma-
◆ When did the loss first occur? Did it nent or temporary. The eyelids may be
occur suddenly or gradually? Does it reddened, edematous, and lacerated.
affect one eye or both eyes? Does it af-
fect all or part of the visual field? Other causes
◆ Are you experiencing blurred vision, Vision loss may also be caused by con-
halo vision, nausea, pain, photosensi- genital rubella or syphilis, herpes zos-
tivity, or vomiting with the vision loss? ter, Marfan’s syndrome, pituitary tu-
◆ Have you had a recent facial or eye mor, retrolental fibroplasia, and drugs,
injury? such as cardiac glycosides, indomethacin
(Indocin), ethambutol (Myambutol), Vitreous hemorrhage

and methanol. Vitreous hemorrhage, or the rupture of
the retinal vessels, produces a shower
Visual floaters of red or black dots or a red haze
across the visual field. Vision blurs
Particles of blood or cellular debris that suddenly in the affected eye, and visu-
move about in the vitreous humor ap- al acuity may be greatly reduced.
pear as spots or dots when they enter
the visual field. Chronic floaters com- Other causes
monly occur in elderly or myopic pa- Visual floaters may also result from
tients. However, sudden onset of visual posterior uveitis.
floaters commonly signals retinal de-
tachment, an ocular emergency. Weight gain
Health history Weight gain occurs when ingested calo-

◆ When did the floaters first appear? ries exceed body requirements for ener-
What do they look like? Did they ap- gy, causing increased adipose tissue
pear suddenly or gradually? If they ap- storage. It can also occur when fluid
peared suddenly, did you also see retention causes edema. When weight
flashing lights and have a curtainlike gain results from overeating, emotional
loss of vision? factors — most commonly anxiety,
◆ Are you nearsighted, and do you guilt, and depression — and social fac-
wear corrective lenses? tors may be the primary causes.
◆ Do you have a history of eye trau- Among elderly people, weight gain
ma or other eye disorders, allergies, commonly reflects a sustained food in-
granulomatous disease, diabetes melli- take in the presence of the normal,
tus, or hypertension? progressive decline in basal metabolic
◆ What medications and supplements rate. Among women, progressive
are you taking? weight gain occurs with pregnancy,
whereas periodic weight gain usually
Physical examination occurs with menstruation.
Inspect the eyes for signs of injury, Weight gain, a primary sign of
such as bruising or edema. Then assess many endocrine disorders, also occurs
the patient’s visual acuity, using the with conditions that limit activity, es-
Snellen alphabet chart, or “E” chart. pecially cardiovascular and pulmonary
disorders. It can also result from drug
Causes therapy that increases appetite or caus-
Retinal detachment es fluid retention or from cardiovascu-
Many floaters and light flashes appear lar, hepatic, and renal disorders that
suddenly in the portion of the visual cause edema.
field where the retina has detached. As
retinal detachment progresses (a pain- Health history
less process), gradual vision loss oc- ◆ Do you have any past patterns of
curs, with the patient seeing a “dark weight gain and loss?
curtain” falling in front of his eyes. ◆ Do you have a family history of
Ophthalmoscopic examination shows a obesity, thyroid disease, or diabetes
gray, opaque, detached retina with an mellitus?
indefinite margin. The retinal vessels ◆ Describe your eating habits. Has
appear almost black. your appetite increased?
◆ Do you exercise regularly or at all? typical findings include paroxysmal

◆ Have you experienced visual distur- nocturnal dyspnea, orthopnea, and fa-
bances, hoarseness, paresthesia, or in- tigue.
creased urination and thirst?
◆ Have you had any episodes of im- Hypercortisolism
potence? Excessive weight gain, usually over the
◆ If the patient is female: Have you trunk and the back of the neck (buffalo
had menstrual irregularities or experi- hump), characteristically occurs in hy-
enced weight gain during menstruation? percortisolism. Other cushingoid fea-
◆ Have you felt anxious or depressed? tures include slender extremities, moon
◆ Are you having any difficulties with face, weakness, purple striae, emotion-
your memory? al lability, and increased susceptibility
◆ What medications and supplements to infection. Men may have gyneco-
are you taking? mastia. Women may have hirsutism,
acne, and menstrual irregularities.
Physical examination
During your physical examination, Hyperinsulinism
measure skin-fold thickness to estimate Hyperinsulinism increases appetite,
fat reserves. Note fat distribution, lo- leading to weight gain. Emotional labil-
calized or generalized edema, and ity, indigestion, weakness, diaphoresis,
overall nutritional status. Also look for tachycardia, visual disturbances, and
other abnormalities, such as abnormal syncope also occur.
body hair distribution or hair loss and
dry skin. Take and record the patient’s Hypogonadism
vital signs. Weight gain is common in hypogonad-
ism. Prepubertal hypogonadism causes
Causes eunuchoid body proportions with rela-
Acromegaly tively sparse facial and body hair and a
Acromegaly causes moderate weight high-pitched voice. Postpubertal hypo-
gain. Other findings include coarsened gonadism causes loss of libido, impo-
facial features, prognathism, enlarged tence, and infertility.
hands and feet, increased sweating,
oily skin, deep voice, back and joint Hypothalamic dysfunction
pain, lethargy, sleepiness, and heat in- Conditions of hypothalamic dysfunc-
tolerance. Occasionally, hirsutism may tion such as Laurence-Moon-Biedl syn-
occur. drome cause a voracious appetite with
subsequent weight gain, along with al-
Diabetes mellitus tered body temperature and sleep
The increased appetite associated with rhythms.
diabetes mellitus may lead to weight
gain, although weight loss sometimes Hypothyroidism
occurs instead. Other findings include With hypothyroidism, weight gain oc-
fatigue, polydipsia, polyuria, nocturia, curs despite anorexia. Related signs
weakness, polyphagia, and somno- and symptoms include fatigue; cold in-
lence. tolerance; constipation; menorrhagia;
slowed intellectual and motor activity;
Heart failure dry, pale, cool skin; dry, sparse hair;
In heart failure, weight gain may result and thick, brittle nails. Myalgia,
from edema despite anorexia. Other hoarseness, hypoactive deep tendon
reflexes, bradycardia, and abdominal Down syndrome, Werdnig-Hoffmann

distention may occur. Eventually, the disease, late stages of muscular dystro-
face assumes a dull expression with phy, severe cerebral palsy, and an ad-
periorbital edema. verse effect from atypical antipsychotic
medications such as risperidone
Nephrotic syndrome (Risperdal).
With nephrotic syndrome, weight gain Nonpathologic causes include poor
results from edema. In severe cases, eating habits, sedentary recreation, and
anasarca develops — increasing body emotional problems, especially among
weight up to 50%. Related effects in- adolescents. Regardless of the cause,
clude abdominal distention, orthostatic discourage fad diets and provide the
hypotension, and lethargy. patient with a balanced weight loss
program. The incidence of obesity is
Pancreatic islet cell tumor increasing among children.
A pancreatic islet cell tumor causes ex-
cessive hunger that leads to weight gain. Weight loss
Other findings include emotional lability,
weakness, malaise, fatigue, restlessness, Weight loss can reflect decreased food
diaphoresis, palpitations, tachycardia, vi- intake, increased metabolic require-
sual disturbances, and syncope. ments, or a combination of the two. Its
causes include endocrine, neoplastic,
Preeclampsia GI, and psychological disorders; nutri-
With preeclampsia, rapid weight gain tional deficiencies; infections; and neu-
(exceeding the normal weight gain of rologic lesions that cause paralysis and
pregnancy) may accompany nausea dysphagia. Weight loss may also ac-
and vomiting, epigastric pain, elevated company conditions that prevent suffi-
blood pressure, and visual blurring or cient food intake, such as painful oral
double vision. lesions, ill-fitting dentures, and tooth
loss. Weight loss may stem from pover-
Sheehan’s syndrome ty, adherence to fad diets, excessive ex-
Sheehan’s syndrome may cause weight ercise, or drug use.
gain and is most common in women
who have severe obstetric hemorrhage. Health history
◆ When did you first notice that you
Other causes were losing weight? How much weight
Corticosteroids, phenothiazines, and have you lost? Was the loss intention-
tricyclic antidepressants cause weight al? If not, can you think of any reason
gain from fluid retention and increased for it?
appetite. Other drugs that can lead to ◆ What do you usually eat in a day?
weight gain include hormonal contra- Have your eating habits changed re-
ceptives, which cause fluid retention; cently? Why?
cyproheptadine, which increases ap- ◆ Have your stools changed recently?
petite; and lithium, which can induce For instance, have you noticed bulky,
hypothyroidism. floating stools, or have you had diar-
Age alert Weight gain in chil- rhea? What about abdominal pain, ex-
dren can result from an endo- cessive thirst, excessive urination, heat
crine disorder, such as hypercortisol- intolerance, nausea, or vomiting?
ism. Other causes include inactivity ◆ Have you felt anxious or depressed?
caused by Prader-Willi syndrome, If so, why?
◆ What medications and supplements Depression

are you taking? Do you take diet pills Patients with severe depression may
or laxatives to lose weight? experience weight loss, anorexia, apa-
thy, fatigue, feelings of worthlessness,
Physical examination and insomnia or hypersomnia. Other
Record the patient’s height and weight. signs and symptoms include incoher-
As you take his vital signs, note his ence, indecisiveness, and suicidal
general appearance. Does he appear thoughts or behavior.
well-nourished? Do his clothes fit? Is
muscle wasting evident? Leukemia
Next, examine his skin for turgor Acute leukemia causes progressive
and abnormal pigmentation, especially weight loss accompanied by bleeding
around the joints. Does he have jaun- tendencies, high fever, and severe pros-
dice or pallor? Examine his mouth, in- tration. Chronic leukemia causes pro-
cluding the condition of his teeth or gressive weight loss with anemia,
dentures. Also, check his eyes for ex- anorexia, bleeding tendencies, enlarged
ophthalmos and his neck for swelling. spleen, fatigue, fever, pallor, and skin
Finally, palpate the patient’s ab- eruptions.
domen for liver enlargement, masses,
and tenderness. Other causes
Weight loss may result from adrenal in-
Causes sufficiency, diabetes mellitus, gastroen-
Anorexia nervosa teritis, cryptosporidiosis, lymphoma,
A psychogenic disorder, anorexia ner- ulcerative colitis, and thyrotoxicosis.
vosa is most common in young women Drugs, such as amphetamines, chemo-
and is characterized by severe, self- therapeutic agents, laxatives, and thy-
imposed weight loss. Weight loss may be roid preparations, can also cause
accompanied by amenorrhea, blotchy weight loss.
or sallow skin, cold intolerance, consti-
pation, frequent infections, loss of fatty
tissue, loss of scalp hair, and skeletal
muscle atrophy.
Cancer
Weight loss is a common sign of can-
cer. Associated signs and symptoms re-
flect the type, location, and stage of
the tumor. They typically include ab-
normal bleeding, anorexia, fatigue,
nausea, pain, a palpable mass, and
vomiting.
Crohn’s disease
Weight loss occurs with abdominal
pain, anorexia, and chronic cramping.
Other findings include abdominal dis-
tention, tenderness, and guarding; diar-
rhea; hyperactive bowel sounds; pain;
and tachycardia.
3 ECGs
Interpreting them with ease
and accuracy
Normal ECG 104

Analyzing the ECG waveform 104
How to read an ECG rhythm strip:
The 8-step method 104
Normal sinus rhythm 107
Arrhythmias 108
Sinus arrhythmia 108
Sinus bradycardia 109
Sinus tachycardia 110
Sinus arrest 111
Premature atrial contractions 112
Atrial tachycardia 113
Atrial flutter 114
Atrial fibrillation 115
Junctional rhythm 116
Accelerated junctional rhythm 117
Junctional tachycardia 118
Premature junctional contractions 119
Premature ventricular contractions 120
Ventricular tachycardia 121
Ventricular fibrillation 122
Idioventricular rhythm 123
Accelerated idioventricular rhythm 124
First-degree atrioventricular block 125
Second-degree atrioventricular block, type I 126
Second-degree atrioventricular block, type II 127
Third-degree atrioventricular block 128
12-lead ECGs 129
Basic components and principles 129
Determining electrical axis 131
How to interpret a 12-lead ECG 134
Acute myocardial infarction 137
Right-sided ECG, leads V1R to V6R 140
Posterior-lead ECG, leads V7 to V9 141
Left bundle-branch block 142
Right bundle-branch block 143
Pericarditis 144
103
104 ECGs
Components of an ECG waveform
This illustration shows the components of a normal ECG waveform.
J point
T
P U
QS
PR interval
QRS complex
ST segment
QT interval
◆ The ST segment represents the end

Normal ECG of ventricular depolarization and the
beginning of ventricular repolarization.
Analyzing the ECG waveform The J point marks the end of the QRS
complex and the beginning of the ST
An electrocardiogram (ECG) complex segment.
represents the electrical events occur- ◆ The T wave represents ventricular
ring in one cardiac cycle. A complex repolarization.
consists of five waveforms labeled with ◆ The QT interval measures the time
the letters P, Q, R, S, and T. The letters needed for ventricular depolarization
Q, R, and S are referred to as a unit and repolarization.
known as the QRS complex. The ECG ◆ The U wave represents His-Purkinje
tracing represents the conduction of repolarization.
electrical impulses from the atria to the
ventricles. (See Components of an ECG How to read an ECG rhythm strip:
waveform.) The 8-step method
◆ The P wave is the first component
of the normal ECG waveform. It repre- Analyzing a rhythm strip is a skill
sents atrial depolarization. that’s developed through practice. You
◆ The PR interval tracks the atrial im- can use several methods, as long as
pulse from the atria through the atri- you’re consistent. (See The 8-step
oventricular (AV) node, the bundle of method of rhythm strip analysis, pages
His, and the right and left bundle 105 and 106.)
branches. It begins with atrial depolar-
ization and ends with the beginning of
ventricular depolarization.
◆ The QRS complex follows the P
wave and represents ventricular depo-
larization. (Text continues on page 107.)
Normal ECG 105
The 8-step method of rhythm strip analysis
Rhythm strip analysis requires a sequen- mation, you shouldn’t rely solely on them
tial and systematic approach. The follow- when assessing your patient. Keep in
ing eight steps provide a good outline for mind that the ECG waveform represents
you to follow. electrical, not mechanical, activity. There-
fore, although an ECG can show that ven-
Step 1: Determine rhythm tricular depolarization has occurred, it
To determine the heart’s atrial and ven- doesn’t mean that ventricular contraction
tricular rhythms, use either the pen-and- has occurred. To determine this, you must
pencil method or the caliper method. assess the patient’s pulse.
To determine the atrial rhythm, mea- ◆ Times-ten method. The simplest, quick-
sure the P-P intervals, the intervals be- est, and most common way to calculate
tween consecutive P waves. These inter- rate is the times-ten method, especially if
vals should occur regularly, with only the rhythm is irregular. ECG paper is
small variations associated with respira- marked in increments of 3 seconds, or 15
tions. Then compare the P-P intervals in large boxes. To calculate the atrial rate,
several cycles. Consistently similar P-P obtain a 6-second strip, count the number
intervals indicate regular atrial rhythm; of P waves that appear on it, and multiply
dissimilar P-P intervals indicate irregular this number by 10. Ten 6-second strips
atrial rhythm. equal 1 minute. Calculate the ventricular
To determine the ventricular rhythm, rate the same way, using the R waves.
measure the intervals between two con- ◆ 1,500 method. If the heart rhythm is
secutive R waves in the QRS complexes. If regular, use the 1,500 method, so named
an R wave isn’t present, use either because 1,500 small squares equal 1
Q waves or S waves of consecutive QRS minute. Count the number of small
complexes. The R-R intervals should occur squares between identical points on two
regularly. Then compare the R-R intervals consecutive P waves, and then divide
in several cycles. As with atrial rhythms, 1,500 by that number to determine the
consistently similar intervals mean a regu- atrial rate. To obtain the ventricular rate,
lar rhythm; dissimilar intervals point to an use the same method with two consecu-
irregular rhythm. tive R waves.
After completing your measurements, ◆ Sequence method. The third method of
ask yourself: estimating heart rate is the sequence
◆ Is the rhythm regular or irregular? method, which requires memorizing a se-
Consider a rhythm with only slight varia- quence of numbers. For the atrial rate,
tions (up to 0.04 second) to be regular. find a P wave that peaks on a heavy black
◆ If the rhythm is irregular, is it slightly line, and assign the following numbers to
irregular or markedly irregular? Does the the next six heavy black lines: 300, 150,
irregularity occur in a pattern (a regularly 100, 75, 60, and 50. Then find the next
irregular pattern)? P-wave peak and estimate the atrial rate,
based on the number assigned to the
Step 2: Calculate rate nearest heavy black line. Estimate the
You can use one of three methods to de- ventricular rate the same way, using the
termine the atrial and ventricular heart R wave.
rates from an ECG waveform. Although
these methods can provide accurate infor- (continued)
106 ECGs
The 8-step method of rhythm strip analysis (continued)
Step 3: Evaluate P waves Step 6: Evaluate T wave

When examining a rhythm strip for Examine the T waves on the ECG strip.
P waves, ask yourself: Then ask yourself:
◆ Are P waves present? ◆ Are T waves present?
◆ Do the P waves have a normal configu- ◆ Do all of the T waves have a normal
ration? shape?
◆ Do all of the P waves have a similar ◆ Could a P wave be hidden in a T wave?
size and shape? ◆ Do all of the T waves have a normal
◆ Is there one P wave for every QRS amplitude?
complex? ◆ Do the T waves have the same deflec-
tion as the QRS complexes?
Step 4: Determine PR interval
duration Step 7: Determine QT interval
To measure the PR interval, count the duration
small squares between the start of the Count the number of small squares be-
P wave and the start of the QRS complex; tween the beginning of the QRS complex
then multiply the number of squares by and the end of the T wave, where the
0.04 second. After you perform this calcu- T wave returns to the baseline. Multiply
lation, ask yourself: this number by 0.04 second. Ask yourself:
◆ Does the duration of the PR interval ◆ Does the duration of the QT interval
fall within normal limits, 0.12 to 0.20 sec- fall within normal limits, 0.36 to 0.44 sec-
ond (or 3 to 5 small squares)? ond?
◆ Is the PR interval constant?
Step 8: Evaluate other components
Step 5: Determine QRS complex Note the presence of ectopic or aberrantly
duration conducted beats or other abnormalities.
When determining QRS complex duration, Also, check the ST segment for abnormali-
make sure to measure straight across ties and look for the presence of a U
from the end of the PR interval to the end wave.
of the S wave, not just to the peak. Re- Next, interpret your findings by classi-
member, the QRS complex has no hori- fying the rhythm strip according to one or
zontal components. To calculate duration, all of the following features:
count the number of small squares be- ◆ Site of origin of the rhythm. For example,
tween the beginning and the end of the sinus node, atria, atrioventricular node, or
QRS complex and multiply this number by ventricles.
0.04 second. Then ask yourself the follow- ◆ Rate. Normal (60 to 100 beats/minute),
ing questions: bradycardia (less than 60 beats/minute),
◆ Does the duration of the QRS complex or tachycardia (greater than 100 beats/
fall within normal limits, 0.06 to 0.10 sec- minute).
ond? ◆ Rhythm. Normal or abnormal; for ex-
◆ Are all QRS complexes the same size ample, flutter, fibrillation, heart block, es-
and shape? (If not, measure each one and cape rhythm, or other arrhythmias.
describe them individually.)
◆ Does a QRS complex appear after
every P wave?
Normal ECG 107
Normal sinus rhythm classified as sinus, atrial, junctional, or

ventricular arrhythmias, or as AV
When the heart functions normally, the blocks. Functional disturbances in the
sinoatrial (SA) node acts as the prima- SA node produce sinus arrhythmias.
ry pacemaker, initiating the electrical Enhanced automaticity of atrial tissue
impulses. The SA node assumes this or reentry may produce atrial arrhyth-
role because its automatic firing rate mias, the most common arrhythmias.
exceeds that of the heart’s other Junctional arrhythmias originate in
pacemakers, allowing cells to depolar- the area around the AV node and bundle
ize spontaneously. of His. These arrhythmias usually result
Normal sinus rhythm records an from a suppressed higher pacemaker or
impulse that starts with the sinus node from blocked impulses at the AV node.
and progresses to the ventricles through Ventricular arrhythmias originate in
a normal conduction pathway — from ventricular tissue below the bifurcation
the sinus node to the atria and AV of the bundle of His. These rhythms
node, through the bundle of His, to the may result from reentry or enhanced
bundle branches, and onto the Purkinje automaticity or may occur after depo-
fibers. Normal sinus rhythm is the stan- larization.
dard against which all other rhythms An AV block results from an abnor-
are compared; you must be able to rec- mal interruption or delay of atrial im-
ognize normal sinus rhythm before you pulse conduction to the ventricles. It
can recognize an arrhythmia. may be partial or total and may occur
Based on the location of the electri- in the AV node, bundle of His, or Purk-
cal disturbance, arrhythmias can be inje system.
Characteristics of normal sinus rhythm
Regular rhythm P wave QRS complex
Lead II
Atrial rhythm: regular QRS complex: within normal limits (0.06

Ventricular rhythm: regular to 0.10 second) (All QRS complexes have
Atrial rate: 60 to 100 beats/minute (80 the same configuration. The duration
beats/minute shown) shown here is 0.12 second.)
Ventricular rate: 60 to 100 beats/ T wave: normally shaped; upright and
minute (80 beats/minute shown) rounded in lead II (Each QRS complex is
P wave: normally shaped (All P waves followed by a T wave.)
have similar size and shape; a P wave QT interval: within normal limits (0.36 to
precedes each QRS complex.) 0.44 second) and constant (0.44-second
PR interval: within normal limits (0.12 to duration shown)
0.20 second) and constant (0.20-second
duration shown)
108 ECGs
These conditions include inferior wall

Arrhythmias myocardial infarction (MI) and digoxin
toxicity.
Sinus arrhythmia Sinus arrhythmia is easily recog-
nized in elderly, pediatric, and sedated
In sinus arrhythmia, the heart rate patients. The patient’s pulse rate in-
stays within normal limits, but the creases with inspiration and decreases
rhythm is irregular and corresponds with expiration. Usually, the patient is
to the respiratory cycle and to varia- asymptomatic.
tions in vagal tone. During inspira-
tion, an increased volume of blood re- Intervention
turns to the heart, reducing vagal Treatment isn’t necessary unless the
tone and increasing sinus rate. During patient is symptomatic or the sinus ar-
expiration, venous return decreases, rhythmia stems from an underlying
vagal tone increases, and sinus rate cause. If symptoms are associated with
slows. symptomatic bradycardia, atropine may
Conditions unrelated to respiration be administered.
may also produce sinus arrhythmia.
Characteristics of sinus arrhythmia
Cyclic, irregular rhythm
Lead II
Atrial rhythm: irregular, corresponding PR interval: within normal limits

to the respiratory cycle (0.16-second, constant interval shown)
Ventricular rhythm: irregular, corre- QRS complex: normal duration and
sponding to the respiratory cycle configuration (0.06-second duration
Atrial rate: within normal limits; varies shown)
with respiration (60 beats/minute shown) T wave: normal size and configuration
Ventricular rate: within normal limits; QT interval: within normal limits
varies with respiration (60 beats/ minute (0.36-second interval shown)
shown) Other: phasic slowing and quickening of
P wave: normal size and configuration the rhythm
(One P wave precedes each QRS com-
plex.)
Arrhythmias 109
Sinus bradycardia dia may occur with sick sinus syn-

drome.
Characterized by a sinus rate of less The patient with sinus bradycardia
than 60 beats/minute, sinus bradycar- is asymptomatic if he can compensate
dia usually occurs as the normal re- for the decrease in heart rate by in-
sponse to a reduced demand for blood creasing stroke volume. If he cannot,
flow. It’s common among athletes, he may have signs and symptoms of
whose well-conditioned hearts can decreased cardiac output, such as hy-
maintain stroke volume with reduced potension, syncope, confusion, and
effort. It may also be caused by drugs, blurred vision.
such as cardiac glycosides, calcium
channel blockers, and beta-adrenergic Intervention
blockers. Sinus bradycardia may occur If the patient is asymptomatic, treat-
after an inferior wall MI involving the ment isn’t necessary. If he has signs
right coronary artery, which supplies and symptoms, the goal of treatment is
the blood to the SA node. This rhythm to identify and correct the underlying
may develop during sleep and in pa- cause. The heart rate may be increased
tients with increased intracranial pres- with drugs such as atropine. A tempo-
sure. It may also result from vagal rary (transcutaneous or transvenous)
stimulation caused by vomiting or or permanent pacemaker may be nec-
defecating. Pathologic sinus bradycar- essary if bradycardia persists.
Characteristics of sinus bradycardia
Regular rhythm with rate

less than 60 beats/minute
Lead II
Atrial rhythm: regular PR interval: within normal limits and

Ventricular rhythm: regular constant (0.14-second duration shown)
Atrial rate: less than 60 beats/minute QRS complex: normal duration and con-
(50 beats/minute shown) figuration (0.08-second duration shown)
Ventricular rate: less than 60 T wave: normal size and configuration
beats/minute (50 beats/minute shown) QT interval: within normal limits
P wave: normal size and configuration (0.40-second interval shown)
(One P wave precedes each QRS complex.)
110 ECGs
Sinus tachycardia cause sinus tachycardia. They include

aminophylline, epinephrine, dobuta-
Sinus tachycardia is an acceleration of mine, and dopamine. Alcohol, caffeine,
firing of the SA node beyond its normal and nicotine may also produce sinus
discharge rate. In an adult, it’s charac- tachycardia.
terized by a sinus rate of more than An elevated heart rate increases my-
100 beats/minute. The rate rarely ex- ocardial oxygen demands. If the patient
ceeds 180 beats/minute except during can’t meet these demands (for exam-
strenuous exercise. The maximum rate ple, because of coronary artery dis-
achieved with exercise decreases with ease), ischemia and further myocardial
age. damage may occur.
A normal response to cellular de-
mands for increased oxygen delivery Intervention
and blood flow commonly produces si- Treatment focuses on finding the pri-
nus tachycardia. Conditions that cause mary cause. If it’s high catecholamine
such a demand include heart failure, levels, a beta-adrenergic blocker may
shock, anemia, exercise, fever, hypoxia, slow the heart rate. After MI, persistent
pain, and stress. Drugs that stimulate sinus tachycardia may precede heart
the beta receptors in the heart also failure or cardiogenic shock.
Characteristics of sinus tachycardia
Regular rhythm with rate

greater than 100 beats/minute
Lead II
Atrial rhythm: regular ing slope of the preceding T wave closely

Ventricular rhythm: regular for notches, indicating presence of the
Atrial rate: 100 to 160 beats/minute P wave. The P wave shown is normal.)
(110 beats/minute shown) PR interval: within normal limits and
Ventricular rate: 100 to 160 beats/ constant (0.16-second duration shown)
minute (110 beats/minute shown) QRS complex: normal duration and con-
P wave: normal size and configuration figuration (0.10-second duration shown)
(One P wave precedes each QRS complex. T wave: normal size and configuration
As the sinus rate reaches about QT interval: within normal limits and
150 beats/minute, the P wave merges constant (0.36-second duration shown)
with the preceding T wave and may be Other: gradual onset and cessation
difficult to identify. Examine the descend-
Arrhythmias 111
Sinus arrest tone, or the use of certain drugs, such

as cardiac glycosides, calcium channel
In sinus arrest, the normal sinus blockers, and beta-adrenergic blockers.
rhythm is interrupted by an occasional, The arrhythmia may also be linked to
prolonged failure of the SA node to ini- sick sinus syndrome. The patient has
tiate an impulse. Therefore, sinus arrest an irregular pulse rate associated with
is caused by episodes of failure in the the pauses in sinus rhythm. If the
automaticity of impulse formation of pauses are infrequent, the patient is
the SA node. The atria aren’t stimulat- asymptomatic. If they occur frequently
ed, and an entire PQRST complex is and last for several seconds, however,
missing from the ECG strip. Except for the patient may have signs of de-
the missing complex, or pause, the creased cardiac output.
ECG usually remains normal.
During a sinus arrest, the sinus Intervention
node resets itself so that when the im- For a symptomatic patient, treatment
pulse is initiated, the complex that oc- focuses on maintaining cardiac output
curs after the pause will be out of the and discovering the cause of sinus ar-
cycle and the rate will usually be dif- rest. If indicated, atropine may be giv-
ferent from the rate before the pause. en or a temporary (transcutaneous or
Sinus arrest may result from an transvenous) or permanent pacemaker
acute inferior wall MI, increased vagal may be inserted.
Characteristics of sinus arrest

Regular Absent
rhythm P wave
Lead II Rate within Absent

normal limits QRS complex
Atrial rhythm: regular, except for the PR interval: within normal limits and
missing PQRST complexes constant when the P wave is present; not
Ventricular rhythm: regular, except for measurable when the P wave is absent
the missing complex (0.20-second duration shown on all com-
Atrial rate: within normal limits but plexes surrounding the arrest)
varies because of pauses (94 beats/ QRS complex: normal duration and con-
minute shown) figuration; absent during pause (0.08-sec-
Ventricular rate: within normal limits but ond duration shown)
varies because of pauses (94 beats/ T wave: normal size and configuration;
minute shown) absent during pause
P wave: normal size and configuration QT interval: within normal limits; not
(One P wave precedes each QRS complex measurable during pause (0.40-second,
but is absent during a pause.) constant interval shown)
112 ECGs
Premature atrial contractions atrial arrhythmia, such as atrial flutter

or atrial fibrillation.
Premature atrial contractions (PACs) Possible causes include digoxin tox-
usually result from an irritable focus in icity, hyperthyroidism, elevated cate-
the atrium that supersedes the SA node cholamine levels, acute respiratory fail-
as the pacemaker for one or more ure, and chronic obstructive pulmonary
beats. disease. Alcohol, caffeine, or tobacco
Although PACs commonly occur in use can also trigger PACs. Patients who
normal hearts, they’re also associated eliminate or control these factors can
with coronary and valvular heart dis- usually correct the arrhythmia.
ease. In an inferior wall MI, PACs may
indicate a concomitant right atrial in- Intervention
farct. In an anterior wall MI, PACs are Symptomatic patients may be treated
an early sign of left-sided heart failure. with beta-adrenergic blockers or calci-
They may also warn of more severe um channel blockers.
Characteristics of premature atrial contractions
Irregular rhythm
Lead II Premature and abnormally shaped P wave
Atrial rhythm: irregular (Incomplete PR interval: usually normal but may be

compensatory pause follows premature shortened or slightly prolonged, depend-
arterial contraction [PAC]. Underlying ing on the origin of ectopic focus (0.16-
rhythm may be regular.) second, constant interval shown)
Ventricular rhythm: irregular (Incom- QRS complex: usually normal duration
plete compensatory pause follows PAC. and configuration (0.08-second, constant
Underlying rhythm may be regular.) duration shown)
Atrial rate: varies with underlying T wave: usually normal configuration;
rhythm (90 beats/minute shown) may be distorted if the P wave is hidden
Ventricular rate: varies with underlying in the previous T wave
rhythm (90 beats/minute shown) QT interval: usually normal (0.36-second,
P wave: premature and abnormally constant interval shown)
shaped; possibly lost in previous T wave Other: may occur in bigeminy or couplets
(Varying configurations indicate multiform
PACs.)
Arrhythmias 113
Atrial tachycardia block, multifocal atrial tachycardia, and

paroxysmal atrial tachycardia.
Atrial tachycardia is a supraventricular
tachycardia, which means that the im- Intervention
pulse originates above the ventricles. If the patient has atrial tachycardia or
In this rhythm, the impulse originates paroxysmal atrial tachycardia and is
in the atria. The rapid atrial rate short- symptomatic, prepare for immediate
ens diastole, resulting in a loss of atrial cardioversion. If the patient is stable,
kick, reduced cardiac output, reduced the physician may perform carotid si-
coronary perfusion, and ischemic my- nus massage (if no bruits are present)
ocardial changes. or order drug therapy, such as adeno-
Although atrial tachycardia can occur sine (Adenocard), a calcium channel
in healthy patients, it’s usually associat- blocker, a beta-adrenergic blocker, or
ed with high catecholamine levels, digoxin (Lanoxin). If these treatments
digoxin toxicity, MI, cardiomyopathy, hy- are ineffective in rhythm conversion,
perthyroidism, hypertension, and valvu- then procainamide or amiodarone may
lar heart disease. Three types of atrial be needed. If these measures fail, car-
tachycardia exist: atrial tachycardia with dioversion may be necessary.
Characteristics of atrial tachycardia

Regular rhythm Rate between 160 and
250 beats/minute
Lead II
Atrial rhythm: regular through the AV node is 1:1. On this strip,

Ventricular rhythm: regular the PR interval isn’t discernible.)
Atrial rate: three or more successive ec- QRS complex: usually normal unless
topic atrial beats at a rate of 160 to 250 aberrant intraventricular conduction is
beats/minute (210 beats/minute shown) present (0.10-second duration shown)
Ventricular rate: varies with T wave: may be normal or inverted if
atrioventricular conduction ratio ischemia is present (inverted T waves
(210 beats/minute shown) shown)
P wave: 1:1 ratio with QRS complex, al- QT interval: usually normal but may be
though commonly indiscernible because shorter because of rapid rate (0.20-second
of rapid rate; may be hidden in previous interval shown)
ST segment or T wave Other: appearance of ST-segment and T-
PR interval: may not be measurable if wave changes if tachyarrhythmia persists
P wave can’t be distinguished from pre- longer than 30 minutes
ceding T wave (If P wave is present,
PR interval is short when conduction
114 ECGs
Atrial flutter Intervention

If the patient is symptomatic, prepare
Characterized by an atrial rate of for immediate cardioversion. The focus
250 beats/minute or more, atrial flutter of treatment for stable patients with
is caused by multiple reentry circuits atrial flutter includes controlling the
within the atrial tissue. On the ECG, rate and converting the rhythm. Specif-
the P waves lose their normal appear- ic interventions depend on the pa-
ance as a result of rapid atrial rate and tient’s cardiac function, the presence of
blend together in a sawtooth configura- preexcitation syndromes, and the dura-
tion known as flutter waves. These tion (less than or greater than 48
waves are the hallmark of atrial flutter. hours) of arrhythmia. For example, in
Causes of atrial flutter include condi- patients with atrial flutter, normal car-
tions that enlarge atrial tissue and elevate diac function, and duration of rhythm
atrial pressures. Atrial flutter is associat- less than 48 hours, cardioversion may
ed with MI, increased catecholamine be considered. When duration is
levels, hyperthyroidism, and digoxin greater than 48 hours, avoid nonemer-
toxicity. gent cardioversion unless adequate an-
If the patient’s pulse rate is normal, ticoagulation has been achieved.
he usually has no symptoms. If his Drugs that may be ordered to con-
pulse rate is high, however, he’ll prob- trol atrial rate include amiodarone, ibu-
ably have signs and symptoms of de- tilide, procainamide, calcium channel
creased cardiac output, such as hy- blockers, and beta-adrenergic blockers.
potension and syncope.
Characteristics of atrial flutter
Four flutter waves for Atrial rate greater

every QRS complex than ventricular rate
Lead II
Atrial rhythm: regular P wave: atrial activity seen as flutter

Ventricular rhythm: may be regular or waves, with a classic sawtooth appear-
irregular, depending on the conduction ance
ratio (regular rhythm shown) PR interval: not measurable
Atrial rate: 300 to 350 beats/minute QRS complex: usually normal but can be
(300 beats/minute shown) distorted by the underlying flutter waves
Ventricular rate: variable (70 beats/ (0.10-second, normal duration shown)
minute shown) T wave: unidentifiable
QT interval: not measurable
Arrhythmias 115
Atrial fibrillation (theophylline ethylenediamine) and

cardiac glycosides.
Atrial fibrillation is chaotic, asynchro-
nous electrical activity in the atrial tis- Intervention
sue. It results from impulses in many If the patient is symptomatic, synchro-
reentry pathways. These multiple and nized cardioversion should be used im-
multidirectional impulses cause the mediately. Vagal stimulation may be
atria to quiver instead of contracting used to slow the ventricular response,
regularly. but it won’t convert the arrhythmia.
With this type of arrhythmia, blood Drugs that may be ordered to slow AV
may pool in the left atrial appendage conduction include calcium channel
and form thrombi that can be ejected blockers and beta-adrenergic blockers.
into the systemic circulation. An asso- Digoxin may be ordered if the patient
ciated rapid ventricular rate can de- is stable. After the rate slows, if con-
crease cardiac output. version to a normal sinus rhythm
Possible causes include valvular dis- hasn’t occurred, amiodarone (Cor-
orders, hypertension, coronary artery darone), flecainide, or sotalol may be
disease, MI, chronic lung disease, ordered. If atrial fibrillation is of sever-
ischemia, thyroid disorders, and Wolff- al days’ duration, anticoagulant thera-
Parkinson-White syndrome. The disor- py is recommended before pharmaco-
der may also result from high adrener- logic or electrical conversion. If atrial
gic tone as a result of physical exer- fibrillation is of recent onset, ibutilide
tion, sepsis, alcohol withdrawal, or the (Corvert) may be used to convert the
use of drugs, such as aminophylline rhythm.
Characteristics of atrial fibrillation
Coarse fibrillatory pattern
Irregular ventricular rhythm

Lead MCL1
Atrial rhythm: grossly irregular the arrhythmia is known as fine atrial fib-
Ventricular rhythm: grossly irregular rillation. On this strip, the f waves are
Atrial rate: greater than 400 beats/ pronounced.)
minute PR interval: indiscernible
Ventricular rate: varies from 40 to QRS complex: duration usually within
250 beats/minute (80 beats/minute shown) normal limits, with aberrant intraventricu-
P wave: absent; appearance of erratic lar conduction (0.08-second duration
baseline fibrillatory waves (f waves) shown)
(When the f waves are pronounced, the T wave: indiscernible
arrhythmia is called coarse atrial fibrilla- QT interval: not measurable
tion. When the f waves aren’t pronounced,
116 ECGs
Junctional rhythm to 60 beats/minute. A junctional

rhythm with a ventricular rate of 60
Junctional rhythm, also known as junc- to 100 beats/minute is known as an
tional escape rhythm, occurs in the AV accelerated junctional rhythm. If the
junctional tissue. It causes retrograde ventricular rate exceeds 100 beats/
depolarization of the atrial tissue and minute, the arrhythmia is called junc-
antegrade depolarization of the ventric- tional tachycardia.
ular tissue. It results from conditions
that depress SA node function, such as Intervention
an inferior wall MI, digoxin toxicity, Treatment aims to identify and manage
and vagal stimulation. The arrhythmia the primary cause of arrhythmia. If the
may also stem from increased auto- patient is symptomatic, treatment may
maticity of the junctional tissue, which include atropine to increase the sinus
can be caused by digoxin toxicity or or junctional rate. Alternately, the
ischemia associated with an inferior physician may insert a pacemaker or
wall MI. use transcutaneous pacing to maintain
Junctional rhythm is a regular an effective heart rate.
rhythm with a ventricular rate of 40
Characteristics of junctional rhythm
Regular rhythm with ventricular rate between

40 and 60 beats/minute
Lead II
Atrial rhythm: regular PR interval: less than 0.12 second and

Ventricular rhythm: regular constant if the P wave precedes the QRS
Atrial rate: if discernible, 40 complex; otherwise, not measurable (not
to 60 beats/minute (On this strip, the rate measurable on this strip)
isn’t discernible.) QRS complex: duration normal; configu-
Ventricular rate: 40 to 60 beats/minute ration usually normal (0.08-second dura-
(40 beats/minute shown) tion shown)
P wave: usually inverted; may precede, T wave: usually normal configuration
follow, or fall within the QRS complex; QT interval: usually normal (0.32-second
may be absent (On this strip, the P wave duration shown)
is absent.)
Arrhythmias 117
Accelerated junctional rhythm causes include electrolyte disturbances,

ventricular heart disease, heart failure,
An accelerated junctional rhythm is an and inferior or posterior MI.
arrhythmia that originates in the AV
junction and is usually caused by en- Intervention
hanced automaticity of the AV junc- Treatment aims to identify and manage
tional tissue. It’s called “accelerated” the primary cause of arrhythmia. As-
because it occurs at a rate of 60 to sessing the patient for signs and symp-
100 beats/minute, exceeding the inher- toms of decreased cardiac output and
ent junctional rate of 40 to 60 beats/ hemodynamic instability is key, as is
minute. monitoring serum digoxin and elec-
Digoxin toxicity is a common cause trolyte levels.
of accelerated junctional rhythm. Other
Characteristics of accelerated junctional rhythm
Regular rhythm with ventricular rate

Lead II between 60 and 100 beats/minute

Atrial rate: if discernible, 60 to complex; otherwise, not measurable (not
100 beats/minute (On this strip, the rate measurable on this strip)
Ventricular rate: 60 to 100 beats/minute ration usually normal (0.10-second dura-
(75 beats/minute shown) tion shown)
is absent.)
118 ECGs
Junctional tachycardia rior MI, heart failure, and electrolyte

imbalances.
In junctional tachycardia, three or
more premature junctional contractions Intervention
(PJCs) occur in a row. This supraven- The goal of treatment is to identify and
tricular tachycardia generally occurs as manage the primary cause of arrhyth-
a result of enhanced automaticity of mia. If the cause is digoxin toxicity, the
the AV junction, which causes the AV drug should be discontinued. Drugs
junction to override the SA node. such as the calcium channel blocker
Digoxin toxicity is the most com- verapamil may slow the heart rate in
mon cause of junctional tachycardia. symptomatic patients.
Other causes include inferior or poste-
Characteristics of junctional tachycardia
Regular rhythm with ventricular rate between

100 and 200 beats/minute
Lead II

Atrial rate: if discernible, 100 to complex; otherwise, not measurable (not
200 beats/minute (On this strip, the rate - measurable on this strip)
Ventricular rate: 100 to 200 beats/ ration usually normal (0.08-second dura-
minute (115 beats/minute shown) tion shown)
is absent.)
Arrhythmias 119
Premature junctional contractions Digoxin toxicity is the most com-

mon cause of PJCs. Other causes in-
In PJCs, a junctional beat occurs before clude ischemia associated with inferior
the next normal sinus beat. Ectopic wall MI, excessive caffeine ingestion,
beats and PJCs commonly result from and excessive levels of amphetamines.
increased automaticity in the bundle of
His or the surrounding junctional tis- Intervention
sue, which interrupts the underlying In most cases, treatment is directed at
rhythm. the underlying cause.
Characteristics of premature junctional contractions
Irregular rhythm Inverted P wave with

PR interval less than
0.12 second
PJC PJC
Lead II
Atrial rhythm: irregular with premature PR interval: less than 0.12 second on the
junctional contractions (PJCs), but underly- PJC if P wave precedes the QRS complex;
ing rhythm may be regular otherwise, not measurable (On this strip,
Ventricular rhythm: irregular with PJCs, the PR interval is 0.14 second and con-
but underlying rhythm may be regular stant on the underlying rhythm and 0.06
Atrial rate: follows the underlying second on the PJC.)
rhythm (100 beats/minute shown) QRS complex: normal duration and con-
Ventricular rate: follows the underlying figuration (0.06-second duration shown)
rhythm (100 beats/minute shown) T wave: usually normal configuration
P wave: usually inverted; may precede, QT interval: usually within normal limits
follow, or fall within the QRS complex; (0.30-second interval shown)
may be absent (shown preceding the QRS
complex)
120 ECGs
Premature ventricular contractions The earlier the PVC, the shorter the
diastolic filling time and the lower the
Premature ventricular contractions stroke volume. Frequent PVCs may
(PVCs) occur singly or in bigeminy, cause palpitations.
trigeminy, quadrigeminy, or clusters.
PVCs may be caused by certain drugs, Intervention
electrolyte imbalance, or stress. If the PVCs are believed to result from
Paired PVCs can produce ventricular a serious cardiac problem, antiarrhyth-
tachycardia (VT) because the second mics, such as lidocaine, procainamide,
PVC usually meets refractory tissue. or amiodarone, may be given to sup-
Three or more PVCs in a row is a run press ventricular irritability. When the
of VT. Multiform PVCs don’t look alike PVCs are believed to result from a non-
and may arise from different ventricu- cardiac problem, treatment aims at cor-
lar sites or be abnormally conducted. recting the underlying cause — an acid-
In the R-on-T phenomenon, the PVC base or electrolyte imbalance, antiar-
occurs so early that it falls on the rhythmic therapy, hypothermia, high
downslope of the previous T wave. catecholamine levels, or hypoxia.
Because the cells haven’t depolarized,
VT or fibrillation can result.
Characteristics of premature ventricular contractions
Premature QRS complex appears

wide and bizarre
Lead MCL1
Atrial rhythm: irregular during premature rhythm; not associated with the PVC
ventricular contractions (PVCs); underlying (0.12-second, constant interval shown)
rhythm may be regular QRS complex: occurs earlier than expected;
Ventricular rhythm: irregular during duration exceeds 0.12 second and complex
PVCs; underlying rhythm may be regular has a bizarre configuration; may be normal
Atrial rate: follows underlying rhythm in the underlying rhythm (On this strip, it’s
(120 beats/minute shown) 0.08 second in the normal beats; it’s bizarre
Ventricular rate: follows underlying and 0.14 second in the PVC.)
rhythm (120 beats/minute shown) T wave: occurs in the direction opposite
P wave: atrial activity independent of the that of the QRS complex; normal in the un-
PVC (If retrograde atrial depolarization ex- derlying complexes
ists, a retrograde P wave will distort the ST QT interval: not usually measured in the
segment of the PVC. On this strip, no PVC but may be within normal limits in the
P wave appears before the PVC, but one underlying rhythm (On this strip, the QT in-
occurs with each QRS complex.) terval is 0.28 second in the underlying
PR interval: determined by underlying rhythm.)
Arrhythmias 121
Ventricular tachycardia Intervention

Treatment depends on the patient’s
The life-threatening arrhythmia VT de- clinical status. This rhythm commonly
velops when three or more PVCs occur degenerates into ventricular fibrillation
in a row and the ventricular rate ex- and cardiovascular collapse, requiring
ceeds 100 beats/minute. VT may result immediate cardiopulmonary resuscita-
from enhanced automaticity or reentry tion and defibrillation. Patients with
within the Purkinje system. The rapid pulseless VT are treated the same as
ventricular rate reduces ventricular fill- those with ventricular fibrillation, and
ing time, and because atrial kick is lost, require immediate defibrillation. If the
cardiac output drops, putting the pa- patient is unstable and has a pulse,
tient at risk for ventricular fibrillation. prepare for immediate synchronized
VT usually results from acute MI, cardioversion followed by antiarrhyth-
coronary artery disease, valvular heart mic therapy. Drug therapy may include
disease, heart failure, or cardiomyopa- amiodarone, lidocaine, magnesium, or
thy. The arrhythmia can also stem from procainamide. Patients with chronic,
an electrolyte imbalance or from toxic recurrent episodes of VT that are unre-
levels of a drug, such as digoxin, pro- sponsive to drug therapy may need an
cainamide, or quinidine. You may de- implantable cardioverter-defibrillator.
tect two variations of this arrhythmia:
ventricular flutter and torsades de
pointes.
Characteristics of ventricular tachycardia
Wide, bizarre Ventricular rate of 100 to

QRS complex 200 beats/minute
Lead MCL1
Atrial rhythm: independent P waves P wave: usually absent; possibly obscured

possibly discernible with slower ventricu- by the QRS complex; retrograde P waves
lar rates (On this strip, the P waves aren’t may be present
visible.) PR interval: not measurable
Ventricular rhythm: usually regular but QRS complex: duration greater than 0.12
may be slightly irregular (On this strip, second; bizarre appearance, usually with
it’s regular.) increased amplitude (0.16-second dura-
Atrial rate: can’t be determined tion shown)
Ventricular rate: usually 100 to T wave: opposite direction of the
200 beats/minute (120 beats/minute QRS complex
shown) QT interval: not measurable
122 ECGs
Ventricular fibrillation sciousness, pulselessness, and respira-

tory arrest. Initially, you may see
Defined as chaotic, asynchronous elec- coarse fibrillatory waves on the ECG
trical activity within the ventricular tis- strip. As acidosis develops, the waves
sue, ventricular fibrillation is a life- become fine and progress to asystole
threatening arrhythmia that results in unless defibrillation restores cardiac
death if the rhythm isn’t stopped im- rhythm.
mediately. Conditions that lead to ven-
tricular fibrillation include myocardial Intervention
ischemia, hypokalemia, cocaine toxici- Perform cardiopulmonary resuscitation
ty, hypoxia, hypothermia, severe acido- until the patient can receive defibrilla-
sis, and severe alkalosis. tion. Administer epinephrine or vaso-
Patients with MI are at greatest risk pressin if the initial defibrillation series
for ventricular fibrillation during the is unsuccessful. Other drugs that may
first 2 hours after the onset of chest be used include amiodarone, lidocaine,
pain. magnesium, and procainamide.
In ventricular fibrillation, lack of
cardiac output results in loss of con-
Characteristics of ventricular fibrillation
Coarse fibrillatory waves
Lead MCL1
Atrial rhythm: can’t be determined PR interval: not measurable

Ventricular rhythm: irregular QRS complex: replaced with fibrillatory
Atrial rate: can’t be determined waves; duration not discernible
Ventricular rate: can’t be determined T wave: can’t be determined
P wave: indiscernible QT interval: not measurable
Arrhythmias 123
Idioventricular rhythm arrhythmia. Measures should be initiat-

ed to increase the patient’s heart rate,
Idioventricular rhythm, also referred to improve cardiac output, and establish a
as ventricular escape rhythm, origi- normal rhythm. Atropine may be ad-
nates in an escape pacemaker site in ministered to increase the heart rate.
the ventricles. The inherent firing rate Alert If atropine isn’t effective
of this ectopic pacemaker is less than or if hypotension or other signs
40 beats/minute. The rhythm acts as a of clinical instability develop, a pace-
safety mechanism when all potential maker (transcutaneous or transve-
pacemakers above the ventricles don’t nous) may be needed to reestablish a
discharge or when a block prevents heart rate that provides enough car-
supraventricular impulses from reach- diac output to perfuse the organs
ing the ventricles. properly.
The slow ventricular rate and loss Alert The goal of treating id-
of atrial kick associated with this ar- ioventricular rhythm doesn’t
rhythmia markedly reduce cardiac out- include suppressing the rhythm be-
put. In turn, reduced cardiac output cause it acts as a safety mechanism to
causes hypotension, confusion, vertigo, protect the heart from ventricular
and syncope. If it isn’t identified rapid- standstill. Idioventricular rhythm
ly and managed appropriately, idioven- should never be treated with antiar-
tricular rhythm may cause death. rhythmics such as lidocaine because
these drugs would suppress the es-
Intervention cape beats.
Treatment aims to identify and manage
the primary problem that triggered the
Characteristics of idioventricular rhythm
Irregular ventricular
rhythm and ventricular
rate less than 40 beats/
minute
Lead II
Atrial rhythm: can’t be determined QRS complex: duration greater than

Ventricular rhythm: usually regular, 0.12 second; complex is wide and has a
except with isolated escape beats bizarre configuration (On this strip, the
(irregular rhythm shown) complex is 0.20 second and bizarre.)
Atrial rate: can’t be determined T wave: directed opposite the terminal
Ventricular rate: less than 40 beats/ forces of the QRS complex
minute (30 beats/minute shown) QT interval: usually greater than
P wave: absent 0.44 second (0.46-second interval shown)
PR interval: usually not measurable
124 ECGs
Accelerated idioventricular rhythm The patient may be symptomatic,

depending on his heart rate and ability
When the pacemaker cells above the to compensate for the loss of the atrial
ventricles do not generate an impulse kick. A symptomatic patient may have
or when a block prevents supraventric- signs and symptoms of decreased car-
ular impulses from reaching the ventri- diac output, including hypotension,
cles, idioventricular rhythms result. confusion, syncope, and loss of con-
When the rate of an idioventricular sciousness.
rhythm ranges from 40 to 100 beats/
minute, it’s considered accelerated id- Intervention
ioventricular rhythm, denoting a rate An asymptomatic patient needs no
greater than that of the inherent pace- treatment. For a symptomatic patient,
maker. treatment focuses on maintaining car-
In this life-threatening arrhythmia, diac output and identifying the cause
the cells of the His-Purkinje system op- of arrhythmia. The patient may require
erate as pacemaker cells. The charac- a transcutaneous or transvenous tem-
teristic waveform results from an area porary pacemaker to enhance cardiac
of enhanced automaticity within the output and may need a permanent
ventricles, which may be associated pacemaker for long-term therapy.
with MI, digoxin toxicity, or metabolic Remember, this rhythm protects the
imbalances. In addition, the arrhythmia heart from ventricular standstill and
commonly occurs during myocardial shouldn’t be treated with antiarrhyth-
reperfusion after thrombolytic therapy. mic agents.
Characteristics of accelerated idioventricular rhythm
T wave
QRS complex Regular ventricular rhythm

Lead V1 and ventricular rate of 40 to
100 beats/minute
Atrial rhythm: can’t be determined QRS complex: duration greater than

Ventricular rhythm: usually regular 0.12 second; wide and bizarre
Atrial rate: can’t be determined configuration
Ventricular rate: 40 to 100 beats/ T wave: deflection usually opposite that
minute of the QRS complex
P wave: absent QT interval: may be within normal limits
PR interval: not measurable or prolonged
Arrhythmias 125
First-degree atrioventricular block associated with aging. Certain drugs,

such as digoxin, calcium channel
First-degree AV block occurs when blockers, and beta-adrenergic blockers,
there’s a delay in the conduction of may also cause this condition.
electrical impulses from the atria to the Most patients with first-degree AV
ventricles. This delay usually occurs at block are asymptomatic.
the level of the AV node but may also
be infranodal. Intervention
First-degree AV block is character- Management of first-degree AV block
ized by a constant PR interval greater includes identifying and treating the
than 0.20 second. It may result from underlying cause and monitoring the
myocardial ischemia, MI, myocarditis, patient for signs of progressive AV
or degenerative changes in the heart block.
Characteristics of first-degree atrioventricular block
PR interval greater than 0.20 second

Regular rhythm
Lead II
Atrial rhythm: regular PR interval: greater than 0.20 second

Ventricular rhythm: regular and constant (0.32-second duration
Atrial rate: usually within normal limits shown)
(60 beats/minute shown) QRS complex: usually normal duration
Ventricular rate: usually within normal and configuration (0.08-second duration
limits (60 beats/minute shown) and normal configuration shown)
P wave: normal size and configuration T wave: normal size and configuration
(One P wave precedes each QRS QT interval: usually within normal limits
complex.) (0.32-second interval shown)
126 ECGs
Second-degree atrioventricular signs and symptoms of decreased car-

block, type I diac output, such as hypotension, con-
fusion, and syncope. These effects oc-
Type I (Wenckebach or Mobitz I) cur especially if the patient’s ventricu-
second-degree AV block occurs when lar rate is slow.
each successive impulse from the SA
node is delayed in the AV node slightly Intervention
longer than the previous impulse. This If the patient is asymptomatic, no in-
pattern of progressive prolongation of tervention is required other than moni-
the PR interval continues until an im- toring the ECG frequently to see if a
pulse is not conducted to the ventri- more serious form of AV block devel-
cles. ops.
Type I block most commonly occurs If the patient is symptomatic, at-
at the level of the AV node and is ropine may be ordered to increase the
caused by inferior wall MI, vagal stim- ventricular rate. Treatment may also in-
ulation, or digoxin toxicity. The ar- clude a temporary pacemaker (transcu-
rhythmia usually doesn’t cause symp- taneous or transvenous) to maintain an
toms; however, a patient may have effective cardiac output.
Characteristics of second-degree atrioventricular

block, type I
Absent QRS complex
Progressively longer PR interval

Lead II
Atrial rhythm: regular QRS complex: normal duration and con-

Ventricular rhythm: irregular figuration; periodically absent
Atrial rate: determined by the underlying (0.08-second duration shown)
rhythm (80 beats/minute shown) T wave: normal size and configuration
Ventricular rate: slower than the atrial QT interval: usually within normal limits
rate (50 beats/minute shown) (0.46-second, constant interval shown)
P wave: normal size and configuration Other: usually distinguished by a pattern
PR interval: progressively prolonged of group beating, referred to as the foot-
with each beat until a P wave appears prints of Wenckebach
without a QRS complex
Arrhythmias 127
Second-degree atrioventricular Intervention

block, type II If the patient is hypotensive, treatment
aims at increasing his heart rate to im-
Produced by a conduction disturbance prove cardiac output. Because the con-
in the His-Purkinje system, a type II duction block occurs in the His-Purkinje
(Mobitz II) second-degree AV block system, drugs that act directly on the
causes intermittent absence of conduc- myocardium usually prove more effec-
tion. In type II block, two or more atri- tive than those that increase the atrial
al impulses are conducted to the ven- rate. As a result, dopamine or epineph-
tricles with constant PR intervals, rine instead of atropine may be ordered
when suddenly, without warning, the to increase the ventricular rate.
atrial impulse is blocked. This type of If the patient has an anterior wall
block occurs in an anterior wall MI, se- MI, the physician will immediately in-
vere coronary artery disease, and sert a temporary pacemaker to prevent
chronic degeneration of the conduction ventricular asystole. A transcutaneous
system. pacemaker should be used until a
Type II second-degree AV block is transvenous pacemaker is placed. For
more serious than type I second-degree long-term management, the patient
AV block and can be a life-threatening may need a permanent pacemaker.
arrhythmia. It requires prompt inter-
vention.
Characteristics of second-degree atrioventricular

block, type II
Irregular ventricular rhythm
Regular atrial Constant PR

Lead II rhythm interval
Atrial rhythm: regular PR interval: constant and frequently

Ventricular rhythm: regular or irregular within normal limits for all conducted
Atrial rate: usually within normal limits beats
(60 beats/minute shown) QRS complex: duration within normal
Ventricular rate: may be within normal limits if the block occurs at the bundle of
limits but less than the atrial rate His; greater than 0.16 second if the block
(40 beats/minute shown) occurs at the bundle branches
P wave: normal size and configuration (0.12-second complex shown)
(Not all P waves are followed by a T wave: usually normal size and configu-
QRS complex.) ration
QT interval: usually within normal limits
(0.44-second interval shown)
128 ECGs
Third-degree atrioventricular block MI or drug toxicity (cardiac glycosides,

beta-adrenergic blockers, calcium chan-
Also called complete heart block, third- nel blockers). Third-degree AV block
degree AV block indicates the complete below the AV node may result from an-
absence of impulse conduction be- terior wall MI or chronic degeneration
tween the atria and ventricles. The atri- of the conduction system.
al rate is generally equal to or faster Some patients with complete heart
than the ventricular rate. Third-degree block are relatively free from symp-
AV block may occur at the level of the toms, complaining only that they can’t
AV node, the bundle of His, or the bun- tolerate exercise or increased activity.
dle branches. Treatment and prognosis However, most patients have signifi-
vary depending on the anatomic level cant signs and symptoms, including se-
of the block. vere fatigue, dyspnea, chest pain, light-
If this type of block originates at the headedness, and changes in mental
AV node, a junctional escape rhythm status. The severity of the symptoms
occurs; if it originates below the AV depends on the ventricular rate and the
node, an idioventricular escape rhythm patient’s ability to compensate for de-
occurs. creased cardiac output.
Third-degree AV block involving the
AV node may result from inferior wall
Characteristics of third-degree atrioventricular block
Regular atrial P wave without QRS complex

rhythm
Regular ventricular
Lead MCL1 rhythm
Atrial rhythm: usually regular cape rhythm, the duration and configura-
Ventricular rhythm: usually regular tion are normal; with an idioventricular
Atrial rate: usually within normal limits escape rhythm, the duration is greater
(90 beats/minute shown) than 0.12 second and the complex is dis-
Ventricular rate: slow (30 beats/minute torted. In the complex shown, the dura-
shown) tion is 0.16 second, the configuration is
P wave: normal size and configuration abnormal, and the complex is distorted.)
PR interval: not measurable because the T wave: normal size and configuration
atria and ventricles beat independently of QT interval: may or may not be within
each other normal limits (0.56-second interval
QRS complex: determined by the site of shown)
the escape rhythm (With a junctional es-
12-lead ECGs 129
Intervention six precordial leads record electrical

Third-degree AV block can be a life- potential from the horizontal plane.
threatening arrhythmia; it requires Each waveform reflects the orientation
prompt intervention. If the patient has of a lead to the wave of depolarization
serious signs and symptoms and car- passing through the myocardium. Nor-
diac output isn’t adequate, interven- mally, this wave moves through the
tions may include transcutaneous or heart from right to left and from top to
transvenous pacing or I.V. atropine, bottom.
dopamine, or epinephrine. Patients
with third-degree AV block at the infra- Bipolar leads
nodal level associated with an exten- Bipolar leads record the difference in
sive anterior MI usually require a per- electrical potential between two points
manent pacemaker. on the patient’s body where you place
Alert Atropine isn’t indicated electrodes.
for third-degree AV block with ◆ Lead I goes from the right arm (–)
new wide QRS complexes. In such to the left arm (+).
cases, a pacemaker is indicated be- ◆ Lead II goes from the right arm (–)
cause atropine rarely increases sinus to the left leg (+).
rate and AV node conduction when ◆ Lead III goes from the left arm (–)
AV block occurs at the His-Purkinje to the left leg (+).
level. Because of the orientation of these
leads to the wave of depolarization,
QRS complexes typically appear up-
12-lead ECGs right. In lead II, these complexes are
usually the tallest because this lead
parallels the wave of depolarization.
Basic components and principles
Unipolar leads
Whereas rhythm strips are used to de- Unipolar leads (the augmented limb
tect arrhythmias, the 12-lead or stan- leads and the precordial leads) have
dard ECG has a different purpose. The only one electrode, which represents
most common procedure for evaluating the positive pole. The negative pole is
cardiac status, this diagnostic test helps computed by the ECG. Lead aVR typi-
to identify various pathologic condi- cally records negative QRS complex de-
tions — most commonly, acute MI. flections because the wave of depolar-
The 12-lead ECG provides 12 views ization moves away from it. In the aVF
of the electrical activity of the heart. lead, QRS complexes are positive; in
(See 12 views of the heart, page 130.) the aVL lead, they’re biphasic.
The 12 leads include: Unipolar precordial leads V1 and V2
◆ three bipolar limb leads (I, II, and usually have a small R wave because
III) the direction of ventricular activation is
◆ three unipolar augmented limb left to right initially. That’s because
leads (aVR, aVL, and aVF) conduction time is normally faster
◆ six unipolar precordial, or chest, down the left bundle branch than it is
leads (V1, V2, V3, V4, V5, and V6). down the right. The wave of depolar-
ization, however, moves toward the left
Leads ventricle and away from these leads,
The six limb leads record electrical po- causing a low S wave.
tential from the frontal plane, and the
130 ECGs
12 views of the heart
Each of the leads on a 12-lead electrocardiogram (ECG) views the heart from a different
angle. These illustrations show the direction of electrical activity (depolarization) moni-
tored by each lead and the 12 views of the heart.
Views reflected on a 12-lead ECG LEAD VIEW OF HEART
Wave of depolarization Standard limb leads

(bipolar)
aVR
aVL I Lateral wall
II Inferior wall
I III Inferior wall
Augmented limb leads

(unipolar)
III II
aVR No specific view
aVF
aVL Lateral wall
aVF Inferior wall

Wave of depolarization
Precordial, or chest, leads
(unipolar)
V1 Septal wall
V2 Septal wall
V6
V3 Anterior wall
V5 V4 Anterior wall
V4 V5 Lateral wall
V1
V2 V3
V6 Lateral wall
In leads V3 and V4, the R and strong wave of depolarization moving

S waves may have the same amplitude, toward the left ventricle. These leads
and you won’t see a Q wave. In leads record a small or absent S wave.
V5 and V6, the initial ventricular acti-
vation appears as a small Q wave; the
following tall R wave represents the
12-lead ECGs 131
Determining electrical axis (positive pole); and lead III connects

the left arm (negative pole) with the
As electrical impulses travel through left leg (positive pole). The augmented
the heart, they generate small electrical limb leads have only one electrode,
forces called instant-to-instant vectors. which represents the positive pole. As
The mean of these vectors represents a result, lead aVR goes from the heart
the direction and force of the wave of toward the right arm (positive pole),
depolarization, also known as the elec- aVL goes from the heart toward the left
trical axis of the heart. arm (positive pole), and aVF goes from
In a healthy heart, the wave of de- the heart to the left leg or leg foot
polarization originates in the SA node (positive pole).
and travels through the atria and the Now, take this mental picture one
AV node and on to the ventricles. The step further and draw an imaginary
normal movement is downward and to line to illustrate the axis of each lead.
the left — the direction of a normal For example, for lead I, you would
electrical axis. draw a horizontal line between the
In an unhealthy heart, the wave of right and left arms; for lead II, between
depolarization (or the direction of the the right arm and left leg; and so on.
electrical axis) varies. That’s because All of the lines should intersect near
the direction of electrical activity the center, somewhere over the heart.
swings away from areas of damage or If you draw a circle to represent the
necrosis. heart, you would end up with a rough
A simple method to determine the pie shape, with each wedge represent-
direction of your patient’s electrical ing a portion of the heart monitored by
axis is the quadrant method. Before each lead. (See Understanding the
you use this method, you must under- hexaxial reference system, page 132.)
stand the hexaxial reference system — a This schematic representation of the
schematic view of the heart that uses heart allows you to plot your patient’s
the six limb leads. electrical axis. If his axis falls in the
As discussed earlier, these leads in- right lower quadrant, between 0 de-
clude the three standard limb leads (I, grees and +90 degrees, it’s considered
II, and III), which are bipolar, and the normal. An axis between +90 degrees
three augmented limb leads (aVR, aVL, and +180 degrees indicates right axis
and aVF), which are unipolar. Com- deviation; one between 0 degrees and
bined, these leads give a view of the –90 degrees, left axis deviation; and
wave of depolarization in the frontal one between –180 degrees and –90 de-
plane, including the right, left, inferior, grees, extreme axis deviation (some-
and superior portions of the heart. times called the no-man’s-land axis or
northwest axis).
Hexaxial reference system
The axes of the six limb leads also Quadrant method
make up the hexaxial reference system, A simple, rapid method for determin-
which divides the heart into six equal ing the heart’s axis is the quadrant
areas. To use the hexaxial reference method. With this method, you ob-
system, picture the position of each serve the main deflection of the QRS
lead: lead I connects the right arm complex in leads I and aVF. The QRS
(negative pole) with the left arm (posi- complex serves as the traditional mark-
tive pole); lead II connects the right er for determining the electrical axis
arm (negative pole) with the left leg because the ventricles produce the
132 ECGs
Understanding the hexaxial reference system
The hexaxial reference system consists of

six bisecting lines, each representing one –90°
–120° –60°
of the six limb leads, and a circle, repre-
senting the heart. The intersection of –30°
–150°
these lines divides the circle into equal aVR aVL
30-degree segments.
Note that 0 degrees appears at the ±180° I +0°
3 o’clock position. Moving counterclock-
wise, the degrees become increasingly +150° +30°
negative until they reach ±180 degrees at III II
aVF
the 9 o’clock position. The bottom half of +120° +60°
+90°
the circle contains the corresponding posi-
tive degrees. It’s important to remember
that a positive-degree designation doesn’t
necessarily mean that the pole is positive.
greatest amount of electrical force the lead, which is at the –90-degree po-
when they contract. Lead I indicates sition of the hexaxial reference system.
whether impulses are moving to the Plotting this information on the
right or left; lead aVF indicates whether hexaxial reference system (with the
they’re moving up or down. horizontal axis representing lead I and
On the waveform for lead I, a posi- the vertical axis representing lead aVF)
tive main deflection of the QRS com- shows the patient’s electrical axis. For
plex indicates that the electrical im- example, if lead I shows a positive de-
pulses are moving to the right, toward flection of the QRS complex, darken
the positive pole of the lead, which is the horizontal axis between the center
at the 0-degree position on the hexaxial of the hexaxial reference system and
reference system. Conversely, a nega- the 0-degree position. If lead aVF also
tive deflection indicates that the im- shows a positive deflection of the QRS
pulses are moving to the left, toward complex, darken the vertical axis be-
the negative pole of the lead, which is tween the center of the reference sys-
at the ±180-degree position on the tem and the +90-degree position. The
hexaxial reference system. On the quadrant between the two axes you’ve
waveform for lead aVF, a positive de- darkened indicates the patient’s electri-
flection of the QRS complex indicates cal axis. In this case, it’s the left lower
that the electrical impulses are travel- quadrant, which indicates a normal
ing downward, toward the positive electrical axis. (See Using the quadrant
pole of the lead, which is at the method.)
+90-degree position of the hexaxial
reference system. A negative deflection Causes of axis deviation
indicates that impulses are traveling Determining a patient’s electrical axis
upward, toward the negative pole of can help to confirm a diagnosis or
12-lead ECGs 133
Using the quadrant method
This chart will help you to determine quickly the direction of a patient’s electrical axis.
Observe the deflections of the QRS complexes in leads I and aVF. Then check the chart
to determine whether the patient’s axis is normal or has a left, right, or extreme axis
deviation.
–90°
Extreme
right-axis Left-axis
deviation deviation
I I
aVF aVF
±180° +90°
Right-axis
deviation Normal
I I
aVF aVF
0°
narrow the range of clinical possibili- conduct electricity. As a result, the ma-
ties. Many factors influence the electri- jor electrical vectors shift to the left, re-
cal axis, including the position of the sulting in left-axis deviation.
heart within the chest, the size of the Typically, the damaged portion of
heart, the conduction pathways, and the heart is the last area to be depolar-
the force of electrical generation. ized. For example, in a left anterior
Cardiac electrical activity swings hemiblock, the left anterior fascicle of
away from areas of damage or necro- the left bundle branch can no longer
sis. More specifically, electrical forces conduct electricity. Therefore, the por-
in the healthy portion of the heart take tion normally served by the left bundle
over for weak or absent electrical branch is the last portion of the heart
forces in the damaged portion. For in- to be depolarized. This shifts electrical
stance, after an inferior wall MI, por- forces to the left; consequently, the
tions of the inferior wall can no longer ECG shows left-axis deviation.
134 ECGs
An opposite shift occurs with right that will help to ensure that you’re in-
bundle-branch block. In this condition, terpreting it accurately:
the wave of impulse travels quickly ◆ Check the ECG tracing to see if it’s
down the normal left side, but much technically correct. Make sure that the
more slowly down the damaged right baseline is free from electrical interfer-
side. This shifts the electrical forces to ence and drift.
the right, causing right-axis deviation. ◆ Scan limb leads I, II, and III. The
An axis shift also takes place when R-wave voltage in lead II should equal
the right or left ventricle is being paced the sum of the R-wave voltage in leads
artificially. Likewise, it takes place I and III. Lead aVR is typically nega-
when the ventricles are depolarizing tive. If these criteria aren’t met, the
abnormally, such as occurs in VT. Both tracing may be recorded incorrectly.
of these conditions can cause left-axis ◆ Locate the lead markers on the
deviation or, occasionally, extreme axis waveform. Lead markers are the points
deviation. where one lead changes to another.
Axis deviation may also result from ◆ Check the standardization markings
ventricular hypertrophy. For example, to make sure that all leads were record-
an enlarged right ventricle generates ed with the amplitude of the ECG ma-
greater electrical forces than normal chine at the same setting. Standardiza-
and would consequently shift the elec- tion markings are usually located at
trical axis to the right. Wolff-Parkinson- the beginning of the strip.
White syndrome may produce right-, ◆ Assess the heart’s rate and rhythm.
left-, or extreme axis deviation, de- ◆ Determine the heart’s electrical axis
pending on which part of the ventricle using the quadrant method.
is activated early. ◆ Examine limb leads I, II, and III.
Age alert Sometimes axis de- The R wave in lead II should be taller
viation may be a normal varia- than the R wave in lead I. The R wave
tion, as in infants and children who in lead III should be a smaller version
normally experience right-axis devia- of the R wave in lead I. The P wave or
tion. It may also stem from noncar- QRS complex may be inverted. Each
diac causes. For example, if the heart lead should have flat ST segments and
is shifted in the chest cavity because upright T waves. Pathologic Q waves
of a high diaphragm as a result of should be absent.
pregnancy, expect to find left-axis de- ◆ Examine limb leads aVL, aVF, and
viation. aVR. The tracings from leads aVL and
If a patient’s heart is situated on the aVF should be similar, but lead aVF
right side of his chest instead of the should have taller P and R waves. Lead
left (a condition called dextrocardia), aVR has little diagnostic value. Its
expect to find right-axis deviation. P wave, QRS complex, and T wave
should be deflected downward.
How to interpret a 12-lead ECG ◆ Examine the R wave in the precor-
dial leads. Normally, the R wave — the
To interpret a 12-lead ECG, use a sys- first positive deflection of the QRS
tematic approach. Compare the pa- complex — gets progressively taller
tient’s previous ECG, if available, with from lead V1 to V5. It gets slightly
the current one. This will help you to smaller in lead V6.
identify changes. You can use various
methods to interpret a 12-lead ECG.
Here’s a logical, easy-to-follow method (Text continues on page 137.)
12-lead ECGs 135
Normal findings
Lead I Lead aVR P wave: inverted
P wave: upright Q wave: none, small, or large

Q wave: small or none R wave: none or small
R wave: large S wave: large (may be QS)
S wave: none or smaller than R wave T wave: inverted
T wave: upright U wave: none
U wave: none ST segment: may vary from +1 to
ST segment: may vary from +1 to –0.5 mm
–0.5 mm
Lead aVL
Lead II
P wave: upright, diphasic, or inverted

P wave: upright Q wave: none, small, or large (A Q wave
Q wave: small or none must also be present in lead I or the pre-
R wave: largest cordial leads to be considered diagnostic.)
S wave: none or smaller than R wave R wave: none, small, or large (A large
T wave: upright wave indicates a horizontal heart.)
U wave: none S wave: none to large (A large wave indi-
ST segment: may vary from +1 to cates a vertical heart.)
–0.5 mm T wave: upright, diphasic, or inverted
Lead III U wave: none
ST segment: may vary from +1 to
–0.5 mm

Q wave: usually small or none (A Q wave
must also be present in lead aVF to be
considered diagnostic.)
R wave: none to large
S wave: none to large, indicating hori-
zontal heart
T wave: upright, diphasic, or inverted
U wave: none
–0.5 mm (continued)
136 ECGs
Normal findings (continued)
Lead aVF U wave: upright; lower amplitude than

T wave
ST segment: may vary from 0 to
+1 mm
Lead V3
P wave: upright
Q wave: none or small
R wave: none, small, or large (A large
wave suggests a vertical heart.)
S wave: none to large (A large wave sug-
gests a horizontal heart.) P wave: upright
T wave: upright, diphasic, or inverted Q wave: none or small
U wave: none R wave: less than, greater than, or equal
ST segment: may vary from +1 to to S wave (Wave may become progres-
–0.5 mm sively larger.)
S wave: large (greater than, less than, or
Lead V1 equal to R wave)
T wave: upright
U wave: upright; lower amplitude than T
wave
ST segment: may vary from 0 to
+1 mm
Lead V4
Q wave: deep QS pattern may be present
R wave: none or less than S wave
S wave: large (part of the QS pattern)
T wave: usually inverted but may be up-
right and diphasic
U wave: none
P wave: upright
ST segment: may vary from 0 to +1 mm
Q wave: none or small
Lead V2 R wave: progressively larger; greater
than S wave
S wave: progressively smaller; less than
R wave
T wave: upright
U wave: upright; lower amplitude than T
wave
P wave: upright
–0.5 mm
Q wave: deep QS pattern may be present
R wave: none or less than S wave (Wave
may become progressively larger.)
S wave: large (part of the QS pattern)
T wave: upright
12-lead ECGs 137
Normal findings (continued)
Lead V5 Lead V6
P wave: upright P wave: upright

Q wave: small Q wave: small
R wave: progressively larger but less R wave: largest wave but less than
than 26 mm 26 mm
S wave: Progressively smaller; less than S wave: smallest; less than S wave in V5
the S wave in V4 T wave: upright
T wave: upright U wave: none
U wave: none ST segment: may vary from +1 to
ST segment: may vary from +1 to –0.5 mm
–0.5 mm
◆ Examine the S wave (the negative Keep in mind that this chart serves as
deflection after an R wave) in the pre- a guideline only. Actual areas of infarc-
cordial leads. It should appear extreme- tion may overlap or may be larger or
ly deep in lead V1 and become progres- smaller than listed.
sively more shallow, usually disappear- – Identify the leads that record
ing by lead V5. ST-segment elevation (or depression
◆ If you suspect MI, start with lead I for reciprocal leads). Use the chart to
and continue through to lead V6, ob- locate the corresponding areas of myo-
serving the waveforms for changes in cardial injury.
ECG characteristics that can indicate – Identify the leads that record T-wave
acute MI, such as T-wave inversion, inversion, and locate the corresponding
ST-segment elevation, and pathologic areas of ischemia.
Q waves. Note the leads in which you
see such changes, and describe the Acute myocardial infarction
changes. When you’re first learning to
interpret the 12-lead ECG, ignore lead Acute MI can arise from any condition
aVR because it won’t provide clues to in which the myocardial oxygen supply
left ventricular infarction or injury. can’t meet oxygen demand. Starved of
◆ Determine the site and extent of oxygen, the myocardium suffers pro-
myocardial damage. (See Locating gressive ischemia, leading to injury
myocardial damage, page 138.) Then and eventually to infarction.
follow these steps: In most cases, an acute MI involves
– Identify the leads that record patho- the left ventricle, although it can also
logic Q waves. Look at the second col- involve the right ventricle or the atria.
umn of the chart to identify those Acute MIs are classified as ST-segment
leads. Then look at the first column to elevation MI or non-ST-segment eleva-
find the corresponding myocardial tion MI.
wall, where infarction has occurred.
138 ECGs
Locating myocardial damage
After you’ve noted characteristic lead changes in an acute myocardial infarction, use this
chart to identify the areas of damage. Match the lead changes (ST elevation, abnormal
Q waves) in the second column with the affected wall in the first column and the in-
volved artery in the third column. The fourth column shows reciprocal lead changes.
AFFECTED LEADS ARTERY RECIPROCAL

WALL INVOLVED CHANGES
Anterior V2, V3, V4 Left coronary artery II, III, aVF

(LCA) and left anterior
descending (LAD)
artery
Anterolateral I, aVL, V3, V4, LAD and diagonal II, III, aVF
V5, V6 branches; circumflex
and marginal branches
Anteroseptal V1, V2, V3, V4 LAD None
Inferior II, III, aVF Right coronary artery I, aVL

(RCA)
Lateral I, aVL, V5, V6 Circumflex branch of II, III, aVF

the LCA
Posterior V8, V9 RCA or circumflex V1, V2, V3, V4 (R

greater than S in V1
and V2, ST-segment
depression, and ele-
vated T wave)
Right ventricular V4R, V5R, V6R RCA None
In an acute MI, the characteristic Ischemia

ECG changes result from the three I’s:
ischemia, injury, and infarction.
◆ Ischemia results from a temporary
interruption of the myocardial blood
supply. Its characteristic ECG change is Ischemia produces T-wave inversion.
T-wave inversion, a result of altered tis-
sue repolarization. ST-segment depres- ◆ Injury to myocardial cells results
sion may also occur. from prolonged interruption of blood
flow. Its characteristic ECG change,
12-lead ECGs 139
ST-segment elevation, reflects altered Hyperacute phase

depolarization. Usually, an elevation The hyperacute phase begins a few
greater than 0.1 mV is considered sig- hours after the onset of acute MI.
nificant. You’ll see ST-segment elevation and
upright (usually peaked) T waves.
Injury
Fully evolved phase
The fully evolved phase starts several
hours after the onset of MI. You’ll see
deep T-wave inversion and pathologic
Injury produces ST-segment elevation. Q waves.
◆ Infarction results from an absence Resolution phase

of blood flow to myocardial tissue, The resolution phase appears within a
leading to necrosis. The ECG shows few weeks of acute MI. You’ll see nor-
pathologic Q waves, reflecting abnormal T waves.
mal depolarization in damaged tissue
or absent depolarization in scar tissue. Stabilized chronic phase
The characteristic of a pathologic After the resolution phase, you’ll see
Q wave is a duration of 0.04 second or permanent pathologic Q waves that
an amplitude that’s at least one-third show an old infarction.
the height of the entire QRS complex. With an acute non–Q-wave MI, you
may see persistent ST-segment depres-
Infarction sion, T-wave inversion, or both; how-
ever, pathologic Q waves may not ap-
pear. To differentiate an acute non–
Q-wave MI from myocardial ischemia,
cardiac enzyme tests must be per-
Infarction produces pathologic Q waves.
formed.
For a true clinical diagnosis of acute
◆ In addition to these three character- MI, a patient must have symptoms,
istic ECG changes, you may see recip- ECG changes, and elevated cardiac bio-
rocal (or mirror image) changes. Recip- marker levels. If the patient shows
rocal changes — most commonly such signs and symptoms as chest
ST-segment depression or tall R pain, left arm pain, diaphoresis, and
waves — occur in the leads opposite nausea, proceed as if he has had an
those that reflect the area of ischemia, acute MI until this possibility has been
injury, or infarction. ruled out.
Acute MI phases
To detect an acute MI, look for ST-
segment elevation first, followed by
T-wave inversion and pathologic
Q waves.
Serial ECG recordings yield the best
evidence of an MI. Normally, an acute
MI progresses through the following
phases.
140 ECGs
Right-sided ECG, leads V1R to V6R ◆ V4R: in the fifth intercostal space at
the right midclavicular line
A right-sided ECG provides information ◆ V5R: in the fifth intercostal space at
about the extent of damage to the right the right anterior axillary line
ventricle, especially during the first 12 ◆ V6R: in the fifth intercostal space at
hours of MI. Right-sided ECG leads, the right midaxillary line.
placed over the right side of the chest
in similar but reversed positions from Viewing the heart
the left precordial leads, are called Chest leads, whether on the left or the
unipolar right-sided chest leads. right side of the chest, view the hori-
zontal plane of the heart. The place-
Placing electrodes ment of left precordial leads gives a
Right-sided ECG leads are precordial good picture of the electrical activity
leads designated by the letter V, a within the left ventricle. Because the
number representing the electrode po- right ventricle lies behind the left ven-
sition, and the letter R, indicating tricle, the ability to evaluate right ven-
placement on the right side of the tricular electrical activity when using
chest. Lead positions are: only left precordial leads is limited.
◆ V1R: in the fourth intercostal space Right-sided ECG leads better visualize
at the left sternal border the right ventricular wall. This may be
◆ V2R: in the fourth intercostal space especially useful when evaluating a pa-
at the right sternal border tient for a right ventricular MI.
◆ V3R: midway between V1R and V4R,
on a line joining these two locations
Right-sided ECG
V1R V2R V3R
V4R V5R V6R

12-lead ECGs 141
Posterior-lead ECG, leads V7 to V9 Placing electrodes

To ensure an accurate ECG reading,
Because of lung and muscle barriers, make sure that the posterior electrodes
the usual chest leads can’t “see” the V7, V8, and V9 are placed at the same
posterior portion of the heart to record level horizontally as lead V6 at the fifth
myocardial damage there. To compen- intercostal space. Lead positions are:
sate, some practitioners add three pos- ◆ V7: at the posterior axillary line
terior leads to the 12-lead ECG: leads ◆ V8: halfway between V7 and V9
V7, V8, and V9. The addition of the ◆ V9: at the paraspinal line.
posterior leads to the 12-lead ECG in-
creases the sensitivity of the ECG in
identifying posterior wall infarction so
that appropriate treatment can begin.
Posterior-lead ECG
V7
V8
V9
142 ECGs
Left bundle-branch block This arrhythmia may indicate un-

derlying heart disease such as coronary
In left bundle-branch block, a conduc- artery disease. It carries a more serious
tion delay or block occurs in both the prognosis than right bundle-branch
left posterior and left anterior fascicles block because of its close correlation
of the left bundle. This delay or block with organic heart disease, and it re-
disrupts the normal left-to-right direc- quires a large lesion to block the thick,
tion of depolarization. As a result, nor- broad left bundle branch.
mal septal Q waves are absent. Be-
cause of the block, the wave of depo- Intervention
larization must move down the right When left bundle-branch block occurs
bundle first, then spread from right to with an anterior wall MI, it usually sig-
left. nals complete heart block, which re-
quires insertion of a pacemaker.
Characteristics of left bundle-branch block
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Rhythm: regular atrial and ventricular Leads I, aVL, and V6 show a wide, tall R
rhythms wave without a Q or S wave.)
Rate: atrial and ventricular rates within T wave: deflection opposite that of the
normal limits QRS complex in most leads
P wave: normal size and configuration QT interval: may be prolonged or within
PR interval: within normal limits normal limits
QRS complex: duration that varies from Other: magnitude of changes paralleling
0.10 to 0.12 second in incomplete left the magnitude of the QRS complex aber-
bundle-branch block (It’s at least 0.12 sec- ration, with normal axis or left axis devia-
ond in complete block. Lead V1 shows a tion; delayed intrinsicoid deflection over
wide, entirely negative rS or QS complex. the left ventricle (lead V6)
12-lead ECGs 143
Right bundle-branch block precordial leads). This late depolariza-

tion also causes the axis to deviate to
In the conduction delay or block asso- the right.
ciated with right bundle-branch block,
the initial left-to-right direction of de- Intervention
polarization isn’t affected. The left ven- One potential complication of an MI is
tricle depolarizes on time, so the intrin- a bundle-branch block. Some blocks
sic deflection in leads V5 and V6 (the require treatment with a temporary
left precordial leads) occurs on time as pacemaker. Others are monitored only
well. However, the right ventricle depo- to detect progression to a more com-
larizes late, causing a late intrinsic de- plete block.
flection in leads V1 and V2 (the right
Characteristics of right bundle-branch block
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Rhythm: regular atrial and ventricular plex is mainly positive, with the R wave
rhythms occurring late. In leads I, aVL, and V6, a
Rate: atrial and ventricular rates within broad S wave can be seen.)
normal limits T wave: in most leads, deflection opposite
PR interval: within normal limits that of the QRS deflection
QRS complex: duration is at least 0.12 QT interval: may be prolonged or within
second in complete block and 0.10 to 0.12 normal limits
second in incomplete block (In lead V1, the Other: in the precordial leads, occurrence
QRS complex is wide and can appear in of triphasic complexes because the right
one of several patterns: an rSR’ complex ventricle continues to depolarize after the
with a wide S and R’ wave; an rsR’ com- left ventricle depolarizes, thereby produc-
plex with a wide R wave; and a wide R ing a third phase of ventricular stimulation
wave with an M-shaped pattern. The com-
144 ECGs
Pericarditis In pericarditis, ECG changes occur

in four stages. Stage 1 coincides with
Pericarditis is the inflammation of the the onset of chest pain. Stage 2 begins
pericardium — the fibroserous sac that within several days. Stage 3 starts sev-
envelops the heart. It can be acute or eral days after stage 2. Stage 4 occurs
chronic. The acute form may be fibri- weeks later.
nous or effusive, with a purulent
serous or hemorrhagic exudate. Chron- Intervention
ic constrictive pericarditis causes dense Pericarditis is usually treated with as-
fibrous pericardial thickening. Regard- pirin or nonsteroidal anti-inflammatory
less of the type, pericarditis can cause drugs. A last resort is corticosteroid
cardiac tamponade if fluid accumulates therapy, quickly tapered over 3 days.
too quickly. It can also cause heart fail-
ure if constriction occurs.
Characteristics of pericarditis
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Rhythm: usually regular atrial and ven- ST segment: in stage 1, elevated 1 to 2

tricular rhythms mm in a concave pattern in leads I, II, and
Rate: atrial and ventricular rates usually III and the precordial leads
within normal limits T wave: flattened in stage 2, inverted in
P wave: normal size and configuration stage 3 (lasting for weeks or months), and
PR interval: usually depressed in all returning to normal in stage 4 (although
leads except V1 and aVR, in which it may sometimes becoming deeply inverted)
be elevated QT interval: within normal limits
QRS complex: within normal limits, with Other: possible atrial fibrillation or tachy-
a possible decrease in amplitude cardia from sinoatrial node irritation
Common
4 laboratory tests
Giving care and interpreting results
Alanine aminotransferase 147

Aldosterone, serum 147
Alkaline phosphatase 148
Amylase, serum 149
Antinuclear antibodies 150
Arterial blood gas analysis 150
Aspartate aminotransferase 152
Bilirubin, serum 153
Blood urea nitrogen 154
Calcium, serum 154
Carcinoembryonic antigen 155
Cerebrospinal fluid analysis 156
Chloride, serum 158
Cholesterol, total 159
Creatine kinase 159
Creatinine, serum 162
Creatinine clearance 162
Erythrocyte sedimentation rate 163
Estrogens 163
Glucose, fasting plasma 164
Glucose, 2-hour postprandial plasma 165
Glucose tolerance test, oral 166
Hematocrit 167
Hemoglobin, glycosylated 167
Hemoglobin, total 168
145
146 Common laboratory tests
Hepatitis B surface antigen 168

Human chorionic gonadotropin, serum 169
Human chorionic gonadotropin, urine 170
Human immunodeficiency virus antibodies 171
Human leukocyte antigen test 174
International Normalized Ratio 174
Lactate dehydrogenase 175
Lipoprotein-cholesterol fractionation 176
Lyme disease serology 176
Magnesium, serum 177
Myoglobin 178
Occult blood, fecal 178
Partial thromboplastin time 179
Phosphate, serum 179
Platelet count 180
Potassium, serum 180
Prostate-specific antigen 181
Protein, urine 182
Protein electrophoresis, serum 183
Prothrombin time 185
Red blood cell count 185
Red blood cell indices 186
Sodium, serum 186
Thyroid-stimulating immunoglobulin 188
Thyroxine 188
Thyroxine, free and triiodothyronine, free 189
Triglycerides 189
Triiodothyronine 190
Triiodothyronine uptake 191
Troponin 192
Uric acid, serum 192
Urinalysis, routine 193
White blood cell count 196
White blood cell differential 197
Aldosterone, serum 147
severe hepatic congestion as a result of

Alanine aminotransferase heart failure.
Slight to moderate elevations of ALT
The alanine aminotransferase (ALT) may appear in any condition that pro-
test is used to measure serum levels of duces acute hepatocellular injury, such
ALT, one of two enzymes that catalyze as active cirrhosis and drug-induced or
a reversible amino group transfer reac- alcoholic hepatitis. Marginal elevations
tion in the Krebs cycle. ALT is neces- occasionally occur in acute myocardial
sary for energy production in tissues. infarction (MI), reflecting secondary
It’s found primarily in the liver, with hepatic congestion or the release of
lesser amounts in the kidneys, heart, small amounts of ALT from myocardial
and skeletal muscles. ALT is a sensitive tissue.
indicator of acute hepatocellular dis-
ease.
Aldosterone, serum
Purpose
◆ To detect acute hepatic disease, es- The aldosterone test measures serum
pecially hepatitis and cirrhosis without aldosterone levels by quantitative
jaundice, and evaluate its treatment analysis and radioimmunoassay. Aldo-
◆ To distinguish between myocardial sterone regulates ion transport across
and hepatic tissue damage (used with cell membranes to promote reabsorp-
aspartate aminotransferase) tion of sodium and chloride in ex-
◆ To assess the hepatotoxicity of some change for potassium and hydrogen
drugs ions. Consequently, it helps to main-
tain blood pressure and volume and
Patient preparation regulate fluid and electrolyte balance.
◆ Explain to the patient that this test This test identifies aldosteronism
is used to assess liver function. and, when supported by plasma renin
◆ Explain that the test requires a levels, distinguishes between the prima-
blood sample, and tell the patient ry and secondary forms of this disorder.
when and where it will be taken.
◆ Inform the patient that he need not Purpose
restrict food or fluids. ◆ To aid in the diagnosis of primary
and secondary aldosteronism, adrenal
Reference values hyperplasia, hypoaldosteronism, and
Serum ALT levels range from 10 to salt-losing syndrome
40 U/L (SI, 0.17 to 0.68 ␮kat/L) in
males and 7 to 35 U/L (SI, 0.12 to Patient preparation
0.60 ␮kat/L) in females. ◆ Explain to the patient that this test
helps determine if symptoms are caused
Abnormal findings by improper hormonal secretion.
Very high ALT levels (up to 50 times ◆ Explain that the test requires a
normal) suggest viral or severe drug- blood sample, and tell the patient
induced hepatitis or other hepatic dis- when and where it will be taken.
ease with extensive necrosis. Moderate ◆ Instruct him to maintain a low-
to high levels may indicate infectious carbohydrate, normal-sodium diet
mononucleosis, chronic hepatitis, intra- (135 mEq or 3 g/day) for at least 2
hepatic cholestasis or cholecystitis, ear- weeks or, preferably, for 30 days before
ly or improving acute viral hepatitis, or the test.
◆ Withhold all drugs that alter fluid, transport. ALP measurements reflect
sodium, and potassium balance — es- the combined activity of several ALP
pecially diuretics, antihypertensives, isoenzymes that are found in the liver,
steroids, hormonal contraceptives, and bones, kidneys, intestinal lining, and
estrogens — for at least 2 weeks or, placenta. Bone and liver ALP is always
preferably, for 30 days before the test, present in adult serum, with liver ALP
as ordered. the most prominent except during the
◆ Withhold all renin inhibitors for 1 third trimester of pregnancy, when
week before the test, as ordered. If about half of all ALP originates in the
they must be continued, note this in- placenta. The intestinal variant of ALP
formation on the laboratory request. can be a normal component (found in
◆ Tell the patient to avoid licorice for less than 10% of normal patterns and
at least 2 weeks before the test because almost exclusively in the sera of pa-
it produces an aldosterone-like effect. tients with blood groups B and O), or
it can be an abnormal finding associat-
Reference values ed with hepatic disease.
Laboratory values vary with the time
of day and with the patient’s posture— Purpose
values are higher when patients are in ◆ To detect and identify skeletal dis-
an upright position. In upright individ- eases that are primarily characterized
uals, a normal value is 7 to 30 ng/dl by marked osteoblastic activity
(SI, 0.19 to 0.83 nmol/L). In supine in- ◆ To detect focal hepatic lesions that
dividuals, values are 3 to 16 ng/dl (SI, cause biliary obstruction, such as a tu-
0.08 to 0.44 nmol/L). mor or abscess
◆ To assess the patient’s response to
Abnormal findings vitamin D in the treatment of rickets
Excessive aldosterone secretion may in- ◆ To supplement information from
dicate a primary or secondary disease. other liver function studies and GI
Primary aldosteronism (Conn’s syn- enzyme tests
drome) may result from adrenocortical
adenoma or carcinoma or from bilater- Patient preparation
al adrenal hyperplasia. Secondary al- ◆ Explain to the patient that this test is
dosteronism can result from renovascu- used to assess liver and bone function.
lar hypertension, heart failure, cirrhosis ◆ Instruct the patient to fast for at least
of the liver, nephrotic syndrome, idio- 8 hours before the test because fat intake
pathic cyclic edema, and the third stimulates intestinal secretion of ALP.
trimester of pregnancy. ◆ Explain that this test requires a
Low serum aldosterone levels may blood sample, and tell the patient
indicate primary hypoaldosteronism, when and where it will be taken.
salt-losing syndrome, eclampsia, or Ad-
dison’s disease. Reference values
Total ALP levels normally range from
25 to 100 U/L (SI, 0.43 to 1.70 mkat/L)
Alkaline phosphatase in females older than 15 years and
males older than 20 years.
The alkaline phosphatase (ALP) test is
used to measure serum levels of ALP, Abnormal findings
an enzyme that affects bone calcifica- Although significant elevations may
tion as well as lipid and metabolite occur with diseases that affect many
Amylase, serum 149
organs, an elevated ALP level usually Purpose

indicates skeletal disease or extrahep- ◆ To diagnose acute pancreatitis
atic or intrahepatic biliary obstruction ◆ To distinguish between acute pan-
causing cholestasis. Many acute he- creatitis and other causes of abdominal
patic diseases cause elevated ALP lev- pain that require immediate surgery
els before they affect serum bilirubin ◆ To evaluate possible pancreatic in-
levels. jury caused by abdominal trauma or
Moderate increases in ALP levels surgery
may reflect acute biliary obstruction as
a result of hepatocellular inflammation Patient preparation
in active cirrhosis, mononucleosis, and ◆ Explain to the patient that this test
viral hepatitis. Moderate increases also is used to assess pancreatic function.
occur in osteomalacia and deficiency- ◆ Inform the patient that he need not
induced rickets. fast before the test but must abstain
Sharp elevations in ALP levels may from alcohol.
indicate complete biliary obstruction ◆ Explain that this test requires a
by malignant or infectious infiltrations blood sample, and tell the patient
or fibrosis. These are most common in when and where it will be taken.
Paget’s disease and occasionally occur
in biliary obstruction, extensive bone Reference values
metastasis, and hyperparathyroidism. Normal serum AML levels range from
Metastatic bone tumors caused by pan- 25 to 125 U/L (SI, 0.4 to 2.1 ␮kat/L)
creatic cancer increase ALP levels with- for adults age 18 and older.
out a concomitant rise in serum ALT
levels. Abnormal findings
Isoenzyme fractionation and addi- After the onset of acute pancreatitis,
tional enzyme tests (gamma glutamyl AML levels begin to rise within 2
transferase, lactate dehydrogenase hours, peak within 12 to 48 hours, and
[LD], 5-nucleotidase, and leucine return to normal within 3 to 4 days.
aminopeptidase) are sometimes per- Urine levels of AML should be mea-
formed when the cause of ALP eleva- sured after normal serum AML results
tion is in doubt. Rarely, low levels of are obtained to rule out pancreatitis.
serum ALP are associated with hy- Moderate serum elevations may accom-
pophosphatasia and protein or magne- pany obstruction of the common bile
sium deficiency. duct, pancreatic duct, or ampulla of
Vater; pancreatic injury from a perfo-
rated peptic ulcer; pancreatic cancer;
Amylase, serum and acute salivary gland disease. Im-
paired kidney function may increase
An enzyme that’s synthesized primari- serum levels.
ly in the pancreas and salivary glands, Levels may be slightly elevated in a
amylase (alpha-amylase, or AML) helps patient who is asymptomatic or re-
to digest starch and glycogen in the sponds unusually to therapy.
mouth, stomach, and intestine. In cas- Decreased levels can occur in
es of suspected acute pancreatic dis- chronic pancreatitis, pancreatic cancer,
ease, measurement of serum or urinary cirrhosis, hepatitis, and toxemia of
AML is the most important laboratory pregnancy.
test.
Reference values
Antinuclear antibodies Test results are reported as positive
(with pattern and serum titer noted) or
In conditions such as systemic lupus negative.
erythematosus (SLE), scleroderma, and
certain infections, the body’s immune Abnormal findings
system may perceive parts of its own Although this test is a sensitive indica-
cell nuclei as foreign and may produce tor of ANAs, it isn’t specific for SLE.
antinuclear antibodies (ANAs). Specific Low titers may occur in patients with
ANAs include antibodies to deoxyri- viral diseases, chronic hepatic disease,
bonucleic acid (DNA), nucleoprotein, collagen vascular disease, and autoim-
histones, nuclear ribonucleoprotein, mune diseases, and in some healthy
and other nuclear constituents. adults; the incidence increases with
Because they don’t penetrate living age. The higher the titer, the more spe-
cells, ANAs are harmless, but they cific the test is for SLE. The titer com-
sometimes form antigen–antibody commonly exceeds 1:256.
plexes that cause tissue damage (as in The pattern of nuclear fluorescence
SLE). Because several organs may be helps identify the type of immune dis-
involved, test results aren’t diagnostic ease present. A peripheral pattern is al-
and can only partially confirm clinical most exclusively associated with SLE
evidence. because it indicates anti-DNA antibod-
ies; sometimes anti-DNA antibodies are
Purpose measured by radioimmunoassay if
◆ To screen for SLE (The absence of ANA titers are high or if a peripheral
ANAs essentially rules out active pattern is observed. A homogeneous,
SLE.) or diffuse, pattern is also associated
◆ To monitor the effectiveness of im- with SLE and related connective tissue
munosuppressive therapy for SLE disorders. A nucleolar pattern is associ-
ated with scleroderma, and a speckled,
Patient preparation irregular pattern is associated with in-
◆ Explain to the patient that this test fectious mononucleosis and mixed con-
evaluates the immune system and that nective tissue disorders (for example,
further testing is usually required for SLE).
diagnosis. A single serum sample, especially
◆ Inform the patient that the test will one collected from a patient with col-
be repeated to monitor his response to lagen vascular disease, may contain
therapy, if appropriate. antibodies to several parts of the nu-
◆ Inform the patient that he need not cleus of the cell. In addition, as
restrict food or fluids. serum dilution increases, the fluores-
◆ Explain that the test requires a cent pattern may change because dif-
blood sample, and tell the patient ferent antibodies are reactive at differ-
when and where it will be taken. ent titers.
◆ Check the patient’s history for
drugs that may affect test results,
such as isoniazid and procainamide. Arterial blood gas analysis
Note the findings on the laboratory
request. Arterial blood gas (ABG) analysis is
used to measure the partial pressure of
Arterial blood gas analysis 151
arterial oxygen (PaO2), the partial ◆ SaO2: 95% to 100% (SI, 0.95 to
pressure of arterial carbon dioxide 1.00)
(PaCO2), and the pH of an arterial sam- ◆ HCO3–: 22 to 26 mEq/L (SI, 22 to
ple. It also measures the oxygen con- 26 mmol/L)
tent (O2CT), arterial oxygen saturation
(SaO2), and bicarbonate (HCO3–) level. Abnormal findings
A blood sample for ABG analysis may Low PaO2, O2CT, and SaO2 levels and a
be drawn by percutaneous arterial high PaCO2 may result from conditions
puncture or with an arterial line. that impair respiratory function, such
as respiratory muscle weakness or
Purpose paralysis, respiratory center inhibition
◆ To evaluate the efficiency of pulmo- (from head injury, brain tumor, or drug
nary gas exchange abuse), and airway obstruction (possi-
◆ To assess the integrity of the venti- bly from mucus plugs or a tumor).
latory control system Similarly, low readings may result from
◆ To determine the acid-base level of obstruction of the bronchioles as a re-
the blood sult of asthma or emphysema, from an
◆ To monitor respiratory therapy abnormal ventilation–perfusion ratio
caused by partially blocked alveoli or
Patient preparation pulmonary capillaries, or from alveoli
◆ Explain to the patient that this test that are damaged or filled with fluid
is used to evaluate how well the lungs because of disease, hemorrhage, or
are delivering oxygen to the blood and near-drowning.
eliminating carbon dioxide. When inspired air contains insuffi-
◆ Tell the patient that the test requires cient oxygen, PaO2, O2CT, and SaO2
a blood sample. Explain when and decrease, but PaCO2 may be normal.
where the test will be performed and Such findings are common in pneu-
tell the patient which site — radial, mothorax, in patients with impaired
brachial, or femoral artery — has been diffusion between the alveoli and
selected for the venipuncture. blood (as a result of interstitial fibrosis,
◆ Inform the patient that he need not for example), and in patients who have
restrict food or fluids. an arteriovenous shunt that permits
◆ Instruct the patient to breathe nor- blood to bypass the lungs.
mally during the test, and warn him Low O2CT — with normal PaO2,
that he may have brief cramping or SaO2 and, possibly, PaCO2 values — may
throbbing pain at the puncture site. result from severe anemia, decreased
blood volume, and reduced capacity to
Reference values carry hemoglobin oxygen.
Normal ABG values fall within the fol- In addition to clarifying blood oxy-
lowing ranges: gen disorders, ABG values can give
◆ PaO2: 80 to 100 mm Hg (SI, 10.6 to considerable information about acid-
13.3 kPa) base disorders. (See Recognizing acid-
◆ PaCO2: 35 to 45 mm Hg (SI, 4.7 to base disorders, page 152.)
5.9 kPa)
◆ pH: 7.35 to 7.45 (SI, 7.35 to 7.45)
◆ O2CT: 15% to 23% (SI, 0.15 to
0.23)
Recognizing acid-base disorders
DISORDER ABG FINDINGS POSSIBLE CAUSES
Respiratory acidosis ◆ pH ⬍ 7.35 ◆ CNS depression from drugs, in-

(excess CO2 retention) ◆ HCO3– ⬎ 26 mEq/L jury, or disease
(if compensating) ◆ Hypoventilation from respirato-
◆ PaCO2 ⬎ 45 mm Hg ry, cardiac, musculoskeletal, or neu-
romuscular disease
Respiratory alkalosis ◆ pH ⬎ 7.45 ◆ Hyperventilation as a result of

(excess CO2 loss) ◆ HCO3– ⬍ 22 mEq/L anxiety, pain, or improper ventila-
(if compensating) tor settings
◆ PaCO2 ⬍ 35 mm Hg ◆ Respiratory stimulation from
drugs, disease, hypoxia, fever, or
high room temperature
◆ Gram-negative bacteremia
Metabolic acidosis ◆ pH ⬍ 7.35 ◆ Depletion of HCO3– from renal

(HCO3– loss or acid ◆ HCO3– ⬍ 22 mEq/L disease, diarrhea, or small-bowel
retention) ◆ PaCO2 ⬍ 35 mm Hg fistulas
(if compensating) ◆ Excessive production of organic
acids from hepatic disease, en-
docrine disorders such as diabetes
mellitus, hypoxia, shock, or drug
toxicity
◆ Inadequate excretion of acids as
a result of renal disease
Metabolic alkalosis ◆ pH ⬎ 7.45 ◆ Loss of hydrochloric acid from

(HCO3– retention or ◆ HCO3– ⬎ 26 mEq/L prolonged vomiting or gastric suc-
acid loss) ◆ PaCO2 ⬎ 45 mm tioning
Hg (if compensating) ◆ Loss of potassium from in-
creased renal excretion (as in di-
uretic therapy) or corticosteroid
overdose
◆ Excessive ingestion of alkali
muscles, kidneys, pancreas, and red

Aspartate blood cells (RBCs). It’s released into
aminotransferase serum in proportion to cellular damage.
Aspartate aminotransferase (AST) is one Purpose

of two enzymes that catalyze the con- ◆ To aid in the detection and differen-
version of the nitrogenous portion of an tial diagnosis of acute hepatic disease
amino acid to an amino acid residue. ◆ To monitor the progress and prog-
It’s essential to energy production in the nosis of patients with cardiac and he-
Krebs cycle. AST is found in the cyto- patic diseases
plasm and mitochondria of many cells,
primarily in the liver, heart, skeletal
Bilirubin, serum 153
◆ To aid in the diagnosis of MI in cor- Moderate to high levels (5 to 10

relation with creatine kinase (CK) and times normal) may indicate dermato-
LD levels myositis, Duchenne muscular dystro-
phy, or chronic hepatitis. Moderate to
Patient preparation high levels also occur during the pro-
◆ Explain to the patient that this test dromal and resolving stages of diseases
is used to assess heart and liver func- that cause high elevations.
tion. Low to moderate levels (two to five
◆ Inform the patient that the test usu- times normal) occur at some time dur-
ally requires three venipunctures (one ing the course of the conditions or dis-
on admission and one each day for the eases discussed earlier or may indicate
next 2 days). hemolytic anemia, metastatic hepatic
◆ Tell the patient that he need not re- tumors, acute pancreatitis, pulmonary
strict food or fluids. emboli, delirium tremens, or fatty liver.
AST levels increase slightly after the
Reference values first few days of biliary duct obstruc-
AST levels range from 14 to 20 U/L (SI, tion.
0.23 to 0.33 ␮kat/L) in males and from
10 to 36 U/L (SI, 0.17 to 0.60 ␮kat/L)
in females. In newborns, levels are 47 Bilirubin, serum
to 150 U/L (SI, 0.78 to 2.5 ␮kat/L). In
children, they are 9 to 80 U/L (SI, 0.15 The bilirubin test is used to measure
to 1.3 ␮kat/L). serum levels of bilirubin, the predomi-
nant pigment in bile. Bilirubin is the
Abnormal findings major product of Hb catabolism. Serum
AST levels fluctuate in response to the bilirubin measurements are especially
extent of cellular necrosis. They are significant in neonates because elevat-
transiently and minimally increased ed unconjugated bilirubin can accumu-
early in the disease process and ex- late in the brain, causing irreparable
tremely increased during the most damage.
acute phase. Depending on when the
initial sample is drawn, AST levels may Purpose
increase, indicating increasing severity ◆ To evaluate liver function
of disease and tissue damage, or they ◆ To aid in the differential diagnosis
may decrease, indicating resolution of of jaundice and monitor its progress
disease and tissue repair. ◆ To aid in the diagnosis of biliary ob-
Maximum elevations (more than 20 struction and hemolytic anemia
times normal) may indicate acute viral ◆ To determine whether a neonate re-
hepatitis, severe skeletal muscle trau- quires an exchange transfusion or pho-
ma, extensive surgery, drug-induced totherapy because of dangerously high
hepatic injury, or severe passive liver levels of unconjugated bilirubin
congestion.
High levels (10 to 20 times normal) Patient preparation
may indicate severe MI, severe infec- ◆ Explain to the patient that this test
tious mononucleosis, or alcoholic cir- is used to evaluate liver function and
rhosis. High levels may also occur dur- the condition of RBCs.
ing the prodromal and resolving stages ◆ Explain that the test requires a
of conditions that cause maximum ele- blood sample, and tell the patient
vations. when and where it will be taken.
◆ Inform the adult patient that he of urea, the chief end product of pro-
need not restrict fluids but should fast tein metabolism. Formed in the liver
for at least 4 hours before the test. from ammonia and excreted by the kid-
(Fasting isn’t necessary for neonates.) neys, urea constitutes 40% to 50% of
◆ If the patient is an infant, tell the the nonprotein nitrogen in the blood.
parents that a small amount of blood The BUN level reflects protein intake
will be drawn from his heel. Tell them and renal excretory capacity but is a
who will be performing the heelstick less reliable indicator of uremia than
and when it will be performed. the serum creatinine level.
Reference values Purpose

In adults, the normal indirect serum ◆ To evaluate kidney function and aid
bilirubin level is 1 mg/dl (SI, 17 ␮mol/ in the diagnosis of renal disease
L) and the direct serum bilirubin level ◆ To aid in the assessment of hydra-
is less than 0.5 mg/dl (SI, ⬍ 6.8 tion
␮mol/L). In neonates, the total serum
bilirubin level is 2 to 12 mg/dl (SI, 34 Patient preparation
to 205 ␮mol/L). ◆ Tell the patient that this test is used
to evaluate kidney function.
Abnormal findings ◆ Inform the patient that he need not
Elevated indirect serum bilirubin lev- restrict food or fluids but should avoid
els usually indicate hepatic damage. a diet high in meat.
High levels of indirect bilirubin are ◆ Explain that the test requires a
also likely in severe hemolytic anemia. blood sample, and tell the patient
If hemolysis continues, levels of both when and where it will be taken.
direct and indirect bilirubin may rise.
Other causes of elevated indirect Reference values
bilirubin levels include congenital en- BUN values normally range from 8 to 20
zyme deficiencies such as Gilbert’s mg/dl (SI, 2.9 to 7.5 mmol/L), with
disease. slightly higher values in elderly patients.
Elevated direct serum bilirubin lev-
els usually indicate biliary obstruction. Abnormal findings
If the obstruction continues, both di- Elevated BUN levels occur in renal dis-
rect and indirect bilirubin levels may ease, reduced renal blood flow (as a re-
rise. In severe chronic hepatic damage, sult of dehydration, for example), uri-
direct bilirubin concentrations may re- nary tract obstruction, and increased
turn to normal or near-normal levels, protein catabolism (such as burn in-
but indirect bilirubin levels remain ele- juries).
vated. Low BUN levels occur in severe he-
In neonates, total bilirubin levels of patic damage, malnutrition, and over-
15 mg/dl (SI, 257 ␮mol/L) or more in- hydration.
dicate the need for an exchange trans-
fusion.
Calcium, serum
Blood urea nitrogen About 99% of the calcium in the body
is found in the teeth. Approximately
The blood urea nitrogen (BUN) test is 1% of total calcium in the body circu-
used to measure the nitrogen fraction lates in the blood. Of this, about 50%
Carcinoembryonic antigen 155
is bound to plasma proteins and 40% total parathyroidectomy, and malab-

is ionized, or free. Evaluation of serum sorption. Decreased serum calcium lev-
calcium levels measures the total els may also occur with Cushing’s syn-
amount of calcium in the blood, and drome, renal failure, acute pancreatitis,
ionized calcium measures the fraction peritonitis, malnutrition with hypoalbu-
of serum calcium that’s in the ionized minemia, renal failure, and blood
form. transfusions (as a result of citrate).
In the patient with hypocalcemia,
Purpose be alert for circumoral and peripheral
◆ To evaluate endocrine function, calci- numbness and tingling, muscle twitch-
um metabolism, and acid-base balance ing, Chvostek’s sign (facial muscle
◆ To guide therapy in patients with re- spasm), tetany, muscle cramping,
nal failure, renal transplant, endocrine Trousseau’s sign (carpopedal spasm),
disorders, malignancies, cardiac dis- seizures, arrhythmias, laryngeal spasm,
ease, and skeletal disorders decreased cardiac output, prolonged
bleeding time, fractures, and prolonged
Patient preparation Q interval.
◆ Explain to the patient that this test
is used to determine blood calcium
levels. Carcinoembryonic antigen
◆ Explain that the test requires a
blood sample, and tell the patient Carcinoembryonic antigen (CEA) is a
when and where it will be taken. protein that’s normally found in em-
◆ Inform the patient that he need not bryonic entodermal epithelium and fe-
restrict food or fluids. tal GI tissue. Production of CEA stops
before birth, but it may begin again lat-
Reference values er if a neoplasm develops. Because bil-
Normally, total calcium levels range iary obstruction, alcoholic hepatitis,
from 8.8 to 10.4 mg/dl (SI, 2.2 to chronic heavy smoking, and other con-
2.6 mmol/L) in adults and from 8.8 to ditions also increase CEA levels, this
10.7 mg/dl (SI, 2.20 to 2.67 mmol/L) in test can’t be used as a general indica-
children. Ionized calcium levels are 4.65 tor of cancer. The measurement of en-
to 5.28 mg/dl (SI, 1.16 to 1.32 mmol/L). zyme CEA levels by immunoassay is
useful for staging and monitoring the
Abnormal findings treatment of certain cancers.
Abnormally high serum calcium levels
(hypercalcemia) may occur in hyper- Purpose
parathyroidism and parathyroid tu- ◆ To monitor the effectiveness of can-
mors, Paget’s disease of the bone, mul- cer therapy
tiple myeloma, metastatic carcinoma, ◆ To assist in the preoperative staging
multiple fractures, and prolonged im- of colorectal cancers, assess the ade-
mobilization. Elevated levels may also quacy of surgical resection, and test for
result from inadequate excretion of cal- recurrence of colorectal cancers
cium, such as in adrenal insufficiency
and renal disease; from excessive in- Patient preparation
gestion of calcium; and from overuse ◆ Explain to the patient that this test
of antacids such as calcium carbonate. detects and measures a special protein
Low calcium levels (hypocalcemia) that isn’t normally present in adults.
may result from hypoparathyroidism,
◆ Inform the patient that the test will ◆ To aid in the diagnosis of viral or
be repeated to monitor the effective- bacterial meningitis, subarachnoid or
ness of therapy, if appropriate. intracranial hemorrhage, tumors, and
◆ Inform the patient that he need not brain abscesses
restrict food, fluids, or medications. ◆ To aid in the diagnosis of neuro-
◆ Explain that the test requires a syphilis and chronic central nervous
blood sample, and tell the patient system infections
when and where it will be taken. ◆ To aid in the diagnosis of dementia
Reference values Patient preparation

Normal serum CEA values are less ◆ Describe the procedure to the pa-
than 5 ng/ml (SI, ⬍ 5 mg/L). tient, and explain that this test ana-
lyzes the fluid around the spinal cord.
Abnormal findings ◆ Inform him that he need not restrict
Persistent elevation of CEA levels sug- food or fluids.
gests residual or recurrent tumor. If ◆ Tell him who will perform the pro-
levels exceed normal before surgical cedure and where it will be performed.
resection, chemotherapy, or radiation ◆ Advise the patient that a headache
therapy, a return to normal within is the most common adverse effect of a
6 weeks suggests successful treatment. lumbar puncture, but reassure him that
High CEA levels are characteristic of his cooperation during the test helps to
various malignant conditions, particu- minimize this effect.
larly entodermally derived neoplasms ◆ Make sure that the patient or his le-
of the GI organs and lungs, and of cer- gal guardian has signed the appropriate
tain nonmalignant conditions, such as consent form.
benign hepatic disease, hepatic cirrho- ◆ If the patient is unusually anxious,
sis, alcoholic pancreatitis, and inflam- assess him and report his vital signs.
matory bowel disease.
Elevated CEA concentrations may Normal findings
occur in nonendodermal carcinomas, For a summary of normal and abnormal
such as breast and ovarian cancers. findings, see Findings in cerebrospinal
fluid analysis.
Normally, CSF pressure is recorded
Cerebrospinal fluid analysis and the appearance of the specimen is
checked. Three tubes of CSF are col-
For qualitative analysis, cerebrospinal lected routinely and are sent to the lab-
fluid (CSF) is most commonly obtained oratory for analysis of protein, sugar,
by lumbar puncture (usually between and cells as well as for serologic test-
the third and fourth lumbar vertebrae) ing, such as the Venereal Disease Re-
and, rarely, by cisternal or ventricular search Laboratory test for neurosyph-
puncture. A CSF specimen may also be ilis. A separate specimen is sent to the
obtained during other neurologic tests laboratory for culture and sensitivity
such as myelography. testing. Electrolyte analysis and Gram
stain may be ordered as supplementary
Purpose tests. CSF electrolyte levels are of spe-
◆ To measure CSF pressure as an aid cial interest in patients with abnormal
in detecting obstruction of CSF circula- serum electrolyte levels or CSF infec-
tion tion and in those receiving hyperosmo-
lar agents.
Cerebrospinal fluid analysis 157
Findings in cerebrospinal fluid analysis
TEST NORMAL ABNORMAL IMPLICATIONS
Pressure 50 to 180 mm Increase ◆ Increased intracranial

H2O pressure
Decrease ◆ Spinal subarachnoid ob-

struction above puncture site
Appearance Clear, colorless Cloudy ◆ Infection
Xanthochromic ◆ Subarachnoid, intracere-

or bloody bral, or intraventricular hem-
orrhage; spinal cord obstruc-
tion; traumatic tap (usually
noted only in initial specimen)
Brown, orange, ◆ Elevated protein levels,

or yellow red blood cell (RBC) break-
down (blood present for at
least 3 days)
Protein 15 to 45 mg/dl Marked increase ◆ Tumors, trauma, hemor-

(SI, 150 to rhage, diabetes mellitus,
450 mg/L) polyneuritis, blood in cere-
brospinal fluid (CSF)
Marked decrease ◆ Rapid production of CSF
Gamma 3% to 12% of Increase ◆ Demyelinating disease,

globulin total protein neurosyphilis, Guillain-Barré
syndrome
Glucose 40 to 70 mg/dl Increase ◆ Systemic hyperglycemia

(SI, 2.2 to 3.9
mmol/L) Decrease ◆ Systemic hypoglycemia,
bacterial or fungal infection,
meningitis, mumps, postsub-
arachnoid hemorrhage
Cell count 0 to 5 white Increase ◆ Active disease: meningitis,

blood cells acute infection, onset of
chronic illness, tumor, ab-
scess, infarction, demyelinat-
ing disease
No RBCs RBCs ◆ Hemorrhage or traumatic

lumbar puncture
(continued)
Findings in cerebrospinal fluid analysis (continued)
TEST NORMAL ABNORMAL IMPLICATIONS
Venereal Nonreactive Positive ◆ Neurosyphilis

Disease
Research Labo-
ratories test for
syphilis, and
other serologic
tests
Chloride 118 to 130 Decrease ◆ Infected meninges

mEq/L (SI, 118
to 130 mmol/L)
Gram stain No organisms Gram-positive ◆ Bacterial meningitis

or gram-
negative
organisms
◆ Inform the patient that he need not

Chloride, serum restrict food or fluids.
The chloride test is used to measure Reference values

serum levels of chloride, the major ex- Normally, serum chloride levels range
tracellular fluid anion. Chloride helps from 98 to 108 mEq/L (SI, 98 to
maintain the osmotic pressure of blood 108 mmol/L) in adults.
and, therefore, helps regulate blood vol-
ume and arterial pressure. Chloride lev- Abnormal findings
els also affect the acid-base balance. Chloride levels are inversely related to
Chloride is absorbed from the intestines bicarbonate levels, reflecting the acid-
and excreted primarily by the kidneys. base balance. Excessive loss of gastric
juices or other secretions that contain
Purpose chloride may cause hypochloremic
◆ To detect an acid-base imbalance metabolic alkalosis; excessive retention
(acidosis or alkalosis) and to aid in the or ingestion of chloride may lead to hy-
evaluation of fluid status and extracel- perchloremic metabolic acidosis.
lular cation–anion balance Increased blood chloride levels oc-
cur in patients with severe dehydra-
Patient preparation tion, complete renal shutdown, head
◆ Explain to the patient that this test injury (producing neurogenic hyper-
is used to evaluate the chloride content ventilation), and primary aldosteron-
of blood. ism.
◆ Explain that the test requires a Decreased blood chloride levels oc-
blood sample, and tell the patient cur in patients with low sodium and
when it will be taken. potassium levels as a result of
Creatine kinase 159
prolonged vomiting, gastric suctioning, ◆ children ages 12 to 18: desirable,

intestinal fistula, chronic renal failure, less than 170 mg/dl (SI, ⬍ 4.40
and Addison’s disease. Heart failure or mmol/L).
edema resulting in excess extracellular
fluid can cause dilutional hypochlor- Abnormal findings
emia. Elevated serum cholesterol levels (hy-
percholesterolemia) may indicate a
risk of CAD as well as incipient he-
Cholesterol, total patitis, lipid disorders, bile duct block-
age, nephrotic syndrome, obstructive
The total cholesterol test, the quantita- jaundice, pancreatitis, and hypothy-
tive analysis of serum cholesterol, is roidism.
used to measure the circulating levels Low serum cholesterol levels (hypo-
of free cholesterol and cholesterol es- cholesterolemia) are commonly associ-
ters. It reflects the level of the two ated with malnutrition, cellular necro-
forms in which this biochemical sis of the liver, and hyperthyroidism.
compound appears in the body. High Patients who have abnormal choles-
serum cholesterol levels may be associ- terol levels typically must undergo fur-
ated with an increased risk of coronary ther testing to pinpoint the cause.
artery disease (CAD).
Purpose Creatine kinase

◆ To assess the risk of CAD
◆ To evaluate fat metabolism CK is an enzyme that catalyzes the
◆ To aid in the diagnosis of nephrot- creatine–creatinine metabolic pathway
ic syndrome, pancreatitis, hepatic dis- in muscle cells and brain tissue. Be-
ease, hypothyroidism, and hyperthy- cause of its intimate role in energy pro-
roidism duction, CK reflects normal tissue ca-
◆ To assess the efficacy of lipid- tabolism. Increased serum levels indi-
lowering drug therapy cate trauma to cells.
Fractionation and measurement of
Patient preparation three distinct CK isoenzymes — CK-BB
◆ Explain to the patient that this test (CK1), CK-MB (CK2), and CK-MM
is used to assess the body’s fat metab- (CK3) — have replaced the use of total
olism. CK levels to localize the site of in-
◆ Explain that the test requires a creased tissue destruction. CK-BB is
blood sample, and tell the patient most commonly found in brain tissue.
when and where it will be taken. CK-MM and CK-MB are found primari-
◆ Instruct the patient not to eat or ly in skeletal and heart muscle. In ad-
drink for 12 hours before the test, but dition, subunits of CK-MB and CK-MM,
inform him that he may have water. called isoforms or isoenzymes, can be
assayed to increase the sensitivity of
Reference values the test.
Total cholesterol concentrations vary
with age and sex. Total cholesterol val- Purpose
ues are: ◆ To detect and diagnose acute MI
◆ adults: desirable, less than 200 and reinfarction (CK-MB is primarily
mg/dl (SI, ⬍ 5.18 mmol/L) used.)
◆ To evaluate possible causes of chest CK-MB levels greater than 6% of

pain and to monitor the severity of the total CK level indicate MI, especial-
myocardial ischemia after cardiac sur- ly if the LD isoenzyme ratio is greater
gery, cardiac catheterization, and car- than 1 (flipped LD). In acute MI and
dioversion (CK-MB is primarily used.) after cardiac surgery, CK-MB begins to
◆ To detect early dermatomyositis and increase within 2 to 4 hours, peaks
musculoskeletal disorders that aren’t within 12 to 24 hours, and usually re-
neurogenic in origin such as Duchenne turns to normal within 24 to 48 hours.
muscular dystrophy (Total CK is pri- Persistent elevations and increasing
marily used.) levels indicate ongoing myocardial
damage. The total CK level follows
Patient preparation roughly the same pattern but increases
◆ Explain to the patient that this test slightly later. CK-MB levels may not in-
is used to assess myocardial and mus- crease in heart failure or during angina
culoskeletal function and that multiple pectoris that’s not accompanied by
blood samples are required to detect myocardial cell necrosis. Serious skele-
fluctuations in serum levels. tal muscle injury that occurs in certain
◆ Tell the patient when and where the muscular dystrophies, polymyositis,
blood samples will be taken. and severe myoglobinuria may cause a
◆ If the patient is being evaluated for mild increase in CK-MB because a
musculoskeletal disorders, advise him small amount of this isoenzyme is pre-
to avoid exercising for 24 hours before sent in some skeletal muscles.
the test. CK-MM values increase after skele-
tal muscle damage as a result of trau-
Reference values ma, such as surgery and I.M. injec-
Total CK values determined by ultravio- tions, and from diseases, such as der-
let or kinetic measurement range from matomyositis and muscular dystrophy
38 to 174 U/L (SI, 0.63 to 2.90 ␮kat/L) (values may be 50 to 100 times nor-
for men and from 26 to 140 U/L (SI, mal). CK-MM levels increase moderate-
0.46 to 2.38 ␮kat/L) for women. CK ly in patients with hypothyroidism;
levels may be significantly higher in sharp increases occur with muscle ac-
muscular people. Infants up to age 1 tivity caused by agitation, such as dur-
have levels two to four times higher ing an acute psychotic episode.
than adult levels, possibly reflecting Total CK levels may be increased in
birth trauma and striated muscle devel- patients with severe hypokalemia, car-
opment. Normal ranges for isoenzyme bon monoxide poisoning, malignant
levels are as follows: CK-BB, unde- hyperthermia, and alcoholic cardiomy-
tectable; CK-MB, less than 6% (SI, opathy. They may also be increased af-
⬍ 0.06); CK-MM, 90% to 100% (SI, ter seizures and, occasionally, in pa-
0.90 to 1.00). tients who have had pulmonary or
cerebral infarctions. Troponin I and
Abnormal findings cardiac troponin C are present in the
CK-MM makes up 99% of the total CK contractile cells of cardiac myocardial
that’s normally present in serum. De- tissue and are released when myocar-
tectable CK-BB isoenzyme may indicate, dial tissue is injured. Troponin levels
but doesn’t confirm, a diagnosis of brain increase within 1 hour of infarction
tissue injury, widespread malignant tu- and may remain elevated for as long as
mors, severe shock, or renal failure. 14 days. (See Serum protein and isoen-
zyme levels after MI.)
Creatine kinase 161
Serum protein and isoenzyme levels after MI
Because they’re released by damaged tissue, serum proteins and isoenzymes (catalytic
proteins that vary in concentration in specific organs) can help identify the compromised
organ and assess the extent of damage after myocardial infarction (MI). The serum pro-
tein and isoenzyme determinations listed below are most significant after MI.
Isoenzymes Proteins
◆ Creatine kinase-MB (CK-MB): in heart ◆ Troponin I and troponin T (the cardiac
muscle and a small amount in skeletal contractile proteins) have greater sensitivi-
muscle ty than CK-MB in detecting myocardial in-
jury
onset of chest pain
30 hours
36 hours
48 hours
12 hours
18 hours
24 hours
42 hours
10 days
11 days
12 days
6 hours
3 days
4 days
5 days
6 days
7 days
8 days
9 days
Enzyme and
isoenzyme levels
50X
20X
Increase above normal
15X
10X
5X
4X
3X
2X
Normal range
KEY Myoglobin Troponin T

CK-MB Troponin I
Creatinine clearance is an excellent

Creatinine, serum diagnostic indicator of renal function.
The test determines how efficiently the
Analysis of serum creatinine levels pro- kidneys are clearing creatinine from
vides a more sensitive measure of renal the blood. The rate of clearance is ex-
damage than BUN levels. Creatinine is pressed in terms of the volume of blood
a nonprotein end product of creatine (in milliliters) that can be cleared of cre-
metabolism that appears in serum in atinine in 1 minute. Creatinine levels
amounts proportional to muscle mass. become abnormal when more than 50%
of the nephrons have been damaged.
Purpose
◆ To assess glomerular filtration Purpose
◆ To screen for renal damage ◆ To assess renal function (primarily
glomerular filtration)
Patient preparation ◆ To monitor the progression of renal
◆ Explain to the patient that this test insufficiency
is used to evaluate kidney function.
◆ Explain that the test requires a Patient preparation
blood sample, and tell the patient ◆ Explain to the patient that this test
when and where it will be taken. assesses kidney function.
◆ Instruct the patient that he need not ◆ Inform the patient that he may need
restrict food or fluids. to avoid meat, poultry, fish, tea, or cof-
fee for 6 hours before the test.
Reference values ◆ Advise the patient to avoid strenu-
Creatinine concentrations normally ous physical exercise during the collec-
range from (0.9 to 1.3 mg/dl (SI, 80 tion period.
to 115 ␮mol/L) in men and 0.6 to ◆ Tell the patient that the test requires
1.1 mg/dl (SI, 53 to 97 ␮mol/L) in a timed urine specimen and at least
women. one blood sample.
◆ Tell the patient how the urine speci-
Abnormal findings men will be collected, and inform him
Elevated serum creatinine levels usual- when and where the blood sample will
ly indicate renal disease that has seri- be taken.
ously damaged 50% or more of the
nephrons. Elevated levels may also be Reference values
associated with gigantism and acro- Normal creatinine clearance varies
megaly. with age; in men, it ranges from
94 to 140 ml/min/1.73 m2 (SI, 0.91 to
1.35 ml/s/m2); in women, 72 to
Creatinine clearance 110 ml/min/1.73 m2 (SI, 0.69 to
1.06 ml/s/m2).
An anhydride of creatine, creatinine is
formed and excreted in constant Abnormal findings
amounts by an irreversible reaction. It Low creatinine clearance may result
functions solely as the main end prod- from reduced renal blood flow (associ-
uct of creatine. Creatinine production is ated with shock or renal artery ob-
proportional to total muscle mass and struction), acute tubular necrosis, acute
is relatively unaffected by urine vol- or chronic glomerulonephritis, ad-
ume, normal physical activity, or diet. vanced bilateral chronic pyelonephritis,
Estrogens 163
advanced bilateral renal lesions (which Abnormal findings

may occur in polycystic kidney disease, The ESR increases in pregnancy, ane-
renal tuberculosis, and cancer), neph- mia, acute or chronic inflammation, tu-
rosclerosis, heart failure, or severe de- berculosis, paraproteinemias (especial-
hydration. ly multiple myeloma and Walden-
High creatinine clearance can sug- ström’s macroglobulinemia), rheumatic
gest poor hydration. fever, rheumatoid arthritis, and some
cancers.
Polycythemia, sickle cell anemia,
Erythrocyte sedimentation hyperviscosity, and low plasma fibrino-
rate gen or globulin levels tend to depress
the ESR.
The erythrocyte sedimentation rate
(ESR) measures the degree of erythro-
cyte settling that occurs in a blood sam- Estrogens
ple during a specified amount of time.
The ESR is a sensitive but nonspecific Estrogens (and progesterone) are se-
test that’s commonly the earliest indica- creted by the ovaries. These hormones
tor of disease when other chemical or are responsible for the development of
physical signs are normal. The ESR secondary female sexual characteristics
usually increases significantly in wide- and for normal menstruation. Levels
spread inflammatory disorders; eleva- are usually undetectable in children.
tions may be prolonged in localized in- These hormones are secreted by the
flammation and malignant disease. ovarian follicular cells during the first
half of the menstrual cycle and by the
Purpose corpus luteum during the luteal phase
◆ To monitor inflammatory or malig- and during pregnancy. In menopause,
nant disease estrogen secretion drops to a constant,
◆ To aid in the detection and diagno- low level.
sis of occult disease, such as tuberculo- This radioimmunoassay measures
sis, tissue necrosis, or connective tissue serum levels of estradiol, estrone, and
disease estriol (the only estrogens that appear
in serum in measurable amounts) and
Patient preparation has diagnostic significance in evaluat-
◆ Explain to the patient that this test ing female gonadal dysfunction. (See
is used to evaluate the condition of Predicting premature labor, page 164.)
RBCs. Tests of hypothalamic-pituitary func-
◆ Explain that a blood sample will be tion may be required to confirm the
needed, and tell the patient when and diagnosis.
where it will be taken.
◆ Inform the patient that he need not Purpose
restrict food or fluids. ◆ To determine sexual maturation and
fertility
Reference values ◆ To aid in the diagnosis of gonadal
The ESR normally ranges from 0 to dysfunction, such as precocious or de-
15 mm/hour (SI, 0 to 15 mm/hour) in layed puberty, menstrual disorders (es-
men and 0 to 20 mm/hour (SI, 0 to pecially amenorrhea), and infertility
20 mm/hour) in women. Rates gradu- ◆ To determine fetal well-being
ally increase with age.
Predicting premature labor
A simple salivary test can help determine whether a pregnant woman is at risk for pre-
mature labor, a complication that’s detrimental to the health of the premature infant.
The test, known as the SalEst test, measures salivary levels of estriol, an estrogen that
increases a thousandfold during pregnancy. For women determined to be at risk, the
SalEst test is 98% accurate in ruling out premature labor and delivery.
The test is performed on women between 22 and 36 weeks’ gestation. The level of
estriol has been found to increase 2 to 3 weeks before the spontaneous onset of labor
and delivery. A positive result indicates that the patient is at risk for premature labor.
With this knowledge and evaluation by a physician, precautions can be instituted to de-
crease the risk of preterm labor and maintain fetal viability.
◆ To aid in the diagnosis of tumors week 30 to 30 ng/ml (SI, 105 nmol/L)

that are known to secrete estrogen by week 40.
Patient preparation Abnormal findings

◆ Tell the patient that this test helps Decreased estrogen levels may indicate
determine if the secretion of female primary hypogonadism, or ovarian fail-
hormones is normal, and explain that ure, as in Turner’s syndrome or ovarian
the test may be repeated during the agenesis; secondary hypogonadism,
various phases of the menstrual cycle. such as in hypopituitarism; or
◆ Tell the patient that she need not re- menopause.
strict food or fluids. Abnormally high estrogen levels
◆ Explain that the test requires a may occur with estrogen-producing tu-
blood sample, and tell the patient mors, in precocious puberty, and in se-
when and where it will be taken. vere hepatic disease (such as cirrhosis)
◆ Withhold all steroid and pituitary- that prevents the clearance of plasma
based hormones, as ordered. If they estrogens. High levels may also result
must be continued, note this on the from congenital adrenal hyperplasia
laboratory request. (increased conversion of androgens to
estrogen).
Reference values
Normal serum estrogen levels for pre-
menopausal women vary widely during Glucose, fasting plasma
the menstrual cycle, ranging from 26 to
149 pg/ml (SI, 90 to 550 pmol/L). The The fasting plasma glucose (or fasting
range for postmenopausal women is 0 blood sugar) test is used to measure
to 34 pg/ml (SI, 0 to 125 pmol/L). plasma glucose levels after a 12- to 14-
Serum estrogen levels in men range hour fast. This test is commonly used
from 12 to 34 pg/ml (SI, 40 to 125 to screen for diabetes mellitus, in
pmol/L). In children younger than age which absence or deficiency of insulin
6, the normal level of serum estrogen allows persistently high glucose levels.
is 3 to 10 pg/ml (SI, 10 to 36 pmol/L).
During pregnancy, the placenta se- Purpose
cretes large amounts of estriol. Levels ◆ To screen for diabetes mellitus
range from 2 ng/ml (SI, 7 nmol/L) by
Glucose, 2-hour postprandial plasma 165
◆ To monitor drug or diet therapy in Low plasma glucose levels can re-
patients with diabetes mellitus sult from hyperinsulinism, insulinoma,
von Gierke’s disease, functional and re-
Patient preparation active hypoglycemia, myxedema, adre-
◆ Explain to the patient that this test nal insufficiency, congenital adrenal
is used to detect disorders of glucose hyperplasia, hypopituitarism, malab-
metabolism and aids in the diagnosis sorption syndrome, and some cases of
of diabetes. hepatic insufficiency.
blood sample, and tell the patient
when and where it will be taken. Glucose, 2-hour postprandial
◆ Instruct the patient to fast for 12 to plasma
14 hours before the test.
◆ Alert the patient to the symptoms of Also called the 2-hour postprandial
hypoglycemia (weakness, restlessness, blood sugar test, the 2-hour postpran-
nervousness, hunger, and sweating), dial plasma glucose test is a valuable
and tell the patient to report such screening tool for detecting diabetes
symptoms immediately. mellitus. The test is performed when
the patient shows symptoms of dia-
Reference values betes (polydipsia and polyuria) or
The normal range for fasting plasma when the results of the fasting plasma
glucose level varies according to the glucose test suggest diabetes.
laboratory procedure. Usually, a normal
true glucose value after a fast of at Purpose
least 8 hours is 70 to 110 mg/dl of ◆ To aid in the diagnosis of diabetes
blood (SI, 3.9 to 6.1 mmol/L). mellitus
◆ To monitor drug or diet therapy in
Abnormal findings patients with diabetes mellitus
Confirmation of diabetes mellitus re-
quires fasting plasma glucose levels of Patient preparation
126 mg/dl (SI, 7 mmol/L) or more ob- ◆ Explain to the patient that this test
tained on two or more occasions. In is used to evaluate glucose metabolism
patients with borderline or transient el- and to detect diabetes.
evated levels, a 2-hour postprandial ◆ Explain that the test requires a
plasma glucose test or an oral glucose blood sample, and tell the patient
tolerance test may be performed to when and where it will be taken.
confirm the diagnosis. ◆ Tell the patient to eat a balanced
Increased fasting plasma glucose meal or one containing 100 g of carbo-
levels can also result from pancreatitis, hydrates before the test and then to
recent acute illness (such as MI), Cush- fast for 2 hours. Instruct him to avoid
ing’s syndrome, acromegaly, and pheo- smoking and strenuous exercise after
chromocytoma. Hyperglycemia may the meal.
also stem from hyperlipoproteinemia
(especially type III, IV, or V), chronic Reference values
hepatic disease, nephrotic syndrome, In a patient who doesn’t have diabetes,
brain tumor, sepsis, or gastrectomy postprandial glucose values are less
with dumping syndrome. It’s also typi- than 145 mg/dl (SI, ⬍ 8 mmol/L) by
cal in eclampsia, anoxia, and seizure the glucose oxidase or hexokinase
disorder.
method; levels are slightly elevated in ◆ To aid in the diagnosis of hypo-

people older than age 50. glycemia and malabsorption syndrome
Abnormal findings Patient preparation

Two 2-hour postprandial blood glucose ◆ Explain to the patient that this test
values of 200 mg/dl (SI, 11.1 mmol/L) is used to evaluate glucose metabo-
or above indicate diabetes mellitus. lism.
High levels may also occur with pan- ◆ Instruct the patient to maintain a
creatitis, Cushing’s syndrome, acro- high-carbohydrate diet for 3 days and
megaly, and pheochromocytoma. then fast for 10 to 16 hours before the
Hyperglycemia may also be caused by test, as instructed by the physician.
hyperlipoproteinemia (especially type ◆ Tell the patient not to smoke, drink
III, IV, or V), chronic hepatic disease, coffee or alcohol, or exercise strenuous-
nephrotic syndrome, brain tumor, sep- ly for 8 hours before or during the test.
sis, gastrectomy with dumping syn- ◆ Tell the patient that this test re-
drome, eclampsia, anoxia, and seizure quires five blood samples and usually
disorders. five urine samples.
Low glucose levels occur in hyper- ◆ Suggest to the patient that he bring
insulinism, insulinoma, von Gierke’s a book or another quiet diversion with
disease, functional and reactive hypo- him to the test. The procedure usually
glycemia, myxedema, adrenal insuffi- takes 3 hours but can last as long as 6
ciency, congenital adrenal hyperplasia, hours.
hypopituitarism, malabsorption syn- ◆ Alert the patient to the symptoms of
drome, and some cases of hepatic in- hypoglycemia (weakness, restlessness,
sufficiency. nervousness, hunger, and sweating),
and tell him to report such symptoms
immediately.
Glucose tolerance test,
oral Reference values
Normal plasma glucose levels peak at
The oral glucose tolerance test is the 160 to 180 mg/dl (SI, 8.8 to 9.9
most sensitive method of evaluating mmol/L) within 30 minutes to 1 hour
borderline cases of diabetes mellitus. after the administration of an oral
Plasma and urine glucose levels are glucose test dose. They return to fast-
monitored for 3 hours after the patient ing levels or lower within 2 to 3 hours.
ingests a challenge dose of glucose. Urine glucose test results remain nega-
This test is performed to assess insulin tive throughout.
secretion and the ability to metabolize
glucose. Abnormal findings
The oral glucose tolerance test isn’t Decreased glucose tolerance, in which
normally used in patients with fasting levels peak sharply before falling slow-
plasma glucose values greater than ly to fasting levels, may confirm dia-
140 mg/dl (SI, ⬎ 7.7 mmol/L) or post- betes mellitus or may result from Cush-
prandial plasma glucose values greater ing’s disease, hemochromatosis, pheo-
than 200 mg/dl (SI, ⬎ 11 mmol/L). chromocytoma, or central nervous
system lesions.
Purpose Increased glucose tolerance, in
◆ To confirm the diagnosis of diabetes which levels may peak at less than
mellitus in selected patients normal, may indicate insulinoma,
Hemoglobin, glycosylated 167
malabsorption syndrome, adrenocorti- performing the test, and the patient’s

cal insufficiency (Addison’s disease), age and sex, as follows:
hypothyroidism, or hypopituitarism. ◆ neonates age 2 weeks: 44% to 64%
(SI, 0.44 to 0.64)
◆ infants age 1 month: 37% to 49%
Hematocrit (SI, 0.37 to 0.49)
◆ infants age 3 months: 30% to 36%
A hematocrit (HCT) test may be done (SI, 0.3 to 0.36)
separately or as part of a complete ◆ infants age 1 year: 29% to 41% (SI,
blood count. It measures the percent- 0.29 to 0.41)
age of packed RBCs by volume in a ◆ children ages 1 to 6 years: 30% to
sample of whole blood; for example, 40% (SI, 0.3 to 0.4)
an HCT of 40% indicates that a 100-ml ◆ children ages 6 to 16 years: 32% to
sample of blood contains 40 ml of 42% (SI, 0.32 to 0.42)
packed RBCs. Packing is achieved by ◆ children ages 16 to 18 years: 34%
centrifuging anticoagulated whole to 44% (SI, 0.34 to 0.44)
blood in a capillary tube so that RBCs ◆ men: 42% to 52% (SI, 0.42 to 0.52)
are packed tightly without hemolysis. ◆ women: 36% to 48% (SI, 0.36 to
0.48)
Purpose
◆ To aid in the diagnosis of poly- Abnormal findings
cythemia, anemia, or abnormal states Low HCT suggests anemia, hemodilu-
of hydration tion, or massive blood loss. High HCT
◆ To aid in the calculation of RBC in- indicates polycythemia or hemoconcen-
dices tration as a result of blood loss and de-
hydration.
Patient preparation
◆ Explain to the patient that HCT is
tested to detect anemia and other ab- Hemoglobin, glycosylated
normal blood conditions.
◆ Explain that the test requires a Also called total fasting Hb, the glyco-
blood sample, and tell the patient sylated Hb test is used to monitor dia-
when and where it will be taken. betes therapy. Measurement of glyco-
◆ If the patient is a child, explain to sylated Hb levels provides informa-
him (if he’s old enough) and his par- tion about the average blood glucose
ents that a small amount of blood will level during the preceding 2 to 3
be taken from the finger or earlobe. months. This test requires only one
◆ Inform the patient that he need not venipuncture every 6 to 8 weeks.
restrict food or fluids. Therefore, it can be used to evaluate
the long-term effectiveness of
Reference values diabetes therapy.
HCT is usually measured electronically.
The results are 3% lower than those Purpose
obtained with manual measurements, ◆ To assess control of diabetes melli-
which trap plasma in the column of tus
packed RBCs.
Reference values vary, depending Patient preparation
on the type of sample, the laboratory ◆ Explain to the patient that this test
is used to evaluate diabetes therapy.
◆ Explain that the test requires a ◆ If the patient is an infant or a child,

blood sample, and tell the patient explain to the parents that a small
when and where it will be taken. amount of blood will be taken from the
◆ Inform the patient that he need not finger or earlobe.
restrict food or fluids, and instruct him ◆ Inform the patient that he need not
to maintain his prescribed medication restrict food or fluids.
and diet regimens.
Reference values
Reference values Hb concentration varies depending on
Glycosylated Hb values are reported as the type of sample drawn and the pa-
a percentage of the total Hb within a tient’s age and sex:
RBC. Glycosylated Hb accounts for 4% ◆ neonates ages 0 to 2 weeks: 14.5 to
to 7%. 24.5 g/dl (SI, 145 to 245 g/L)
◆ infants ages 2 to 8 weeks: 12.5 to
Abnormal findings 20.5 g/dl (SI, 125 to 205 g/L)
A patient with diabetes has good con- ◆ infants ages 2 to 6 months: 10.7 to
trol of blood glucose concentrations 17.3 g/dl (SI, 107 to 173 g/L)
when the glycosylated Hb value is less ◆ infants ages 6 months to 1 year: 9.9
than 8%. A glycosylated Hb value to 14.5 g/dl (SI, 99 to 145 g/L)
greater than 10% indicates poor control. ◆ children ages 1 to 6 years: 9.5 to
14.1 g/dl (SI, 95 to 141 g/L)
◆ children ages 6 to 16 years: 10.3 to
Hemoglobin, total 14.9 g/dl (SI, 103 to 149 g/L)
◆ adolescents ages 16 to 18 years:
Total Hb is used to measure the 11.1 to 15.7 g/dl (SI, 111 to 157 g/L)
amount of Hb found in a deciliter (dl, ◆ men: 14 to 17.4 g/dl (SI, 140 to
or 100 ml) of whole blood. It’s usually 174 g/L)
part of a complete blood count. Hb ◆ women: 12 to 16 g/dl: (SI, 120 to
concentration correlates closely with 160 g/L)
the RBC count and affects the Hb-RBC Those who are more physically ac-
ratio (mean corpuscular Hb [MCH] and tive or who live in high altitudes may
mean corpuscular Hb concentration have higher values.
[MCHC]).
Abnormal findings
Purpose Low Hb concentration may indicate
◆ To measure the severity of anemia anemia, recent hemorrhage, or fluid re-
or polycythemia and monitor the retention, causing hemodilution.
sponse to therapy Elevated Hb suggests hemoconcen-
◆ To obtain data to calculate MCH tration from polycythemia or dehydra-
and MCHC tion.
Patient preparation
◆ Explain to the patient that this test Hepatitis B surface antigen
is used to detect anemia or poly-
cythemia or to assess his response to Hepatitis B surface antigen (HBsAg),
treatment. also called hepatitis-associated antigen
◆ Explain that a blood sample will be or Australia antigen, appears in the
needed, and tell the patient when and sera of patients with hepatitis B virus.
where it will be taken. It can be detected by radioimmunoas-
Human chorionic gonadotropin, serum 169
say or, less commonly, by reverse pas- diseases other than hepatitis, such as
sive hemagglutination during the ex- hemophilia, Hodgkin’s disease, and
tended incubation period and usually leukemia. If HBsAg is found in donor
during the first 3 weeks of acute infec- blood, that blood must be discarded
tion or if the patient is a carrier. because it carries a risk of transmitting
Because the transmission of hepati- hepatitis. Blood samples with positive
tis is one of the gravest complications results should be retested, however, be-
associated with blood transfusion, all cause inaccurate results occur.
donors must be screened for hepatitis
B before their blood is stored. This
screening, which is required by the Human chorionic
Food and Drug Administration Bureau gonadotropin, serum
of Biologics, has helped to reduce the
incidence of hepatitis. This test doesn’t Human chorionic gonadotropin (hCG)
screen for hepatitis A virus (infectious is a glycoprotein hormone that’s pro-
hepatitis). duced in the placenta. If conception
occurs, a specific assay for hCG — com-
Purpose monly called the beta-subunit assay —
◆ To screen blood donors for hepatitis may detect this hormone in the blood
B infection 9 days after ovulation occurs. This in-
◆ To screen people at high risk for terval coincides with the implantation
contracting hepatitis B such as he- of the fertilized ovum into the uterine
modialysis nurses wall. Although the precise function of
◆ To aid in the differential diagnosis hCG is unclear, it appears that hCG,
of viral hepatitis with progesterone, maintains the cor-
pus luteum during early pregnancy.
Patient preparation The production of hCG increases
◆ Explain to the patient that this test steadily during the first trimester, peak-
helps identify a type of viral hepatitis. ing around 10 weeks’ gestation. During
◆ Explain that the test requires a the remainder of the pregnancy, levels
blood sample, and tell the patient decrease to less than 10% of the first-
when and where it will be taken. trimester peak levels. About 2 weeks
◆ Inform the patient that he need not after delivery, the hormone may no
restrict food or fluids. longer be detectable.
◆ Check the patient’s history for ad- This serum immunoassay, a quanti-
ministration of hepatitis B vaccine. tative analysis of hCG beta-subunit lev-
el, is both more sensitive and more ex-
Normal findings pensive than the routine pregnancy test
Normal serum is negative for HBsAg. that’s performed with a urine sample.
Abnormal findings Purpose

The presence of HBsAg in a patient ◆ To detect early pregnancy
with hepatitis confirms the diagnosis of ◆ To determine the adequacy of hor-
hepatitis B. In chronic carriers and in mone production in high-risk pregnan-
people with chronic active hepatitis, cies (for example, in a patient with ha-
HBsAg may be present in the serum bitual abortion)
several months after the onset of acute ◆ To aid in the diagnosis of tropho-
infection. It may also occur in more blastic tumors, such as hydatidiform
than 5% of patients with certain
moles and choriocarcinoma, and tu- tion. The production of hCG, a glyco-
mors that secrete hCG ectopically protein that prevents degeneration of
◆ To monitor treatment for the induc- the corpus luteum at the end of the
tion of ovulation and conception normal menstrual cycle, begins after
conception. During the first trimester,
Patient preparation hCG levels increase steadily and
◆ Explain to the patient that this test rapidly, peaking around the 10th week
determines if she’s pregnant. If detec- of gestation, and subsequently taper-
tion of pregnancy isn’t the diagnostic ing off to less than 10% of peak
objective, explain why the test is being levels.
done. The most common method of evalu-
◆ Explain that the test requires a ating hCG in urine is hemagglutination
blood sample, and tell the patient inhibition. This laboratory procedure
when and where it will be taken. can provide both qualitative and quan-
◆ Inform her that she need not restrict titative information. The qualitative
food or fluids. urine test is easier and less expensive
than the serum hCG test (beta-subunit
Reference values assay); therefore, it’s used more com-
Normally, hCG levels are less than monly to detect pregnancy.
4 IU/L. During pregnancy, hCG levels
vary widely, depending in part on the Purpose
number of days since the patient’s last ◆ To detect and confirm pregnancy
normal menstrual period. ◆ To aid in the diagnosis of hydatidi-
form mole or hCG-secreting tumors,
Abnormal findings threatened abortion, or dead fetus
Elevated hCG beta-subunit levels indi-
cate pregnancy; significantly higher Patient preparation
concentrations are present in a multi- ◆ If appropriate, explain to the patient
ple pregnancy. Increased levels may that this test determines whether she’s
also suggest hydatidiform mole, tro- pregnant or determines the status of
phoblastic neoplasms of the placenta, her pregnancy. Alternatively, explain
and nontrophoblastic carcinomas that how the test is used to screen for some
secrete hCG (including gastric, pan- types of cancer.
creatic, and ovarian adenocarcino- ◆ Tell the patient that she need not re-
mas). Low hCG beta-subunit levels strict food but should restrict fluids for
can occur in ectopic pregnancy or 8 hours before the test.
pregnancy of less than 9 days. The ◆ Inform the patient that the test re-
beta-subunit level can’t differentiate quires a first-voided morning specimen
between pregnancy and tumor recur- or urine collection over a 24-hour peri-
rence because levels are high in both od, depending on whether a qualitative
conditions. or quantitative test is done.
Normal findings
Human chorionic In a qualitative immunoassay analysis,
gonadotropin, urine results are reported as negative (non-
pregnant) or positive (pregnant) for
Qualitative analysis of urine levels of hCG. In a quantitative analysis, urine
hCG allows for the detection of preg- hCG levels in the first trimester of a
nancy as early as 14 days after ovula-
normal pregnancy may be as high as also be performed to detect antibodies.

500,000 IU/24 hours; in the second (See HIV testing, pages 172 and 173.)
trimester, they range from 10,000 to
25,000 IU/24 hours; and in the third Purpose
trimester, from 5,000 to 15,000 IU/24 ◆ To screen for HIV infection in high-
hours. risk patients
Measurable levels of hCG don’t nor- ◆ To screen donated blood for HIV
mally appear in the urine of men or
nonpregnant women. Patient preparation
Abnormal findings detects HIV infection.
During pregnancy, elevated urine hCG ◆ Provide adequate counseling about
levels may indicate multiple pregnan- the reasons for performing the test,
cy or erythroblastosis fetalis; de- which is usually requested by the pa-
pressed urine hCG levels may indicate tient’s physician.
threatened abortion or ectopic preg- ◆ If the patient has questions about
nancy. his condition, provide full and accurate
Measurable levels of hCG in men information.
and nonpregnant women may indicate ◆ Explain that the test requires a
choriocarcinoma, ovarian or testicular blood sample. Tell the patient who will
tumors, melanoma, multiple myeloma, perform the venipuncture and when
or gastric, hepatic, pancreatic, or breast and where it will be performed.
cancer.
Normal findings
Test results are normally negative.
Human immunodeficiency
virus antibodies Abnormal findings
The test detects previous exposure to
The human immunodeficiency virus the virus. However, it doesn’t identify
(HIV) antibody test detects antibodies patients who have been exposed to the
to HIV in the serum. HIV is the virus virus but haven’t yet made antibodies.
that causes acquired immunodeficiency Most patients with AIDS have antibod-
syndrome (AIDS). Transmission occurs ies to HIV. A positive result on a test
by direct exposure of the blood to body for the HIV antibody can’t determine
fluids that contain the virus. The virus whether a patient harbors an actively
may be transmitted from one person to replicating virus or when the patient
another through exchange of contami- will show the signs and symptoms of
nated blood and blood products, dur- AIDS.
ing sexual intercourse with an infected Many apparently healthy people
partner, when needles used to inject have been exposed to HIV and have
I.V. drugs are shared, and from an in- circulating antibodies. The test results
fected mother to her child during preg- for such people aren’t false-positive
nancy or breast-feeding. findings. Furthermore, patients with
Initial identification of HIV is usual- late stages of AIDS may show no de-
ly achieved through enzyme-linked im- tectable antibody in their sera because
munosorbent assay. Positive findings they can no longer mount an antibody
are confirmed by Western blot test and response.
immunofluorescence. Other tests may
(Text continues on page 174.)
HIV testing
TEST TYPE SPECIMEN (MODE TEST COMPLEXITY*

OF COLLECTION)
Standard human immuno- Serum or plasma High

deficiency virus (HIV) test (phlebotomy)
Rapid test Serum, plasma, or whole blood Moderate§

(phlebotomy, fingerstick)
Home sample collection Dried blood spot (fingerstick) High

test††
Oral fluid test Oral mucosal transudate (oral High

fluid collection device)
Urine-based test Urine (urine cup) High
KEY:
* Complexity of specimen culture and testing as categorized by the Clinical Laboratory Improvements Amend-
ments (CLIA) (Schochetman, G., and George, J.R., eds. AIDS Testing: A Comprehensive Guide to Technical, Medical,
Social, Legal, and Management Issues, 2nd ed. New York: Springer-Verlag, 1994).
† All licensed enzyme immunoassays (EIAs) detect HIV-1, but not all detect HIV-2. EIAs that can detect HIV-1
and HIV-2 are required for blood donor screening and are recommended for diagnostic screening only where
HIV-2 infection is likely. No licensed confirmatory test exists for HIV-2. Although current tests detect most
HIV-1 group infections, few detect all such infections.
§ The one rapid test licensed by FDA, Abbott Murex Single Use Diagnostic System (SUDS) HIV-1 test (Abbott
Laboratories, Inc., Abbott Park, Ill.), is classified as a moderate-complexity test and requires onsite laboratory
testing capability. Future rapid tests could be classified by CLIA as “waived” and may not require the capabili-
ty for on-site laboratory testing, depending on the expertise required to perform this test correctly.
¶ Future rapid tests may be able to be confirmed with a second rapid test to provide an immediate test re-
sult with high sensitivity, specificity, and predictive value comparable with EIA or Western blot (Stetter H.C.,
SCREENING; STRAINS RESULTS

CONFIRMATION DETECTED†
Enzyme immunoassay HIV-1 and HIV negative:

(EIA); Western blot or HIV-2 Test result at return visit (typically a few days to
immunofluorescence 1 to 2 weeks)
assay (IFA) HIV positive:
Confirmed result at return visit
HIV-1 HIV negative:

Rapid EIA: Western Test result at time of testing (typically 10 to 60
blot or IFA¶ minutes)
HIV positive:
Preliminary positive test result at time of
testing**; confirmed result at return visit
EIA; Western blot or HIV-1 HIV negative:

IFA Test result when patient calls (typically 3 to 7
days)
HIV positive:
Confirmed result when patient calls
EIA; oral mucosal HIV-1 HIV negative:

transudate Western Test result at return visit (typically 1 to 2 weeks)
blot HIV positive:
Confirmed result at return visit
EIA; urine Western HIV-1 HIV negative:

blot Test result at return visit (typically 1 to 2 weeks)
HIV positive:
Test result at return visit; further confirmation by
blood sample recommended because of lower
specificity of urine Western blot compared with
serum-based Western blot or IFA
et al. “Field Evaluation of Rapid HIV Serologic tests for Screening and Confirming HIV-1 Infection in Hon-
duras,” AIDS 11:369-375, 1997).
** Information on providing “preliminary” positive test results from a single rapid test is available elsewhere
(CDC. “Update: HIV Counseling and Testing using Rapid Tests — United States, 1995,” MMWR 47:21-15,
1998).
†† Home sample collection is different from home-use testing. FDA has approved home sample collection,
but not home-use HIV test kits (Kassler, W.J. “Advances in HIV Testing Technology and Their Potential Impact
on Prevention,” AIDS Education Preview 9 [suppl B]:27-40, 1997).
Reprinted from Centers for Disease Control and Prevention. “Revised Guidelines for HIV Counseling, Testing,
and Referral,” Morbidity and Mortality Weekly Report 50(RR-19):1-57, November 2001, with permission
of the publisher.
Abnormal findings
Human leukocyte antigen test Incompatible HLA-A, HLA-B, HLA-C,
and HLA-D groups may cause unsuc-
The human leukocyte antigen (HLA) test cessful tissue transplantation.
identifies a group of antigens present on Many diseases have a strong associ-
the surface of all nucleated cells but ation with certain types of HLA. For
that’s most easily detected on lympho- example, HLA-DR5 is associated with
cytes. There are four types of HLA: HLA- Hashimoto’s thyroiditis. B8 and Dw3
A, HLA-B, HLA-C, and HLA-D. These are associated with Graves’ disease,
antigens are essential to immunity and whereas B8 alone is associated with
determine the degree of histocompatibil- chronic autoimmune hepatitis, celiac
ity between transplant recipients and disease, and myasthenia gravis. Dw3
donors. Many antigenic determinants alone is associated with Addison’s dis-
(⬎ 60, for instance, at the HLA-B locus) ease, Sjögren’s syndrome, dermatitis
are present for each site; one set of each herpetiformis, and SLE.
antigen is inherited from each parent. In paternity testing, a putative father
A high incidence of specific HLA who has a phenotype (two haplotypes:
types has been linked to specific dis- one from the father and one from the
eases, such as rheumatoid arthritis and mother) with no haplotype or antigen
multiple sclerosis, but these findings pair identical to one of the child’s is ex-
have little diagnostic significance. cluded as the father. A putative father
with one haplotype identical to one of
Purpose the child’s may be the father; the prob-
◆ To provide histocompatibility typing ability varies with the incidence of the
of transplant recipients and donors haplotype in the population.
◆ To aid genetic counseling
◆ To aid paternity testing
International Normalized
Patient preparation Ratio
detects antigens on WBCs. The International Normalized Ratio
◆ Explain that the test requires a (INR) system is considered the best
blood sample, and tell the patient method for standardizing the measure-
when and where it will be taken. ment of prothrombin time (PT) to
◆ Inform the patient that he need not monitor oral anticoagulant therapy. It
restrict food or fluids. isn’t used as a screening test for coagu-
◆ Check the patient’s history for re- lopathies.
cent blood transfusions. HLA testing
may need to be postponed if he has re- Purpose
cently undergone a transfusion. ◆ To evaluate the effectiveness of oral
anticoagulant therapy
Normal findings
In HLA-A, HLA-B, and HLA-C testing, Patient preparation
lymphocytes that react with the test an- ◆ Explain to the patient that this test
tiserum undergo lysis; they’re detected is used to determine the effectiveness
by phase microscopy. In HLA-D testing, of oral anticoagulant therapy.
leukocyte incompatibility is marked by ◆ Explain that a blood sample will be
blast formation, deoxyribonucleic acid needed, and tell the patient when and
synthesis, and proliferation. where it will be taken.
Lactate dehydrogenase 175
Reference values ◆ Explain that the test requires a

A normal INR for patients receiving blood sample, and tell the patient
warfarin therapy is 2.0 to 3.0 (SI, 2.0 when and where it will be taken.
to 3.0). For those with mechanical ◆ Inform the patient that he need not
prosthetic heart valves, an INR of 2.5 restrict food or fluids.
to 3.5 (SI, 2.5 to 3.5) is suggested. ◆ If MI is suspected, tell the patient
that the test will be repeated on the
Abnormal findings next two mornings to monitor progres-
An increased INR may indicate dissem- sive changes.
inated intravascular coagulation, cir-
rhosis, hepatitis, vitamin K deficiency, Reference values
salicylate intoxication, uncontrolled Total LD levels normally range from 71
oral anticoagulation, or massive blood to 207 U/L (SI, 1.2 to 3.52 ␮kat/L).
transfusion. Normal distribution is as follows:
◆ LD1: 17% to 27% (SI, 0.17 to 0.27)
of total
Lactate dehydrogenase ◆ LD2: 29% to 39% (SI, 0.29 to 0.39)
of total
Lactate dehydrogenase (LD) catalyzes ◆ LD3: 19% to 27% (SI, 0.19 to 0.27)
the reversible conversion of muscle lac- of total
tic acid into pyruvic acid, an essential ◆ LD4: 8% to 16% (SI, 0.08 to 0.16)
step in the metabolic processes that ul- of total
timately produce cellular energy. Be- ◆ LD5: 6% to 16% (SI, 0.06 to 0.16)
cause LD is present in almost all body of total.
tissues, cellular damage increases the
total serum LD level, limiting the diag- Abnormal findings
nostic usefulness of LD. Because many common diseases in-
Five tissue-specific isoenzymes can crease total LD levels, isoenzyme
be identified and measured: LD1 and electrophoresis is usually necessary
LD2 appear primarily in the heart, RBCs, for diagnosis. In some disorders, the
and kidneys; LD3 is found primarily in total LD level may be within normal
the lungs; and LD4 and LD5 occur in the limits, but abnormal proportions of
liver, skin, and skeletal muscles. each enzyme indicate tissue damage
to specific organs. For instance, in
Purpose acute MI, the concentration of LD1 is
◆ To aid in the differential diagnosis greater than that of LD2 within 12 to
of MI, pulmonary infarction, anemias, 48 hours after the onset of symptoms;
and hepatic disease therefore, the LD1/LD2 ratio is greater
◆ To support the results of CK isoen- than 1. This reversal of the normal
zyme tests in diagnosing MI or to pro- isoenzyme pattern is typical of my-
vide a diagnosis when CK-MB samples ocardial damage and is known as
are obtained too late to show an increase flipped LD.
◆ To monitor patient response to Midzone fractions (LD2, LD3, LD4)
some forms of chemotherapy can be increased in granulocytic leuke-
mia, lymphomas, and platelet disor-
Patient preparation ders.
is used primarily to detect tissue alter-
ations.
45 mg/dl. An HDL level greater than

Lipoprotein-cholesterol 60 mg/dl is considered heart healthy.
fractionation Optimally, the LDL level should be
less than 100 mg/dl, with levels of
Cholesterol fractionation tests are used 130 mg/dl or greater considered high.
to isolate and measure the types of
cholesterol in serum. The types of cho- Abnormal findings
lesterol are low-density lipoproteins High LDL levels increase the risk of
(LDLs) and high-density lipoproteins CAD. Elevated HDL levels usually indi-
(HDLs). The HDL level is inversely re- cate a healthy state but can also indi-
lated to the risk of CAD; the higher the cate chronic hepatitis, early-stage pri-
HDL level, the lower the incidence of mary biliary cirrhosis, and alcohol con-
CAD. In contrast, the higher the LDL sumption. Increased HDL levels can
level, the higher the incidence of CAD. occur as a result of long-term aerobic
and vigorous exercise. Rarely, a sharp
Purpose increase (to as high as 100 mg/dl [SI,
◆ To assess the risk of CAD 2.58 mmol/L]) in a second type of
◆ To assess the efficacy of lipid- HDL (alpha2-HDL) signals CAD.
lowering drug therapy
Patient preparation Lyme disease serology

◆ Tell the patient that this test is used
to determine the risk of CAD. Lyme disease is a multisystem disorder
◆ Explain that the test requires a that’s characterized by dermatologic,
blood sample, and tell the patient neurologic, cardiac, and rheumatic man-
when and where it will be taken. ifestations in various stages. Epidemio-
◆ Instruct the patient to maintain his logic and serologic studies implicate a
normal diet for 2 weeks before the test, common tickborne spirochete, Borrelia
to abstain from alcohol for 24 hours be- burgdorferi, as the causative agent.
fore the test, and to fast and avoid exer- Serologic tests for Lyme disease, both
cise for 12 to 14 hours before the test. indirect immunofluorescent and en-
zyme-linked immunosorbent assays,
Reference values measure antibody response to this spiro-
Normal lipoprotein values vary by age, chete and indicate current infection or
sex, geographic area, and ethnic group; previous exposure. Serologic tests can
check the laboratory for reference val- identify 50% of patients with early-stage
ues. HDL levels range from 37 to Lyme disease and all patients with later
70 mg/dl (SI, 0.96 to 1.8 mmol/L) for complications of carditis, neuritis, and
men and from 40 to 85 mg/dl for arthritis as well as patients in remission.
women (SI, 1.03 to 2.2 mmol/L). LDL
levels are less than 130 mg/dl (SI, Purpose
⬍ 3.36 mmol/L) in people who don’t ◆ To confirm the diagnosis of Lyme
have CAD. Borderline high levels disease
are greater than 160 mg/dl (SI,
⬎ 4.1 mmol/L). Patient preparation
The American College of Cardiology ◆ Explain to the patient that this test
recommends an HDL level of 40 mg/dl helps determine whether his symptoms
or greater, with women maintaining are caused by Lyme disease.
an HDL cholesterol level of at least
Magnesium, serum 177
◆ Explain that the test requires a ◆ Explain that the test requires a
blood sample, and tell the patient blood sample, and tell the patient
when and where it will be taken. when and where it will be taken.
◆ Instruct the patient to fast for 12 ◆ Instruct the patient not to use mag-
hours before the sample is drawn but nesium salts (such as milk of magnesia
to drink fluids as usual. or Epsom salt) for at least 3 days be-
fore the test, but tell him that he need
Reference values not restrict food or fluids.
Normal serum values are nonreactive.
Reference values
Abnormal findings Serum magnesium levels for adults
A positive test result can help confirm range from 1.8 to 2.6 mg/dl (SI, 0.74 to
the diagnosis, but it isn’t definitive. 1.07 mmol/L).
Other treponemal diseases and high
rheumatoid factor titers can cause Abnormal findings
false-positive results. More than 15% Elevated serum magnesium levels (hy-
of patients with Lyme disease don’t permagnesemia) most commonly oc-
have antibodies. cur in renal failure, when the kidneys
excrete inadequate amounts of magne-
sium, and also with the administra-
Magnesium, serum tion or ingestion of magnesium.
Adrenal insufficiency (Addison’s dis-
The magnesium test is used to measure ease) can also increase serum magne-
serum levels of magnesium, an elec- sium levels.
trolyte that’s vital to neuromuscular In suspected or confirmed hyper-
function. It also helps in intracellular magnesemia, observe the patient for
metabolism, activates many essential lethargy; flushing; diaphoresis; de-
enzymes, and affects the metabolism of creased blood pressure; slow, weak
nucleic acids and proteins. Magnesium pulse; muscle weakness; diminished
also helps to transport sodium and deep tendon reflexes; slow, shallow
potassium across cell membranes and respiration; and electrocardiogram
influences intracellular calcium levels. (ECG) changes (prolonged PR interval,
Most magnesium is found in bone and wide QRS complex, elevated T waves,
intracellular fluid; a small amount is atrioventricular block, premature ven-
found in extracellular fluid. Magnesium tricular contractions).
is absorbed by the small intestine and Decreased serum magnesium levels
excreted in urine and stools. (hypomagnesemia) most commonly
result from chronic alcoholism. Other
Purpose causes include malabsorption syn-
◆ To evaluate electrolyte status drome, diarrhea, faulty absorption after
◆ To assess neuromuscular and renal bowel resection, prolonged bowel or
function gastric aspiration, acute pancreatitis,
primary aldosteronism, severe burns,
Patient preparation hypercalcemic conditions (including
◆ Explain to the patient that this test hyperparathyroidism), malnutrition,
is used to determine the magnesium and certain diuretic therapy.
content of the blood. In hypomagnesemia, watch for leg
and foot cramps, hyperactive deep ten-
don reflexes, arrhythmias, muscle weak-

ness, seizures, twitching, tetany, tremors, Occult blood, fecal
and ECG changes (premature ventricular
contractions and ventricular fibrillation). Fecal occult blood is detected by micro-
scopic analysis or by chemical tests for
Hb, such as the guaiac test. Normally,
Myoglobin stools contain small amounts of blood (2
to 2.5 ml/day); therefore, tests for occult
Myoglobin, which is usually found in blood detect larger quantities. Testing is
skeletal and cardiac muscle, functions indicated when clinical symptoms and
as an oxygen-binding muscle protein. preliminary blood studies suggest GI
It’s released into the bloodstream in is- bleeding. Additional tests are required to
chemia, trauma, and muscle inflamma- pinpoint the origin of the bleeding.
tion.
Purpose
Purpose ◆ To detect GI bleeding
◆ As a nonspecific test, to estimate ◆ To aid in the early diagnosis of colo-
damage to skeletal or cardiac muscle rectal cancer
tissue
◆ To predict flare-ups of polymyositis Patient preparation
◆ Specifically, to determine if MI has ◆ Explain to the patient that this test
occurred helps detect abnormal GI bleeding.
◆ Tell him that the test requires col-
Patient preparation lection of three stool specimens. Occa-
◆ Explain the purpose of the test to sionally, only a random specimen is
the patient. collected.
◆ Explain that a blood sample is re- ◆ Instruct him to maintain a high-
quired, and tell the patient when and fiber diet and to refrain from eating red
where it will be obtained. meat, turnips, and horseradish for 48
◆ Obtain a patient history, including to 72 hours before the test and
disorders that may be associated with throughout the collection period.
increased myoglobin levels.
◆ Inform the patient that the results Normal findings
must be correlated with the results of Less than 2.5 ml of blood should be
other tests to obtain a definitive diag- present in stools, resulting in a green
nosis. reaction.
Reference values Abnormal findings

Normal myoglobin values are 5 to A positive test result indicates GI
70 ng/ml (SI, 5 to 70 mcg/L). bleeding, which may result from many
disorders, such as varices, peptic ulcer,
Abnormal findings carcinoma, ulcerative colitis, dysentery,
Besides MI, increased myoglobin levels or hemorrhagic disease. This test is
may occur in acute alcohol intoxica- particularly important for the early di-
tion, dermatomyositis, hypothermia agnosis of colorectal cancer. Further
(with prolonged shivering), muscular tests, such as barium swallow, analysis
dystrophy, polymyositis, rhabdomyoly- of gastric contents, and endoscopic
sis, severe burn injuries, trauma, se- procedures, are necessary to define the
vere renal failure, and SLE. site and extent of bleeding.
Phosphate, serum 179
Partial thromboplastin time Phosphate, serum
The partial thromboplastin time (PTT) The phosphate test is used to measure
is used to evaluate the clotting factors serum levels of phosphate, which is
of the intrinsic pathway — except the primary anion in intracellular fluid.
platelets — by measuring the time re- Phosphates are essential in energy stor-
quired for a fibrin clot to form after a age and use, calcium regulation, RBC
calcium and phospholipid emulsion is function, acid-base balance, bone for-
added to a plasma sample. An activator mation, and carbohydrate, protein, and
such as kaolin is used to shorten clot- fat metabolism. The intestines absorb
ting time. most phosphates from dietary sources;
the kidneys excrete phosphates and
Purpose serve as a regulatory mechanism. Ab-
◆ To screen for deficiencies of the clot- normal concentrations of serum phos-
ting factors in the intrinsic pathways phates usually result from improper ex-
◆ To monitor the response to heparin cretion rather than faulty ingestion or
therapy absorption from dietary sources.
Normally, calcium and phosphate
Patient preparation levels have an inverse relationship; if
◆ Explain to the patient that this test one is increased, the other is decreased.
is used to determine if his blood clots
normally. Purpose
◆ Explain that a blood sample will be ◆ To aid in the diagnosis of renal dis-
needed, and tell the patient when and orders and acid-base imbalance
where it will be taken. ◆ To detect endocrine, skeletal, and
◆ When appropriate, tell a patient calcium disorders
who is receiving heparin therapy that
this test may be repeated at regular in- Patient preparation
tervals to assess the response to treat- ◆ Explain to the patient that this test
ment. is used to measure phosphate levels in
◆ Inform the patient that he need not the blood.
restrict food or fluids. ◆ Explain that the test requires a
Reference values when and where it will be taken.
Normally, a fibrin clot forms 21 to 35 ◆ Inform the patient that he need not
seconds (SI, 21 to 35 s) after reagents restrict food or fluids.
are added. If the patient is receiving an-
ticoagulant therapy, ask the attending Reference values
physician to specify the reference values Normally, serum phosphate levels in
for the therapy that’s being delivered. adults range from 2.7 to 4.5 mg/dl (SI,
0.87 to 1.45 mmol/L). In children, the
Abnormal findings normal range is 4.5 to 5.5 mg/dl (SI,
Prolonged PTT may indicate a deficien- 1.45 to 1.78 mmol/L).
cy of certain plasma clotting factors, the
presence of heparin, or the presence of Abnormal findings
fibrin split products, fibrinolysins, or Decreased phosphate levels (hypophos-
circulating anticoagulants that are anti- phatemia) may result from malnutri-
bodies to specific clotting factors. tion, malabsorption syndromes,
hyperparathyroidism, renal tubular aci- ◆ Inform the patient that he need not
dosis, and treatment of diabetic ke- restrict food or fluids.
toacidosis. In children, hypophos-
phatemia can suppress normal growth. Reference values
Symptoms of hypophosphatemia in- Normal platelet counts range from
clude anemia, prolonged bleeding, 140,000 to 400,000/mm3 (SI, 140 to
bone demineralization, decreased WBC 400 ⳯ 109/L) in adults and from
count, and anorexia. 150,000 to 450,000/mm3 (SI, 150 to
Increased levels (hyperphosphate- 450 ⳯ 109/L) in children.
mia) may result from skeletal disease,
healing fractures, hypoparathyroidism, Abnormal findings
acromegaly, diabetic ketoacidosis, high A decreased platelet count (thrombo-
intestinal obstruction, lactic acidosis (as cytopenia) can result from aplastic or
a result of hepatic impairment), and re- hypoplastic bone marrow; infiltrative
nal failure. Hyperphosphatemia is sel- bone marrow disease, such as leukemia
dom clinically significant, but it can al- or disseminated infection; megakaryo-
ter bone metabolism if it’s prolonged. cytic hypoplasia; ineffective thrombo-
Symptoms of hyperphosphatemia in- poiesis as a result of folic acid or vitamin
clude tachycardia, muscular weakness, B12 deficiency; pooling of platelets in an
diarrhea, cramping, and hyperreflexia. enlarged spleen; increased platelet de-
struction as a result of drugs or immune
disorders; disseminated intravascular co-
Platelet count agulation; Bernard-Soulier syndrome; or
mechanical injury to platelets.
Platelets, or thrombocytes, are the small- An increased platelet count (throm-
est formed elements in blood. They pro- bocytosis) can result from hemorrhage,
mote coagulation and the formation of a infectious disorders, iron deficiency ane-
hemostatic plug in vascular injury. mia, recent surgery, pregnancy, splenec-
Platelet count is one of the most im- tomy, or inflammatory disorders. In
portant screening tests of platelet func- such cases, the platelet count returns to
tion. Accurate counts are vital. normal after the patient recovers from
the primary disorder. However, the
Purpose count remains elevated in primary
◆ To evaluate platelet production thrombocythemia, myelofibrosis with
◆ To assess the effects of chemothera- myeloid metaplasia, polycythemia vera,
py or radiation therapy on platelet pro- and chronic myelogenous leukemia.
duction When the platelet count is abnor-
◆ To diagnose and monitor severe mal, the diagnosis usually requires fur-
thrombocytosis or thrombocytopenia ther studies, such as a complete blood
◆ To confirm a visual estimate of the count, bone marrow biopsy, direct
number and morphologic features of antiglobulin test (direct Coombs’ test),
platelets from a stained blood film and serum protein electrophoresis.
Patient preparation
◆ Explain to the patient that this test Potassium, serum
is used to determine if his blood clots
normally. The potassium test is used to measure
◆ Explain that a blood sample will be serum levels of potassium, the major
needed, and tell the patient when and intracellular cation. Potassium helps
where it will be taken. maintain osmotic equilibrium in the
Prostate-specific antigen 181
cells as well as to regulate muscle ac- The patient with hyperkalemia may
tivity, enzyme activity, and acid-base have weakness, malaise, nausea, diar-
balance. It also affects renal function. rhea, colicky pain, and muscle irritabil-
The body has no efficient method for ity that progresses to flaccid paralysis,
conserving potassium; the kidneys ex- oliguria, and bradycardia. The ECG
crete nearly all ingested potassium, even shows flattened P waves; a prolonged
when the body’s supply is depleted. PR interval; a wide QRS complex; a
Potassium deficiency can develop rapid- tall, tented T wave; and ST-segment de-
ly and is quite common. Dietary intake pression. Cardiac arrest may occur
of at least 40 mEq/day is essential. without warning.
Decreased potassium levels com-
Purpose monly result from aldosteronism or
◆ To evaluate the clinical signs of Cushing’s syndrome, loss of body flu-
potassium excess (hyperkalemia) or ids (such as long-term diuretic therapy,
potassium depletion (hypokalemia) vomiting, or diarrhea), and excessive
◆ To monitor renal function, acid-base ingestion of licorice. Although serum
balance, and glucose metabolism values and clinical symptoms can indi-
◆ To evaluate neuromuscular and en- cate a potassium imbalance, an ECG al-
docrine disorders lows a definitive diagnosis.
◆ To detect the origin of arrhythmias A patient with hypokalemia may
show decreased reflexes; a rapid,
Patient preparation weak, irregular pulse; mental confu-
◆ Explain to the patient that this test sion; hypotension; anorexia; muscle
is used to determine the potassium weakness; and paresthesia. An ECG
content of blood. shows a flattened T wave, ST-segment
◆ Explain that the test requires a depression, and U-wave elevation. In
blood sample, and tell the patient severe cases, ventricular fibrillation,
when and where it will be taken. respiratory paralysis, and cardiac arrest
◆ Inform the patient that he need not can develop.
restrict food or fluids.
Reference values Prostate-specific antigen

Normally, serum potassium levels
range from 3.5 to 5 mEq/L (SI, 3.5 to Prostate-specific antigen (PSA) appears
5 mmol/L). in normal, benign hyperplastic, and
malignant prostatic tissue as well as in
Abnormal findings metastatic prostatic carcinoma. Serum
Abnormally high serum potassium lev- PSA levels are used to monitor the
els are common in conditions in which spread or recurrence of prostate cancer
excess cellular potassium enters the and to evaluate the patient’s response
blood, such as burn injuries, crush in- to treatment. Measurement of serum
juries, diabetic ketoacidosis, transfu- PSA levels, along with a digital rectal
sions of large amounts of blood, and examination, is now recommended as
MI. Hyperkalemia may also indicate a screening test for prostate cancer in
reduced sodium excretion, possibly men older than age 50. It’s also useful
from renal failure (preventing normal in assessing response to treatment in
exchange of sodium and potassium) or patients with stage B3 to D1 prostate
Addison’s disease (as a result of potas- cancer as well as in detecting tumor
sium buildup and sodium depletion). spread or recurrence.
Purpose these proteins and normally excrete a

◆ To screen for prostate cancer in men small amount that’s undetectable by a
older than age 50 screening test. A damaged glomerular
◆ To monitor the course of prostate capillary membrane and impaired
cancer and aid in the evaluation of tubular reabsorption allow excretion of
treatment proteins in the urine.
A qualitative screening usually pre-
Patient preparation cedes this test. A positive result requires
◆ Explain to the patient that this test quantitative analysis of a 24-hour urine
is used to screen for prostate cancer or, specimen by acid precipitation tests.
if appropriate, to monitor the course of Electrophoresis can detect Bence Jones
treatment. protein, Hb, myoglobin, or albumin.
blood sample, and tell the patient Purpose
when and where it will be taken. ◆ To aid in the diagnosis of pathologic
◆ Inform the patient that he need not states characterized by proteinuria, pri-
restrict food or fluids. marily renal disease
Reference values Patient preparation

Normal values are as follows: ◆ Explain to the patient that this test
◆ ages 40 to 49: 0 to 2.5 ng/ml (SI, 0 detects proteins in the urine.
to 2.5 mcg/L) ◆ Tell the patient that the test usually
◆ ages 50 to 59: 0 to 3.5 ng/ml (SI, 0 requires urine collection over a 24-hour
to 3.5 mcg/L) period; random collection can be done.
◆ ages 60 to 69: 0 to 4.5 ng/ml (SI, 0 ◆ Inform the patient that he need not
to 4.5 mcg/L) restrict food or fluids.
◆ ages 70 and older: 0 to 6.5 ng/ml
(SI, 0 to 6.5 mcg/L) Normal findings
At rest, normal urine protein values
Abnormal findings range from 10 to 140 mg/L (SI, 1 to
About 80% of patients with prostate 14 mg/dl) in a 24-hour urine sample
cancer have pretreatment PSA values for adult males and 30 to 100 mg/L (SI,
greater than 4 ng/ml. However, PSA re- 3 to 10 mg/dl) in a 24-hour urine sam-
sults alone don’t confirm a diagnosis of ple for adult females.
prostate cancer. About 20% of patients
with benign prostatic hyperplasia also Abnormal findings
have levels greater than 4 ng/ml. Fur- Proteinuria is a chief characteristic of
ther assessment and testing, including renal disease. When proteinuria is pre-
tissue biopsy, are needed to confirm sent in a single specimen, a 24-hour
the diagnosis of prostate cancer. urine collection is required to identify
specific renal abnormalities.
Proteinuria can result from glomeru-
Protein, urine lar leakage of plasma proteins (a major
cause of protein excretion), from over-
A protein test is a quantitative test for flow of filtered proteins of low molecu-
proteinuria. Normally, the glomerular lar weight (when these are present in
membrane allows only proteins of low excessive concentrations), from im-
molecular weight to enter the filtrate. paired tubular reabsorption of filtered
The renal tubules reabsorb most of proteins, and from the presence of
Protein electrophoresis, serum 183
renal proteins derived from the break- position. Functional proteinuria, which
down of kidney tissue. is associated with exercise and emo-
Persistent proteinuria indicates renal tional or physiologic stress, is usually
disease as a result of increased glomeru- transient.
lar permeability. Minimal proteinuria
(⬍ 0.5 g/24 hours), however, is com-
monly associated with renal diseases in Protein electrophoresis,
which glomerular involvement isn’t a serum
major factor, as in chronic pyelone-
phritis. Protein electrophoresis is used to mea-
Moderate proteinuria (0.5 to 4 g/24 sure the levels of serum albumin and
hours) occurs in several types of renal globulins, which are the major blood
disease — acute or chronic glomeru- proteins. This test separates the pro-
lonephritis, amyloidosis, toxic nephrop- teins into five distinct fractions: albu-
athies — or in diseases in which renal min and alpha1, alpha2, beta, and gam-
failure usually develops as a late com- ma proteins.
plication (diabetes or heart failure, for
example). Heavy proteinuria (⬎ 4 g/24 Purpose
hours) is commonly associated with ◆ To aid in the diagnosis of hepatic
nephrotic syndrome. disease, protein deficiency, renal disor-
When accompanied by an elevated ders, and GI and neoplastic diseases
WBC count, proteinuria indicates uri-
nary tract infection. When accompanied Patient preparation
by hematuria, proteinuria indicates local ◆ Explain to the patient that this test
or diffuse urinary tract disorders. Other is used to determine the protein con-
pathologic states (infections and lesions tent of blood.
of the central nervous system, for exam- ◆ Explain that the test requires a
ple) can also result in detectable blood sample, and tell the patient
amounts of protein in the urine. when and where it will be taken.
Many drugs (such as amphotericin ◆ Inform the patient that he need not
B, gold preparations, aminoglycosides, restrict food or fluids.
polymyxins, and trimethadione) cause
renal damage that leads to true protein- Reference values
uria. For this reason, routine evaluation Normally, total serum protein levels
of urine protein is essential during range from 6.4 to 8.3 g/dl (SI, 64 to
such treatment. In all forms of protein- 83 g/L), and the albumin fraction
uria, fractionation results obtained by ranges from 3.5 to 5 g/dl (SI, 35 to
electrophoresis provide more precise 50 g/L). The alpha1-globulin fraction
information than the screening test. For ranges from 0.1 to 0.3 g/dl (SI, 1 to
example, excessive Hb in the urine in- 3 g/L); alpha2-globulin ranges from
dicates intravascular hemolysis; an ele- 0.6 to 1 g/dl (SI, 6 to 10 g/L). Beta-
vated myoglobin level suggests muscle globulin ranges from 0.7 to 1.1 g/dl (SI,
damage; an increased albumin level, 7 to 11 g/L); gamma-globulin ranges
increased glomerular permeability; and from 0.8 to 1.6 g/dl (SI, 8 to 16 g/L).
a high level of Bence Jones protein,
multiple myeloma. Abnormal findings
Not all forms of proteinuria have For common abnormal findings, see
pathologic significance. Benign protein- Clinical implications of abnormal pro-
uria can result from changes in body tein levels, page 184.
Clinical implications of abnormal protein levels
◆ Chronic inflamma- ◆ Multiple myeloma ◆ Chronic syphilis

tory disease (such as ◆ Collagen diseases
rheumatoid arthritis ◆ Diabetes mellitus
or early-stage Laën- ◆ Hodgkin’s disease
◆ Multiple myeloma
INCREASED LEVELS
nec’s cirrhosis)
◆ Dehydration ◆ Rheumatoid ar-
◆ Diabetic ketoaci- thritis
dosis ◆ Subacute bacterial
◆ Fulminating and endocarditis
chronic infections ◆ Systemic lupus
◆ Multiple myeloma erythematosus (SLE)
◆ Monocytic leuke- ◆ Tuberculosis
mia
◆ Vomiting, diarrhea
Total proteins Albumin Globulins
◆ Benzene and car- ◆ Acute cholecystitis ◆ Benzene and car-

bon tetrachloride poi- ◆ Collagen diseases bon tetrachloride poi-
soning ◆ Diarrhea soning
◆ Blood dyscrasias ◆ Essential hyperten- ◆ Blood dyscrasias
◆ Essential hypertension ◆ Essential hyperten-
sion ◆ Hepatic disease sion
◆ GI disease ◆ Hodgkin’s disease ◆ GI disease
◆ Heart failure ◆ Hyperthyroidism ◆ Heart failure
DECREASED LEVELS
◆ Hepatic dysfunc- ◆ Hypogammaglobu- ◆ Hepatic dysfunc-

tion linemia tion
◆ Hemorrhage ◆ Malnutrition ◆ Hemorrhage
◆ Hodgkin’s disease ◆ Metastatic carcino- ◆ Hodgkin’s disease
◆ Hyperthyroidism ma ◆ Hyperthyroidism
◆ Malabsorption ◆ Nephritis, nephro- ◆ Malabsorption
◆ Malnutrition sis ◆ Malnutrition
◆ Nephrosis ◆ Peptic ulcer ◆ Nephrosis
◆ Severe burns ◆ Plasma loss from ◆ Severe burns
◆ Surgical and trau- burns ◆ Surgical and trau-
matic shock ◆ Rheumatoid arthri- matic shock
◆ Toxemia of preg- tis ◆ Toxemia of preg-
nancy ◆ Sarcoidosis nancy
◆ Uncontrolled dia- ◆ SLE ◆ Uncontrolled dia-
betes mellitus betes mellitus
Red blood cell count 185
ulant therapy. Prolonged PT that ex-

Prothrombin time ceeds 2.5 times the control value is
commonly associated with abnormal
PT measures the time required for a bleeding.
fibrin clot to form in a citrated plas-
ma sample after the addition of calci-
um ions and tissue thromboplastin Red blood cell count
(factor III).
The RBC count, also called erythrocyte
Purpose count, is part of a complete blood
◆ To evaluate the extrinsic coagulation count. It’s used to detect the number
system (factors V, VII, and X and proof RBCs in a microliter (␮l), or cubic
thrombin and fibrinogen) millimeter (mm3), of whole blood.
◆ To monitor the response to oral an-
ticoagulant therapy Purpose
◆ To provide data for calculating MCV
Patient preparation and MCH, which show RBC size and
◆ Explain to the patient that this test Hb content
is used to determine if his blood clots ◆ To support other hematologic tests
normally. that are used to diagnose anemia or
◆ When appropriate, explain that this polycythemia
test is used to monitor the effects of
oral anticoagulants; the test will be Patient preparation
performed daily when therapy begins ◆ Explain to the patient that this test
and will be repeated at longer intervals is used to evaluate the number of RBCs
when medication levels stabilize. and to detect possible blood disorders.
◆ Explain that a blood sample will be ◆ Explain that a blood sample will be
needed, and tell the patient when and needed, and tell the patient when and
where it will be taken. where it will be taken.
◆ Inform the patient that he need not ◆ If the patient is a child, explain to
restrict food or fluids. him (if he’s old enough) and his par-
ents that a small amount of blood will
Reference values be taken from his finger or earlobe.
Normally, PT values range from 10 to ◆ Inform the patient that he need not
14 seconds (SI, 10 to 14 s). Values restrict food or fluids.
vary, however, depending on the
source of tissue thromboplastin and the Reference values
type of sensing devices used to mea- Normal RBC values vary, depending on
sure clot formation. In a patient who’s the type of sample and the patient’s
receiving oral anticoagulants, PT is age and sex, as follows:
usually maintained between 1 and 21⁄2 ◆ men: 4.5 to 5.5 million RBCs/␮l (SI,
times the normal control value. 4.5 to 5.5 ⳯ 1012/L) of venous blood
◆ women: 4 to 5 million RBCs/␮l (SI,
Abnormal findings 4 to 5 ⳯ 1012/L) of venous blood
Prolonged PT may indicate deficiencies ◆ children: 4.6 to 4.8 million/␮l (SI,
in fibrinogen; prothrombin; factor V, 4.6 to 4.8 ⳯ 1012/L) of venous blood
VII, or X (specific assays can pinpoint ◆ full-term neonates: 4.4 to 5.8 mil-
such deficiencies); or vitamin K. It may lion/␮l (SI, 4.4 to 5.8 ⳯ 1012/L) of
also result from ongoing oral anticoag-
capillary blood at birth, decreasing to cytic), or normal (normocytic). MCH,

3 to 3.8 million/␮l (SI, 3 to 3.8 ⳯ the Hb-RBC ratio, gives the weight of
1012/L) at age 2 months, and increas- Hb in an average RBC. MCHC, the ratio
ing slowly thereafter. of Hb weight to HCT, defines the con-
Normal values may exceed these centration of Hb in 100 ml of packed
levels in patients who live at high alti- RBCs. It helps distinguish normally col-
tudes or are very active. ored (normochromic) RBCs from paler
(hypochromic) RBCs.
Abnormal findings The range of normal RBC indices is
An elevated RBC count may indicate as follows:
absolute or relative polycythemia. A ◆ MCV: 84 to 99 ␮m3
depressed count may indicate anemia, ◆ MCH: 26 to 32 pg/cell
fluid overload, or hemorrhage more ◆ MCHC: 30 to 36 g/dl
than 24 hours ago. Further tests, such
as stained cell examination, hematocrit Abnormal findings
(HCT), Hb, RBC indices, and white Low MCV and MCHC indicate micro-
blood cell (WBC) studies, are needed cytic, hypochromic anemias caused by
to confirm the diagnosis. iron deficiency anemia, pyridoxine-
responsive anemia, or thalassemia. A
high MCV suggests macrocytic anemia
Red blood cell indices caused by megaloblastic anemia, folic
acid or vitamin B12 deficiency, inherit-
Using the results of the RBC count, ed disorders of deoxyribonucleic acid
HCT, and total Hb tests, RBC indices synthesis, or reticulocytosis. Because
(erythrocyte indices) provide important MCV reflects the average volume of
information about the size, Hb concen- many cells, a value within the normal
tration, and Hb weight of an average range can encompass RBCs of varying
RBC. size, from microcytic to macrocytic.
(See Comparative red cell indices in
Purpose anemias.)
◆ To aid in the diagnosis and classifi-
cation of anemias
Sodium, serum
Patient preparation
◆ Explain to the patient that this test The sodium test is used to measure
helps determine if he has anemia. serum levels of sodium in relation to
◆ Explain that a blood sample will be the amount of water in the body. Sodi-
needed, and tell the patient when and um, the major extracellular cation, af-
where it will be taken. fects the distribution of water in the
body, maintains the osmotic pressure
Reference values of extracellular fluid, and helps pro-
The indices tested include mean cor- mote neuromuscular function. It also
puscular volume (MCV), MCH, and helps maintain the acid-base balance
MCHC. and influences chloride and potassium
MCV, the ratio of HCT (packed cell levels.
volume) to the RBC count, expresses
the average size of the erythrocytes Purpose
and indicates whether they’re under- ◆ To evaluate the fluid–electrolyte
sized (microcytic), oversized (macro- balance and the acid-base balance and
Sodium, serum 187
Comparative red cell indices in anemias
NORMAL IRON DEFICIENCY PERNICIOUS

FINDINGS ANEMIA ANEMIA
(Normocytic, (Microcytic, (Macrocytic,
Normochromic) hypochromic) normochromic)
MCV 84 to 99 ␮m3 60 to 80 ␮m3 96 to 150 ␮m3
MCH 26 to 34 pg/cell 5 to 25 pg/cell 33 to 53 pg/cell
MCHC 32 to 36 g/dl 20 to 30 g/dl 33 to 38 g/dl
KEY
MCV ⫽ Mean corpuscular volume
MCH ⫽ Mean corpuscular hemoglobin
MCHC ⫽ Mean corpuscular hemoglobin concentration
related neuromuscular, renal, and adre- ally, severe vomiting or diarrhea), and
nal functions sodium retention (such as aldosteron-
ism). Hypernatremia can also result
Patient preparation from excessive sodium intake. If a pa-
◆ Explain to the patient that this test tient has hypernatremia and associated
is used to determine the sodium con- loss of water, observe him for signs of
tent of blood. thirst, restlessness, dry and sticky mu-
◆ Explain that the test requires a cous membranes, flushed skin, olig-
blood sample, and tell the patient uria, and diminished reflexes. If in-
when and where it will be taken. creased total body sodium causes wa-
◆ Inform the patient that he need not ter retention, observe the patient for
restrict food or fluids. hypertension, dyspnea, edema, and
heart failure.
Reference values Abnormally low serum sodium lev-
Normally, serum sodium levels range els (hyponatremia) may result from in-
from 136 to 145 mEq/L (SI, 136 to adequate sodium intake or from exces-
145 mmol/L). sive sodium loss as a result of profuse
sweating, GI suctioning, diuretic thera-
Abnormal findings py, diarrhea, vomiting, adrenal insuffi-
Sodium imbalance can result from a ciency, burns, and chronic renal insuf-
loss or gain of sodium or from a ficiency with acidosis. Urine sodium
change in the patient’s state of hydra- measurements are usually more sensi-
tion. Increased serum sodium levels tive to early changes in sodium bal-
(hypernatremia) may be caused by in- ance and should be evaluated simulta-
adequate water intake, water loss in neously with serum sodium levels.
excess of sodium loss (such as diabetes If a patient has hyponatremia,
insipidus, impaired renal function, pro- watch him for apprehension, lassitude,
longed hyperventilation and, occasion- headache, decreased skin turgor,
abdominal cramps, and tremors that toxicosis), and recurrence of hyperthy-

may progress to seizures. roidism.
Thyroid-stimulating Thyroxine
immunoglobulin
Thyroxine (T4) is an amine that’s se-
Thyroid-stimulating immunoglobulin creted by the thyroid gland in response
(TSI), formerly called long-acting thy- to thyroid-stimulating hormone (TSH)
roid stimulator, appears in the blood of and, indirectly, thyrotropin-releasing
most patients with Graves’ disease. It hormone. The rate of secretion is nor-
stimulates the thyroid gland to produce mally regulated by a complex system of
and excrete excessive amounts of thy- negative and positive feedback mecha-
roid hormone. nisms.
Reportedly, 90% of people with Only a fraction of T4 (about 0.05%)
Graves’ disease have elevated TSI lev- circulates freely in the blood; the rest
els. Positive test results strongly sug- binds strongly to plasma proteins, pri-
gest Graves’ disease, despite normal marily T4-binding globulin (TBG). This
results on routine thyroid tests, in pa- minute fraction is responsible for the
tients who are still suspected of having clinical effects of thyroid hormone.
Graves’ disease or progressive exoph- TBG binds so tenaciously that T4 sur-
thalmos. vives in the plasma for a relatively long
time, with a half-life of about 6 days.
Purpose This immunoassay, one of the most
◆ To aid in the evaluation of suspect- common thyroid diagnostic tools, mea-
ed thyroid disease sures the total circulating T4 level
◆ To aid in the diagnosis of suspected when TBG is normal. An alternative
thyrotoxicosis, especially in patients test is the Murphy-Pattee test, or T4
with exophthalmos (D) test, which is based on competitive
◆ To monitor the treatment of thyro- protein binding.
toxicosis
Purpose
Patient preparation ◆ To evaluate thyroid function
◆ Explain to the patient that this test ◆ To aid in the diagnosis of hyperthy-
evaluates thyroid function, as appropri- roidism and hypothyroidism
ate. ◆ To monitor the response to antithy-
◆ Explain that the test requires a roid medication in hyperthyroidism or
blood sample, and tell the patient to thyroid replacement therapy in
when and where it will be taken. hypothyroidism (TSH estimates are
needed to confirm hypothyroidism.)
Reference values
TSI doesn’t normally appear in serum. Patient preparation
However, it’s considered normal at lev- ◆ Explain to the patient that this test
els equal to or greater than the 1.3 in- helps evaluate the function of the thy-
dex. roid gland.
Abnormal findings blood sample, and tell the patient
Increased TSI levels are associated with when and where it will be taken.
exophthalmos, Graves’ disease (thyro-
Triglycerides 189
◆ Inform him that he need not fast or of patients in whom standard T3 or T4

restrict activity. tests don’t produce diagnostic results.
Reference values Purpose

Normally, total T4 levels range from ◆ To measure the metabolically active
5.4 to 11.5 mcg/dl (SI, 57 to form of the thyroid hormones
148 nmol/L). ◆ To aid in the diagnosis of hyperthy-
roidism and hypothyroidism when TBG
Abnormal findings levels are abnormal
Abnormally elevated T4 levels are con-
sistent with primary and secondary hy- Patient preparation
perthyroidism, including excessive T4 ◆ Explain to the patient that this test
(levothyroxine) replacement therapy helps evaluate thyroid function.
(factitious or iatrogenic hyperthyroid- ◆ Explain that the test requires a
ism). Low levels suggest primary or blood sample, and tell the patient
secondary hypothyroidism or may be when and where it will be taken.
caused by T4 suppression by normal,
elevated, or replacement levels of tri- Reference values
iodothyronine (T3). If the diagnosis of The normal range for FT4 is 0.9 to
hypothyroidism is in doubt, TSH levels 2.3 ng/dl (SI, 10 to 30 pmol/L); for
may be obtained. FT3, it’s 260 to 480 pg/dl (SI, 4.0 to
Normal T4 levels don’t guarantee 7.4 pmol/L). Values vary, depending
euthyroidism; for example, normal on the laboratory.
readings occur in T3 toxicosis. Overt
signs of hyperthyroidism require fur- Abnormal findings
ther testing. Elevated FT4 and FT3 levels indicate
hyperthyroidism, unless peripheral re-
sistance to thyroid hormone is pre-
Thyroxine, free and sent. T3 toxicosis, a distinct form of
triiodothyronine, free hyperthyroidism, yields high FT3 lev-
els with normal or low FT4 values.
The free thyroxine (FT4) and free tri- Low FT4 levels usually indicate hy-
iodothyronine (FT3) tests, which are pothyroidism, except in patients who
commonly performed simultaneously, are receiving T3 replacement therapy.
measure serum levels of FT4 and FT3, Patients who are receiving thyroid
the minute portions of T4 and T3 that therapy may have varying levels of
are not bound to TBG and other serum FT4 and FT3, depending on the prepa-
proteins. These unbound hormones are ration used and the time of sample
responsible for the thyroid’s effects on collection.
cellular metabolism. Measurement of
free hormone levels is the best indica-
tor of thyroid function. Triglycerides
Because of disagreement as to
whether FT4 or FT3 is the better indica- Serum triglyceride analysis provides a
tor, laboratories commonly measure quantitative analysis of triglycerides —
both. Disadvantages of these tests in- the main storage form of lipids —
clude a cumbersome and difficult labo- which constitute about 95% of fatty
ratory method, inaccessibility, and tissue. Although not in itself diagnos-
cost. This test may be useful in the 5% tic, the triglyceride test permits early
identification of hyperlipidemia and Decreased serum triglyceride levels

helps determine the risk of CAD. are rare and occur mainly in malnutri-
tion and abetalipoproteinemia.
Purpose
◆ To screen for hyperlipidemia or pan-
creatitis Triiodothyronine
◆ To help identify nephrotic syndrome
and patients with poorly controlled di- The T3 test is a highly specific radioim-
abetes mellitus munoassay that measures total (bound
◆ To determine the risk of CAD and free) serum content of T3 to inves-
◆ To calculate the LDL cholesterol lev- tigate clinical indications of thyroid
el using the Friedewald equation dysfunction. Like T4 secretion, T3 se-
cretion occurs in response to TSH and,
Patient preparation secondarily, thyrotropin-releasing hor-
◆ Explain to the patient that this test mone.
is used to detect disorders of fat metab- Although T3 is present in the blood-
olism. stream in minute quantities and is
◆ Explain that the test requires a metabolically active for only a short
blood sample, and tell the patient time, its effect on body metabolism
when and where it will be taken. dominates that of T4. Another signifi-
◆ Instruct the patient to fast for at cant difference between the two major
least 12 hours before the test and to thyroid hormones is that T3 binds less
abstain from alcohol for 24 hours. Tell firmly to TBG. Consequently, T3 per-
the patient that he can drink water. sists in the bloodstream for a short
time. Half of T3 disappears in about
Reference values 1 day, whereas half of T4 disappears in
Triglyceride values vary with age and 6 days.
sex. There’s some controversy about
the most appropriate normal ranges, Purpose
but values of 0.30 to 148 mg/dl (SI, ◆ To aid in the diagnosis of T3 toxico-
0.34 to 1.67 mmol/L) for men and 32 sis
to 131 mg/dl (SI, 0.36 to 1.48 mmol/L) ◆ To aid in the diagnosis of hypothy-
for women are widely accepted. roidism and hyperthyroidism
◆ To monitor the clinical response to
Abnormal findings thyroid replacement therapy in hypo-
Increased or decreased serum triglyc- thyroidism
eride levels suggest a clinical abnor-
mality; additional tests are required for Patient preparation
a definitive diagnosis. ◆ Explain to the patient that this test
A mild to moderate increase in se- helps evaluate the function of the thy-
rum triglyceride levels indicates biliary roid gland and determine the cause of
obstruction, diabetes mellitus, his symptoms.
nephrotic syndrome, endocrinopathies, ◆ Explain that the test requires a
or overconsumption of alcohol. blood sample, and tell the patient
Markedly increased levels without an when and where it will be taken.
identifiable cause reflect congenital hy- ◆ Withhold medications, such as
perlipoproteinemia and necessitate steroids, propranolol, and cholestyra-
lipoprotein phenotyping to confirm the mine, which may affect thyroid func-
diagnosis. tion, as ordered. If they must be
Triiodothyronine uptake 191
continued, record this information on The results of T3 uptake are usually

the laboratory request. combined with a T4 radioimmunoassay
or a T4 (D) test (competitive protein-
Reference values binding test) to determine the FT4 in-
Normal serum T3 levels range from 80 dex, which is a mathematical calcula-
to 200 ng/dl (SI, 1.2 to 3 nmol/L). tion that’s believed to reflect FT4 by
correcting for TBG abnormalities.
Abnormal findings The T3 uptake test has become less
Serum T3 and T4 levels usually rise popular recently because rapid tests
and fall in tandem. However, in T3 tox- for T3, T4, and TSH are readily avail-
icosis, T3 levels rise, whereas total and able.
free T4 levels remain normal. T3 toxi-
cosis occurs in patients with Graves’ Purpose
disease, toxic adenoma, or toxic nodu- ◆ To aid in the diagnosis of hypothy-
lar goiter. T3 levels also surpass T4 lev- roidism and hyperthyroidism when the
els in patients who are receiving thy- TBG level is normal
roid replacement therapy containing ◆ To aid in the diagnosis of primary
more T3 than T4. In iodine-deficient disorders of TBG levels
areas, the thyroid may produce larger
amounts of the more cellularly active Patient preparation
T3 than of T4 in an effort to maintain ◆ Explain to the patient that this test
the euthyroid state. helps evaluate thyroid function.
Usually, T3 levels appear to be a ◆ Explain that the test requires a
more accurate diagnostic indicator of blood sample, and tell the patient
hyperthyroidism. Although T3 and T4 when and where it will be taken.
levels are increased in about 90% of ◆ Tell him that the laboratory requires
patients with hyperthyroidism, there’s several days to complete the analysis.
a disproportionate increase in T3. In ◆ Withhold medications, such as es-
some patients with hypothyroidism, T3 trogens, androgens, phenytoin, salicy-
levels may fall within the normal range lates, and thyroid preparations, that
and may not be diagnostically signifi- may interfere with test results, as or-
cant. dered. If they must be continued, note
A rise in serum T3 levels normally this information on the laboratory re-
occurs during pregnancy. Low T3 levels quest.
may appear in euthyroid patients who
have a systemic illness (especially he- Reference values
patic or renal disease), during severe Normal T3 uptake values are 25% to
acute illness, and after trauma or major 35%.
surgery. In such patients, TSH levels
are within normal limits. Low serum Abnormal findings
T3 levels are found in some euthyroid A high T3 uptake percentage in the
patients with malnutrition. presence of elevated T4 levels indicates
hyperthyroidism (implying few TBG
free binding sites and high FT4 levels).
Triiodothyronine uptake A low uptake percentage, together with
low T4 levels, indicates hypothyroidism
The T3 uptake test measures FT4 levels (implying more TBG free binding sites
indirectly by showing the availability and low FT4 levels). Thus, in primary
of serum protein-binding sites for T4. thyroid disease, T4 and T3 uptake vary
in the same direction; the availability ◆ Explain that a blood sample will be
of binding sites varies inversely. needed, and tell the patient when and
Discordant variance in T4 and T3 where it will be taken.
uptake suggests a TBG abnormality. ◆ Inform the patient that he need not
For example, the finding of a high T3 restrict food or fluids.
uptake percentage and a low or normal
FT4 level suggests decreased TBG lev- Reference values
els. Such decreased levels may result Laboratory results may vary. Some la-
from protein loss (as in nephrotic syn- boratories may consider a test result
drome), decreased production (as a re- positive if detectable levels are found;
sult of excess androgen or genetic or others may give a range for abnormal re-
idiopathic causes), or competition for sults. Normally, cTnI levels are less than
T4 binding sites by certain drugs (sali- 0.35 ng/ml (SI, ⬍ 0.35 mcg/L); cTnT
cylates, phenylbutazone, and pheny- levels are less than 0.1 ng/ml (SI, ⬍ 0.1
toin). Conversely, the finding of a low mcg/L). A cTnI level greater than 2.0
T3 uptake percentage and a high or ng/ml (SI, ⬎ 2.0 mcg/L) suggests car-
normal FT4 level suggests increased diac injury. Results of a qualitative cTnT
TBG levels. Such increased levels may rapid immunoassay that are greater than
be caused by exogenous or endogenous 0.1 ng/ml (SI, ⬎ 0.1 mcg/L) are consid-
estrogen (pregnancy) or may result ered positive for cardiac injury. As long
from idiopathic causes. Thus, in pri- as tissue injury continues, the troponin
mary disorders of TBG levels, values of levels will remain high.
measured T4 and free sites change in
the same direction. Abnormal findings
◆ Troponin levels increase rapidly and
are detectable within 1 hour of injury
Troponin to the myocardial cells. Levels of cTnI
aren’t detectable in people who don’t
Cardiac troponin I (cTnI) and cardiac have cardiac injury.
troponin T (cTnT) are proteins in the
striated cells that are specific markers
of cardiac damage. When the myocar- Uric acid, serum
dial tissue is injured, these proteins are
released into the bloodstream. Eleva- The uric acid test is used to measure
tions in troponin levels can be seen serum levels of uric acid, the major end
within 1 hour of MI and persist for a metabolite of purine. Disorders of
week or longer. purine metabolism, rapid destruction of
nucleic acids, and conditions that cause
Purpose impaired renal excretion characteristi-
◆ To detect and diagnose acute MI cally increase serum uric acid levels.
and reinfarction
◆ To evaluate possible causes of chest Purpose
pain ◆ To confirm the diagnosis of gout
◆ To help detect renal dysfunction
Patient preparation
◆ Explain to the patient that this test Patient preparation
helps assess myocardial injury and that ◆ Explain to the patient that this test
multiple samples may be drawn to de- is used to detect gout and kidney dys-
tect fluctuations in serum levels. function.
◆ Explain that the test requires a Patient preparation

blood sample, and tell the patient ◆ Explain to the patient that this test
when and where it will be taken. aids in the diagnosis of renal or urinary
◆ Instruct the patient to fast for 8 tract disease and help evaluate overall
hours before the test. body function.
◆ Inform the patient that food or flu-
Reference values ids need not be restricted before the
Uric acid concentrations in men nor- test.
mally range from 3.4 to 7 mg/dl (SI,
202 to 416 ␮mol/L); in women, normal Normal findings
levels range from 2.3 to 6 mg/dl (SI, See Normal findings in routine urinaly-
143 to 357 ␮mol/L). sis, page 194.
Abnormal findings Abnormal findings

Increased uric acid levels may indicate Nonpathologic variations in normal
gout or impaired kidney function. Lev- values may result from diet, nonpatho-
els may also increase in heart failure, logic conditions, the time of specimen
glycogen storage disease (type I, von collection, and other factors.
Gierke’s disease), infections, hemolytic Urine pH, which is greatly affected
and sickle cell anemia, polycythemia, by diet and medications, affects the
neoplasms, and psoriasis. appearance of urine and the composi-
Low uric acid levels may indicate tion of crystals. An alkaline pH
defective tubular absorption (such as (⬎ 7.0) — characteristic of a vegetari-
Fanconi’s syndrome) or acute hepatic an diet — causes turbidity and the for-
atrophy. mation of phosphate, carbonate, and
amorphous crystals. An acid pH
(⬍ 7.0) — typical of a high-protein
Urinalysis, routine diet — produces turbidity and the for-
mation of oxalate, cystine, leucine,
A routine urinalysis is done to evaluate tyrosine, amorphous urate, and uric
urinary and systemic disorders. This acid crystals.
test evaluates the physical characteris- Protein, which is normally absent
tics (color, odor, turbidity, and opacity) from the urine, may be present in a be-
of urine; determines its specific gravity nign condition known as orthostatic
and pH; detects and measures protein, (postural) proteinuria. Most common
glucose, and ketone bodies; and exam- in patients ages 10 to 20, this condition
ines the sediment for blood cells, casts, is intermittent, appears after prolonged
and crystals. standing, and disappears after the pa-
Diagnostic laboratory methods in- tient assumes a recumbent position.
clude visual examination, reagent strip Transient benign proteinuria can also
screening, refractometry for specific occur with fever, exposure to cold,
gravity, and microscopic inspection of emotional stress, or strenuous exercise.
centrifuged sediment. Systemic diseases that may cause pro-
teinuria include lymphoma, hepatitis,
Purpose diabetes mellitus, toxemia, hyperten-
◆ To screen the patient’s urine for re- sion, lupus erythematosus, and febrile
nal or urinary tract disease illnesses.
◆ To help detect metabolic or systemic
disease unrelated to renal disorders
◆ To detect substance (drug) use
Normal findings in routine urinalysis
ELEMENT FINDINGS
Macroscopic
Color ◆ Straw to dark yellow
Odor ◆ Slightly aromatic
Appearance ◆ Clear
Specific gravity ◆ 1.005 to 1.035
pH ◆ 4.5 to 8
Protein ◆ None
Glucose ◆ None
Ketone bodies ◆ None
Bilirubin ◆ None
Urobilinogen ◆ Normal
Hemoglobin ◆ None
Erythrocytes (RBCs) ◆ None
Nitrites (bacteria) ◆ None
Leukocytes (WBCs) ◆ None
Microscopic
RBCs ◆ 0 to 2/high-power field
WBCs ◆ 0 to 5/high-power field
Epithelial cells ◆ 0 to 5/high-power field
Casts ◆ None, except 1 to 2 hyaline casts/low-power field
Crystals ◆ Present
Bacteria ◆ None
Yeast cells ◆ None
Parasites ◆ None
Sugars, which are usually absent ◆ Odor: In diabetes mellitus, starva-

from the urine, may appear under nor- tion, and dehydration, a fruity odor ac-
mal conditions. The most common companies the formation of ketone
sugar found in urine is glucose. Tran- bodies. In urinary tract infections, a
sient nonpathologic glycosuria may re- fetid odor commonly is associated with
sult from emotional stress or pregnancy Escherichia coli. Maple syrup urine dis-
and may follow ingestion of a high- ease and phenylketonuria also cause
carbohydrate meal. distinctive odors. Other abnormal
Centrifuged urine sediment contains odors include those similar to a brew-
cells, casts, crystals, bacteria, yeast, ery, sweaty feet, cabbage, fish, and
and parasites. RBCs don’t usually ap- sulfur.
pear in urine without pathologic signif- ◆ Turbidity: Turbid urine may contain
icance; however, strenuous exercise RBCs or WBCs, bacteria, fat, or chyle
can cause hematuria. and may reflect renal infection.
The following abnormal findings ◆ Specific gravity: Low specific gravity
suggest pathologic conditions: (⬍ 1.005) is characteristic of diabetes
◆ Color: Color change can result from insipidus, nephrogenic diabetes insi-
diet, drugs, and many diseases. pidus, acute tubular necrosis, and
pyelonephritis. Fixed specific gravity,
in which the value remains 1.010 re- tonuria may also occur in starvation
gardless of fluid intake, occurs in states, low- or no-carbohydrate diets,
chronic glomerulonephritis with severe and after diarrhea or vomiting.
renal damage. High specific gravity ◆ Bilirubin: Bilirubin in urine may
(⬎ 1.035) occurs in nephrotic syn- occur in liver disease resulting from
drome, dehydration, acute glomeru- obstructive jaundice or hepatotoxic
lonephritis, heart failure, liver failure, drugs or toxins or from fibrosis of the
and shock. biliary canaliculi (which may occur in
◆ pH: Alkaline urine pH may result cirrhosis).
from Fanconi’s syndrome, urinary tract ◆ Urobilinogen: Intestinal bacteria in
infection, and metabolic or respiratory the duodenum change bilirubin into
alkalosis. Acid urine pH is associated urobilinogen. The liver reprocesses the
with renal tuberculosis, pyrexia, phenyl- remainder into bile. Increased urobili-
ketonuria, alkaptonuria, and acidosis. nogen in the urine may indicate liver
◆ Protein: Proteinuria suggests renal damage, hemolytic disease, or severe
failure or disease (including nephrosis, infection. Decreased levels may occur
glomerulosclerosis, glomerulonephritis, with biliary obstruction, inflammatory
nephrolithiasis, nephrotic syndrome, disease, antimicrobial therapy, severe
and polycystic kidney disease) or, pos- diarrhea, or renal insufficiency.
sibly, multiple myeloma. ◆ Cells: Hematuria indicates bleeding
◆ Sugars: Glycosuria usually indicates within the genitourinary tract and may
diabetes mellitus but may result from result from infection, obstruction, in-
pheochromocytoma, Cushing’s syn- flammation, trauma, tumors, glomeru-
drome, impaired tubular reabsorption, lonephritis, renal hypertension, lupus
advanced renal disease, and increased nephritis, renal tuberculosis, renal vein
intracranial pressure. I.V. solutions con- thrombosis, renal calculi, hydronephro-
taining glucose and total parenteral nu- sis, pyelonephritis, scurvy, malaria,
trition containing 10% to 50% glucose parasitic infection of the bladder, suba-
can cause glucose to spill over the re- cute bacterial endocarditis, polyarteritis
nal threshold, leading to glycosuria. nodosa, and hemorrhagic disorders.
Fructosuria, galactosuria, and pento- Strenuous exercise or exposure to toxic
suria usually suggest rare hereditary chemicals may also cause hematuria.
metabolic disorders (except for lacto- An excess of WBCs in the urine usually
suria during pregnancy and breast- implies urinary tract inflammation, es-
feeding). However, an alimentary form pecially cystitis or pyelonephritis. The
of pentosuria and fructosuria may oc- finding of WBC and WBC casts in the
cur after excessive ingestion of pentose urine suggests renal infection or nonin-
or fructose. When the liver doesn’t me- fective inflammatory disease. Numer-
tabolize these sugars, they spill into ous epithelial cells suggest renal tubu-
the urine because the renal tubules lar degeneration, such as heavy metal
don’t reabsorb them. poisoning, eclampsia, and kidney
◆ Ketone bodies: Ketonuria occurs in transplant rejection.
diabetes mellitus when cellular energy ◆ Casts (plugs of gelled proteinaceous
needs exceed available cellular glucose. material [high-molecular-weight muco-
In the absence of glucose, cells metab- protein]): Casts form in the renal
olize fat for energy. Ketone bodies — tubules and collecting ducts by aggluti-
the end products of incomplete fat me- nation of protein cells or cellular debris
tabolism — accumulate in the plasma and are flushed loose by urine flow.
and are excreted in the urine. Ke- Excessive numbers of casts indicate
renal disease. Hyaline casts are associ-

ated with renal parenchymal disease, cells in a microliter (␮l), or cubic mil-
inflammation, trauma to the glomeru- limeter (mm3), of whole blood.
lar capillary membrane, and some WBC counts may vary by as much
physiologic states (such as after exer- as 2,000 cells/␮l (SI, 2 ⳯ 109/L) on
cise); epithelial casts, with renal tubu- any given day as a result of strenuous
lar damage, nephrosis, eclampsia, amy- exercise, stress, or digestion. The WBC
loidosis, and heavy metal poisoning; count may increase or decrease signifi-
coarse and fine granular casts, with cantly in certain diseases but is diag-
acute or chronic renal failure, nostically useful only when the pa-
pyelonephritis, and chronic lead intoxi- tient’s WBC differential and clinical
cation; fatty and waxy casts, with status are considered.
nephrotic syndrome, chronic renal dis-
ease, and diabetes mellitus; RBC casts, Purpose
with renal parenchymal disease (espe- ◆ To identify infection or inflamma-
cially glomerulonephritis), renal infarction
tion, subacute bacterial endocarditis, ◆ To determine the need for further
vascular disorders, sickle cell anemia, tests, such as WBC differential or bone
scurvy, blood dyscrasias, malignant hy- marrow biopsy
pertension, collagen disease, and acute ◆ To monitor the response to
inflammation; and WBC casts, with chemotherapy or radiation therapy
acute pyelonephritis and glomeru-
lonephritis, nephrotic syndrome, pyo- Patient preparation
genic infection, and lupus nephritis. ◆ Explain to the patient that the test
◆ Crystals: Some crystals normally ap- is used to detect an infection or inflam-
pear in urine, but numerous calcium mation.
oxalate crystals suggest hypercalcemia ◆ Explain that a blood sample will be
or ingestion of ethylene glycol. Cystine needed, and tell the patient when and
crystals (cystinuria) reflect an inborn where it will be taken.
error of metabolism. ◆ Inform the patient that he should
◆ Other components: Bacteria, yeast avoid strenuous exercise for 24 hours
cells, and parasites in urine sediment before the test. Also tell him that he
reflect genitourinary tract infection or should avoid eating a heavy meal be-
contamination of external genitalia. fore the test.
Yeast cells, which may be mistaken for ◆ If the patient is being treated for an
RBCs, are identifiable by their ovoid infection, advise him that this test will
shape, lack of color, variable size and, be repeated to monitor his progress.
commonly, signs of budding. The most ◆ Notify the laboratory and physician
common parasite in sediment is Tri- of medications that the patient is tak-
chomonas vaginalis, which causes ing that may affect test results; they
vaginitis, urethritis, and prostatovesi- may need to be restricted.
culitis.
Reference values
WBC count ranges from 4,000 to
White blood cell count 10,000/␮l (SI, 4 to 10 ⫻ 109/L).
A WBC count, also called a leukocyte Abnormal findings

count, is part of a complete blood An elevated WBC count (leukocytosis)
count. It indicates the number of white commonly signals infection, such as an
White blood cell differential 197
Interpreting WBC differential values
The differential count measures the types However, this patient’s neutrophil
of white blood cells (WBCs) as a percent- count (30%) (SI, 0.30) is low; when this
age of the total WBC count (relative val- figure is multiplied by the WBC count
ue). The absolute value is obtained by (6,000 ⳯ 30% ⫽ 1,800 neutrophils/ml)
multiplying the relative value of each cell (SI, 6 ⳯ 109/L ⳯ 0.30 ⫽ 1.8 ⳯ 109/L
type by the total WBC count. The relative neutrophils), the result is a low absolute
and absolute values must be considered number, which may mean depressed
to obtain an accurate diagnosis. bone marrow.
For example, consider a patient whose The normal percentages of WBC type
WBC count is 6,000/␮l (SI, 6 ⳯ 109/L) in adults are:
and whose differential shows 30% (SI, Neutrophils: 54% to 75% (SI, 0.54 to
0.30) neutrophils and 70% (SI, 0.70) 0.75)
lymphocytes. His relative lymphocyte Eosinophils: 1% to 4% (SI, 0.01 to 0.04)
count seems high (lymphocytosis), but Basophils: 0% to 1% (SI, 0 to 0.01)
when this figure is multiplied by his WBC Monocytes: 2% to 8% (SI, 0.02 to 0.08)
count (6,000 ⳯ 70% ⫽ 4,200 lympho- Lymphocytes: 25% to 40% (SI, 0.25 to
cytes/␮l), (SI, 6 ⳯ 109/L ⳯ 9.79 ⫽ 0.40).
4.2 ⳯ 109/L lymphocytes), it’s well with-
in the normal range.
abscess, meningitis, appendicitis, or WBCs are classified as one of five

tonsillitis. A high count may also result major types — neutrophils, eosinophils,
from leukemia and tissue necrosis from basophils, lymphocytes, and mono-
burns, MI, or gangrene. cytes — and the percentage of each
A low WBC count (leukopenia) in- type is determined. The differential
dicates bone marrow depression that count is the percentage of each type of
may result from viral infection or from WBC in the blood. The total number of
a toxic reaction, such as those that oc- each type of WBC is obtained by multi-
cur after treatment with antineoplas- plying the percentage of each type by
tics, ingestion of mercury or other the total WBC count.
heavy metals, or exposure to benzene High levels of these leukocytes are
or arsenicals. Leukopenia characteristi- associated with various allergic dis-
cally accompanies influenza, typhoid eases and reactions to parasites. An
fever, measles, infectious hepatitis, eosinophil count is sometimes ordered
mononucleosis, and rubella. as a follow-up test when the eosinophil
level is elevated or depressed.
White blood cell differential Purpose

◆ To evaluate the body’s capacity to
The WBC differential is used to evalu- resist and overcome infection
ate the distribution and morphologic ◆ To detect and identify various types
features of WBCs, providing more spe- of leukemia
cific information about a patient’s im- ◆ To determine the stage and severity
mune system than the WBC count of an infection
alone.
◆ To detect allergic reactions and par-

asitic infections and assess their severi-
ty (eosinophil count)
◆ To distinguish viral infections from
bacterial infections
◆ To monitor the effects of chemother-
apeutic agents on the immune system
Patient preparation
is used to evaluate the immune system.
◆ Explain that this test requires a
when and where it will be taken.
◆ Notify the laboratory and physician
of medications the patient is taking
that may affect test results; they may
need to be restricted.
◆ Inform the patient that he need not
restrict food or fluids but should refrain
from strenuous exercise for 24 hours
before the test.
Reference values
For normal values for the five types of
WBCs classified in the differential for
adults and children, see Interpreting
WBC differential values, page 197. For
an accurate diagnosis, differential test
results must always be interpreted in
relation to the total WBC count.
Abnormal findings
Abnormal differential patterns provide
evidence of a wide range of disease
states and other conditions.
5 Common disorders
Treating and preventing diseases
Alzheimer’s disease 201

Arterial occlusive disease 202
Asthma 204
Breast cancer 206
Bronchitis, chronic 208
Colorectal cancer 210
Coronary artery disease 211
Diabetes mellitus 213
Emphysema 215
Gastroenteritis 217
Gastroesophageal reflux disease 218
Heart failure 220
Hepatitis, viral 221
Human immunodeficiency virus and
acquired immunodeficiency syndrome 224
Hypertension 225
Influenza 227
Metabolic syndrome 228
Methicillin-resistant Staphylococcus aureus 230
Multiple sclerosis 232
Myocardial infarction 234
Osteoarthritis 236
Osteoporosis 238
199
200 Common disorders
Parkinson’s disease 239

Peptic ulcer 241
Pneumonia 242
Prostate cancer 244
Pulmonary embolism 245
Renal failure, acute 247
Renal failure, chronic 249
Rheumatoid arthritis 250
Seizure disorder 253
Stroke 254
Thrombophlebitis 257
Tuberculosis 258
Vancomycin-resistant enterococci 260
Alzheimer’s disease 201
◆ Suspicious and fearful of imaginary

Alzheimer’s disease people and situations
◆ Misperceives own environment
Overview ◆ Misidentifies objects and people
◆ Complains of stolen or misplaced
◆ Degenerative disorder of the cere- objects
bral cortex (especially the frontal lobe). ◆ Labile emotions
Alzheimer’s disease accounts for more ◆ Mood swings, sudden angry out-
than 50% of all cases of dementia bursts, and sleep disturbances
◆ Poor prognosis
◆ No cure or definitive treatment Physical findings
◆ Impaired sense of smell (usually an
Causes early symptom)
◆ Unknown ◆ Impaired stereognosis
◆ Gait disorders
Risk factors ◆ Tremors
Neurochemical ◆ Loss of recent memory
◆ Deficiencies of the neurotransmit- ◆ Positive snout reflex
ters ◆ Organic brain disease in adults
◆ Urinary or fecal incontinence
Environmental ◆ Seizures
◆ Aluminum and manganese
◆ Repeated head trauma Diagnostic tests
◆ Genetic abnormality on chromo- ◆ Diagnosis is made by exclusion;
some 21 tests are performed to rule out other
◆ Slow-growing central nervous sys- diseases.
tem viruses ◆ Positive diagnosis is made on
autopsy.
Assessment
Imaging
History ◆ Positron emission tomography
◆ History obtained from a family shows metabolic activity of the cere-
member or caregiver bral cortex.
◆ Insidious onset ◆ Computed tomography scan shows
◆ Initial changes almost imperceptible excessive and progressive brain atro-
◆ Forgetfulness and subtle memory phy.
loss ◆ Magnetic resonance imaging rules
◆ Recent memory loss out intracranial lesions.
◆ Difficulty learning and remembering ◆ Cerebral blood flow studies show
new information abnormalities in blood flow to the
◆ General deterioration in personal brain.
hygiene
◆ Inability to concentrate Diagnostic procedures
◆ Tendency to perform repetitive ac- ◆ Cerebrospinal fluid analysis shows
tions and experience restlessness chronic neurologic infection.
◆ Negative personality changes (irri- ◆ Electroencephalogram evaluates the
tability, depression, paranoia, hostility) brain’s electrical activity and may
◆ Nocturnal awakening show slowing of brain waves in late
◆ Disorientation stages of the disease.
Other Patient teaching

◆ Neuropsychologic tests may show
impaired cognitive ability and reason- ◆ Be sure to cover:
ing. – the disease process
– the exercise regimen
Treatment – the importance of cutting food and
providing finger foods, if indicated
General – the need to use plates with rim
◆ Behavioral interventions (patient- guards, built-up utensils, and cups
centered or caregiver training) focused with lids
on managing cognitive and behavioral – promotion of independence.
changes ◆ Refer the patient (and his family or
◆ Well-balanced diet (may need to be caregivers) to the Alzheimer’s Associa-
monitored) tion.
◆ Safe activities, as tolerated (may ◆ Refer the patient (and his family or
need to be monitored) caregivers) to a local support group.
◆ Refer the patient (and his family or
Medications caregivers) to social services for addi-
◆ N-methyl-D-aspartate antagonist tional support.
◆ Cerebral vasodilators
◆ Psychostimulators
◆ Antidepressants Arterial occlusive disease
◆ Anxiolytics
◆ Neurolytics
◆ Anticonvulsants (experimental) Overview
◆ Anti-inflammatories (experimental)
◆ Anticholinesterase agents ◆ Obstruction or narrowing of the lu-
◆ Vitamin E men of arteries
◆ May affect any artery; commonly af-
Nursing interventions fects the aortic, iliac, carotid, vertebral,
◆ Provide an effective communication femoral, popliteal, anterior tibial, pos-
system. terior tibial, renal, mesenteric, and celi-
◆ Use soft tones and a slow, calm ac arteries
manner when speaking to the patient. ◆ Prognosis depends on the location
◆ Allow the patient sufficient time to of the occlusion and the development
answer questions. of collateral circulation that counteracts
◆ Protect the patient from injury. reduced blood flow
◆ Provide rest periods. ◆ Ninety percent of acute peripheral
◆ Provide an exercise program. arterial occlusions occur in the lower
◆ Encourage independence. extremities
◆ Offer frequent toileting.
◆ Assist with hygiene and dressing. Causes
◆ Give prescribed drugs. ◆ Atherosclerosis
◆ Provide familiar objects to help with ◆ Immune arteritis
orientation and behavior control. ◆ Embolism
◆ Monitor fluid intake, nutritional ◆ Thrombosis
status, and safety. ◆ Thromboangiitis obliterans
◆ Raynaud’s disease
Arterial occlusive disease 203
◆ Fibromuscular disease ◆ Duplex ultrasonography shows de-

◆ Atheromatous debris (plaques) creased blood flow distal to the ob-
◆ Indwelling arterial catheter struction.
◆ Direct blunt or penetrating trauma ◆ Magnetic resonance angiography
and computed tomography scan may
Risk factors show arterial abnormalities.
◆ Smoking
◆ Hypertension Other
◆ Dyslipidemia ◆ Segmental limb pressures and pulse
◆ Diabetes mellitus volume measurements show the loca-
◆ Advanced age tion and severity of the obstruction.
◆ Ophthalmodynamometry indirectly
Assessment helps determine the degree of obstruc-
tion in the internal carotid artery.
History ◆ Electrocardiogram and echocardio-
◆ One or more risk factors gram may show cardiovascular disease.
◆ Family history of vascular disease
◆ Intermittent claudication Treatment
◆ Pain on resting
◆ Poor healing of wounds or ulcers General
◆ Impotence ◆ Smoking cessation
◆ Dizziness or near syncope ◆ Control of hypertension, diabetes,
◆ Symptoms of transient ischemic at- and dyslipidemia
tack ◆ Foot and leg care
◆ Weight control
Physical findings ◆ Low-fat, low-cholesterol, high-fiber
◆ Trophic changes of the involved diet
arm or leg ◆ Regular walking program
◆ Diminished or absent pulses in the
carotid artery, arm, or leg Medications
◆ Ischemic ulcers ◆ Antiplatelets
◆ Pallor with elevation of the arm or ◆ Lipid-lowering agents
leg ◆ Hypoglycemic agents
◆ Dependent rubor ◆ Antihypertensives
◆ Arterial bruit ◆ Thrombolytics
◆ Hypertension ◆ Anticoagulation
◆ Pain ◆ Niacin or vitamin B complex
◆ Pallor
◆ Pulselessness distal to the occlusion Surgery
◆ Paralysis and paresthesia in the af- ◆ Embolectomy
fected arm or leg ◆ Endarterectomy
◆ Poikilothermy ◆ Atherectomy
◆ Laser angioplasty
Diagnostic tests ◆ Endovascular stent placement
Imaging ◆ Endovascular stent graft
◆ Arteriography shows the type, loca- ◆ Percutaneous transluminal angio-
tion, and degree of obstruction and the plasty
establishment of collateral circulation. ◆ Laser surgery
◆ Patch arterioplasty Patient teaching

◆ Bypass graft
◆ Amputation ◆ Be sure to cover:
◆ Bowel resection – the disorder, diagnosis, and treat-
ment
Nursing interventions – medications and potential adverse
For chronic arterial occlusive disease reactions
◆ Use preventive measures, such as – when to notify the physician
minimal pressure mattresses, heel pro- – dietary restrictions
tectors, a foot cradle, or a footboard. – the regular exercise program
◆ Avoid restrictive clothing such as – foot care
antiembolism stockings. – signs and symptoms of graft occlu-
◆ Give prescribed drugs. sion
◆ Allow the patient to express fears – signs and symptoms of arterial in-
and concerns. sufficiency and occlusion
– the need to avoid crossing the legs
For preoperative care during an acute and wearing constrictive clothing or
episode garters
◆ Assess the patient’s circulatory sta- – modification of risk factors
tus. – the need to avoid temperature ex-
◆ Give prescribed analgesics. tremes.
◆ Give prescribed heparin or throm- ◆ Refer the patient to a physical and
bolytics. occupational therapist, as indicated.
◆ Wrap the patient’s affected foot in ◆ Refer the patient to a podiatrist for
soft cotton batting, and reposition it foot care, as needed.
frequently to prevent pressure on any ◆ Refer the patient to an endocrinolo-
one area. gist for glucose control, as indicated.
◆ Strictly avoid elevating or applying ◆ Refer the patient to a smoking-
heat to the affected leg. cessation program, as indicated.
For postoperative care

◆ Watch the patient closely for signs Asthma
of hemorrhage.
◆ If the patient has mesenteric artery Overview
occlusion, connect a nasogastric tube
to low intermittent suction. ◆ A chronic reactive airway disorder
◆ Give prescribed analgesics. that involves episodic, reversible air-
◆ Assist with early ambulation, but way obstruction caused by broncho-
don’t allow the patient to sit for an ex- spasms, increased secretion of mucus,
tended period. and mucosal edema
◆ If amputation has occurred, check ◆ Signs and symptoms that range
the stump carefully for drainage and from mild wheezing and dyspnea to
note and record the color and amount life-threatening respiratory failure
of drainage as well as the time. ◆ Signs and symptoms of bronchial
◆ Elevate the stump, as ordered. airway obstruction that may persist be-
◆ Perform neurovascular checks, as tween acute episodes
ordered.
Asthma 205
Causes accompanied by a cough that produces

◆ Sensitivity to specific external aller- thick, clear, or yellow sputum.
gens
◆ Internal, nonallergenic factors Physical findings
◆ Visible dyspnea
Extrinsic asthma (atopic asthma) ◆ Ability to speak only a few words
◆ Pollen before pausing for breath
◆ Animal dander ◆ Use of accessory respiratory mus-
◆ House dust or mold cles
◆ Kapok or feather pillows ◆ Diaphoresis
◆ Food additives that contain sulfites ◆ Increased anteroposterior thoracic
or other sensitizing substances diameter
◆ Hyperresonance
Intrinsic asthma (nonatopic asthma) ◆ Tachycardia, tachypnea, and mild
◆ Emotional stress systolic hypertension
◆ Genetic factors ◆ Inspiratory and expiratory wheezes
◆ Prolonged expiratory phase of respi-
Bronchoconstriction ration
◆ Hereditary predisposition ◆ Diminished breath sounds
◆ Sensitivity to allergens or irritants ◆ Cyanosis, confusion, and lethargy,
such as pollutants which indicate onset of life-threatening
◆ Viral infections status asthmaticus and respiratory fail-
◆ Drugs, such as aspirin, beta- ure
adrenergic blockers, and nonsteroidal
anti-inflammatory drugs Diagnostic tests
◆ Tartrazine Laboratory
◆ Psychological stress ◆ Arterial blood gas analysis shows
◆ Cold air hypoxemia.
◆ Exercise ◆ Increased serum immunoglobulin E
levels are caused by an allergic reac-
Assessment tion.
◆ A complete blood count with differ-
History ential shows an increased eosinophil
◆ Intrinsic asthma is commonly pre- count.
ceded by severe respiratory tract infec-
tions, especially in adults. Imaging
◆ Irritants, emotional stress, fatigue, ◆ Chest X-rays may show hyperinfla-
endocrine changes, temperature and tion, with areas of focal atelectasis.
humidity variations, and exposure to
noxious fumes may aggravate intrinsic Diagnostic procedures
asthma attacks. ◆ Pulmonary function tests may show
◆ An asthma attack may begin dra- decreased peak flow and forced expira-
matically, with simultaneous onset of tory volume in 1 second, low-normal
severe, multiple symptoms, or insidi- or decreased vital capacity, and in-
ously, with gradually increasing respi- creased total lung and residual capaci-
ratory distress. ties.
◆ Exposure to a particular allergen is ◆ Skin testing may identify specific al-
followed by sudden onset of dyspnea, lergens.
wheezing, and tightness in the chest
◆ Bronchial challenge testing shows ◆ Assist with intubation and mechani-

the clinical significance of allergens cal ventilation, if appropriate.
that are identified by skin testing. ◆ Perform postural drainage and chest
percussion, if tolerated.
Other ◆ Suction an intubated patient, as
◆ Pulse oximetry measurements may needed.
show decreased oxygen saturation. ◆ Treat the patient’s dehydration with
I.V. or oral fluids, as tolerated.
Treatment ◆ Anticipate bronchoscopy or
bronchial lavage.
General ◆ Keep the room temperature comfort-
◆ Identification and avoidance of pre- able.
cipitating factors ◆ Use an air conditioner or a fan in
◆ Desensitization to specific antigens hot, humid weather.
◆ Establishment and maintenance of a
patent airway Patient teaching
◆ Fluid replacement
◆ Activity as tolerated ◆ Be sure to cover:
◆ In patients who are unresponsive – the disorder, diagnosis, and treat-
to drug therapy, possible admission ment
for further treatment, which may in- – medications and potential adverse
clude intubation or mechanical venti- reactions
lation – when to notify the physician
– the importance of avoiding known
Medications allergens and irritants
◆ Bronchodilators – the use of a metered-dose inhaler or
◆ Corticosteroids dry powder inhaler
◆ Histamine antagonists – pursed-lip and diaphragmatic
◆ Leukotriene antagonists breathing
◆ Anticholinergic bronchodilators – the use of a peak flow meter
◆ Low-flow oxygen – effective coughing techniques
◆ Antibiotics – the importance of maintaining ade-
◆ Trial of heliox (helium-oxygen mix- quate hydration.
ture) before intubation ◆ Refer the patient to a local asthma
◆ I.V. magnesium sulfate (controver- support group.
sial)
Nursing interventions Breast cancer

◆ Give prescribed drugs.
◆ Place the patient in high Fowler’s Overview
position.
◆ Encourage pursed-lip and diaphrag- ◆ Malignant proliferation of the ep-
matic breathing. ithelial cells that line the ducts or lob-
◆ Administer prescribed humidified ules of the breast
oxygen. ◆ Prognosis considerably affected by
◆ Adjust oxygen administration ac- early detection and treatment
cording to the patient’s vital signs and
arterial blood gas values. Causes
◆ Unknown
Breast cancer 207
Risk factors ◆ A hormonal receptor assay deter-

◆ Family history of breast cancer, par- mines whether the tumor is estrogen-
ticularly in first-degree relatives, includ- or progesterone-dependent and guides
ing the patient’s parents and siblings decisions to use therapy that blocks the
◆ Positive results on tests for genetic action of the hormone estrogen that
mutations (BRCA 1) supports tumor growth.
◆ Older than age 45 and pre-
menopausal Imaging
◆ Long menstrual cycles ◆ Mammography can show a tumor
◆ Early onset of menses, late that’s too small to palpate.
menopause ◆ Ultrasonography can distinguish
◆ Nulliparous or first pregnancy after between a fluid-filled cyst and a solid
age 30 mass.
◆ High-fat diet ◆ Magnetic resonance imaging can
◆ History of endometrial or ovarian show very small tumors.
cancer ◆ Chest X-rays can show metastases
◆ History of unilateral breast cancer to the lung.
◆ Radiation exposure ◆ Scans of the bone, brain, liver, and
◆ Estrogen therapy other organs can detect distant metas-
◆ Antihypertensive therapy tases.
◆ Alcohol or tobacco use
◆ Preexisting fibrocystic disease Diagnostic procedures
Age alert Breast cancer is the ◆ Fine-needle aspiration and excisional
leading cause of cancer deaths biopsy provide cells for histologic exam-
among women ages 35 to 54. ination that may confirm the diagnosis.
Assessment Treatment
History General
◆ Detection of a painless lump or ◆ The choice of treatment usually de-
mass in the breast pends on the stage and type of disease,
◆ Change in breast tissue the woman’s age and menopausal sta-
◆ History of risk factors tus, and the disfiguring effects of
surgery.
Physical findings ◆ Therapy may include any combina-
◆ Clear, milky, or bloody nipple dis- tion of surgery, radiation therapy,
charge, nipple retraction, scaly skin chemotherapy, and hormone therapy.
around the nipple, and skin changes, ◆ Some patients benefit from preoper-
such as dimpling or inflammation ative breast irradiation.
◆ Edema of the arm ◆ The patient may require arm-
◆ Hard lump, mass, or thickening of stretching exercises after surgery.
breast tissue ◆ The patient may need primary radi-
◆ Lymphadenopathy ation therapy.
Diagnostic tests Medications

Laboratory ◆ Chemotherapy such as a combination
◆ Elevated alkaline phosphatase levels of drugs, including cyclophosphamide,
and liver function test results may indi- fluorouracil, methotrexate, doxorubicin,
cate distant metastases. vincristine, paclitaxel, and prednisone
◆ Antiestrogen therapy, such as ta- ◆ Severity linked to the amount of

moxifen, or anastrozole cigarette smoke or other pollutants in-
◆ Hormonal therapy, including estro- haled and the duration of inhalation
gen, progesterone, androgen, or antian- ◆ Exacerbation of the cough and relat-
drogen aminoglutethimide therapy ed symptoms by respiratory tract infec-
tions
Surgery ◆ Development of significant airway
◆ Lumpectomy obstruction in few patients with chron-
◆ Partial, total, or modified radical ic bronchitis
mastectomy
◆ Sentinel node biopsy or axillary Causes
node dissection ◆ Cigarette smoking
◆ Possible genetic predisposition
Nursing interventions ◆ Environmental pollution
◆ Provide information about the dis- ◆ Exposure to organic or inorganic
ease process, diagnostic tests, and dusts and noxious gas
treatment.
◆ Give prescribed drugs. Assessment
◆ Provide emotional support.
History
Patient teaching ◆ Longtime smoker
◆ Frequent upper respiratory tract in-
◆ Be sure to cover: fections
– all procedures and treatments ◆ Productive cough
– activities or exercises that promote ◆ Exertional dyspnea
healing ◆ Cough, initially prevalent in winter,
– breast self-examination but gradually becoming year-round
– the risks and the signs and symp- ◆ Increasingly severe coughing
toms of recurrence episodes
– the need to avoid venipuncture or ◆ Worsening dyspnea
blood pressure monitoring on the af-
fected arm. Physical findings
◆ Refer the patient to local and na- ◆ Cough that produces copious gray,
tional support groups. white, or yellow sputum
◆ Cyanosis, also called a blue bloater
◆ Use of accessory respiratory muscles
Bronchitis, chronic ◆ Tachypnea
◆ Substantial weight gain
Overview ◆ Pedal edema
◆ Jugular vein distention
◆ Inflammation of the lining of the ◆ Wheezing
bronchial tubes ◆ Prolonged expiratory time
◆ A form of chronic obstructive pul- ◆ Rhonchi
monary disease
◆ Characterized by excessive produc- Diagnostic tests
tion of tracheobronchial mucus with a Laboratory
cough for at least 3 months each year ◆ Arterial blood gas analysis shows
for 2 consecutive years decreased partial pressure of oxygen
Bronchitis, chronic 209
and normal or increased partial pres- ◆ Encourage the patient to express his
sure of carbon dioxide. fears and concerns.
◆ Sputum culture shows many micro- ◆ Include the patient and his family
organisms and neutrophils. in care decisions.
◆ Perform chest physiotherapy.
Imaging ◆ Provide a high-calorie, protein-rich
◆ Chest X-ray may show hyperinfla- diet.
tion and increased bronchovascular ◆ Offer small, frequent meals.
markings. ◆ Encourage energy-conservation
techniques.
Diagnostic procedures ◆ Ensure adequate oral fluid intake.
◆ Pulmonary function test results ◆ Provide frequent mouth care.
show increased residual volume, de- ◆ Encourage daily activity.
creased vital capacity and forced expi- ◆ Provide diversional activities, as ap-
ratory flow, and normal static compli- propriate.
ance and diffusing capacity. ◆ Provide frequent rest periods.

◆ Electrocardiography may show atrial
arrhythmias; peaked P waves in leads ◆ Be sure to cover:
II, III, and aVF; and right ventricular – the disorder, diagnosis, and treat-
hypertrophy. ment
– medications and possible adverse
Treatment reactions
– when to notify the physician
General – infection control practices
◆ Smoking cessation – the importance of influenza and
◆ Avoidance of air pollutants pneumococcus immunizations
◆ Chest physiotherapy – the importance of home oxygen
◆ Ultrasonic or mechanical nebulizer therapy, if required, including a
treatments demonstration, if needed
◆ Adequate fluid intake – postural drainage and chest percus-
◆ High-calorie, protein-rich diet sion
◆ Activity, as tolerated, with frequent – coughing and deep-breathing exer-
rest periods cises
– inhaler use
Medications – high-calorie, protein-rich meals
◆ Oxygen – adequate hydration
◆ Antibiotics – avoidance of inhaled irritants
◆ Bronchodilators – prevention of bronchospasm.
◆ Corticosteroids ◆ Refer the patient to a smoking-
◆ Diuretics cessation program, if indicated.
◆ Refer the patient to the American
Surgery Lung Association for information and
◆ Tracheostomy in advanced disease support.
Nursing interventions
Physical findings
Colorectal cancer ◆ Abdominal distention or visible
masses
Overview ◆ Enlarged abdominal veins
◆ Enlarged inguinal and supraclavicu-
◆ Malignant tumors of the colon or lar nodes
rectum are almost always adenocarci- ◆ Abnormal bowel sounds
nomas (About half are sessile lesions ◆ Abdominal masses (Tumors on the
of the rectosigmoid area; all others are right side usually feel bulky; tumors of
polypoid lesions.) the transverse portion are more easily
◆ Slow progression detected.)
◆ Five-year survival rate of 50%; po- ◆ Generalized abdominal tenderness
tentially curable in 75% of patients if
early diagnosis allows resection before Diagnostic tests
involvement of nodes Laboratory
◆ Third most common type of cancer ◆ A fecal occult blood test may show
in Europe and North America blood in the stools, a warning sign of
rectal cancer.
Causes ◆ The carcinoembryonic antigen test
◆ Unknown permits patient monitoring before and
after treatment to detect metastasis or
Risk factors recurrence.
◆ Excessive intake of saturated animal
fat Imaging
◆ Smoking ◆ Excretory urography verifies bilater-
◆ Older than age 50 al renal function and allows inspection
◆ History of ulcerative colitis to detect displacement of the kidneys,
◆ History of familial polyposis ureters, or bladder by a tumor pressing
◆ Family history of colon cancer against these structures.
◆ High-protein, low-fiber diet ◆ Barium enema studies use dual con-
◆ Excessive alcohol intake trast of barium and air to show the
location of lesions that aren’t detect-
Assessment able manually or visually. This test
shouldn’t precede colonoscopy or ex-
History cretory urography because barium sul-
◆ Tumors of the right side of the fate interferes with these tests.
colon: no signs and symptoms in the ◆ A computed tomography scan al-
early stages because stool is liquid in lows better visualization if a barium
that part of the colon enema test yields inconclusive results
◆ Black, tarry stools or if metastasis to the pelvic lymph
◆ Abdominal aching, pressure, or dull nodes is suspected.
cramps
◆ Weakness Diagnostic procedures
◆ Diarrhea, anorexia, obstipation, ◆ Proctoscopy or sigmoidoscopy per-
weight loss, and vomiting mits visualization of the lower GI tract.
◆ Rectal bleeding It can detect up to 76% of colorectal
◆ Intermittent abdominal fullness cancers.
◆ Rectal pressure ◆ Colonoscopy permits visual inspec-
◆ Urgent need to defecate on arising tion and photography of the colon up
Coronary artery disease 211
to the ileocecal valve and provides ac- Postoperative

cess for polypectomy and biopsy of ◆ Vital signs
suspected lesions. ◆ Intake and output
◆ Hydration and nutritional status
Other ◆ Electrolyte levels
◆ Digital rectal examination can be ◆ Wound site
used to detect one-third of malignant ◆ Postoperative complications
tumors of the distal colon and rectum; ◆ Bowel function
specifically, it can be used to detect ◆ Pain control
suspicious rectal and perianal lesions. ◆ Psychological status
Treatment Patient teaching
General ◆ Be sure to cover:

◆ Radiation preoperatively and post- – the disease process, treatment, and
operatively to induce tumor regression postoperative course
◆ High-fiber diet – stoma care
◆ After surgery, avoidance of heavy – the need to avoid heavy lifting
lifting and contact sports – the need to keep follow-up appoint-
ments
Medications – risk factors and signs of reoccurrence.
◆ Chemotherapy for metastasis, residual ◆ Refer the patient to resource and
disease, or recurrent inoperable tumor support services.
◆ Analgesics
Surgery Coronary artery disease

◆ Resection or right hemicolectomy
for advanced disease (Surgery may in- Overview
clude resection of the terminal segment
of the ileum, cecum, ascending colon, ◆ Heart disease that results from nar-
and right half of the transverse colon rowing of the coronary arteries over
with corresponding mesentery.) time as a result of atherosclerosis
◆ Right colectomy that includes the ◆ Primary effect: loss of oxygen and
transverse colon and mesentery corre- nutrients to myocardial tissue because
sponding to the midcolic vessels, or of decreased coronary blood flow
segmental resection of the transverse
colon and associated midcolic vessels Causes
◆ Resection usually limited to the sig- ◆ Atherosclerosis
moid colon and mesentery ◆ Dissecting aneurysm
◆ Anterior or low anterior resection ◆ Infectious vasculitis
(A newer method that uses a stapler al- ◆ Syphilis
lows for much lower resections than ◆ Congenital defects
were possible in the past.) ◆ Coronary artery spasm
◆ Abdominoperineal resection and
permanent sigmoid colostomy required Risk factors
◆ Family history
Nursing interventions ◆ Increasing age
◆ Provide support and encourage the ◆ Gender
patient to express his concerns. ◆ Race
◆ High cholesterol level Diagnostic tests

◆ Smoking Imaging
◆ Diabetes ◆ Myocardial perfusion imaging with
◆ Hypertension thallium 201 during treadmill exercise
◆ Hormonal contraceptives shows ischemic areas of the myocardi-
◆ Obesity um. These are visualized as “cold
◆ Sedentary lifestyle spots.”
◆ Stress ◆ Pharmacologic myocardial perfusion
◆ Increased homocystine levels imaging in arteries with stenosis shows
a decrease in blood flow that’s propor-
Assessment tional to the percentage of occlusion.
◆ Multiple-gated acquisition scanning
History shows cardiac wall motion and reflects
◆ Angina that may radiate to the left injury to cardiac tissue.
arm, neck, jaw, or shoulder blade
◆ Angina that commonly occurs after Diagnostic procedures
physical exertion but may also follow ◆ Electrocardiographic findings may
emotional excitement, exposure to be normal between anginal episodes.
cold, or a large meal During angina, the findings may show
◆ May develop during sleep (Symp- ischemic changes.
toms wake the patient.) ◆ Exercise testing may be performed
◆ Nausea to detect ST-segment changes during
◆ Vomiting exercise, which indicate ischemia, and
◆ Fainting to determine a safe exercise prescrip-
◆ Sweating tion.
◆ Stable angina (predictable and re- ◆ Coronary angiography shows the lo-
lieved by rest or nitrates) cation and degree of coronary artery
◆ Unstable angina (increased frequen- stenosis or obstruction, the collateral
cy and duration, more easily induced, circulation, and the condition of the
generally indicates extensive or wors- artery beyond the narrowing.
ening disease and, untreated, may ◆ Stress echocardiography may show
progress to myocardial infarction) abnormal wall motion.
◆ Crescendo angina (effort-induced
pain that occurs with increasing frequen- Treatment
cy and with decreasing provocation)
◆ Prinzmetal’s or variant angina pec- General
toris (severe, non-effort-produced pain ◆ Stress reduction techniques are es-
that occurs at rest without provocation) sential, especially if known stressors
precipitate pain
Physical findings ◆ Lifestyle modifications, such as
◆ Cool extremities smoking cessation and maintaining
◆ Xanthoma ideal body weight
◆ Arteriovenous nicking of the eye ◆ Low-fat, low-sodium diet
◆ Obesity ◆ Possible restrictions on the patient’s
◆ Hypertension activity
◆ Positive Levine sign (holding the fist ◆ Regular exercise
to the chest)
◆ Decreased or absent peripheral
pulses
Diabetes mellitus 213
Medications – effective coping mechanisms for

◆ Aspirin dealing with stress
◆ Nitrates – the need to follow the prescribed
◆ Beta blockers drug regimen
◆ Calcium channel blockers – the importance of following a low-
◆ Antiplatelets sodium, low-calorie diet
◆ Antilipemics – the importance of regular, moderate
◆ Antihypertensives exercise.
◆ Refer the patient to a weight-loss
Surgery program, if needed.
◆ Coronary artery bypass graft ◆ Refer the patient to a smoking-
◆ “Keyhole,” or minimally invasive cessation program, if needed.
surgery ◆ Refer the patient to a cardiac reha-
◆ Angioplasty bilitation program, if indicated.
◆ Placement of an endovascular stent
◆ Laser angioplasty
◆ Atherectomy Diabetes mellitus
Nursing interventions Overview
◆ Ask the patient to grade the severity
of his pain on a scale of 1 to 10, with ◆ Chronic disease of absolute or rela-
10 being the most severe. tive insulin deficiency or resistance
◆ Keep nitroglycerin available for im- ◆ Characterized by disturbances in
mediate use. Instruct the patient to call the metabolism of carbohydrates, pro-
the nurse immediately whenever he teins, and fats
feels pain and before he takes nitro- ◆ Two primary forms:
glycerin. – Type 1, which is characterized by
◆ Monitor the patient’s electrocardio- absolute insufficiency of insulin
gram for ST-T segment changes. – Type 2, which is characterized by
◆ Observe the patient for signs and insulin resistance with varying degrees
symptoms that may signify worsening of insulin secretory defects
of his condition.
◆ Perform vigorous chest physiothera- Causes
py and guide the patient in pulmonary ◆ Genetic factors
self-care. ◆ Autoimmune disease (type 1)
◆ Monitor abnormal bleeding and dis-
tal pulses after interventions or proce- Risk factors (Type 2)
dures. ◆ Family history of diabetes
◆ Monitor drainage of the chest tube ◆ Race
after surgery. ◆ Sedentary lifestyle
◆ Obesity (BMI ⱖ 25 kg/m2)
Patient teaching ◆ History of gestational diabetes,
glucose intolerance, or delivery of a
◆ Be sure to cover: ⬎ 9 pound baby
– risk factors for coronary artery dis- ◆ HDL ⱕ 35 mg/dl or triglygeride lev-
ease el ⱖ 130 mg/dl
– the need to avoid activities that pre- ◆ Hypertension
cipitate episodes of pain ◆ Age ⱖ 45 years
Age alert Unless a diabetic ◆ Obesity, particularly in the abdomi-

woman’s glucose levels are well nal area (type 2)
controlled before conception and dur- ◆ Poor skin turgor
ing pregnancy, her neonate has two to ◆ Dry mucous membranes
three times the risk of congenital mal- ◆ Decreased peripheral pulses
formations and fetal distress. ◆ Cool skin temperature
◆ Diminished deep tendon reflexes
Assessment ◆ Orthostatic hypotension
◆ Characteristic “fruity” breath odor
History in ketoacidosis
◆ Polyuria, nocturia ◆ Possible hypovolemia and shock in
◆ Dehydration ketoacidosis and hyperosmolar hyper-
◆ Polydipsia glycemic state
◆ Dry mucous membranes
◆ Poor skin turgor Diagnostic tests
◆ Weight loss and hunger Laboratory
◆ Weakness and fatigue ◆ Fasting plasma glucose level is
◆ Vision changes 126 mg/dl or greater on at least two
◆ Frequent skin and urinary tract in- occasions.
fections ◆ Random blood glucose level is
◆ Dry, itchy skin 200 mg/dl or greater along with symp-
◆ Sexual problems toms of diabetes.
◆ Numbness or pain in the hands or ◆ Two-hour postprandial blood glu-
feet cose level is 200 mg/dl or greater.
◆ Postprandial feeling of nausea or ◆ Glycosylated hemoglobin value is
fullness increased.
◆ Nocturnal diarrhea
Diagnostic procedures
Type 1 ◆ Ophthalmologic examination may
◆ Rapidly developing symptoms show diabetic retinopathy.
Type 2 Treatment
◆ Vague, long-standing symptoms that
develop gradually General
◆ Family history of diabetes mellitus ◆ Exercise and diet control
◆ Pregnancy ◆ Tight glycemic control for preven-
◆ Severe viral infection tion of complications
◆ Other endocrine diseases ◆ Modest calorie restriction for weight
◆ Recent stress or trauma loss or maintenance
◆ Use of drugs that increase blood ◆ American Diabetes Association rec-
glucose levels ommendations to reach target glucose,
hemoglobin A1c lipid, and blood pres-
Physical findings sure levels
◆ Retinopathy or cataract formation ◆ Regular aerobic exercise
◆ Skin changes, especially on the legs
and feet Medications
◆ Muscle wasting and loss of subcuta- ◆ Exogenous insulin (type 1 or possi-
neous fat (type 1) bly type 2)
Emphysema 215
◆ Oral antihyperglycemic drugs – safety precautions

(type 2) – management of diabetes during ill-
ness.
Surgery ◆ Refer the patient to a dietitian.
◆ Pancreas transplantation ◆ Refer the patient to a podiatrist if
indicated.
Nursing interventions ◆ Refer the patient to an ophthalmolo-
◆ Give prescribed drugs. gist.
◆ Give rapidly absorbed carbohydrates ◆ Refer adult diabetic patients who
for hypoglycemia or, if the patient is are planning families for preconception
unconscious, give glucagon or I.V. dex- counseling.
trose, as ordered. ◆ Refer the patient to the Juvenile Di-
◆ Administer I.V. fluids and insulin re- abetes Research Foundation, the Amer-
placement for hyperglycemic crisis, as ican Association of Diabetes Educators,
ordered. and the American Diabetes Associa-
◆ Monitor electrolytes and administer tion, as appropriate, to obtain addition-
replacements, as ordered. al information.
◆ Provide meticulous skin care, espe-
cially to the feet and legs.
◆ Treat all injuries, cuts, and blisters Emphysema
immediately.
◆ Avoid constricting hose, slippers, or Overview
bed linens.
◆ Encourage adequate fluid intake. ◆ Chronic lung disease characterized
◆ Encourage the patient to express his by permanent enlargement of air
feelings. spaces distal to the terminal bronchi-
◆ Offer emotional support. oles and by exertional dyspnea
◆ Help the patient to develop effective ◆ One of several diseases usually la-
coping strategies. beled collectively as chronic obstruc-
tive pulmonary disease or chronic ob-
Patient teaching structive lung disease
◆ Be sure to cover: Causes

– the disorder, diagnosis, and treat- ◆ Genetic deficiency of alpha1-
ment antitrypsin
– medication and potential adverse re- ◆ Cigarette smoking
actions
– when to notify the physician Assessment
– the prescribed meal plan
– the prescribed exercise program History
– signs and symptoms of infection, ◆ Smoking
hypoglycemia, hyperglycemia, and dia- ◆ Shortness of breath
betic neuropathy ◆ Chronic cough
– self-monitoring of blood glucose ◆ Anorexia and weight loss
level ◆ Malaise
– complications of hyperglycemia
– foot care Physical findings
– the importance of annual regular ◆ Barrel chest
ophthalmologic examinations ◆ Pursed-lip breathing
◆ Use of accessory muscles Treatment

◆ Cyanosis
◆ Clubbed fingers and toes General
◆ Tachypnea ◆ Chest physiotherapy
◆ Decreased tactile fremitus ◆ Possible transtracheal catheteriza-
◆ Decreased chest expansion tion and home oxygen therapy
◆ Hyperresonance ◆ Adequate hydration
◆ Decreased breath sounds ◆ High-protein, high-calorie diet
◆ Crackles ◆ Activity, as tolerated
◆ Inspiratory wheeze
◆ Prolonged expiratory phase with Medications
grunting respirations ◆ Bronchodilators
◆ Distant heart sounds ◆ Anticholinergics
◆ Mucolytics
Diagnostic tests ◆ Corticosteroids
Laboratory ◆ Antibiotics
◆ Arterial blood gas analysis shows ◆ Oxygen
decreased partial pressure of oxygen;
the partial pressure of carbon dioxide Surgery
is normal until late in the course of ◆ Insertion of a chest tube for pneu-
disease. mothorax
◆ The red blood cell count shows an ◆ Lung volume reduction surgery for
increased hemoglobin level late in the patients who meet criteria
course of disease.
Imaging ◆ Give prescribed drugs.
◆ Chest X-ray may show: ◆ Provide supportive care.
– a flattened diaphragm ◆ Help the patient adjust to lifestyle
– reduced vascular markings at the changes that are necessitated by a
lung periphery chronic illness.
– overaeration of the lungs ◆ Encourage the patient to express his
– a vertical heart fears and concerns.
– enlarged anteroposterior chest di- ◆ Perform chest physiotherapy.
ameter ◆ Provide a high-calorie, protein-rich
– a large retrosternal air space. diet.
◆ Give small, frequent meals.
Diagnostic procedures ◆ Encourage daily activity and diver-
◆ Pulmonary function tests typically sional activities.
show: ◆ Provide frequent rest periods.
– increased residual volume and total
lung capacity Patient teaching
– reduced diffusing capacity
– increased inspiratory flow. ◆ Be sure to cover:
◆ Electrocardiography may show tall, – the disorder, diagnosis, and treat-
symmetrical P waves in leads II, III, ment
and aVF; a vertical QRS axis; and signs – medication and potential adverse re-
of right ventricular hypertrophy late in actions
the course of disease. – when to notify the physician
Gastroenteritis 217
– the importance of avoiding smoking ◆ Parasites, such as Ascaris, Entero-

and areas where smoking is permitted bius, and Trichinella spiralis
– the need to avoid crowds and peo- ◆ Viruses, such as noroviruses,
ple with known infections echoviruses, and coxsackieviruses
– home oxygen therapy, if indicated ◆ Ingestion of toxins, such as poiso-
– transtracheal catheter care, if nous plants and toadstools
needed ◆ Drug reactions from antibiotics
– coughing and deep-breathing exer- ◆ Food allergens
cises ◆ Enzyme deficiencies
– the proper use of handheld inhalers
– the importance of a high-calorie, Assessment
protein-rich diet
– adequate oral fluid intake History
– avoidance of respiratory irritants ◆ Acute onset of diarrhea
– signs and symptoms of pneumo- ◆ Abdominal pain and discomfort
thorax. ◆ Nausea and vomiting
Alert Urge the patient to notify ◆ Malaise and fatigue
the physician if he has sudden ◆ Exposure to contaminated food
onset of worsening dyspnea or sharp ◆ Recent travel
pleuritic chest pain that’s exacerbated
by chest movement, breathing, or Physical findings
coughing. ◆ Slight abdominal distention
◆ Refer the patient to a smoking- ◆ Poor skin turgor (with dehydration)
cessation program if indicated. ◆ Hyperactive bowel sounds
◆ Refer the patient for influenza and ◆ Decreased blood pressure
pneumococcal pneumonia immuniza-
tions as needed. Diagnostic tests
◆ Refer the family of a patient with Laboratory
familial emphysema for screening for ◆ Gram stain, stool culture (by direct
alpha1-antitrypsin deficiency. rectal swab), or blood culture shows
the causative agent.
Gastroenteritis Treatment
Overview General
◆ Supportive treatment for nausea,
◆ Self-limiting inflammation of the vomiting, and diarrhea
stomach and small intestine ◆ Rehydration
◆ Intestinal flu, traveler’s diarrhea, vi- ◆ Initially, clear liquids as tolerated
ral enteritis, and food poisoning ◆ Electrolyte solutions
◆ Avoidance of milk products
Causes ◆ Activity, as tolerated (Encourage
◆ Bacteria, such as Staphylococcus au- mobilization.)
reus, Salmonella, Shigella, Clostridium
botulinum, Clostridium perfringens, Medications
and Escherichia coli ◆ Antidiarrheal therapy
◆ Amoebae, especially Entamoeba his- ◆ Antiemetics
tolytica ◆ Antibiotics
◆ I.V. fluids
Nursing interventions ladonna, propantheline) or other drugs

◆ Allow uninterrupted rest periods. (morphine, diazepam, calcium channel
◆ Replace lost fluids and electrolytes blockers, meperidine)
through diet or I.V. fluids. ◆ Nasogastric intubation for more
◆ Give prescribed drugs. than 4 days
Patient teaching Assessment
◆ Be sure to cover: History

– the disorder, diagnosis, and treat- ◆ Minimal or no symptoms in one-
ment third of patients
– dietary modifications ◆ Heartburn that typically occurs 11⁄2
– all prescribed drugs, including ad- to 2 hours after eating
ministration and possible adverse ef- ◆ Heartburn that worsens with vigor-
fects ous exercise, bending, lying down,
– preventive measures wearing tight clothing, coughing, con-
– how to perform warm sitz baths stipation, or obesity
three times per day to relieve anal irri- ◆ Relief obtained by using antacids or
tation. sitting upright
◆ Regurgitation without associated
nausea or belching
Gastroesophageal reflux ◆ Sensation of accumulation of fluid
disease in the throat without a sour or bitter
taste
Overview ◆ Chronic pain radiating to the neck,
jaws, and arms that may mimic angina
◆ Backflow of gastric or duodenal pectoris
contents, or both, into the esophagus ◆ Nocturnal hypersalivation and
and past the lower esophageal sphinc- wheezing
ter (LES), without associated belching
or vomiting Physical findings
◆ Reflux of gastric acid, causing acute ◆ Odynophagia (sharp substernal pain
epigastric pain, usually after a meal on swallowing), possibly followed by a
◆ Commonly called heartburn dull substernal ache
◆ Also called GERD ◆ Bright red or dark brown blood in
the vomitus
Causes ◆ Laryngitis and morning hoarseness
◆ Pyloric surgery (alteration or re- ◆ Chronic cough
moval of the pylorus), which allows re-
flux of bile or pancreatic juice Diagnostic tests
◆ Hiatal hernia with an incompetent Imaging
sphincter ◆ Barium swallow with fluoroscopy
◆ Any condition or position that in- shows evidence of recurrent reflux.
creases intra-abdominal pressure
Risk factors ◆ An esophageal acidity test shows
◆ Any agent that lowers LES pressure: the degree of gastroesophageal reflux.
acidic and fatty food, alcohol, ciga- ◆ Gastroesophageal scintillation test-
rettes, anticholinergics (atropine, bel- ing shows reflux.
Gastroesophageal reflux disease 219
Factors affecting LES pressure
Various dietary and lifestyle factors can increase or decrease lower esophageal sphinc-
ter (LES) pressure. Take these factors into account when you plan the patient’s treatment
program.
Factors that increase LES pressure Factors that decrease LES pressure
◆ Protein ◆ Fat
◆ Carbohydrates ◆ Whole milk
◆ Nonfat milk ◆ Orange juice
◆ Low-dose ethanol ◆ Tomatoes
◆ Antiflatulent (simethicone)
◆ Chocolate
◆ High-dose ethanol
◆ Cigarette smoking
◆ Lying on the right or left side
◆ Sitting
◆ Esophageal manometry shows ab- ◆ Histamine-2 receptor antagonists

normal LES pressure and sphincter in- ◆ Proton pump inhibitors
competence.
◆ The result of an acid perfusion Surgery
(Bernstein) test confirms esophagitis. ◆ Hiatal hernia repair
◆ The results of esophagoscopy and ◆ Vagotomy or pyloroplasty
biopsy confirm pathologic changes in ◆ Esophagectomy
the mucosa.
Treatment ◆ Offer emotional and psychological
support.
General ◆ Assist with diet modification.
◆ Modification of lifestyle ◆ Perform chest physiotherapy.
◆ Positional therapy ◆ Use semi-Fowler’s position for the
◆ Removal of the cause patient with a nasogastric tube.
◆ Weight reduction, if appropriate
◆ Avoidance of dietary causes Patient teaching
◆ Avoidance of eating 2 hours before
sleep (See Factors affecting LES pres- ◆ Be sure to cover:
sure.) – the disorder, diagnosis, and treatment
◆ Parenteral nutrition or tube feedings – the causes of gastroesophageal re-
◆ No activity restrictions for medical flux disease
treatment – the prescribed antireflux regimen
◆ Lifting restrictions for surgical treat- of medication, diet, and positional
ment therapy
– development of a dietary plan
Medications – the need to identify situations or ac-
◆ Antacids tivities that increase intra-abdominal
◆ Cholinergics pressure
– the need to avoid substances that ◆ Anorexia

reduce sphincter control ◆ Nausea
– signs and symptoms to watch for ◆ Sense of abdominal fullness (partic-
and report. ularly in right-sided heart failure)
◆ Substance abuse (alcohol, drugs, to-
bacco)
Heart failure
Physical findings
Overview ◆ Cough that produces pink, frothy
sputum
◆ Buildup of fluid in the heart that oc- ◆ Cyanosis of the lips and nail beds
curs when the myocardium can’t pro- ◆ Pale, cool, clammy skin
vide sufficient cardiac output ◆ Diaphoresis
◆ Usually occurs in a damaged left ◆ Distention of the jugular veins
ventricle, but may occur in the right ◆ Ascites
ventricle primarily, or secondary to ◆ Tachycardia
left-sided heart failure ◆ Pulsus alternans
◆ Hepatomegaly and, possibly,
Causes splenomegaly
◆ Mitral stenosis secondary to ◆ Decreased pulse pressure
rheumatic heart disease, constrictive ◆ S3 and S4 heart sounds
pericarditis, or atrial fibrillation ◆ Moist, bibasilar crackles, rhonchi,
◆ Mitral or aortic insufficiency and expiratory wheezing
◆ Arrhythmias ◆ Decreased pulse oximetry
◆ Hypertension ◆ Peripheral edema
◆ Atherosclerosis with myocardial in- ◆ Decreased urinary output
farction
◆ Myocarditis Diagnostic tests
◆ Ventricular and atrial septal defects Laboratory
◆ Constrictive pericarditis ◆ B-type natriuretic peptide im-
◆ Pregnancy munoassay value is elevated.
◆ Thyrotoxicosis
◆ Pulmonary embolism Imaging
◆ Infections ◆ Chest X-rays show increased pul-
◆ Anemia monary vascular markings, interstitial
◆ Emotional stress edema, or pleural effusion, and car-
◆ Increased intake of salt or water diomegaly.
Assessment Diagnostic procedures

◆ Electrocardiography shows heart
History strain, enlargement, or ischemia. It
◆ A disorder or condition that can may also show atrial enlargement or
precipitate heart failure fibrillation, tachycardia, or extrasystole.
◆ Dyspnea or paroxysmal nocturnal ◆ Pulmonary artery pressure monitor-
dyspnea ing typically shows elevated pulmonary
◆ Peripheral edema artery and pulmonary artery wedge
◆ Fatigue pressures, left ventricular end-diastolic
◆ Weakness pressure in left-sided heart failure, and
◆ Insomnia
elevated right atrial or central venous ◆ Monitor the patient’s weight daily
pressure in right-sided heart failure. to detect peripheral edema and other
signs and symptoms of fluid overload.
Treatment
Patient teaching
General
◆ Antiembolism stockings ◆ Be sure to cover:
◆ Elevation of the legs – the disorder, diagnosis, and treat-
◆ Sodium-restricted diet ment
◆ Fluid restriction – signs and symptoms of worsening
◆ Calorie restriction, if indicated heart failure
◆ Low-fat diet, if indicated – when to notify the physician
◆ Walking program – the importance of follow-up care
◆ Activity, as tolerated – the need to avoid high-sodium
foods
Medications – the need to avoid fatigue
◆ Diuretics – instructions about fluid restrictions
◆ Oxygen – the need for the patient to weigh
◆ Inotropic drugs himself every morning at the same
◆ Vasodilators time, before eating and after urinating;
◆ Angiotensin-converting enzyme in- to keep a record of his weight; and to
hibitors report a weight gain of 3 to 5 lb (1.5 to
◆ Angiotensin receptor blockers 2.5 kg) in 1 week
◆ Cardiac glycosides – the importance of smoking cessa-
◆ Diuretics tion, if appropriate
◆ Potassium supplements – weight reduction, as needed
◆ Beta-adrenergic blockers – medication dosage, administration,
◆ Anticoagulants potential adverse effects, and monitor-
ing needs.
Surgery ◆ Encourage follow-up care.
◆ For valvular dysfunction with recur- ◆ Refer the patient to a smoking-
rent acute heart failure, surgical re- cessation program, if appropriate.
placement
◆ Heart transplantation
◆ Placement of a ventricular assist de- Hepatitis, viral
vice
◆ Placement of a stent Overview
Nursing interventions ◆ Infection and inflammation of the

◆ Place the patient in Fowler’s posi- liver caused by a virus
tion, and give supplemental oxygen. ◆ Six types now recognized (A, B, C,
◆ Provide continuous cardiac monitor- D, E, and G), and a seventh suspected
ing during the acute and advanced ◆ Marked by hepatic cell destruction,
stages of disease. necrosis, and autolysis, leading to
◆ Assist the patient with range-of- anorexia, jaundice, and hepatomegaly
motion exercises. ◆ In most patients, eventual regenera-
◆ Apply antiembolism stockings. tion of hepatic cells, with little or no
Check for calf pain and tenderness. residual damage, allowing recovery
◆ Complications more likely with ad- ◆ Revelation of a source of transmis-

vanced age and serious underlying dis- sion
orders
◆ Poor prognosis if edema and hepatic Prodromal stage
encephalopathy develop ◆ Fatigue and generalized malaise
◆ Anorexia and mild weight loss
Causes ◆ Depression
◆ Infection with the causative virus ◆ Headache and photophobia
for each of the six major forms ◆ Weakness
◆ Arthralgia and myalgia (hepatitis B)
Type A ◆ Nausea and vomiting
◆ Transmission by the fecal–oral or ◆ Changes in the senses of taste and
parenteral route smell
◆ Ingestion of contaminated food,
milk, or water Clinical jaundice stage
◆ Pruritus
Type B ◆ Abdominal pain or tenderness
◆ Transmission by contact with conta- ◆ Indigestion
minated human blood, secretions, and ◆ Anorexia
stools ◆ Possible jaundice of the sclerae, mu-
cous membranes, and skin
Type C
◆ Transmission primarily by sharing Posticteric stage
of needles by I.V. drug users, through ◆ Most symptoms decreasing
blood transfusions, or through tattoo
needles Physical findings
Prodromal stage
Type D ◆ Fever (100⬚ to 102⬚ F [37.8⬚ to
◆ Found only in patients with an 38.9⬚ C])
acute or a chronic episode of hepati- ◆ Dark urine
tis B ◆ Clay-colored stools
Type E Clinical jaundice stage

◆ Transmission by the parenteral ◆ Rashes, erythematous patches, or
route and often water-borne hives
◆ Abdominal tenderness in the right
Type G upper quadrant
◆ Believed to be blood-borne, with ◆ Tender, enlarged liver
routes of transmission similar to those ◆ Splenomegaly
of hepatitis B and C ◆ Cervical adenopathy
Assessment Posticteric stage

◆ Decrease in liver enlargement
History
◆ No signs or symptoms of disease in Diagnostic tests
50% to 60% of people with hepatitis B Laboratory
◆ No signs or symptoms of disease in ◆ In patients with suspected viral hep-
80% of people with hepatitis C atitis, a hepatitis profile is routinely
performed. The result identifies anti-
bodies specific to the causative virus Treatment

and establishes the type of hepatitis:
– Type A: An antibody to hepatitis A General
confirms the diagnosis. For hepatitis C
– Type B: Hepatitis B surface antigens ◆ Aimed at clearing hepatitis C virus
and hepatitis B antibodies confirm the from the body, stopping or slowing he-
diagnosis. patic damage, and providing sympto-
– Type C: The diagnosis depends on matic relief
serologic testing for the specific anti- ◆ Symptomatic
body 1 or more months after the onset ◆ Small, high-calorie, high-protein
of acute illness. Until then, the diagno- meals (Protein intake is reduced if
sis is established principally by obtain- signs of precoma—lethargy, confusion,
ing negative test results for hepatitis A, and mental changes—develop.)
B, and D. ◆ Parenteral feeding, if appropriate
– Type D: Intrahepatic delta antigens ◆ Alcohol cessation
or immunoglobulin (Ig) M antidelta ◆ Frequent rest periods, as needed
antigens are detected in acute disease ◆ Avoidance of contact sports and
(or, in chronic disease, IgM and IgG), strenuous activity
establishing the diagnosis.
– Type E: The detection of hepatitis E Medications
antigens supports the diagnosis; how- ◆ Standard Ig
ever, the diagnosis may also rule out ◆ Vaccine
hepatitis C. ◆ Alfa-2b interferon (hepatitis B
– Type G: The detection of hepatitis G and C)
ribonucleic acid supports the diagnosis. ◆ Antiemetics
(Serologic assays are being developed.) ◆ Cholestyramine
◆ Additional findings from liver func- ◆ Lamivudine (hepatitis B)
tion studies support the diagnosis: ◆ Ribavirin (hepatitis C)
– Serum aspartate aminotransferase
and serum alanine aminotransferase Surgery
levels are increased in the prodromal ◆ Possible liver transplantation (hep-
stage of acute viral hepatitis. atitis C)
– Serum alkaline phosphatase levels
are slightly increased. Nursing interventions
– Serum bilirubin levels are elevated ◆ Observe standard precautions to
and may remain elevated late in the prevent transmission of the disease.
course of disease, especially in patients ◆ Provide rest periods throughout the
with severe disease. day.
– Prothrombin time is prolonged (> 3 ◆ Give prescribed drugs.
seconds longer than normal, indicating ◆ Encourage oral fluid intake.
severe liver damage).
– White blood cell counts commonly Patient teaching
show transient neutropenia and lym-
phopenia, followed by lymphocytosis. ◆ Be sure to cover:
– the disorder, diagnosis, and treat-
Diagnostic procedures ment
◆ Liver biopsy shows chronic hepati- – measures to prevent the spread of
tis. disease
– the importance of rest and a proper Assessment

diet that includes a variety of healthy
foods History
– the need to abstain from alcohol ◆ A mononucleosis-like syndrome oc-
– medication administration, dosage, curring after a high-risk exposure; may
and possible adverse effects be followed by an asymptomatic period
– the need to avoid over-the-counter that may last for years
medications unless approved by the ◆ A latent stage in which the only
physician sign of HIV infection is laboratory evi-
– the need for follow-up care. dence of seroconversion
◆ Refer the patient to Alcoholics
Anonymous, if indicated. Physical findings
◆ Persistent generalized adenopathy
◆ Nonspecific symptoms (weight loss,
Human immunodeficiency fatigue, night sweats, fevers)
virus and acquired ◆ Neurologic symptoms resulting from
immunodeficiency syndrome HIV encephalopathy
◆ Opportunistic infection or cancer
(Kaposi’s sarcoma)
Overview Age alert Bacterial infections
occur more often in children.
◆ Human immunodeficiency virus
(HIV) type 1; retrovirus causing ac- Diagnostic tests
quired immunodeficiency syndrome Laboratory
(AIDS) ◆ A CD4+ T-cell count of at least 200
◆ HIV type 2; related to HIV type 1; cells/ml confirms HIV infection.
also found to cause AIDS ◆ A screening test (enzyme-linked
◆ Increases susceptibility to oppor- immunosorbent assay) and a confirma-
tunistic infections, unusual cancers, tory test (Western blot) show HIV anti-
and other abnormalities bodies, which indicate HIV infection.
◆ Marked by progressive failure of the
immune system Treatment
◆ Transmitted by contact with infect-
ed blood or body fluids and associated General
with identifiable high-risk behaviors ◆ Variety of therapeutic options avail-
able for opportunistic infections (the
Causes leading cause of morbidity and mortali-
◆ Infection with HIV, a retrovirus ty in patients infected with HIV)
◆ Disease-specific therapy for a vari-
Risk factors ety of neoplastic and premalignant dis-
◆ Sharing of needles or syringes by eases and organ-specific syndromes
I.V. drug users ◆ Symptom management (fatigue and
◆ Unprotected sexual intercourse anemia)
◆ Placental transmission ◆ Well-balanced diet
◆ History of sexually transmitted dis- ◆ Regular exercise, as tolerated, with
ease adequate rest periods
◆ Homosexual lifestyle
◆ Contact with infected blood
Hypertension 225
Medications
◆ Immunomodulatory agents
Hypertension
◆ Anti-infective agents
◆ Antineoplastic agents Overview
◆ Highly active antiretroviral therapy
◆ Intermittent or sustained elevation
Primary therapy of systolic blood pressure greater than
◆ Protease inhibitors 140 mm Hg and diastolic blood pres-
◆ Nucleoside reverse transcriptase in- sure greater than 90 mm Hg
hibitors ◆ Disease usually benign initially, pro-
◆ Nonnucleoside reverse transcriptase gressing slowly to accelerated or malig-
inhibitors nant state
◆ Two major types: essential (also
Nursing interventions called primary, or idiopathic) hyperten-
◆ Help the patient cope with an altered sion and secondary hypertension,
body image, the emotional burden of which results from renal disease or an-
serious illness, and the threat of death. other identifiable cause
◆ Avoid using glycerin swabs on the ◆ A severe, fulminant form commonly
mucous membranes. Use normal saline arising from both types — malignant
or bicarbonate mouthwash for daily hypertension — which is a medical
oral rinsing. emergency
◆ Ensure adequate fluid intake during
episodes of diarrhea. Causes
◆ Provide meticulous skin care, espe- ◆ Unknown
cially in the debilitated patient.
◆ Encourage the patient to maintain Risk factors
as much physical activity as he can tol- ◆ Family history
erate. Make sure his schedule includes ◆ Black race (in the United States)
time for exercise and rest. ◆ Stress
◆ Monitor for progression of lesions in ◆ Obesity
Kaposi’s sarcoma. ◆ Diet high in sodium and saturated
◆ Monitor for opportunistic infections fat
or signs of disease progression. ◆ Use of tobacco
◆ Use of hormonal contraceptives
Patient teaching ◆ Excess alcohol intake
◆ Sedentary lifestyle
◆ Be sure to cover: ◆ Aging
– medication regimens
– the importance of informing poten- Assessment
tial sexual partners, caregivers, and
health care workers of HIV infection History
– the signs of impending infection ◆ In many cases, no symptoms, with
and the importance of seeking immedi- disorder detected incidentally during
ate medical attention evaluation for another disorder or dur-
– the symptoms of AIDS dementia ing routine blood pressure screening
and its stages and progression. ◆ Symptoms that show the effect of
◆ Refer the patient to a local support hypertension on the organ systems
group.
◆ Refer the patient to hospice care, as
indicated.
◆ Awakening with a headache in the ◆ Chest X-rays may show cardio-

occipital region that subsides sponta- megaly.
neously after a few hours ◆ Renal arteriography may show renal
◆ Dizziness, fatigue, and confusion artery stenosis.
◆ Palpitations, chest pain, and dys-
pnea Diagnostic procedures
◆ Epistaxis ◆ Electrocardiography may show left
◆ Hematuria ventricular hypertrophy or ischemia.
◆ Blurred vision ◆ An oral captopril challenge may be
done to test for renovascular hyperten-
Physical findings sion.
◆ Bounding pulse ◆ Ophthalmoscopy shows arteriove-
◆ S4 heart sound nous nicking and, in hypertensive en-
◆ Peripheral edema in the late stages cephalopathy, edema.
of disease
◆ Hemorrhages, exudates, and pa- Treatment
pilledema of the eye in the late stages
of disease, if hypertensive retinopathy General
is present ◆ Lifestyle modification, such as
◆ A pulsating abdominal mass, sug- weight control, limiting alcohol use,
gesting an abdominal aneurysm regular exercise, and smoking cessation
◆ Elevated blood pressure on at least ◆ For a patient with secondary hyper-
two consecutive occasions after initial tension, correction of the underlying
screenings cause and control of hypertensive effects
◆ Bruits over the abdominal aorta and ◆ A diet that’s low in sodium and sat-
femoral arteries or the carotids urated fat
◆ Adequate calcium, magnesium, and
Diagnostic tests potassium in diet
Laboratory ◆ A regular exercise program
◆ Urinalysis may show protein, red
blood cells, or white blood cells (sug- Medications
gesting renal disease) or glucose (sug- ◆ Diuretics
gesting diabetes mellitus). ◆ Beta-adrenergic blockers
◆ Serum potassium levels are less ◆ Calcium channel blockers
than 3.5 mEq/L, possibly indicating ◆ Angiotensin-converting enzyme in-
adrenal dysfunction (primary hyperal- hibitors
dosteronism). ◆ Alpha-receptor antagonists
◆ Blood urea nitrogen levels are nor- ◆ Vasodilators
mal or elevated to more than 20 mg/dl, ◆ Angiotensin receptor blockers
and serum creatinine levels are normal ◆ Aldosterone antagonist
or elevated to more than 1.5 mg/dl,
suggesting renal disease. Nursing interventions
◆ Administer medications, as ordered.
Imaging ◆ Encourage dietary changes, as ap-
◆ Excretory urography may show re- propriate.
nal atrophy, indicating chronic renal ◆ Help the patient identify risk factors
disease; one kidney more than 5⁄8⬙ and modify his lifestyle, as appropriate.
(1.6 cm) shorter than the other sug- ◆ Monitor vital signs, especially blood
gests unilateral renal disease. pressure.
Influenza 227
Patient teaching ◆ Type B: also annual, but causes epi-

demics only every 4 to 6 years
◆ Be sure to cover: ◆ Type C: endemic and causes only
– the disorder, diagnosis, and treatment sporadic cases
– how to use a self-monitoring blood ◆ Infection transmitted by inhaling a
pressure cuff and record the reading in respiratory droplet from an infected
a journal for review by the physician person or by indirect contact (drinking
– the importance of complying with from a contaminated glass)
antihypertensive therapy and establish-
ing a daily routine for taking medica- Assessment
tions
– the need to report adverse effects of History
drugs ◆ Usually, recent exposure (typically
– the need to avoid high-sodium ant- within 48 hours) to a person with in-
acids and over-the-counter cold and si- fluenza
nus medications that contain potential- ◆ No influenza vaccine received dur-
ly harmful vasoconstrictors ing the past season
– the need for the patient to examine ◆ Headache
and modify his lifestyle, including diet ◆ Malaise
– the need for a routine exercise pro- ◆ Myalgia
gram, particularly aerobic walking ◆ Fatigue, listlessness, and weakness
– dietary restrictions
– the importance of follow-up care. Physical findings
◆ Refer the patient to stress-reduction ◆ Fever (usually higher in children)
therapy or support groups, as needed. ◆ Signs of croup or dry cough
◆ Red, watery eyes; clear nasal dis-
charge
Influenza ◆ Erythema of the nose and throat
without exudate
Overview ◆ Tachypnea, shortness of breath, and
cyanosis
◆ Acute, highly contagious infection ◆ With bacterial pneumonia, purulent
of the respiratory tract or bloody sputum
◆ Capacity for antigenic variation ◆ Cervical adenopathy and tenderness
(ability to mutate into different strains ◆ Diminished breath sounds in areas
so that no immunologic resistance is of consolidation
present in those at risk)
◆ Antigenic variation characterized as Diagnostic tests
antigenic drift (minor changes that oc- ◆ After an epidemic is confirmed, di-
cur yearly or every few years) and anti- agnosis requires only observation of
genic shift (major changes that lead to the clinical signs and symptoms.
pandemics)
◆ Also called the grippe or the flu Laboratory
◆ Inoculation of chicken embryos
Causes with nasal secretions from an infected
◆ Type A: most prevalent; strikes an- patient shows the influenza virus.
nually, with new serotypes causing epi- ◆ Throat swabs, nasopharyngeal
demics every 3 years washes, or sputum cultures show isola-
tion of the influenza virus.
◆ Immunodiagnostic techniques show

viral antigens in tissue culture or in ex- Metabolic syndrome
foliated nasopharyngeal cells obtained
by washings. Overview
◆ White blood cell counts are elevated
in secondary bacterial infection. ◆ A cluster of conditions triggered by
◆ White blood cell counts are de- insulin resistance
creased in overwhelming viral or bacte- ◆ Confirmed if a patient has three or
rial infection. more of the following traits: increased
abdominal fat with or without obesity;
Treatment high blood pressure; high blood glu-
cose levels; and high triglyceride levels
General ◆ Associated with increased risk of di-
◆ Fluid and electrolyte replacement abetes, heart disease, and stroke
◆ Oxygen and assisted ventilation, if ◆ Also known as metabolic X syn-
indicated drome, insulin resistance syndrome,
◆ Increased fluid intake dysmetabolic syndrome, and multiple
◆ Rest periods, as needed metabolic syndrome
◆ Currently affects approximately
Medications 25% of adults in the United States
◆ Acetaminophen or aspirin
◆ Guaifenesin or an expectorant Causes
◆ Amantadine ◆ Insulin resistance, which results in
◆ Antibiotics cells being unable to respond to in-
sulin, elevating both blood glucose and
Nursing interventions insulin levels
◆ Administer medications, as ordered. ◆ High levels of circulating insulin,
◆ Follow standard precautions. which raise triglyceride levels, affect re-
◆ Administer oxygen therapy, if war- nal function, and elevate blood pressure
ranted.
◆ Monitor for signs and symptoms of Risk factors
dehydration ◆ Genetic predisposition to hyperinsu-
linemia and impaired glucose tolerance
Patient teaching ◆ Hispanic or Asian ethnicity
◆ Family history of type 2 diabetes
◆ Be sure to cover: ◆ Diabetes
– the disorder, diagnosis, and treatment ◆ Gestational diabetes
– the use of mouthwash or warm ◆ Aging
saline gargles to ease sore throat ◆ Polycystic ovary syndrome
– the importance of increasing fluid ◆ High-fat, high-carbohydrate diet
intake to prevent dehydration ◆ Insufficient physical activity
– the use of a warm bath or a heating ◆ Obesity
pad to relieve myalgia ◆ Smoking
– the importance of covering coughs,
following proper hand-washing tech- Assessment
nique, and properly disposing of tissues
to prevent the virus from spreading History
– the need for influenza immuniza- ◆ Family history of metabolic syndrome
tion. ◆ History of gestational diabetes
Metabolic syndrome 229
Why abdominal obesity is dangerous
People with excess weight around the waist have a greater risk of developing metabolic
syndrome than people with excess weight around the hips. That’s because intra-abdominal
fat tends to be more resistant to insulin than fat in other areas of the body. Insulin
resistance increases the release of free fatty acid into the portal system, leading to
increased apolipoprotein B, increased low-density lipoprotein, decreased high-density
lipoprotein, and increased triglyceride levels. As a result, the risk of cardiovascular
disease increases.
◆ Hypertension levels after a standard I.V. infusion of

◆ High low-density lipoprotein (LDL) insulin; it may be helpful in obese pa-
levels tients and those with polycystic ovari-
◆ Elevated triglyceride levels an syndrome.
◆ Low high-density lipoprotein (HDL)
levels Treatment
◆ Abdominal obesity
◆ Sedentary lifestyle General
◆ Poor diet ◆ Weight-reduction program
◆ Smoking ◆ Low alcohol intake
◆ Low-cholesterol diet high in com-
Physical findings plex carbohydrates (grains, beans, veg-
◆ Obesity etables, fruit) and low in refined carbo-
◆ Large abdominal girth (See Why ab- hydrates (soft drinks, table sugar, high-
dominal obesity is dangerous.) fructose corn syrup)
◆ Waist circumference greater than ◆ Moderately intense physical activity
35⬘⬘ in women and 40⬘⬘ in men for at least 20 minutes a day, prefer-
◆ Body mass index (BMI) greater than ably for 30 to 60 minutes a day
25 kg/m2 ◆ Smoking cessation
◆ Systolic blood pressure greater than
130 mm Hg or diastolic blood pressure Medications
greater than 85 mm Hg ◆ Oral glucose-lowering drugs
◆ Insulin
Diagnostic tests ◆ Antihypertensive drugs
Laboratory ◆ Cholesterol-lowering drugs
◆ Fasting serum glucose level is equal ◆ Weight-loss drugs (orlistat, sibu-
to or greater than 100 mg/dl. tramine)
◆ LDL level is equal to or greater than ◆ Vitamin supplements
130 mg/dl. ◆ Low-dose aspirin
◆ HDL level is less than 40 mg/dl for
men and less than 50 mg/dl for women. Surgery
◆ Triglyceride level is equal to or ◆ Possible gastric bypass procedure
greater than 150 mg/dl. for patients with BMI greater than
◆ High sensitivity C-reactive protein is 40 kg/m2 or, for patients with other
equal to or greater than 1 mg/L. obesity-related conditions, BMI greater
◆ Insulin tolerance test (not widely than 35 kg/m2
used) measures glucose and insulin
Nursing interventions ◆ About 90% of S. aureus isolates or

◆ Promote an exercise program for strains penicillin-resistant
30 to 60 minutes per day. ◆ Approximately 27% of all S. aureus
◆ Recommend smoking cessation; re- isolates resistant to methicillin, a peni-
fer the patient to a smoking-cessation cillin derivative
program as needed. ◆ Strains resistant to penicillin first
◆ Assist the patient with dietary identified in 1961; to methicillin, in
choices, and answer all questions relat- 1968; and to vancomycin, in 2002
ed to necessary dietary and weight ◆ Invasion, proliferation, and infec-
changes. tion occur when natural defense sys-
◆ Monitor the patient’s blood pressure tems break down (such as following
and blood glucose, cholesterol, and invasive procedures, trauma, or
triglyceride levels. chemotherapy)
◆ Easily spread by direct person-to-
Patient teaching person contact
◆ Health care–associated MRSA (HA-
◆ Be sure to cover: MRSA) occurs in people who are or
– the disorder, diagnosis, and treatment have recently been in the hospital
– the principles of a healthy diet and ◆ Community-associated MRSA (CA-
the importance of low alcohol intake MRSA) generally occurs in healthy peo-
– the relationship of diet, inactivity, ple who haven’t been in the hospital
and obesity to metabolic syndrome recently
– the benefits of increased physical ◆ CA-MRSA infections can also pre-
activity sent as severe, invasive disease, includ-
– prescribed medications, including ing necrotizing pneumonia, necrotizing
administration and possible adverse re- fasciitis, severe osteomyelitis, and
actions sepsis
– the importance of follow-up care ◆ HA-MRSA and CA-MRSA different
with the patient’s health care provider biologically and genetically, with CA-
to monitor weight loss, laboratory re- MRSA possibly transmitted more easily
sults, and blood pressure. than HA-MRSA
◆ Endemic in nursing homes, long-
term health care facilities, and commu-
Methicillin-resistant nity facilities
Staphylococcus aureus ◆ Typically colonizes in the anterior
nares; 40% of adults and most children
Overview transient nasal carriers
◆ Colonizes less commonly in the
◆ Mutation of the very common, usu- groin, armpits, and intestines
ally benign, bacterium Staphylococcus
aureus Causes
◆ Also known by the acronym MRSA ◆ Transmission from an infected pa-
◆ Resistant to the class of penicillin- tient or from a colonized patient or
like antibiotics called beta-lactam an- health care worker (symptom-free car-
tibiotics rier of the bacteria)
◆ Some strains also resistant to
cephalosporins, aminoglycosides, ery- Risk factors
thromycin, tetracycline, and clin- ◆ Burns
damycin ◆ Surgical or traumatic wounds
Methicillin-resistant Staphylococcus aureus 231
◆ Indwelling medical device, central ◆ D-zone disk diffusion test evaluates

venous access device, or other invasive for inducible clindamycin resistance in
catheter CA-MRSA resistant to erythromycin.
◆ Abscesses Imaging
◆ Contact dermatitis ◆ Ultrasonography delineates abscesses.
◆ Immunosuppression
◆ Prolonged hospital stays Treatment
◆ Extended therapy with multiple or
broad-spectrum antibiotics General
◆ Proximity to others colonized or in- ◆ Transmission precautions, including
fected with MRSA contact isolation for wound, skin, and
◆ Young age urine infections and respiratory isola-
◆ Participation in contact sports tion for respiratory infections
◆ Sharing athletic equipment ◆ In MRSA outbreaks, possibly sur-
◆ Living in crowded conditions (such veillance and decolonization of health
as in long-term care facilities or prisons) care personnel, consisting of a combi-
nation of topical mupirocin applied to
Assessment the nares, oral antibiotics, and antimi-
crobial baths
History ◆ No treatment for patients with colo-
◆ Possible risk factors for MRSA nization only
◆ History of other household mem- ◆ Removal of indwelling medical de-
bers or close contacts with skin or soft- vices as soon as possible
tissue infections ◆ Moist heat for small furuncles
◆ Possibly no signs or symptoms (car- ◆ Treatment of underlying conditions
riers) such as tinea pedis
◆ High-protein diet
Physical findings
◆ Signs and symptoms related to the Medications
primary diagnosis (respiratory, cardiac, ◆ Sulfamethoxazole/trimethoprim
or other major system symptoms) in ◆ Doxycycline or minocycline
symptomatic patients ◆ Clindamycin
◆ Small, red bumps that resemble ◆ Linezolid
pimples, boils, or spider bites that de- ◆ Vancomycin
velop into deep, painful abscesses, fu- ◆ Daptomycin
runcles, or carbuncles ◆ Mupirocin
◆ Fever
◆ Purulent wound drainage Surgery
◆ Erythema ◆ Incision and drainage of purulent
◆ Edema lesions, including obtaining cultures
◆ Pain and tenderness and performing susceptibility testing
Diagnostic tests Nursing interventions

Laboratory ◆ Maintain contact isolation in health
◆ Cultures from skin, urine, blood, or care settings.
wounds show MRSA. ◆ Consider grouping infected patients
◆ Organism susceptibility testing iden- together and having the same health
tifies the best antimicrobial drug. care providers care for them.
◆ Employ proper hand-washing tech- Causes

niques (the most effective way to pre- ◆ Exact cause unknown
vent transmission of MRSA). ◆ Slow-acting viral infection
◆ Monitor enhanced environmental ◆ Autoimmune response of the ner-
cleaning. vous system
◆ Obtain cultures and monitor results. ◆ Allergic response
◆ Provide appropriate wound care. ◆ Events that precede the onset of dis-
◆ Evaluate the patient for adverse ease:
drug reactions. – emotional stress
◆ Provide teaching and emotional – overwork
support to the patient and family mem- – fatigue
bers. – pregnancy
– acute respiratory tract infections
Patient teaching ◆ Genetic factors possibly also involved
◆ Be sure to cover: Risk factors

– the disorder, diagnosis, and treat- ◆ Trauma
ment ◆ Anoxia
– the difference between MRSA infec- ◆ Toxins
tion and colonization ◆ Nutritional deficiencies
– how cultures are obtained ◆ Vascular lesions
– how to prevent the spread of MRSA ◆ Anorexia nervosa
– the importance of proper hand-
washing technique for the patient and Assessment
family members
– the purpose of contact precautions History
and how to comply with them ◆ Symptoms related to the extent and
– medication administration, dosage, site of myelin destruction, the extent of
and possible adverse effects remyelination, and the adequacy of sub-
– the importance of taking antibiotics sequent restored synaptic transmission
for the full prescription period, even if ◆ Symptoms transient or lasting for
the patient begins to feel better. hours or weeks
◆ Symptoms unpredictable and diffi-
cult to describe
Multiple sclerosis ◆ Visual problems and sensory im-
pairment (the first signs)
Overview ◆ Blurred vision or diplopia
◆ Urinary problems
◆ Progressive demyelination of the ◆ Emotional lability
white matter of the brain and spinal ◆ Dysphagia
cord ◆ Bowel disturbances (involuntary
◆ Characterized by exacerbations and evacuation or constipation)
remissions ◆ Fatigue (typically the most disabling
◆ In some cases, rapid progression, symptom)
with death occurring within months
◆ Variable prognosis (Most patients Physical findings
with multiple sclerosis [70%] lead ◆ Poor articulation
active lives with prolonged remissions.) ◆ Muscle weakness of the involved
◆ Also known as MS area
Multiple sclerosis 233
Understanding types of multiple sclerosis
Various terms are used to describe different types of multiple sclerosis (MS).
◆ Relapsing-remitting: clear relapses (or acute attacks or exacerbations), with full re-
covery and lasting disability. Between attacks, the disease doesn’t worsen.
◆ Primary progressive: steadily progressing or worsening, with minor recovery or
plateaus. This form is uncommon and may involve different brain and spinal cord dam-
age from other forms.
◆ Secondary progressive: beginning as a pattern of clear relapses and recovery, but
becoming steadily progressive and worsening between acute attacks.
◆ Progressive-relapsing: steadily progressing from the onset but with clear, acute at-
tacks. This form is rare. In addition, the differential diagnosis must rule out spinal cord
compression, foramen magnum tumor (which may mimic the exacerbations and remis-
sions of MS), multiple small strokes, syphilis or another infection, thyroid disease, and
chronic fatigue syndrome.
◆ Spasticity and hyperreflexia Treatment

◆ Intention tremor
◆ Gait ataxia General
◆ Paralysis, ranging from monoplegia ◆ Symptomatic treatment for acute ex-
to quadriplegia acerbations and related signs and
◆ Nystagmus and scotoma symptoms
◆ Optic neuritis ◆ Diet high in fluid and fiber in case
◆ Ophthalmoplegia of constipation
◆ Frequent rest periods
Diagnostic tests
◆ Diagnosis may require years of test- Medications
ing and observation. ◆ I.V. steroids followed by oral
steroids
Laboratory ◆ Immunosuppressants
◆ Cerebrospinal fluid analysis shows ◆ Antimetabolites
mononuclear cell pleocytosis, an elevat- ◆ Alkylating drugs
ed level of total immunoglobulin (Ig) G, ◆ Biologic response modifiers
and the presence of oligoclonal Ig.
Imaging ◆ Provide emotional and psychologi-
◆ Magnetic resonance imaging is the cal support.
most sensitive method for detecting fo- ◆ Assist with the physical therapy
cal lesions associated with multiple program.
sclerosis. ◆ Provide adequate rest periods.
◆ Promote emotional stability.
Other ◆ Keep the bedpan or urinal readily
◆ Electroencephalographic abnormali- available because the need to void is
ties occur in one-third of patients with immediate.
multiple sclerosis. ◆ Provide bowel and bladder training,
◆ Evoked potential studies show if indicated.
slowed conduction of nerve impulses. ◆ Give prescribed drugs.
◆ Monitor functional changes: speech, ◆ Elevated serum triglyceride, low-

vision, energy, sensory impairment, density lipoprotein, and cholesterol lev-
and muscle dysfunction. els, and decreased serum high-density
lipoprotein levels
Patient teaching ◆ Excessive intake of saturated fats,
carbohydrates, or salt
◆ Be sure to cover: ◆ Hypertension
– the disease process (See Under- ◆ Obesity
standing types of multiple sclerosis, ◆ Family history of coronary artery
page 233.) disease
– medication and adverse effects ◆ Sedentary lifestyle
– the importance of avoiding stress, ◆ Smoking
infections, and fatigue ◆ Stress or type A personality
– the importance of maintaining inde- ◆ Use of drugs, such as ampheta-
pendence mines or cocaine
– the need to avoid exposure to bacte-
rial and viral infections Assessment
– nutritional management
– the importance of adequate fluid in- History
take and regular urination. ◆ Possible coronary artery disease
◆ Refer the patient to the National with increasing frequency, severity, or
Multiple Sclerosis Society. duration of angina
◆ Refer the patient to physical and oc- ◆ Cardinal symptom: persistent,
cupational rehabilitation programs, as crushing substernal pain or pressure
indicated. that may radiate to the left arm, jaw,
neck, and shoulder blades, and may
persist for 12 hours or longer
Myocardial infarction ◆ Little or no pain in an elderly pa-
tient or a patient with diabetes; pain
Overview possibly mild and confused with indi-
gestion in other patients
◆ Reduced blood flow through one or ◆ Fatigue, nausea, vomiting, and
more coronary arteries, causing myo- shortness of breath, accompanied by a
cardial ischemia and necrosis feeling of impending doom
◆ Site of infarction dependent on the ◆ Sudden death (may be the first and
vessels involved only indication of MI)
◆ Also called MI and heart attack ◆ Possible intermittent claudication
Causes Physical findings

◆ Atherosclerosis ◆ Extreme anxiety and restlessness
◆ Thrombosis ◆ Dyspnea
◆ Platelet aggregation ◆ Diaphoresis
◆ Coronary artery stenosis or spasm ◆ Tachycardia
◆ Hypertension
Risk factors ◆ In inferior MI, bradycardia and hy-
◆ Middle age or older (40 to 70) potension
◆ Diabetes mellitus ◆ An S4 heart sound, an S3 heart
sound, and paradoxical splitting of the
Myocardial infarction 235
S2 heart sound with ventricular dys- and helps evaluate the ejection frac-
function tion.
◆ A systolic murmur of mitral insuffi-
ciency Diagnostic procedures
◆ Pericardial friction rub with trans- ◆ Serial 12-lead electrocardiography
mural MI or pericarditis (ECG) readings may be normal or in-
◆ Low-grade fever for the next few conclusive during the first few hours
days after an MI. Characteristic abnormali-
ties include ST-segment elevation and
Diagnostic tests Q waves, representing scarring and
Laboratory necrosis.
◆ The serum creatine kinase (CK) lev- ◆ Pulmonary artery catheterization
el is elevated, especially the CK-MB may be performed to detect left- or
isoenzyme, which is the cardiac mus- right-sided heart failure and to monitor
cle fraction of CK. the response to treatment.
◆ The serum lactate dehydrogenase
(LD) level is elevated; the LD1 isoen- Treatment
zyme level (found in cardiac tissue) is
higher than the LD2 level (in serum). General
◆ An elevated white blood cell count ◆ For arrhythmias, a pacemaker or
usually appears on the second day and electrical cardioversion
lasts for 1 week. ◆ Intra-aortic balloon pump for car-
◆ Myoglobin (the hemoprotein found diogenic shock
in cardiac and skeletal muscle) is de- ◆ Low-fat, low-cholesterol diet
tected. It’s released with muscle dam- ◆ Calorie restriction, if indicated
age, as soon as 2 hours after an MI. ◆ Bed rest, with a commode available
◆ The level of troponin I is elevated at the bedside
only when muscle damage occurs. It is ◆ Gradual increase in activity, as tol-
more specific than the CK-MB level. erated
(Troponin levels increase within 4 to 6
hours of myocardial injury and may re- Medications
main elevated for 5 to 11 days.) ◆ I.V. thrombolytic therapy started
within 3 hours of the onset of symp-
Imaging toms
◆ Nuclear medicine scans performed ◆ Aspirin
with I.V. technetium 99m pertechnetate ◆ Antiarrhythmics and antianginals
can identify acutely damaged muscle ◆ Calcium channel blockers
by detecting accumulations of radioac- ◆ I.V. heparin
tive nucleotide. An area of accumula- ◆ I.V. morphine
tion appears as a “hot spot” on the ◆ Inotropic drugs
film. Myocardial perfusion imaging ◆ Beta-adrenergic blockers
with thallium 201 shows a “cold spot” ◆ Angiotensin-converting inhibitors
(a poorly perfused area of the heart ◆ Stool softeners
where thallium does not appear) in ◆ Oxygen
most patients during the first few
hours after a transmural MI. Surgery
◆ Echocardiography shows ventricular ◆ Surgical revascularization
wall dyskinesia with a transmural MI ◆ Percutaneous revascularization
◆ Assess pain and give analgesics, as
Osteoarthritis
ordered. Record the severity, location,
Overview
type, and duration of pain. Avoid I.M.
injections. ◆ Chronic degeneration of joint carti-
◆ Check the patient’s blood pressure lage
before and after giving nitroglycerin. ◆ Most common form of arthritis
◆ During episodes of chest pain, ob- ◆ Range of disability, from minor limi-
tain ECG. tation to near immobility
◆ Organize patient care and activities ◆ Knees and hips most commonly af-
to provide periods of uninterrupted fected
rest. ◆ Varying rates of progression
◆ Provide a low-cholesterol, low-
sodium diet with caffeine-free bever- Causes
ages. ◆ Advancing age
◆ Allow the patient to use a bedside ◆ Possible hereditary factors
commode. ◆ Secondary osteoarthritis
◆ Assist with range-of-motion exercises. ◆ Traumatic injury
◆ Provide emotional support, and ◆ Congenital abnormality
help reduce stress and anxiety. ◆ Endocrine disorders such as dia-
◆ If the patient has undergone percu- betes mellitus
taneous transluminal coronary angio- ◆ Metabolic disorders such as chon-
plasty, sheath care is necessary. Watch drocalcinosis
for bleeding. Keep the leg with the ◆ Repetitive use (recreational or occu-
sheath insertion site immobile. Main- pational)
tain strict bed rest. Check peripheral
pulses in the affected leg frequently. Assessment
Patient teaching History

◆ Predisposing traumatic injury
◆ Be sure to cover: ◆ Deep, aching joint pain
– procedures (answering questions for ◆ Pain after exercise or weight bearing
the patient and family members) ◆ Pain that may be relieved by rest
– medication dosages, adverse reac- ◆ Stiffness in the morning and after
tions, and signs of toxicity to watch for exercise
and report ◆ Aching during changes in weather
– dietary restrictions ◆ “Grating” feeling when the joint
– progressive resumption of sexual ac- moves
tivity ◆ Limited movement
– appropriate responses to new or re-
current symptoms Physical findings
– typical and atypical chest pain and ◆ Contractures
the need to report pain to the physician. ◆ Joint swelling
◆ Refer the patient to a cardiac reha- ◆ Muscle atrophy
bilitation program. ◆ Deformity of the involved areas
◆ Refer the patient to a smoking- ◆ Gait abnormalities
cessation program, if needed.
◆ Refer the patient to a weight-
reduction program, if needed.
Osteoarthritis 237
◆ Hard nodes on the distal and proxi- Medications

mal interphalangeal joints that may be ◆ Analgesics
red, swollen, and tender ◆ Nonsteroidal anti-inflammatory
◆ Loss of finger dexterity drugs
◆ Muscle spasms, limited movement,
and joint instability Surgery
◆ Arthroplasty (partial or total)
Diagnostic tests ◆ Arthrodesis
Laboratory ◆ Osteoplasty
◆ Synovial fluid analysis rules out in- ◆ Osteotomy
flammatory arthritis.
Imaging ◆ Allow adequate time for self-care.
◆ X-rays of the affected joint may ◆ Adjust pain medications to allow for
show narrowing of the joint space or maximum rest.
margins, cystlike bony deposits in the ◆ Identify techniques that promote
joint space and margins, sclerosis of rest and relaxation.
the subchondral space, joint deformity ◆ Administer anti-inflammatory med-
or articular damage, bony growths at ications.
weight-bearing areas, and possible ◆ If the hand joints are affected, use
joint fusion. hot soaks and paraffin dips.
◆ Radionuclide bone scan may be ◆ If the lumbosacral spinal joints are
used to rule out inflammatory arthritis affected, provide a firm mattress.
by showing normal uptake of the ra- ◆ If the cervical spinal joints are af-
dionuclide. fected, apply a cervical collar.
◆ Magnetic resonance imaging shows ◆ If the hip is affected, apply moist
the affected joint, adjacent bones, and heat pads and administer antispasmod-
progression of disease. ic drugs.
◆ If the knee is affected, help with
Diagnostic procedures range-of-motion exercises.
◆ Neuromuscular tests may show re- ◆ Apply elastic supports or braces.
duced muscle strength. ◆ Check the patient’s crutches, cane,
braces, or walker for proper fit.
Other
◆ Arthroscopy shows the internal joint Patient teaching
structures and identifies soft-tissue
swelling. ◆ Be sure to cover:
Treatment ment
– the need for adequate rest during
General the day, after exertion, and at night
◆ Pain relief – methods to conserve energy
◆ Improved mobility – the need to take medications exactly
◆ Minimized disability as prescribed
◆ Activity, as tolerated – adverse reactions to medications
◆ Physical therapy – the need to wear support shoes that
◆ Assistive mobility devices fit well and the importance of repairing
◆ Weight reduction worn heels
– the need to install safety devices at ◆ Faulty protein metabolism (caused

home by estrogen deficiency)
– the importance of range-of-motion ◆ Sedentary lifestyle
exercises and the need to perform them
as gently as possible Assessment
– the need to maintain proper body
weight History
– the use of crutches or other ortho- ◆ Postmenopausal patient
pedic devices. ◆ Condition known to cause sec-
◆ Refer the patient to occupational or ondary osteoporosis
physical therapy, as indicated. ◆ Snapping sound or sudden pain in
the lower back when bending down to
lift something
Osteoporosis ◆ Possible slow development of pain
(over several years)
Overview ◆ With vertebral collapse, backache
and pain radiating around the trunk
◆ Loss of calcium and phosphate from ◆ Pain aggravated by movement or
bones, causing increased vulnerability jarring
to fractures
◆ Primary or secondary to underlying Physical findings
disease ◆ Humped back
◆ Types of primary osteoporosis: post- ◆ Markedly aged appearance
menopausal osteoporosis (type I) and ◆ Loss of height
age-associated osteoporosis (type II) ◆ Muscle spasm
◆ Secondary osteoporosis: caused by ◆ Decreased spinal movement, with
an identifiable agent or disease flexion more limited than extension
Causes Laboratory
◆ Exact cause unknown ◆ Normal serum calcium, phosphorus,
◆ Prolonged therapy with steroids or and alkaline levels
heparin ◆ Elevated parathyroid hormone level
◆ Bone immobilization
◆ Alcoholism Imaging
◆ Malnutrition ◆ X-ray studies show characteristic
◆ Rheumatoid arthritis degeneration in the lower thoracolum-
◆ Liver disease bar vertebrae.
◆ Malabsorption ◆ Computed tomography scan assess-
◆ Scurvy es spinal bone loss.
◆ Lactose intolerance ◆ Bone scans show injured or dis-
◆ Hyperthyroidism eased areas.
◆ Osteogenesis imperfecta
◆ Sudeck’s atrophy (localized in the Diagnostic procedures
hands and feet, with recurring attacks) ◆ Bone biopsy shows thin, porous,
but otherwise normal bone.
Risk factors
◆ Mild, prolonged negative calcium
balance
◆ Declining gonadal adrenal function
Parkinson’s disease 239

◆ Dual or single photon absorptiome-
try (measurement of bone mass) shows ◆ Be sure to cover:
loss of bone mass. – the disorder, diagnosis, and treat-
ment
Treatment – the prescribed drug regimen
– how to recognize significant adverse
General reactions
◆ Control of bone loss – the need to perform monthly breast
◆ Prevention of additional fractures self-examination while receiving estro-
◆ Control of pain gen therapy
◆ Reduction and immobilization of – the need to report vaginal bleeding
fractures promptly
◆ Diet rich in vitamin D, calcium, and – the need to report new pain sites
protein immediately
◆ Exposure to sunlight to aid in the – the importance of sleeping on a
synthesis of vitamin D firm mattress
◆ Physical therapy program of gentle – the need to avoid excessive bed rest
exercise and activity – the use of a back brace, if appropri-
◆ Supportive devices ate
– the use of proper body mechanics
Medications – the use of home safety devices
◆ Estrogen – the importance of a calcium-rich
◆ Sodium fluoride diet.
◆ Calcium and vitamin D supplements ◆ Refer the patient to physical and oc-
◆ Calcitonin cupational therapy, as appropriate.
Surgery
◆ Open reduction and internal fixation Parkinson’s disease
for femur fractures
Overview
◆ Encourage careful positioning, am- ◆ Brain disorder associated with de-
bulation, and prescribed exercises. creased levels of the neurotransmitter
◆ Promote self-care, and allow ade- dopamine that causes progressive dete-
quate time. rioration, with muscle rigidity, akine-
◆ Encourage mild exercise. sia, and involuntary tremors
◆ Assist with walking. ◆ Usual cause of death: aspiration
◆ Perform passive range-of-motion ex- pneumonia
ercises. ◆ One of the most common crippling
◆ Promote physical therapy sessions. diseases in the United States
◆ Use safety precautions.
◆ Administer analgesia, as ordered. Causes
◆ Apply heat. ◆ Usually unknown
◆ Monitor the skin for redness, ◆ Exposure to toxins, such as man-
warmth, and new sites of pain. ganese dust and carbon monoxide
◆ Monitor exercise tolerance and joint ◆ Type A encephalitis
mobility. ◆ Drug-induced effect (haloperidol
[Haldol], methyldopa, reserpine)
Assessment Medications
◆ Dopamine replacement drugs
History ◆ Anticholinergics
◆ Muscle rigidity ◆ Antihistamines
◆ Akinesia ◆ Antiviral agents
◆ Insidious (unilateral pill-roll) ◆ Enzyme-inhibiting agents
tremor, which increases during stress ◆ Tricyclic antidepressants
or anxiety and decreases with purpose- ◆ Catechol-O-methyltransferase in-
ful movement and sleep hibitors
◆ Dysphagia
◆ Fatigue with activities of daily living Surgery
◆ Muscle cramps of the legs, neck, ◆ Used when drug therapy is unsuc-
and trunk cessful
◆ Oily skin ◆ Stereotaxic neurosurgery
◆ Increased perspiration ◆ Destruction of the ventrolateral nu-
◆ Insomnia cleus of the thalamus
◆ Mood changes
◆ Dysarthria Nursing interventions
◆ Take measures to prevent aspira-
Physical findings tion.
◆ Tremors, especially in upper extrem- ◆ Protect the patient from injury.
ities ◆ Stress the importance of rest periods
◆ High-pitched, monotonous voice between activities.
◆ Drooling ◆ Ensure adequate nutrition.
◆ Masklike facial expression ◆ Provide frequent warm baths and
◆ Difficulty walking massage.
◆ Lack of parallel motion in gait ◆ Encourage the patient to enroll in a
◆ Loss of posture control with walking physical therapy program.
◆ Oculogyric crises (eyes fixed upward, ◆ Provide emotional and psychologi-
with involuntary tonic movements) cal support.
◆ Muscle rigidity causing resistance to ◆ Encourage the patient to be inde-
passive muscle stretching pendent.
◆ Difficulty pivoting ◆ Assist with ambulation and range-
◆ Loss of balance of-motion exercises.
◆ Postoperatively, monitor for signs of
Diagnostic tests hemorrhage and increased intracranial
Imaging pressure.
◆ Computed tomography scan or mag-
netic resonance imaging rules out other Patient teaching
disorders such as intracranial tumors.
◆ Be sure to cover:
Treatment – the disorder, diagnosis, and treat-
ment
General – administration, dosages, and ad-
◆ Small, frequent meals verse reactions to medications
◆ High-bulk foods – measures to prevent pressure ulcers
◆ Physical therapy and occupational and contractures
therapy – household safety measures
◆ Assistive devices to aid ambulation – the importance of daily bathing
Peptic ulcer 241
– methods to improve communication Assessment

– the importance of a swallowing ther-
apy regimen (aspiration precautions). History
◆ Refer the patient to occupational and ◆ Periods of symptom exacerbation
physical rehabilitation, as indicated. and remission, with remissions lasting
longer than exacerbations
◆ History of a predisposing factor
Peptic ulcer ◆ Left epigastric pain described as
heartburn or indigestion and accompa-
Overview nied by a feeling of fullness or disten-
tion
◆ Circumscribed lesion in the mucosal
membrane of the lower esophagus, Gastric ulcer
stomach, duodenum, or jejunum ◆ Recent loss of weight or appetite
◆ Occurs in two major forms: duo- ◆ Nausea or vomiting
denal ulcer and gastric ulcer (both ◆ Pain triggered or worsened by eat-
chronic) ing
◆ Duodenal ulcers: account for about
80% of peptic ulcers, affect the proxi- Duodenal ulcer
mal part of the small intestine, and fol- ◆ Pain relieved by eating; may occur
low a chronic course characterized by 11⁄2 to 3 hours after food intake
remissions and exacerbations (About ◆ Pain that awakens the patient from
5% to 10% of patients with duodenal sleep
ulcers have complications that necessi- ◆ Weight gain
tate surgery.)
◆ Gastric ulcers: occur in the gastric Physical findings
mucosa. They have a wide spectrum of ◆ Pallor
clinical presentations, ranging from ◆ Epigastric tenderness
asymptomatic to vague epigastric pain, ◆ Hyperactive bowel sounds
nausea, and iron deficiency anemia to
acute life-threatening hemorrhage. Diagnostic tests
Laboratory
Causes ◆ Complete blood count shows anemia.
◆ Helicobacter pylori ◆ Testing shows occult blood in the
◆ Use of glucocorticoids or non- stools.
steroidal anti-inflammatory drugs ◆ Venous blood sample shows H. py-
(NSAIDs) lori antibodies.
◆ Pathologic hypersecretory states ◆ White blood cell count is elevated.
◆ Urea breath test shows low levels of
Risk factors exhaled carbon 13.
◆ Type A blood (for gastric ulcer) ◆ The fasting serum gastrin level rules
◆ Type O blood (for duodenal ulcer) out Zollinger-Ellison syndrome.
◆ Other genetic factors
◆ Exposure to irritants Imaging
◆ Cigarette smoking ◆ Barium swallow or upper GI and
◆ Trauma small-bowel series may show the ulcer.
◆ Psychogenic factors ◆ Upper GI tract X-rays show mucosal
◆ Normal aging abnormalities.
Diagnostic procedures bilateral vagotomy, pyloroplasty, and

◆ Upper GI endoscopy or esophago- gastrectomy
gastroduodenoscopy confirms the ulcer
and permits cytologic studies and biop- Nursing interventions
sy to rule out H. pylori or cancer. ◆ Administer medications as ordered.
◆ Gastric secretory studies show hy- ◆ Provide six small meals or small
perchlorhydria. hourly meals, as ordered.
◆ Offer emotional support.
Treatment ◆ Monitor the patient for signs and
symptoms of bleeding.
General ◆ Provide pain control.
◆ Symptomatic
◆ Iced saline lavage, possibly contain- If patient had surgery
ing norepinephrine ◆ Nasogastric tube function and
◆ Laser or cautery during endoscopy drainage
◆ Stress reduction ◆ Bowel function
◆ Smoking cessation ◆ Fluid and nutritional status
◆ Avoidance of dietary irritants ◆ Wound site
◆ Nothing by mouth if GI bleeding is ◆ Signs and symptoms of metabolic
evident alkalosis or perforation
Medications Patient teaching

For H. pylori
◆ Amoxicillin, clarithromycin (Biax- ◆ Be sure to cover:
in), and omeprazole (Prilosec) – the disorder, diagnosis, and treat-
ment
For gastric or duodenal ulcer – administration, dosage, and possible
◆ Proton pump inhibitors reactions to medications
◆ Antacids – warnings against using over-the-
◆ Histamine-receptor antagonists or counter medications, especially aspirin,
gastric acid pump inhibitor aspirin-containing products, and
◆ Coating agents (for duodenal ulcer) NSAIDs, unless the physician approves
◆ Antisecretory agents if the ulcer re- – warnings against using caffeine and
sulted from NSAID use, when NSAIDs alcohol during exacerbations
must be continued – appropriate lifestyle changes
◆ Sedatives and tranquilizers (for gas- – dietary modifications.
tric ulcer) ◆ Refer the patient to a smoking-
◆ Anticholinergics (for duodenal ul- cessation program, if indicated.
cers; usually contraindicated in gastric
ulcers)
◆ Prostaglandin analogues Pneumonia
Surgery Overview
◆ Indicated for perforation, lack of re-
sponse to conservative treatment, sus- ◆ Acute infection of the lung paren-
pected cancer, or other complications chyma that impairs gas exchange
◆ Type varies with the location and ◆ May be classified by etiology, loca-
extent of the ulcer; major operations: tion, or type
Pneumonia 243
Causes Aspiration pneumonia

Bacterial and viral pneumonia ◆ Fever
◆ Chronic illness and debilitation ◆ Weight loss
◆ Cancer ◆ Malaise
◆ Abdominal and thoracic surgery
◆ Atelectasis Physical findings
◆ Bacterial or viral respiratory infec- ◆ Fever
tion ◆ Sputum production
◆ Chronic respiratory disease ◆ Dullness over the affected area
◆ Influenza ◆ Crackles, wheezing, or rhonchi
◆ Smoking ◆ Decreased breath sounds
◆ Malnutrition ◆ Decreased fremitus
◆ Alcoholism ◆ Tachypnea
◆ Sickle cell disease ◆ Use of accessory muscles
◆ Tracheostomy
◆ Exposure to noxious gases Diagnostic tests
◆ Aspiration Laboratory
◆ Immunosuppressive therapy ◆ Complete blood count shows leuko-
◆ Endotracheal intubation or mechan- cytosis.
ical ventilation ◆ Blood culture findings are positive
for the causative organism.
Aspiration pneumonia ◆ Arterial blood gas values show hy-
◆ Caustic substance entering the airway poxemia.
◆ Fungal or acid-fast bacilli cultures
Risk factors identify the etiologic agent.
◆ Advanced age ◆ Assay shows Legionella-soluble anti-
◆ Debilitation gen in urine.
◆ Nasogastric (NG) tube feedings ◆ Sputum culture, Gram stain, and
◆ Impaired gag reflex smear show the infecting organism.
◆ Poor oral hygiene
◆ Decreased level of consciousness Imaging
Age alert Incidence and mor- ◆ Chest X-rays usually show patchy or
tality rates are highest in elderly lobar infiltrates.
patients.
Assessment ◆ Bronchoscopy or transtracheal aspi-
ration specimens identify the etiologic
History agent.
Bacterial pneumonia
◆ Sudden onset of: Other
– pleuritic chest pain ◆ Pulse oximetry may show decreased
– cough oxygen saturation.
– production of purulent sputum
– chills. Treatment
Viral pneumonia General

◆ Nonproductive cough ◆ Mechanical ventilation (positive
◆ Constitutional symptoms end-expiratory pressure) for respiratory
◆ Fever failure
◆ High-calorie, high-protein diet – the need for adequate fluid intake

◆ Adequate fluids – the importance of getting adequate
◆ Bed rest initially, with progress as rest
tolerated – deep-breathing and coughing exer-
cises
Medications – chest physiotherapy
◆ Antibiotics – the need to avoid irritants that stim-
◆ Humidified oxygen ulate secretions
◆ Antitussives – when to notify the physician
◆ Analgesics – home oxygen therapy, if required
◆ Bronchodilators – ways to prevent pneumonia.
◆ Refer the patient to a smoking-
Surgery cessation program, if indicated.
◆ Drainage of parapneumonic pleural
effusion or lung abscess
Prostate cancer
◆ Administer medications as ordered. Overview
◆ Administer I.V. fluids and electrolyte
replacement as ordered. ◆ Proliferation of cancer cells that
◆ Maintain a patent airway and ade- usually takes the form of adenocarcino-
quate oxygenation. mas and typically originate in the pos-
◆ Administer supplemental oxygen as terior prostate gland
ordered. Give oxygen cautiously if the ◆ May progress to widespread bone
patient has chronic lung disease. metastases and death
◆ Suction the patient as needed. ◆ The leading cause of cancer death
◆ Obtain sputum specimens as in men
needed.
◆ Provide a high-calorie, high-protein Causes
diet of soft foods. ◆ Unknown
◆ Administer supplemental oral feed-
ings, NG tube feedings, or parenteral Risk factors
nutrition if needed. ◆ Older than age 40
◆ Take steps to prevent aspiration dur- ◆ Infection
ing NG feedings. ◆ Smoking
◆ Dispose of secretions properly. ◆ Family history
◆ Provide a quiet, calm environment ◆ Exposure to heavy metals
with frequent rest periods. ◆ Race
◆ Include the patient in care decisions ◆ High-fat diet
whenever possible.
Assessment
Patient teaching
History
◆ Be sure to cover: ◆ Symptoms rare in early stages of
– the disorder, diagnosis, and treat- disease
ment ◆ Later, urinary problems, such as dif-
– medications and possible adverse ficulty initiating a urinary stream, drib-
reactions bling, and retention of urine
Pulmonary embolism 245
Physical findings ◆ Transurethral resection of the

◆ In early stages: a flat, firm, nodular prostate
mass with a sharp edge ◆ Cryosurgical ablation
◆ In advanced disease: edema of the
scrotum or leg, with a hard lump in Nursing interventions
the prostate region ◆ Administer medications as ordered.
◆ Encourage the patient to express his
Diagnostic tests feelings.
◆ Provide emotional support.
Laboratory
◆ Serum prostate-specific antigen Patient teaching
(PSA) level is elevated. (An elevated
PSA level may indicate cancer with or ◆ Be sure to cover:
without metastases.) – the disorder, diagnosis, and treatment
– perineal exercises that decrease in-
Imaging continence
◆ Transrectal prostatic ultrasonogra- – the importance of follow-up care
phy shows the size of the prostate and – administration, dosages, and possi-
the presence of abnormal growths. ble adverse reaction to medication.
◆ Bone scan and excretory urography ◆ Refer the patient to appropriate
determine the extent of disease. resources and support services, as
◆ Magnetic resonance imaging and needed.
computed tomography scan define the
extent of the tumor.
Pulmonary embolism
Other
◆ The standard screening tests are Overview
digital rectal examination and PSA test.
Positive results on these tests identify ◆ Obstruction of the pulmonary arteri-
cancer. The American Cancer Society al bed that occurs when a mass (such
recommends yearly screening for men as a dislodged thrombus) lodges in the
older than age 40. main pulmonary artery or branch, par-
tially or completely obstructing it
Treatment ◆ Usually originates in the deep veins
of the leg or pelvis
General ◆ Can be asymptomatic, but some-
◆ Varies with stage of cancer times causes rapid death from pulmo-
◆ Radiation therapy or internal beam nary infarction
radiation
◆ Well-balanced diet Causes
◆ Deep vein thrombosis
Medications ◆ Pelvic, renal, and hepatic vein
◆ Hormonal therapy thrombosis
◆ Chemotherapy ◆ Right heart thrombus
◆ Upper-extremity thrombosis
Surgery ◆ Valvular heart disease
◆ Prostatectomy ◆ Rarely, other types of emboli, such
◆ Orchiectomy as bone, air, fat, amniotic fluid, tumor
◆ Radical prostatectomy cells, or a foreign body
Risk factors ◆ Chest X-rays may show a small in-

◆ Various disorders and treatments filtrate or effusion.
◆ Surgery, venous stasis, venous in- ◆ Spiral chest computed tomography
jury, increased blood coagulability, and scan may show central pulmonary em-
predisposing disorders, such as throm- boli.
boembolism and thrombophlebitis
◆ Thrombophilias Diagnostic procedures
◆ Electrocardiography may show right
Assessment axis deviation, right bundle-branch
block, or atrial fibrillation.
History ◆ Echocardiography may show right
◆ Predisposing factor atrial and ventricular enlargement or
◆ Shortness of breath for no apparent thrombus.
reason ◆ Duplex ultrasonography of the leg or
◆ Sudden pleuritic pain or angina pelvic veins may indicate the embolic
source.
Physical findings
◆ Tachycardia Treatment
◆ Low-grade fever
◆ Weak, rapid pulse General
◆ Hypotension ◆ Maintenance of adequate cardiovas-
◆ Productive cough, possibly with cular and pulmonary function
blood-tinged sputum ◆ Mechanical ventilation, if indicated
◆ Warmth, tenderness, and edema of ◆ Possible fluid restriction
the lower leg ◆ Bed rest during the acute phase
◆ Dyspnea and restlessness
◆ Transient pleural friction rub Medications
◆ Crackles ◆ Oxygen therapy
◆ S3 and S4 gallop, with increased ◆ Thrombolytics
intensity of the pulmonic component ◆ Anticoagulation
of S2 ◆ Corticosteroids (controversial)
◆ If the embolus is large, cyanosis, ◆ Diuretics
syncope, and distended jugular veins ◆ Antiarrhythmics
◆ Vasopressors (for hypotension)
Diagnostic tests ◆ Antibiotics (for septic embolus)
Laboratory
◆ Arterial blood gas values show hy- Surgery
poxemia. ◆ Vena caval interruption
◆ D-dimer level is elevated. ◆ Vena caval filter placement
◆ Pulmonary embolectomy
Imaging
◆ Lung ventilation-perfusion scan Nursing interventions
shows a ventilation-perfusion mis- ◆ Administer medications as ordered.
match. ◆ Avoid I.M. injections.
◆ Pulmonary angiography shows a ◆ Encourage active and passive range-
pulmonary vessel filling defect or an of-motion exercises, unless contraindi-
abrupt vessel ending as well as the located.
cation and extent of pulmonary em- ◆ Avoid massage of the lower legs.
bolism. ◆ Apply antiembolism stockings.
Renal failure, acute 247
◆ Provide adequate nutrition. ◆ Urine output drops to less than

◆ Assist with ambulation as soon as 400 ml/day.
the patient is stable. ◆ Excess fluid volume, azotemia, and
◆ Encourage the use of incentive electrolyte imbalance occur.
spirometry. ◆ Local mediators are released, caus-
ing intrarenal vasoconstriction.
Patient teaching ◆ Medullary hypoxia causes cellular
swelling and adherence of neutrophils
◆ Be sure to cover: to capillaries and venules.
– the disease, diagnosis, and treat- ◆ Hypoperfusion occurs.
ment ◆ Cellular injury and necrosis occur.
– medications and possible adverse ◆ Reperfusion causes reactive oxygen
reactions species to form, leading to further cel-
– ways to prevent deep vein thrombo- lular injury.
sis and pulmonary embolism
– signs and symptoms of abnormal Diuretic phase
bleeding ◆ Renal function is recovered.
– how to prevent abnormal bleeding ◆ Urine output gradually increases.
– how to monitor anticoagulant ef- ◆ The glomerular filtration rate im-
fects proves, although tubular transport sys-
– dietary sources of vitamin K tems remain abnormal.
– when to notify the physician.
◆ Refer the patient to a weight man- Recovery phase
agement program, if indicated. ◆ The recovery phase may last 3 to
12 months or longer.
◆ Renal function gradually returns to
Renal failure, acute normal or near normal.
Overview Causes
Prerenal failure
◆ Sudden interruption of renal func- ◆ Hypovolemia
tion as a result of obstruction, reduced ◆ Hemorrhagic blood loss
circulation, or renal parenchymal dis- ◆ Loss of plasma volume
ease ◆ Water and electrolyte losses
◆ Classified as prerenal failure, in- ◆ Hypotension or hypoperfusion
trarenal failure (also called intrinsic, or ◆ Renal artery or vein obstruction
parenchymal, failure), or postrenal fail-
ure Intrarenal failure
◆ Usually reversible with medical ◆ Acute tubular necrosis
treatment ◆ Glomerulopathy
◆ If not treated, may progress to end- ◆ Malignant hypertension
stage renal disease, uremia, and death ◆ Coagulation defects
◆ Normally, three distinct phases:
oliguric, diuretic, and recovery Postrenal failure
◆ Obstructive uropathy, which is usu-
Oliguric phase ally bilateral
◆ This phase may last a few days or ◆ Ureteral destruction
several weeks. ◆ Bladder neck obstruction
Assessment ◆ retrograde pyelography

◆ computed tomography scan
History ◆ nephrotomography.
◆ Predisposing disorder
◆ Recent fever, chills, or a central ner- Diagnostic procedures
vous system disorder ◆ Electrocardiography shows tall,
◆ Recent GI problem peaked T waves; a widening QRS com-
plex; and disappearing P waves if hy-
Physical findings perkalemia is present.
◆ Oliguria or anuria, depending on
the phase of renal failure Treatment
◆ Tachycardia
◆ Bibasilar crackles General
◆ Irritability, drowsiness, or confusion ◆ Hemodialysis, peritoneal dialysis (if
◆ Altered level of consciousness appropriate), or continuous renal re-
◆ Bleeding abnormalities placement therapies
◆ Dry, pruritic skin ◆ High-calorie, low-protein, low-
◆ Dry mucous membranes sodium, and low-potassium diet
◆ Uremic breath odor ◆ Fluid restriction
◆ Rest periods when fatigued
Diagnostic tests
Laboratory Medications
◆ Blood urea nitrogen, serum crea- ◆ Supplemental vitamins
tinine, and potassium levels are elevated. ◆ Diuretics
◆ Hematocrit, blood pH, bicarbonate, ◆ In hyperkalemia, hypertonic
and hemoglobin levels are decreased. glucose-and-insulin infusions, sodium
◆ Urine casts and cellular debris are bicarbonate, and sodium polystyrene
present, and the specific gravity is de- sulfonate
creased.
◆ In glomerular disease, proteinuria Surgery
and urine osmolality are near the ◆ Creation of vascular access for he-
serum osmolality level. modialysis
◆ The urine sodium level is less than
20 mEq/L if oliguria results from de- Nursing interventions
creased perfusion. ◆ Administer medication as ordered.
◆ The urine sodium level is greater ◆ Encourage the patient to express his
than 40 mEq/L if oliguria results from feelings.
an intrarenal problem. ◆ Provide emotional support.
◆ Urine creatinine clearance is used to ◆ Identify patients at risk for acute
measure the glomerular filtration rate tubular necrosis, and take preventive
and estimate the number of remaining steps.
functioning nephrons. ◆ Monitor the patient’s weight daily.
◆ Monitor the dialysis access site.
Imaging
The following imaging tests may show Patient teaching
the cause of renal failure:
◆ kidney ultrasonography ◆ Be sure to cover:
◆ kidney-ureter-bladder radiography – the disorder, diagnosis, and treatment
◆ excretory urography renal scan
Renal failure, chronic 249
– administration, dosages, and possi- ◆ Muscle cramps

ble adverse reactions to medications ◆ Fasciculations and twitching
– the recommended fluid allowance ◆ Infertility and decreased libido
– the importance of complying with ◆ Amenorrhea
the diet and medication regimen ◆ Impotence
– the importance of monitoring ◆ Pathologic fractures
weight daily and reporting changes of
3 lb (1.4 kg) or more immediately Physical findings
– the signs and symptoms of edema ◆ Decreased urine output
and the importance of reporting them ◆ Hypotension or hypertension
to the physician. ◆ Altered level of consciousness
◆ Peripheral edema
◆ Cardiac arrhythmias
Renal failure, chronic ◆ Bibasilar crackles
◆ Pleural friction rub
Overview ◆ Gum ulceration and bleeding
◆ Uremic fetor
◆ End result of a gradually progressive ◆ Abdominal pain on palpation
loss of renal function ◆ Poor skin turgor
◆ Few symptoms until more than 75% ◆ Pale, yellow-bronze skin color
of glomerular filtration is lost, with ◆ Thin, brittle fingernails and dry,
symptoms worsening as renal function brittle hair
declines ◆ Growth retardation (in children)
◆ Fatal unless treated; to sustain life,
maintenance dialysis or kidney trans- Diagnostic tests
plantation may be needed Laboratory
◆ Blood urea nitrogen, serum creati-
Causes nine, sodium, and potassium levels are
◆ Chronic glomerular disease elevated.
◆ Chronic infections such as chronic ◆ Arterial blood gas values show de-
pyelonephritis creased arterial pH and bicarbonate
◆ Congenital anomalies such as poly- levels.
cystic kidney disease ◆ Hematocrit and hemoglobin level
◆ Vascular diseases are low; red blood cell (RBC) survival
◆ Obstructive processes such as cal- time is decreased.
culi ◆ Mild thrombocytopenia and platelet
◆ Collagen diseases such as systemic defects appear.
lupus erythematosus ◆ Aldosterone secretion is increased.
◆ Nephrotoxic agents ◆ Hyperglycemia and hypertriglyc-
◆ Endocrine disease eridemia occur.
◆ High-density lipoprotein levels are
Assessment decreased.
◆ Arterial blood gas values show
History metabolic acidosis.
◆ Predisposing factor ◆ Urine specific gravity is fixed at
◆ Dry mouth 1.010.
◆ Fatigue ◆ Proteinuria, glycosuria, and urinary
◆ Nausea RBCs, leukocytes, casts, and crystals
◆ Hiccups are detected.
Imaging Patient teaching

◆ Kidney-ureter-bladder radiography,
excretory urography, nephrotomogra- ◆ Be sure to cover:
phy, renal scan, and renal arteriogra- – the disorder, diagnosis, and treat-
phy show reduced kidney size. ment
– dietary changes
Diagnostic procedures – fluid restrictions
◆ Renal biopsy allows histologic iden- – care of the dialysis site, as appropri-
tification of the underlying pathology. ate
◆ Electroencephalography shows – the importance of wearing or carry-
changes that suggest metabolic ening medical identification.
cephalopathy. ◆ Refer the patient to appropriate re-
sources and support services.
Treatment
General Rheumatoid arthritis

◆ Hemodialysis or peritoneal dialysis
◆ Low-protein (with peritoneal dialy- Overview
sis, high-protein), high-calorie, low-
sodium, low-phosphorus, and low- ◆ Chronic, systemic, symmetrical in-
potassium diet flammatory disease
◆ Fluid restriction ◆ Peripheral joints and surrounding
◆ Rest periods when fatigued muscles, tendons, ligaments, and blood
vessels primarily affected
Medications ◆ Marked by spontaneous remissions
◆ Loop diuretics and unpredictable exacerbations
◆ Cardiac glycosides ◆ Potentially crippling
◆ Antihypertensives
◆ Antiemetics Causes
◆ Iron and folate supplements ◆ Unknown
◆ Erythropoietin ◆ Possible effect of infection (viral or
◆ Antipruritics bacterial), hormonal factors, and
◆ Supplementary vitamins and essen- lifestyle
tial amino acids
Assessment
Surgery
◆ Creation of vascular access for dial- History
ysis ◆ Insidious onset of nonspecific symp-
◆ Possible kidney transplantation toms including fatigue, malaise, persis-
tent low-grade fever, anorexia, weight
Nursing interventions loss, and vague articular symptoms
◆ Administer medication as ordered. ◆ Later, more specific localized articu-
◆ Perform meticulous skin care. lar symptoms, commonly in the fingers
◆ Encourage the patient to express his ◆ Bilateral, symmetrical symptoms
feelings. that may extend to the wrists, elbows,
◆ Provide emotional support. knees, and ankles
◆ Monitor the patient’s weight and ◆ Stiff joints
signs and symptoms of fluid overload ◆ Stiff, weak, or painful muscles
daily.
Rheumatoid arthritis 251
◆ Numbness or tingling in feet, or Other

weakness or loss of sensation in fin- ◆ Synovial tissue biopsy shows in-
gers flammation.
◆ Pain on inspiration
◆ Shortness of breath Treatment
Physical findings General

◆ Joint deformities and contractures ◆ Adequate sleep (8 to 10 hours every
◆ Red, painful, swollen arms night)
◆ Foreshortened hands ◆ Splinting
◆ Boggy wrists ◆ Range-of-motion (ROM) exercises
◆ Rheumatoid nodules and carefully individualized muscle-
◆ Leg ulcers strengthening exercises
◆ Eye redness ◆ Application of moist heat
◆ Joints that are warm to the touch ◆ Frequent rest periods between activ-
◆ Pericardial friction rub ities
◆ Positive Babinski’s sign
Medications
Diagnostic tests ◆ Salicylates
Laboratory ◆ Nonsteroidal anti-inflammatory
◆ Rheumatoid factor test result is pos- drugs
itive in 75% to 80% of patients, as in- ◆ Antimalarials (hydroxychloroquine)
dicated by a titer of 1:160 or higher. ◆ Gold salts
◆ Synovial fluid analysis shows in- ◆ Penicillamine
creased volume and turbidity but de- ◆ Corticosteroids
creased viscosity and complement (C3 ◆ Antineoplastic agents
and C4) levels; white blood cell count
may exceed 10,000/µl. Surgery
◆ Serum globulin levels are elevated. ◆ Metatarsal head and distal ulnar re-
◆ Erythrocyte sedimentation rate is el- sectional arthroplasty and insertion of
evated. a silicone prosthesis between the
◆ Complete blood count shows mod- metacarpophalangeal and proximal in-
erate anemia and slight leukocytosis. terphalangeal joints
(See Classifying rheumatoid arthritis, ◆ Arthrodesis (joint fusion)
page 252.) ◆ Synovectomy
◆ Osteotomy
Imaging ◆ Repair of ruptured tendon
◆ In early stages of the disease, X-rays ◆ In advanced disease, joint recon-
show bone demineralization and soft- struction or total joint arthroplasty
tissue swelling. Later, they help deter-
mine the extent of cartilage and bone Nursing interventions
destruction, erosion, subluxations, and ◆ Administer analgesics as ordered,
deformities and show the characteristic and watch for adverse reactions.
pattern of these abnormalities. ◆ Perform meticulous skin care.
◆ Magnetic resonance imaging and ◆ Supply adaptive devices, such as a
computed tomography scans may pro- zipper-pull, easy-to-open beverage car-
vide information about the extent of tons, lightweight cups, and unpackaged
damage. silverware.
Classifying rheumatoid arthritis
A patient who meets four of the seven American College of Rheumatology criteria is
classified as having rheumatoid arthritis. The patient must experience the first four cri-
teria for at least 6 weeks, and a physician must observe the second through fifth crite-
ria.
Criteria
1. Morning stiffness in and around the joints that lasts for 1 hour before full improve-
ment
2. Arthritis in three or more joint areas, with at least three joint areas (as observed by
a physician) exhibiting soft-tissue swelling or joint effusions, not just bony overgrowth
(The 14 possible areas involved include the right and left proximal interphalangeal,
metacarpophalangeal, wrist, elbow, knee, ankle, and metatarsophalangeal joints.)
3. Arthritis of the hand joints, including the wrist, metacarpophalangeal joint, or proxi-
mal interphalangeal joint
4. Arthritis that involves the same joint areas on both sides of the body
5. Subcutaneous rheumatoid nodules over bony prominences
6. The finding of abnormal amounts of serum rheumatoid factor by any method that
produces a positive result in fewer than 5% of patients without rheumatoid arthritis
7. Radiographic changes, usually on posteroanterior radiographs of the hand and
wrist, that show erosions or unequivocal bony decalcification localized in or most no-
ticeable adjacent to the involved joints
After total knee or hip arthroplasty a leg that appears shorter than the oth-
◆ Administer blood replacement prod- er leg.
ucts, antibiotics, and pain medication ◆ Assist the patient in activities, keep-
as ordered. ing his weight on the unaffected side.
◆ Have the patient perform active dor-
siflexion; immediately report inability Patient teaching
to do so.
◆ Supervise isometric exercises every ◆ Be sure to cover:
2 hours. – the disorder, diagnosis, and treat-
◆ After total hip arthroplasty, check ment
traction for pressure areas and keep the – the chronic nature of rheumatoid
head of the bed raised 30 to 45 de- arthritis and the possible need for ma-
grees. jor lifestyle changes
◆ Change or reinforce dressings, as – the importance of a balanced diet
needed, using aseptic technique. and weight control
◆ Have the patient turn, cough, and – the importance of adequate sleep
breathe deeply every 2 hours. – sexual concerns.
◆ After total knee arthroplasty, keep ◆ If the patient requires total knee or
the leg extended and slightly elevated. hip arthroplasty, be sure to cover:
◆ After total hip arthroplasty, keep the – preoperative and surgical proce-
hip in abduction. Watch for and imme- dures
diately report inability to rotate the hip – postoperative exercises, with super-
or bear weight on it, increased pain, or vision of the patient’s practice to
Seizure disorder 253
ensure that he is performing the exer- ◆ Meningitis, encephalitis, or brain

cises correctly abscess
– deep-breathing and coughing exer- ◆ Traumatic injury
cises to perform after surgery ◆ Ingestion of toxins, such as mer-
– the need to perform frequent ROM cury, lead, or carbon monoxide
leg exercises after surgery ◆ Stroke
– the use of a constant-passive- ◆ Apparent familial incidence in some
motion device after total knee arthro- seizure disorders
plasty or placement of an abduction
pillow between the legs after total hip Assessment
arthroplasty
– how to use a trapeze to move about History
in bed ◆ Seizure occurrence unpredictable
– dosages and possible adverse reac- and unrelated to activities
tions to medications. ◆ Precipitating factors or events possi-
◆ Refer the patient to the Arthritis bly reported
Foundation. ◆ Headache
◆ Refer the patient to physical and oc- ◆ Mood changes
cupational therapy. ◆ Lethargy
◆ Myoclonic jerking
◆ Description of an aura
Seizure disorder ◆ Description of a pungent smell
◆ GI distress
Overview ◆ Rising or sinking feeling in the
stomach
◆ Neurologic condition characterized ◆ Dreamy feeling
by recurrent seizures ◆ Unusual taste in the mouth
◆ Intelligence not affected ◆ Visual disturbance
◆ Good seizure control achieved in
about 80% of patients with strict ad- Physical findings
herence to prescribed treatment ◆ Findings possibly normal while the
◆ Also known as epilepsy patient isn’t having a seizure and when
◆ Classified as two main types: partial the cause is idiopathic
and generalized ◆ Findings related to the underlying
cause of the seizure
Causes
◆ Idiopathic in half of cases Diagnostic tests
Laboratory
Nonidiopathic epilepsy ◆ Serum glucose and calcium test re-
◆ Birth trauma sults rule out other diagnoses.
◆ Anoxia
◆ Perinatal infection or injury Imaging
◆ Genetic abnormalities (tuberous ◆ Computed tomography scan and
sclerosis and phenylketonuria) magnetic resonance imaging may indi-
◆ Metabolic abnormalities (hypo- cate abnormalities in internal struc-
glycemia, pyridoxine deficiency, hypo- tures.
parathyroidism) ◆ Skull radiography may show skull
◆ Brain tumors or other space- fractures or certain neoplasms within
occupying lesions the brain.
◆ Brain scan may show malignant le- Patient teaching

sions when the X-ray findings are nor-
mal or questionable. ◆ Be sure to cover:
◆ Cerebral angiography may show – the disorder, diagnosis, and treat-
cerebrovascular abnormalities, such as ment
aneurysm or tumor. – the importance of maintaining a
normal lifestyle
Other – the importance of complying with
◆ Electroencephalogram shows parox- the prescribed drug schedule
ysmal abnormalities. (A negative find- – adverse drug effects
ing doesn’t rule out epilepsy because – care during a seizure
paroxysmal abnormalities occur inter- – the importance of regular meals and
mittently.) checking with the physician before di-
eting
Treatment – the importance of carrying a med-
ical identification card or wearing med-
General ical identification jewelry.
◆ Protection of the airway during ◆ Refer the patient to the Epilepsy
seizures Foundation.
◆ Stimulation of the vagal nerve by a ◆ Refer the patient to his state’s motor
pacemaker vehicle department for information
◆ Detailed presurgical evaluation to about obtaining a driver’s license.
characterize the seizure type, frequen-
cy, and site of onset and the patient’s
psychological functioning and degree Stroke
of disability to select candidates for
surgery when medical treatment is un- Overview
successful
◆ No dietary restrictions ◆ Sudden impairment of circulation in
◆ Safety measures the blood vessels to the brain
◆ Activity as tolerated ◆ Third most common cause of death
in the United States
Medications ◆ 700,000 people affected each year;
◆ Anticonvulsants half of cases result in death
◆ Most common cause of neurologic
Surgery disability
◆ Removal of a demonstrated focal le- ◆ About 50% of stroke survivors per-
sion manently disabled
◆ Correction of the underlying prob- ◆ Recurrence possible within weeks,
lem months, or years
◆ Also known as cerebrovascular acci-
Nursing interventions dent or brain attack
◆ Institute seizure precautions.
◆ Prepare the patient for surgery if in- Causes
dicated. Cerebral thrombosis
◆ Give prescribed anticonvulsants. ◆ Most common cause of stroke
◆ Monitor seizure activity. ◆ Obstruction of a blood vessel in the
extracerebral vessels
◆ Site possibly intracerebral
Stroke 255
Cerebral embolism ◆ Loss of consciousness, sudden

◆ Second most common cause of aphasia, or loss of vision in one eye
stroke
◆ History of rheumatic heart disease Physical findings
◆ Endocarditis ◆ With stroke in the left hemisphere,
◆ Posttraumatic valvular disease signs and symptoms on the right side
◆ Cardiac arrhythmias ◆ With stroke in the right hemisphere,
◆ Post open-heart surgery signs and symptoms on the left side
◆ With stroke that causes cranial
Cerebral hemorrhage nerve damage, signs and symptoms on
◆ Third most common cause of stroke the same side
◆ Chronic hypertension ◆ Change in the level of conscious-
◆ Cerebral aneurysms ness
◆ Arteriovenous malformation ◆ With a conscious patient, anxiety
along with communication and mobili-
Risk factors ty difficulties
◆ History of transient ischemic attack ◆ Urinary incontinence
◆ Heart disease ◆ Loss of voluntary muscle control
◆ Hypertension ◆ Hemiparesis or hemiplegia on one
◆ Smoking side of the body
◆ Familial history of cerebrovascular ◆ Decreased deep tendon reflexes
disease ◆ Hemianopia on the affected side of
◆ Obesity the body
◆ Excessive alcohol use ◆ With left-sided hemiplegia, prob-
◆ High red blood cell count lems with visuospatial relations
◆ Cardiac arrhythmias ◆ Sensory losses
◆ Diabetes mellitus
◆ Gout Diagnostic tests
◆ High serum triglyceride levels Laboratory
◆ Use of hormonal contraceptives in ◆ Laboratory tests — including levels
conjunction with smoking and hyper- of anticardiolipin antibodies, antiphos-
tension pholipid, factor V (Leiden) mutation,
◆ Elevated cholesterol and triglyceride antithrombin III, protein S, and protein
levels C — may show increased risk of throm-
bosis.
Assessment
Imaging
History ◆ Magnetic resonance imaging and
◆ Varying clinical features, depending magnetic resonance angiography allow
on: the size and location of the lesion to be
– the artery affected evaluated.
– the severity of damage ◆ Cerebral angiography details the
– the extent of collateral circulation disruption of cerebral circulation and is
◆ One or more risk factors the test of choice for examining the en-
◆ Sudden onset of hemiparesis or tire cerebral blood flow.
hemiplegia ◆ Computed tomography scan detects
◆ Gradual onset of dizziness, mental structural abnormalities.
disturbances, or seizures
◆ Positron emission tomography pro- Surgery

vides data on cerebral metabolism and ◆ Craniotomy
changes in cerebral blood flow. ◆ Endarterectomy
◆ Extracranial–intracranial bypass
Other ◆ Ventricular shunts
◆ Transcranial Doppler studies are
used to evaluate the velocity of blood Nursing interventions
flow. ◆ Maintain a patent airway and oxy-
◆ Carotid Doppler is used to measure genation.
flow through the carotid and vertebral ◆ Offer the urinal or bedpan every
arteries. 2 hours.
◆ Two-dimensional echocardiogram is ◆ Insert an indwelling urinary
used to evaluate the heart for dysfunc- catheter if necessary.
tion. ◆ Ensure adequate nutrition.
◆ Cerebral blood flow studies are used ◆ Provide careful mouth care.
to measure blood flow to the brain. ◆ Provide meticulous eye care.
◆ Electrocardiogram shows reduced ◆ Follow the physical therapy pro-
electrical activity in an area of cortical gram, and assist the patient with exer-
infarction. cise.
◆ Establish and maintain communica-
Treatment tion with the patient.
◆ Provide psychological support.
General ◆ Set realistic short-term goals.
◆ Careful management of blood pres- ◆ Protect the patient from injury.
sure ◆ Provide careful positioning to pre-
◆ Varies, depending on the cause and vent aspiration and contractures.
clinical manifestations ◆ Take steps to prevent complications.
◆ Pureed dysphagia diet or tube feed- ◆ Administer medications as ordered.
ings, if indicated ◆ Monitor the patient for the develop-
◆ Physical, speech, and occupational ment of deep vein thrombosis and pul-
rehabilitation monary embolus.
◆ Care measures to help the patient
adapt to specific deficits Patient teaching
Medications ◆ Be sure to cover:

◆ Tissue plasminogen activator when – the disorder, diagnosis, and treat-
the cause isn’t hemorrhagic (emer- ment
gency care within 3 hours of onset of – occupational and speech therapy
the symptoms) programs
◆ Anticonvulsants – dietary regimen
◆ Stool softeners – medication regimen
◆ Anticoagulants – adverse drug reactions
◆ Analgesics – stroke prevention.
◆ Antidepressants ◆ Refer the patient to home care ser-
◆ Antiplatelets vices.
◆ Lipid-lowering agents ◆ Refer the patient to outpatient ser-
◆ Antihypertensives vices, speech, and occupational reha-
bilitation programs, as indicated.
Thrombophlebitis 257
◆ Lymphadenitis in patients with ex-

Thrombophlebitis
tensive vein involvement
◆ Nonpitting edema with deep vein
Overview thrombosis
◆ Development of a thrombus that Diagnostic tests

may cause vessel occlusion or em- Diagnostic procedures
bolization ◆ Duplex ultrasonography shows re-
◆ Acute condition characterized by induced blood flow to a specific area and
flammation and thrombus formation obstruction to venous flow, particularly
◆ May occur in deep or superficial in iliofemoral deep vein throm-
veins bophlebitis.
◆ Typically occurs at the valve cusps ◆ Phlebography shows filling defects
because venous stasis encourages accu- and diverted blood flow but is rarely
mulation and adherence of platelet and used.
fibrin
Treatment
Causes
◆ May be idiopathic General
◆ Prolonged bed rest ◆ Application of warm, moist com-
◆ Trauma presses to the affected area
◆ Surgery ◆ Antiembolism stockings
◆ Pregnancy and childbirth ◆ Bed rest, with elevation of the af-
◆ Hormonal contraceptives such as fected extremity
estrogens
◆ Neoplasms Medications
◆ Fracture of the spine, pelvis, femur, ◆ Anticoagulants
or tibia ◆ Thrombolytics
◆ Venous insufficiency ◆ Analgesics
◆ Venulitis
◆ Thrombophilias Surgery
◆ Simple ligation to vein plication, or
Assessment clipping
◆ Embolectomy
History ◆ Caval interruption with transvenous
◆ Asymptomatic in up to 50% of pa- placement of a vena cava filter
tients with deep vein thrombophlebitis
◆ Possible tenderness, aching, or se- Nursing interventions
vere pain in the affected leg or arm; ◆ Enforce bed rest as ordered and ele-
fever, chills, and malaise vate the patient’s affected arm or leg,
but avoid compressing the popliteal
Physical findings space.
◆ Redness, swelling, and tenderness ◆ Apply warm compresses or a cov-
of the affected leg or arm ered aquathermia pad.
◆ Possible positive Homans’ sign ◆ Give analgesics, as ordered.
◆ Positive cuff sign ◆ Mark, measure, and record the cir-
◆ Possible sensation of warmth in the cumference of the affected arm or leg
affected leg or arm daily, and compare this measurement
with that of the other arm or leg.
◆ Administer anticoagulants, as or- Causes

dered. ◆ Exposure to Mycobacterium tubercu-
◆ Perform or encourage range-of- losis
motion exercises. ◆ In some cases, exposure to other
◆ Use pneumatic compression de- strains of mycobacteria
vices.
◆ Apply antiembolism stockings. Risk factors
◆ Monitor the results of laboratory ◆ Close contact with a patient newly
tests. diagnosed with tuberculosis
◆ Monitor for signs and symptoms of ◆ History of previous exposure to tu-
pulmonary embolism. berculosis
◆ Multiple sexual partners
Patient teaching ◆ Recent immigration from Africa,
Asia, Mexico, or South America
◆ Be sure to cover: ◆ Gastrectomy
– the disorder, diagnosis, and treat- ◆ History of silicosis, diabetes, malnu-
ment trition, cancer, Hodgkin’s disease, or
– the importance of follow-up blood leukemia
studies to monitor anticoagulant thera- ◆ Drug and alcohol abuse
py ◆ Residence in a nursing home, men-
– how to give injections (if the patient tal health facility, or prison
requires subcutaneous anticoagulation ◆ Immunosuppression and use of cor-
therapy after discharge) ticosteroids
– the need to avoid prolonged sitting ◆ Homelessness
or standing to help prevent a recur- ◆ Working in health care
rence
– the proper application and use of Assessment
antiembolism stockings
– the importance of adequate hydra- History
tion In primary infection
– the need to use an electric razor ◆ May be asymptomatic after a 4- to
and to avoid products that contain as- 8-week incubation period
pirin. ◆ Weakness and fatigue
◆ Anorexia and weight loss
◆ Low-grade fever
Tuberculosis ◆ Night sweats
Overview In reactivated infection

◆ Chest pain
◆ Acute or chronic lung infection ◆ Productive cough (blood or muco-
characterized by pulmonary infiltrates purulent or blood-tinged sputum)
and the formation of granulomas with ◆ Low-grade fever
caseation, fibrosis, and cavitation
◆ Excellent prognosis with proper Physical findings
treatment and compliance ◆ Dullness over the affected area
◆ Also known as TB ◆ Crepitant crackles
◆ Increase in cases related to emer- ◆ Bronchial breath sounds
gence of multidrug-resistant strains of ◆ Wheezes
TB ◆ Whispered pectoriloquy
Tuberculosis 259
Diagnostic tests Surgery

Laboratory ◆ For complications that require inva-
◆ Tuberculin skin test result is posi- sive or surgical intervention
tive in both active and inactive tuber-
culosis. Nursing interventions
◆ Stains and cultures of sputum, cere- ◆ Administer drug therapy.
brospinal fluid, urine, abscess drainage, ◆ Isolate the patient in a quiet, prop-
or pleural fluid show heat-sensitive, erly ventilated room, and maintain tu-
nonmotile, aerobic, acid-fast bacilli. berculosis precautions.
◆ Provide diversional activities.
Imaging ◆ Dispose of secretions properly.
◆ Chest X-rays show nodular lesions, ◆ Provide adequate rest periods.
patchy infiltrates, cavity formation, ◆ Provide a well-balanced, high-
scar tissue, and calcium deposits. calorie diet.
◆ Computed tomography or magnetic ◆ Provide small, frequent meals.
resonance imaging shows the presence ◆ Consult with a dietitian if oral sup-
and extent of lung damage. plements are needed.
◆ Perform chest physiotherapy.
Diagnostic procedures ◆ Provide supportive care.
◆ Bronchoscopy specimens show ◆ Include the patient in care deci-
heat-sensitive, nonmotile, aerobic, acid- sions.
fast bacilli. ◆ Monitor visual acuity if the patient
is taking ethambutol.
Treatment
Patient teaching
General
◆ After 2 to 4 weeks, when the dis- ◆ Be sure to cover:
ease is no longer infectious, resump- – the disorder, diagnosis, and treat-
tion of normal activities while continu- ment
ing to take medication – medications and potential adverse
◆ Well-balanced, high-calorie diet reactions
◆ Rest initially, with resumption of ac- – when to notify the physician
tivity as tolerated – the need for isolation
– the importance of postural drainage
Medications and chest percussion
◆ Antitubercular therapy for at least 6 – the importance of coughing and
months with daily oral doses of: deep-breathing exercises, including a
– isoniazid demonstration, if needed
– rifampin – the importance of regular follow-up
– pyrazinamide examinations
– ethambutol added in some cases. – the signs and symptoms of recur-
◆ Second-line drugs include: ring tuberculosis
– capreomycin – the possibility that rifampin may de-
– streptomycin crease the effectiveness of hormonal
– aminosalicylic acid (para-aminosali- contraceptives
cylic acid) – the need for a balanced, high-
– pyrazinamide calorie, high-protein diet
– cycloserine. – measures to prevent tuberculosis.
(See Preventing tuberculosis, page 260.)
Preventing tuberculosis
Explain respiratory and standard precautions to a hospitalized patient with tuberculosis.

Before discharge, tell him that he must take precautions to prevent spreading the dis-
ease, such as wearing a mask around others, until his physician tells him that he’s no
longer contagious. He should tell all health care providers he sees, including his dentist
and optometrist, that he has tuberculosis so that they can institute infection-control pre-
cautions.
Teach the patient other specific precautions to avoid spreading the infection. Tell
him to cough and sneeze into tissues and to dispose of the tissues properly. Stress the
importance of washing his hands thoroughly in hot, soapy water after handling his
own secretions. Also instruct him to wash his eating utensils separately in hot, soapy
water.
◆ Refer anyone exposed to an infected have the ability to acquire and share
patient for testing and follow-up. genetic information with other bacteria
◆ Refer the patient to a support ◆ Can survive on dry surfaces from 7
group, such as the American Lung As- days to 4 months
sociation. ◆ Most likely to cause urinary tract in-
◆ Refer the patient to a smoking- fection, bacteremia, endocarditis, or
cessation program, if indicated. meningitis
◆ Has been reported in facilities in
more than 40 states
Vancomycin-resistant ◆ Incidence as high as 14% in oncolo-
enterococci gy units
Overview Causes
◆ Direct contact with an infected pa-
◆ Mutation of a common bacterium tient or colonized patient or health care
normally found in the GI tract worker
◆ Vancomycin-resistant enterococci ◆ Contact with a contaminated sur-
(VRE) first identified in the United face, such as an overbed table
States in 1989
◆ Easily spread by direct person-to- Risk factors
person contact ◆ Immunocompromised condition
◆ Also called glycopeptide-resistant ◆ Severe underlying illness
enterococci ◆ Older age
◆ Resistance mediated by enzymes ◆ Indwelling medical device, central
that substitute a different molecule for venous access device, or other invasive
the terminal amino acid so that van- catheter
comycin can’t bind ◆ Major surgery
◆ Rare strains with intrinsic resistance ◆ Open wounds
have inherited, low-level resistance to ◆ History of taking vancomycin or a
vancomycin third-generation cephalosporin, antibi-
◆ More commonly found strains have otics targeted at anaerobic bacteria, or
acquired resistance to vancomycin and multiple courses of antibiotics
Vancomycin-resistant enterococci 261
Taking precautions at home
Tell the patient’s caregivers to:

◆ wash their hands with soap and water after physical contact with the patient and be-
fore leaving the home
◆ use towels only once when drying hands after contact
◆ wear disposable gloves if they expect to come in contact with the patient’s body flu-
ids and to wash hands after removing the gloves
◆ change linens routinely and whenever they become soiled
◆ clean the patient’s environment routinely and when it becomes soiled with body fluids
◆ tell physicians and other health care personnel caring for the patient that the patient
is infected with an organism resistant to multiple drugs.
◆ History of enterococcal bacteremia, Treatment

often linked to endocarditis
◆ Organ transplantation General
◆ Prolonged or repeated hospital ad- ◆ Possibly no treatment with an
missions asymptomatic infection
◆ Cancer ◆ Contact isolation for a colonized pa-
◆ Cardiothoracic or intra-abdominal tient until patient is culture-negative or
surgery is discharged
◆ Wounds draining into the pelvic or ◆ No known method to decolonize
intra-abdominal area VRE carrier
◆ Pressure ulcers
◆ Chronic renal failure Medications
◆ Exposure to contaminated equip- ◆ Antimicrobials (VRE isolates not
ment or a VRE-positive patient susceptible to vancomycin are general-
ly susceptible to other antimicrobial
Assessment drugs)
◆ Linezolid
History ◆ Quinupristin/dalfopristin
◆ Possible breach in the immune sys-
tem, surgery, or condition predisposing Nursing interventions
the patient to infection ◆ Consider grouping infected patients
◆ Multiple antibiotic use together and having the same health
◆ Possible risk factors for VRE care providers care for them.
◆ Institute contact precautions.
Physical findings ◆ Use infection-control practices, such
◆ Carrier commonly asymptomatic as wearing gloves and employing prop-
er hand-washing techniques, to reduce
Diagnostic tests the spread of VRE.
Laboratory ◆ Consider chlorhexidine baths,
◆ Culture and susceptibility testing which have shown reduction in skin
performed on stool samples or rectal contamination of patients with VRE.
swabs confirms VRE.
◆ Ensure judicious and careful use of

antibiotics. Encourage physicians to
limit the use of antibiotics.
◆ Monitor the patient’s response to
treatment, and watch for complica-
tions.
Patient teaching
◆ Be sure to cover:
ment (See Taking precautions at home,
page 261.)
– the importance of family and visi-
tors using personal protective equip-
ment when visiting the patient
– the importance of proper hand-
washing technique for the patient and
family members
– how to dispose of protective equip-
ment
– medication administration, dosage,
and possible adverse effects
– the importance of taking antibiotics
for the full prescription period, even if
the patient begins to feel better.
Common
6 procedures
Performing them safely and accurately
Arterial pressure monitoring 265

Automated external defibrillation 271
Bladder irrigation, continuous 273
Cardiac monitoring 275
Cardiac output measurement 280
Cardiopulmonary resuscitation, adult 282
Central venous access device insertion
and removal 286
Central venous pressure monitoring 291
Chest physiotherapy 297
Colostomy and ileostomy care 300
Colostomy irrigation 304
Defibrillation 307
Doppler use 310
Feeding tube insertion and removal 311
Gastric lavage 313
Gastrostomy feeding button care 317
Incentive spirometry 319
Latex allergy protocol 321
Lumbar puncture 324
Manual ventilation 327
Mechanical ventilation 329
263
264 Common procedures
Nasogastric tube insertion and removal 334

Obstructed airway, adult 339
Peripheral I.V. catheter insertion 340
Peripheral I.V. line maintenance 352
Peritoneal dialysis, continuous ambulatory 355
Pulse oximetry 359
Seizure management 361
Sequential compression therapy 364
Surgical site verification 367
Synchronized cardioversion 368
Temporary pacemaker insertion and care 370
Thoracic drainage 375
Tracheal suction 379
Transfusion of blood and blood products 384
Tube feedings 393
Venipuncture 398
drapes ◆ sterile towels ◆ prepared

Arterial pressure monitoring pressure transducer system ◆ ordered
local anesthetic ◆ sutures ◆ syringe
Direct monitoring of arterial pressure and 21G to 25G 1 needle ◆ tubing and
permits continuous measurement of medication labels ◆ site-care kit (con-
systolic, diastolic, and mean pressures taining sterile dressing, antimicrobial
and allows sampling of arterial blood. ointment, and hypoallergenic tape) ◆
Direct measurement, which reflects arm board and soft wrist restraint (for
systemic vascular resistance and blood a femoral site, an ankle restraint) ◆
flow, is generally more accurate than sterile marker and label ◆ optional:
indirect methods, which are based on electric clippers (for femoral artery
blood flow. insertion)
Direct monitoring is indicated when
highly accurate or frequent blood pres- For blood sample collection from an
sure measurements are required — for open system
example, in patients with low cardiac Sterile 4 4 gauze pads ◆ Vacutainer
output and high systemic vascular re- ◆ needleless Vacutainer luer-lock
sistance. It may be used for hospital- adapter needle ◆ appropriate blood
ized patients if obesity or edema make specimen collection tubes ◆ laboratory
indirect measurement difficult. It may requests, labels and transport bag
also be used for patients who are re-
ceiving titrated doses of vasoactive For blood sample collection from a
drugs or who need frequent blood closed system
sampling. Syringes with attached cannulae of ap-
Indirect monitoring, which carries propriate size and number for ordered
few associated risks, is commonly per- laboratory tests ◆ laboratory requests,
formed by applying pressure to an labels and transport bag ◆ alcohol
artery (such as by inflating a blood swabs ◆ blood transfer unit ◆ Vacu-
pressure cuff around the arm or using tainers
an automated noninvasive system) to
decrease blood flow. As pressure is re- For arterial line tubing changes
leased, flow resumes and can be pal- Sheet protector ◆ preassembled arterial
pated or auscultated. Korotkoff sounds pressure tubing with flush device and
presumably result from a combination disposable pressure transducer ◆ ster-
of blood flow and vibrations of the ile gloves ◆ 500-ml bag of I.V. flush so-
arterial wall; with reduced flow, these lution (usually normal saline solution)
vibrations may be less pronounced. ◆ 500 or 1,000 units of heparin ◆ sy-
ringe and 21G to 25G 1 needle ◆ I.V.
Equipment and preparation pole ◆ alcohol swabs ◆ medication
and tubing labels ◆ pressure bag ◆
Sheet protector ◆ gloves, gown, mask, site-care kit (containing a sterile
protective eyewear dressing)
For arterial catheter insertion For arterial catheter removal

Sterile gloves ◆ 20G catheter (type and Sterile 4 4 gauze pad ◆ sheet pro-
length depend on the insertion site, the tector ◆ sterile suture removal set ◆
patient’s size, and other anticipated dressing ◆ alcohol swabs ◆ hypoaller-
uses of the line) ◆ preassembled genic tape
preparation kit (if available) ◆ sterile
For femoral line removal thetizes the insertion site. He covers

Additional four sterile 4 4 gauze the surrounding area with either sterile
pads ◆ small sandbag (which you may drapes or sterile towels. The physician
wrap in a towel or place in a pillow- inserts the catheter into the artery us-
case) ◆ adhesive bandage ing sterile gloves and other protective
equipment. Then the fluid-filled pres-
For a catheter-tip culture sure tubing is attached.
Sterile 4 4 gauze pad ◆ sterile scis- ◆ While the physician holds the cath-
sors ◆ sterile container ◆ specimen eter in place, activate the fast-flush re-
label lease to flush blood from the catheter.
Before setting up and priming the After each fast-flush operation, observe
monitoring system, wash your hands the drip chamber to verify that the
thoroughly. Maintain asepsis by wear- continuous flush rate is as desired. A
ing personal protective equipment waveform should appear on the bed-
throughout preparation. Label all med- side monitor.
ications, medication containers, and ◆ The physician may suture the cath-
other solutions on and off the sterile eter in place, or you may secure it with
field. hypoallergenic tape. Apply antimicro-
After you’ve prepared the equip- bial ointment and cover the insertion
ment, set the alarms on the bedside site with a sterile dressing, as specified
monitor according to facility policy. by facility policy.
◆ Immobilize the insertion site. With
Implementation a radial or brachial site, use an arm
board and a soft wrist restraint (if re-
◆ Confirm the patient’s identity using quired by the patient’s condition).
two patient identifiers. With a femoral site, assess the need for
◆ Explain the procedure to the patient an ankle restraint. Keep the patient on
and his family, including the purpose bed rest, with the head of the bed
of arterial pressure monitoring and the raised no more than 15 to 30 degrees,
anticipated duration of catheter place- to prevent the catheter from kinking.
ment. Verify that a consent form has Level the zeroing stopcock of the pres-
been signed. sure transducer with the phlebostatic
◆ Check the patient’s history for an axis. Then zero the system to atmos-
allergy or a hypersensitivity to iodine, pheric pressure.
the ordered local anesthetic, or latex. ◆ Activate the monitor alarms as ap-
◆ Maintain asepsis by wearing person- propriate.
al protective equipment throughout all
of the procedures described here. Obtaining a blood sample from
◆ Position the patient for easy access an open system
to the catheter insertion site. Place a ◆ Assemble the equipment, taking
sheet protector under the site. care not to contaminate the nonvented
◆ If the catheter will be inserted into cap, stopcock, and syringes. Attach the
the radial artery, perform Allen’s test to needleless luer-lock adapter to the Va-
assess collateral circulation in the cutainer. Turn off or temporarily si-
hand. lence the monitor alarms, depending
on facility policy. (Some facilities re-
Inserting an arterial catheter quire that alarms be left on.)
◆ Using a preassembled preparation ◆ Locate the blood sampling port of
kit, the physician prepares and anes- the stopcock nearest the patient. Open
a sterile 4 4 gauze pad. Remove Obtaining a blood sample from

the nonvented cap from the stopcock, a closed system
and place it on the gauze pad. ◆ Assemble the equipment, maintain-
◆ Connect the needleless adapter of ing aseptic technique. Locate the
the Vacutainer into the sampling port of closed-system reservoir and the blood-
the stopcock and turn the stopcock off sampling site. Turn off or temporarily
to the flush solution. Attach a blood silence the monitor alarms, depending
specimen collection tube for the discard on facility policy. (Some facilities re-
sample into the stopcock. (This sample quire that alarms be left on.)
is discarded because it’s diluted with ◆ Holding the reservoir upright, grasp
flush solution.) Follow facility policy on the flexures and slowly fill the reser-
how much discard blood to collect. In voir with blood over 3 to 5 seconds.
most cases, you’ll withdraw 5 to 10 ml. (This blood is the discard blood.) If
◆ Remove the discard-specimen blood you feel resistance, reposition the af-
collection tube from the Vacutainer. fected extremity and check the catheter
◆ Next, attach each blood specimen site for obvious problems (such as
collection tube to the Vacutainer, keep- kinking). Then withdraw the blood.
ing the stopcock turned off to the flush ◆ Turn off the one-way valve to the
solution. Because the Vacutainer is a reservoir by turning the handle perpen-
nonvented system, there won’t be any dicular to the tubing. Clean the sam-
backflow of blood from the patient. pling site with an alcohol swab. Using a
◆ If the physician has ordered coagu- syringe with an attached cannula, in-
lation tests, obtain blood for this sam- sert the cannula into the sampling site.
ple from the final syringe to prevent di- (Make sure that the plunger is de-
lution from the flush device. pressed to the bottom of the syringe
◆ After you’ve obtained blood for the barrel.) Slowly fill the syringe. Then
final sample, turn the stopcock off to grasp the cannula near the sampling
the sampling port and activate the fast- site, and remove the syringe and can-
flush release to clear the tubing. Turn nula as one unit. Repeat the procedure
off the stopcock to the patient and as needed to fill the required number of
attach an empty blood specimen col- syringes. If the physician has ordered
lection tube, or place a sterile 4 4 coagulation tests, obtain blood for
gauze pad beneath the sampling port those tests from the final syringe to pre-
of the stopcock and activate the fast- vent dilution from the flush solution.
flush release to clear the stopcock port ◆ After you fill the syringes, turn the
of any remaining blood. one-way valve to its original position,
◆ Turn the stopcock off to the stop- parallel to the tubing. Smoothly and
cock port, and remove the Vacutainer. evenly, push down on the plunger until
Put a new sterile nonvented cap on the the flexures lock in place in the fully
blood sampling port. Reactivate the closed position and all fluid has been
monitor alarms. Label all blood speci- reinfused. The fluid should be reinfused
men collection tubes with correct la- over a 3- to 5-second period. Then acti-
bels and send all samples to the labo- vate the fast-flush release to clear blood
ratory in a laboratory transport bag from the tubing and the reservoir.
with the laboratory request. ◆ Clean the sampling site with an alco-
◆ Check the monitor for return of the hol swab. Reactivate the monitor
arterial waveform and the pressure alarms. Using the blood-transfer unit,
reading. (See Understanding the arteri- transfer blood samples to the appropri-
al waveform, page 268.) ate Vacutainers, labeling them according
Understanding the arterial waveform
Normal arterial blood pressure produces As blood continues to flow into the pe-
a characteristic waveform that represents ripheral vessels, arterial pressure falls and
ventricular systole and diastole. The the waveform begins a downward trend.
waveform has five distinct components: This part is called the dicrotic limb. Arterial
the anacrotic limb, systolic peak, dicrotic pressure usually continues to fall until pres-
limb, dicrotic notch, and end diastole. sure in the ventricle is less than pressure in
The anacrotic limb marks the initial up- the aortic root. When this occurs, the aortic
stroke of the waveform, which results as valve closes. This event appears as a small
blood is rapidly ejected from the ventricle notch (dicrotic notch) on the downside of
through the open aortic valve into the the waveform. When the aortic valve closes,
aorta. The rapid ejection causes a sharp diastole begins, and it progresses until the
rise in arterial pressure, which appears as aortic root pressure gradually descends to
the highest point of the waveform (called its lowest point. On the waveform, this
the systolic peak). point is known as end diastole.
Normal arterial waveform
Dicrotic
Systolic notch
Anacrotic peak
limb
End
Dicrotic
diastole
limb
to facility policy. Send all of the samples ting problems, use heparin with cau-
to the laboratory with the appropriate tion. The heparin should be drawn up
documentation. into the syringe with the needle at-
tached and injected into the flush solu-
Changing arterial line tubing tions after the port is swabbed with al-
◆ Wash your hands and follow stan- cohol. Prime the pressure tubing and
dard precautions. transducer system. Add medication and
◆ Consult facility policy to determine tubing labels. Apply 300 mm Hg of
the appropriate length of tubing to pressure to the system. Then hang the
change. I.V. bag on a pole.
◆ Inflate the pressure bag to 300 mm ◆ Place the sheet protector under the
Hg, and check it for air leaks. Then re- affected extremity. Remove the dressing
lease the pressure. from the catheter insertion site, taking
◆ Prepare the I.V. flush solution by care not to dislodge the catheter or
adding the heparin to the flush solu- cause vessel trauma. Turn off or tem-
tion as facility policy dictates and fol- porarily silence the monitor alarms, de-
lowing physicians’ orders. If your pa- pending on facility policy. (Some facili-
tient has a history of bleeding or clot- ties require that alarms be left on.)
◆ Turn off the flow clamp of the tubing utes (longer if bleeding or oozing per-
segment that you’ll change. Disconnect sists). Apply additional pressure if a
the tubing from the catheter hub, taking femoral site was used or if the patient
care not to dislodge the catheter. Imme- has coagulopathy or is receiving an an-
diately insert the primed pressure tub- ticoagulant. In some facilities, a com-
ing with the transducer system into the pression device may be used to apply
catheter hub. Secure the tubing, and ac- pressure to the femoral site.
tivate the fast-flush release to clear it. ◆ Cover the site with an appropriate
◆ Reactivate the monitor alarms. Ap- dressing, and secure it with hypoaller-
ply an appropriate sterile dressing ac- genic tape. If stipulated by facility poli-
cording to facility protocol. cy, make a pressure dressing by folding
◆ Level the zeroing stopcock of the in half four sterile 4 4 gauze pads,
transducer with the phlebostatic axis, and apply the dressing. Cover the
and zero the system to atmospheric dressing tightly with an adhesive ban-
pressure. dage. For a patient with a femoral site,
refer to your facility’s policy for main-
Removing an arterial line taining bed rest after the procedure.
◆ Consult facility policy to determine ◆ Avoid raising the head of the bed
whether you’re permitted to perform higher than 30 to 45 degrees, and avoid
this procedure. flexing the affected hip during this time.
◆ Explain the procedure to the patient. ◆ If the physician has ordered a culture
◆ Assemble all equipment. Wash your of the catheter tip to diagnose a sus-
hands. Observe standard precautions, pected infection, culture the tip by swip-
including wearing personal protective ing it across a solid growth medium
equipment. such as an agar plate. (Don’t cut the
◆ Record the patient’s systolic, dia- catheter tip and send it to the laboratory
stolic, and mean blood pressures. If a in a sterile container because that
manual, indirect blood pressure hasn’t method of organism isolation may be
been assessed recently, obtain one now unreliable.)
to establish a new baseline. Check the ◆ Observe the site for bleeding. As-
patient’s coagulation studies before re- sess circulation in the extremity distal
moving the catheter to determine if to the site by evaluating color, pulses,
you’ll need to apply pressure for a and sensation. Repeat this assessment
longer time to achieve hemostasis. every 15 minutes for the first 4 hours,
◆ Turn off the monitor alarms and the every 30 minutes for the next 2 hours,
flow clamp to the flush solution. and then hourly for the next 6 hours.
◆ Carefully remove the dressing over
the insertion site. Remove any sutures, Special considerations
using the sterile suture removal set,
and carefully check that all sutures ◆ Observing the pressure waveform on
have been removed. the monitor can enhance the assess-
◆ Withdraw the catheter with a gen- ment of arterial pressure. An abnormal
tle, steady motion. Keep the catheter waveform may reflect an arrhythmia
parallel to the artery during withdrawal (such as atrial fibrillation) or other car-
to reduce the risk of traumatic injury. diovascular problems, such as aortic
◆ Immediately after you withdraw the stenosis, aortic insufficiency, alternating
catheter, apply pressure to the site with pulse, or paradoxical pulse. (See Recog-
a sterile 4 4 gauze pad. Maintain nizing abnormal arterial waveforms,
constant pressure for at least 15 min- page 270.)
Recognizing abnormal arterial waveforms
Understanding a normal arterial waveform is relatively straightforward. An abnormal

waveform, however, is more difficult to decipher. Abnormal patterns and markings may
provide important diagnostic clues to the patient’s cardiovascular status, or they may
simply signal trouble in the monitor. Use this chart to help you recognize and resolve
waveform abnormalities.
ABNORMALITY POSSIBLE NURSING INTERVENTIONS

CAUSES
Alternating high and low Ventricular ◆ Check the electrocardiogram to con-

waves in a regular pattern bigeminy firm ventricular bigeminy. The tracing
should reflect premature ventricular con-
tractions every second beat.
Cardiac ◆ Assess the patient for signs of tam-
tamponade ponade.
Flattened waveform Overdamped ◆ Check the blood pressure with a

waveform or a sphygmomanometer. If the reading is
patient with high, suspect overdamping. Correct the
hypotension problem by trying to aspirate the arterial
line. If you succeed, flush the line. If the
reading is very low or absent, suspect hy-
potension.
Slightly rounded waveform Patient on ◆ Check the systolic blood pressure reg-
with consistent variations ventilator with ularly. The difference between the highest
in systolic height positive end- systolic pressure and the lowest systolic
expiratory pressure should be less than 10 mm Hg.
pressure If the difference exceeds that amount,
suspect paradoxical pulse, possibly from
cardiac tamponade.
Slow upstroke Aortic stenosis ◆ Check the heart sounds for signs of
aortic stenosis. Also, notify the physician,
who will document suspected aortic
stenosis.
Diminished amplitude on Paradoxical ◆ Note the systolic pressure during in-

inspiration pulse, possibly spiration and expiration. If the inspiratory
from cardiac pressure is at least 10 mm Hg less than
tamponade, the expiratory pressure, call the physi-
constrictive cian.
pericarditis, or ◆ If you’re also monitoring pulmonary
lung disease artery pressure, watch for a diastolic
plateau. This occurs when the mean cen-
tral venous pressure (right atrial pres-
sure), mean pulmonary artery pressure,
and mean pulmonary artery wedge pres-
sure (pulmonary artery obstructive pres-
sure) are within 5 mm Hg of one another.
Automated external defibrillation 271
◆ Following facility policy regarding need for early defibrillation, which is

frequency, change the pressure tubing considered the most effective treatment
(usually every 2 to 3 days) and change for ventricular fibrillation. Some facili-
the dressing at the catheter site. Regu- ties require an AED in every noncritical
larly assess the site for signs of infec- care unit. Their use is also common in
tion, such as redness and swelling, and such public places as shopping malls,
notify the physician immediately if you sports stadiums, and airplanes. Instruc-
find any. tion in using an AED is required as
◆ Erroneous pressure readings may be part of basic life support (BLS) and ad-
caused by a catheter that’s clotted or vanced cardiac life support (ACLS)
positional or by loose connections, training.
added stopcocks or extension tubing, The 2005 American Heart Associa-
inadvertent entry of air into the system, tion guidelines for cardiopulmonary re-
or improper calibration, leveling, or ze- suscitation (CPR) and emergency car-
roing of the monitoring system. If the diovascular care recommend the inte-
catheter lumen clots, the flush system gration of CPR with the use of an AED.
may be improperly pressurized. Regu- Age alert AEDs can be used
larly assess the amount of flush solu- in children ages 1 to 8. For this
tion in the I.V. bag, and maintain 300 age-group, an AED with a pediatric
mm Hg of pressure in the pressure bag. dose attenuator system should be
◆ Monitor the patient for complica- used, if available.
tions, such as arterial bleeding, infec- AEDs are used increasingly to pro-
tion, air embolism, arterial spasm, and vide early defibrillation, even when no
thrombosis. health care provider is present. The
AED interprets the victim’s cardiac
Documentation rhythm and gives the operator step-by-
step directions on how to proceed if
Document the date of system setup. defibrillation is indicated. Most AEDs
Document the systolic, diastolic, and have a “quick look” feature that allows
mean pressure readings as well. Record you to see the rhythm with the paddles
circulation in the extremity distal to the before the electrodes are connected.
site by assessing color, pulses, and sen- The AED is equipped with a micro-
sation. Carefully document the amount computer that senses and analyzes a
of flush solution infused to ensure accu- patient’s heart rhythm at the push of a
rate assessment of the patient’s fluid button. Then it audibly or visually
status. Document the date and time the prompts you to deliver a shock. All
catheter was removed, how long pres- models have the same basic function,
sure was held, the condition of the site, but they operate differently. For exam-
and any complications that occurred. ple, all AEDs communicate directions
Document the patient’s position through messages shown on a display
when obtaining blood pressure read- screen, by voice commands, or both.
ings to help determine trends. Some AEDs display a patient’s heart
rhythm simultaneously.
All devices record your interactions
Automated external with the patient during defibrillation,
defibrillation either on a cassette tape or in a solid-
state memory module. Some AEDs
Automated external defibrillators have an integral printer that allows im-
(AEDs) are commonly used to meet the mediate documentation of the event.
Facility policy determines who’s re- everyone to stand clear, and press the
sponsible for reviewing all AED inter- ANALYZE button when you are prompt-
actions; the patient’s physician always ed by the machine. Be careful not to
has that option. Local and state regula- touch or move the patient while the
tions govern who’s responsible for col- AED is in analysis mode. (If you get
lecting AED case data for reporting the message “Check electrodes,” make
purposes. sure that the electrodes are correctly
placed and that the patient cable is se-
Equipment curely attached; then press the ANALYZE
button again.)
AED ◆ two prepackaged electrodes ◆ ◆ In 15 to 30 seconds, the AED will
electrode connector cables analyze the patient’s rhythm. When
the patient needs a shock, the AED
Implementation will display a “Stand clear” message
and emit a beep that changes into a
◆ After you discover that your patient steady tone as it’s charging.
is unresponsive to your questions, ◆ When an AED is fully charged and
pulseless, and apneic, follow BLS and ready to deliver a shock, it prompts
ACLS protocols. Ask a colleague to you to press the SHOCK button. (Some
bring the AED into the patient’s room fully automatic AED models automati-
and set it up before the code team ar- cally deliver a shock within 15 seconds
rives. after analyzing the patient’s rhythm. If
◆ Firmly press the ON button, and a shock isn’t needed, the AED displays
wait while the machine performs a a “No shock indicated” message and
brief self-test. Most AEDs indicate their prompts you to “Check patient.”)
readiness by sounding a computerized ◆ Make sure that no one is touching
voice that says “Stand clear” or by the patient or his bed, and call out
emitting a series of loud beeps. (If the “Stand clear.” Then press the SHOCK
AED isn’t functioning properly, it con- button on the AED. Most AEDs are
veys the message “Don’t use the AED. ready to deliver a shock within 15 sec-
Remove and continue cardiopulmonary onds.
resuscitation [CPR].”) Remember to re- ◆ After the first shock, continue CPR,
port any AED malfunctions according beginning with five cycles of chest
to facility procedure. compression for about 2 minutes. Don’t
◆ Open the foil packets that contain delay compressions to recheck rhythm
the two electrode pads. Attach the elec- or pulse. After five cycles of CPR, the
trode cable to the AED. AED should analyze the rhythm and
◆ Expose the patient’s chest. Remove deliver another shock, if indicated.
the plastic backing film from the elec- ◆ If a nonshockable rhythm is detect-
trode pads, and place one electrode pad ed, the AED should instruct you to
on the right upper portion of the pa- resume CPR. Then continue the algo-
tient’s chest, just beneath his clavicle. rithm sequence until the code team
◆ Place the second pad to the left of leader arrives.
the apex of the heart. (Placement for
the electrode pads is the same for both Special considerations
manual defibrillation and cardiover-
sion.) ◆ AEDs vary from one manufacturer
◆ Now the machine is ready to ana- to another, so familiarize yourself with
lyze the patient’s heart rhythm. Ask the equipment at your facility.
Bladder irrigation, continuous 273
◆ The operation of the AED should be Equipment and preparation

checked according to your facility’s
policy. One 4,000-ml container or two 2,000-
◆ Defibrillation can cause accidental ml containers of sterile irrigating solu-
electric shock to those providing care. tion (usually normal saline solution) or
the prescribed amount of medicated
Documentation solution ◆ Y-type tubing made specifi-
cally for bladder irrigation ◆ alcohol or
After the code, remove and transcribe antiseptic pad ◆ I.V. pole or bedside
the computer memory module or tape, pole attachment ◆ drainage bag and
or prompt the AED to print a rhythm tubing
strip with the code data. Follow facility Normal saline solution is usually
policy for analyzing and storing the prescribed for bladder irrigation after
code data. Document the code on the prostate or bladder surgery. Large vol-
appropriate form, including such infor- umes of irrigating solution are usually
mation as the patient’s name, age, required during the first 24 to 48 hours
medical history, and reason for seeking after surgery. Y-type tubing is used be-
care; the time that you found the pa- cause it allows immediate irrigation
tient in arrest; the time that CPR be- with reserve solution.
gan; the time that the AED was ap- Before you start continuous bladder
plied; the number of shocks that the irrigation, double-check the irrigating
patient received; the time that the solution against the physician’s order.
pulse was regained; the postarrest care If the solution contains an antibiotic,
that was given; and the findings of check the patient’s chart to make sure
physical assessment. that he isn’t allergic to the drug. Unless
specified otherwise, the patient should
remain on bed rest while receiving
Bladder irrigation, continuous continuous bladder irrigation.
Continuous bladder irrigation can help Implementation

to prevent obstruction of the urinary
tract by flushing out small blood clots ◆ Confirm the patient’s identity using
that form after prostate or bladder two patient identifiers.
surgery. It may also be used to treat an ◆ Wash your hands. Assemble all
irritated, inflamed, or infected bladder equipment at the patient’s bedside.
lining. Explain the procedure and provide
This procedure requires placement privacy.
of a triple-lumen catheter. One lumen ◆ Insert the spike of the Y-type tubing
controls balloon inflation, one allows into the container of irrigating solution.
irrigant inflow, and one allows irrigant (If you have a two-container system,
outflow. The continuous flow of irrigat- insert one spike into each container.)
ing solution through the bladder also (See Setup for continuous bladder irri-
creates a mild tamponade that may gation, page 274.)
help to prevent venous hemorrhage. ◆ Squeeze the drip chamber on the
Although a catheter is typically insert- spike of the tubing.
ed while the patient is in the operating ◆ Open the flow clamp and flush the
room after prostate or bladder surgery, tubing to remove air, which could
a catheter may be inserted at the bed- cause bladder distention. Then close
side in nonsurgical patients. the clamp.
Setup for continuous bladder irrigation
During continuous bladder irrigation, a triple-lumen catheter allows irrigating solution

to flow into the bladder through one lumen and to flow out through another, as shown
in the inset. The third lumen is used to inflate the balloon that holds the catheter in
place.
Cross section of Irrigating solution

a catheter
Drip chamber
Clamp
Irrigation tubing
Indwelling catheter
Irrigation
channel
Drainage
channel
Drainage tubing
Channel to
retention Urine drainage bag
balloon
◆ To begin, hang the irrigating solu- under the nearly empty container and
tion on the I.V. pole. open the flow clamp under the reserve
◆ Clean the opening to the inflow lu- container. This prevents reflux of irri-
men of the catheter with the alcohol or gating solution from the reserve con-
antiseptic pad. tainer into the nearly empty one. Hang
◆ Insert the distal end of the Y-type a new reserve container on the I.V.
tubing securely into the inflow lumen pole and insert the tubing, maintaining
(third port) of the catheter. asepsis.
◆ Make sure that the outflow lumen is ◆ Empty the drainage bag about every
securely attached to the tubing of the 4 hours or as often as needed. Use
drainage bag. sterile technique to avoid the risk of
◆ Open the flow clamp under the con- contamination.
tainer of irrigating solution, and set the ◆ Monitor the patient’s vital signs at
drip rate as ordered. least every 4 hours during irrigation,
◆ To prevent air from entering the sys- increasing the frequency if the patient’s
tem, replace the primary container be- condition becomes unstable.
fore it empties completely. ◆ Monitor urine output at least hourly
◆ If you have a two-container system, for the first 4 hours. Check for bladder
simultaneously close the flow clamp distention or abdominal pain.
Special considerations
Cardiac monitoring
◆ Check the inflow and outflow lines
periodically for kinks to make sure that Because it allows continuous observa-
the solution is running freely. If the so- tion of the electrical activity of the
lution flows rapidly, check the lines heart, cardiac monitoring is used for
frequently. patients who have conduction distur-
◆ Measure the outflow volume accu- bances and for those who are at risk
rately. It should, allowing for urine for life-threatening arrhythmias. Like
production, exceed inflow volume. If other forms of electrocardiography
the inflow volume exceeds the outflow (ECG), cardiac monitoring uses elec-
volume postoperatively, suspect blad- trodes that are placed on the patient’s
der rupture at the suture lines or renal chest to transmit electrical signals that
damage, and notify the physician im- are converted into a tracing of cardiac
mediately. rhythm on an oscilloscope.
◆ Assess outflow for changes in ap- Two types of monitoring may be
pearance and for blood clots, especially performed: hardwire or telemetry. With
if irrigation is being performed postop- hardwire monitoring, the patient is
eratively to control bleeding. If the connected to a monitor at his bedside,
drainage is bright red, irrigating solu- where the rhythm display appears; it
tion is usually infused rapidly, with the may also be transmitted to a console at
clamp wide open, until the drainage a remote location. With telemetry mon-
clears. Notify the physician at once if itoring, the patient is connected to a
you suspect hemorrhage. If the drain- small transmitter that sends electrical
age is clear, the solution is usually giv- signals to a monitor in another loca-
en at a rate of 40 to 60 drops/minute. tion. Battery-powered and portable,
The physician typically specifies the telemetry frees the patient from cum-
rate for antibiotic solutions. bersome wires and cables. In addition
◆ Encourage oral fluid intake of 2 to to being able to walk around, the pa-
3 qt/day (2 to 3 L/day), unless con- tient is safely isolated from the electri-
traindicated. cal leakage and accidental shock occa-
◆ Watch for interruptions in the con- sionally associated with hardwire mon-
tinuous irrigation system; these can itoring. Telemetry is especially useful
predispose the patient to infection. for monitoring arrhythmias that occur
◆ Check frequently for obstruction in during sleep, rest, exercise, or stressful
the outflow lumen of the catheter. situations. However, unlike hardwire
Obstruction can lead to bladder dis- monitoring, telemetry can monitor only
tention. cardiac rate and rhythm.
Regardless of the type of monitor
Documentation used, cardiac monitors can display the
patient’s heart rate and rhythm, pro-
Each time you finish a container of so- duce a printed record of the cardiac
lution, record the date, the time, and rhythm, and sound an alarm if the
the amount of fluid given on the intake heart rate exceeds or falls below speci-
and output record. Also, record the fied limits. Monitors also recognize and
time and the amount of fluid each time count abnormal heartbeats as well as
you empty the drainage bag. Note the changes. For example, a relatively new
appearance of the drainage as well as technique, ST-segment monitoring,
any complaints that the patient reports. helps to detect myocardial ischemia,
electrolyte imbalance, coronary artery carefully that each leadwire is in its

spasm, and hypoxic events. The ST seg- correct outlet.
ment represents early ventricular repo- For telemetry monitoring, insert a
larization, and changes in this wave- new battery into the transmitter. Make
form component reflect alterations in sure that the poles on the battery
myocardial oxygenation. Any monitor- match the polar markings on the trans-
ing lead that views an ischemic heart mitter case. Some units have a battery
region will show ST-segment changes. test feature. If this feature is available,
The software establishes a template of test the unit to check that the battery is
the patient’s normal QRST pattern from operational. If the leadwires aren’t per-
the selected leads. Then the monitor manently affixed to the telemetry unit,
displays ST-segment changes. Some attach them securely. If they must be
monitors display these changes contin- attached individually, make sure that
uously, and others show them only on you connect each one to the correct
command. outlet.
Equipment and preparation Implementation
For hardwire monitoring Hardwire monitoring

Cardiac monitor ◆ leadwires ◆ patient ◆ Confirm the patient’s identity using
cable ◆ disposable pregelled electrodes two patient identifiers.
(3–5 electrodes, depending on the pa- ◆ Explain the procedure to the pa-
tient’s needs) ◆ alcohol pad ◆ 4 4 tient, provide privacy, and ask him to
gauze pads ◆ optional: clippers and expose his chest. Wash your hands.
washcloth ◆ Determine the positions of the elec-
trodes on the patient’s chest, based on
For telemetry monitoring which system and lead you’re using.
Transmitter ◆ pouch for transmitter ◆ (See Positioning monitoring leads.)
telemetry battery pack, leadwires, and ◆ If the leadwires and patient cable
disposable pregelled electrodes aren’t permanently attached, verify
For hardwire monitoring, plug the that the electrode placement corre-
cardiac monitor into an electrical outlet sponds to the label on the patient ca-
and turn it on to warm up the unit ble.
while you prepare the equipment and ◆ If necessary, clip an area about 4
the patient. Insert the cable into the (10 cm) in diameter around each elec-
appropriate socket in the monitor. Con- trode site. Clean the area with an alco-
nect the leadwires to the cable. In most hol pad, and dry it completely to re-
systems, the leadwires are permanently move skin secretions that may interfere
secured to the cable. Each leadwire with electrode function. Gently abrade
should indicate the location for attach- the dried area by rubbing it briskly un-
ment to the patient: right arm (RA), til it reddens to remove dead skin cells
left arm (LA), right leg (RL), left leg and to promote better electrical contact
(LL), and ground (C or V). This desig- with living cells. (Some electrodes have
nation should appear on the lead- a small, rough patch for abrading the
wire — if it’s permanently connected — skin; otherwise, use a dry washcloth or
or at the connection of the leadwires a dry gauze pad.)
and cable to the patient. Connect an ◆ Remove the backing from the dis-
electrode to each leadwire, checking posable pregelled electrode. Check the
Positioning monitoring leads
These illustrations show the correct elec- the lead you want. In some cases, you’ll
trode positions for the monitoring leads need to reposition the electrodes.
you’ll use most often. For each lead, you’ll In the telemetry system, you can create
see electrode placement for a five-lead- the same lead with two electrodes that
wire system, a three-leadwire system, and you do with three, simply by eliminating
a telemetry system. the ground electrode.
In the two-hardwire systems, the elec- The illustrations below use these ab-
trode positions for one lead may be iden- breviations: RA, right arm; LA, left arm;
tical to those for another lead. In this RL, right leg; LL, left leg; C, chest; and G,
case, you simply change the lead selector ground.
switch to the setting that corresponds to
FIVE-LEADWIRE THREE-LEADWIRE TELEMETRY

SYSTEM SYSTEM SYSTEM
Lead I
RA LA RA LA
LL LL
RL G
Lead II
RA LA RA LA
LL LL
RL G
Lead III
RA LA RA LA
LL LL
RL G
(continued)
Positioning monitoring leads (continued)
FIVE-LEADWIRE THREE-LEADWIRE TELEMETRY

SYSTEM SYSTEM SYSTEM
Lead MCL1
RA LA RA LA G
C LL

LL
RL
Lead MCL6
RA LA LA G
RA
C LL
LL
RL
Sternal lead
RA LA RA
C LA G
LL LL
RL
Lewis lead
G
RA LA RA LA
C LL
LL
RL
gel for moistness. If the gel is dry, dis- that the pouch fits snugly but comfort-
card it and replace it with a fresh elec- ably. If no pouch is available, place the
trode. transmitter in the patient’s bathrobe
◆ Apply the electrode to the site and pocket.
press firmly to ensure a tight seal. Re- ◆ Check the patient’s waveform for
peat with the remaining electrodes. clarity, position, and size. Adjust the
◆ When all of the electrodes are in gain and baseline as needed. (If neces-
place, check for a tracing on the car- sary, ask the patient to remain resting
diac monitor. Assess the quality of the or sitting in his room while you locate
ECG. his telemetry monitor at the central
◆ To verify that the monitor is detect- station.)
ing each beat, compare the digital ◆ To obtain a rhythm strip, press the
heart rate display with your count of RECORD key at the central station. Label
the patient’s heart rate. the strip with the patient’s name and
◆ If necessary, use the gain control to room number, the date, and the time.
adjust the size of the rhythm tracing. Also, identify the rhythm. Place the
Use the position control to adjust the rhythm strip in the appropriate location
position of the waveform on the in the patient’s chart.
recording paper.
◆ Set the upper and lower limits of Special considerations
the heart rate alarm, based on facility
policy. Turn the alarm on. ◆ Make sure that all electrical equip-
ment and outlets are grounded to avoid
Telemetry monitoring electric shock and interference (arti-
◆ Confirm the patient’s identity using facts). Ensure that the patient is clean
two patient identifiers. and dry to prevent electric shock.
◆ Wash your hands. Explain the pro- ◆ Avoid opening the electrode pack-
cedure to the patient and provide pri- ages until just before using them, to
vacy. prevent the gel from drying out.
◆ Expose the patient’s chest, and se- ◆ Avoid placing the electrodes on
lect the lead arrangement. Remove the bony prominences, hairy locations, ar-
backing from one of the disposable eas where defibrillator pads will be
pregelled electrodes. Check the gel for placed, or areas where the chest will
moistness. If it’s dry, discard the elec- be compressed.
trode and obtain a new one. ◆ If the patient’s skin is very oily,
◆ Apply the electrode to the appropri- scaly, or diaphoretic, rub the electrode
ate site by pressing one side of the site with a dry 4 4 gauze pad be-
electrode against the patient’s skin, fore applying the electrode to help re-
pulling gently, and then pressing the duce interference in the tracing. In-
other side against the skin. Press your struct the patient to breathe normally
fingers in a circular motion around the during the procedure. If his respirations
electrode to fix the gel and stabilize the distort the recording, ask him to hold
electrode. Repeat this procedure for his breath briefly to reduce baseline
each electrode. wander in the tracing.
◆ Attach an electrode to the end of ◆ Assess the integrity of the patient’s
each leadwire. skin, and reposition the electrodes
◆ Place the transmitter in the pouch. every 24 hours or as needed.
Tie the pouch strings around the pa-
tient’s neck and waist, making sure
Patient teaching tips If the right ventricle into the pulmonary artery.
patient is being monitored by A thermistor on the catheter registers
telemetry, show him how the transmit- the change in the temperature of the
ter works. If applicable, show him the flowing blood. A computer plots the
button that can produce a recording of temperature change over time as a
his ECG at the central station. Teach curve and calculates the flow based on
him how to push the button whenever the area under the curve.
he has symptoms. Explain that push- Iced or room-temperature injectant
ing the button causes the central con- may be used. The choice is based on
sole to print a rhythm strip. Tell the facility policy as well as the patient’s
patient to remove the transmitter if he status. The accuracy of the bolus ther-
takes a shower or bath, but explain modilution technique depends on the
that he should let you know before he ability of the computer to differentiate
removes the unit. the temperature change that the injec-
tant causes in the pulmonary artery as
Documentation well as the temperature changes in the
artery. Because it’s colder than room-
Record in your nurses’ notes the date temperature injectant, iced injectant
and time that monitoring begins and provides a stronger signal and thus is
the monitoring lead used. Document a more easily detected.
rhythm strip at least every 8 hours and Typically, however, room-tempera-
if any changes occur in the patient’s ture injectant is more convenient to
condition (or as stated by facility poli- use and provides equally accurate mea-
cy). Label the rhythm strip with the surements. Iced injectant may be more
patient’s name and room number, the accurate for patients with high or low
date, and the time. CO, hypothermic patients, or patients
with volume restrictions.
Cardiac output measurement Equipment and preparation
Cardiac output (CO) — the amount of For the thermodilution method

blood ejected by the heart in 1 min- Thermodilution PA catheter in position
ute — helps to evaluate cardiac func- ◆ CO computer, temperature injectate
tion. The most widely used method of probe, and cable (or a module for the
calculating this measurement is the bo- bedside cardiac monitor) ◆ closed or
lus thermodilution technique. Per- open injectant delivery system ◆ 10-ml
formed at the patient’s bedside, the syringe ◆ 500-ml bag of I.V. solution
thermodilution technique is the most (dextrose 5% in water or normal saline
practical method of evaluating the car- solution) ◆ crushed ice and water and
diac status of critically ill patients and Styrofoam container (if iced injectant is
those suspected of having cardiac dis- used)
ease. Other methods include the Fick Newer bedside cardiac monitors
method and the dye dilution test. measure CO continuously, either inva-
To measure CO, a quantity of solu- sively or noninvasively. If your bedside
tion that’s colder than the patient’s monitor doesn’t have this capability,
blood is injected into the right atrium you’ll need a freestanding CO computer.
via a port on a pulmonary artery (PA) Wash your hands thoroughly, and
catheter. This indicator solution mixes assemble the equipment at the pa-
with the blood as it travels through the tient’s bedside. Insert the closed
Cardiac output measurement 281
injectant system tubing into the 500-ml not more than 20 degrees. Tell him not
bag of I.V. solution. Connect the 10-ml to move during the procedure.
syringe to the system tubing, and prime ◆ Explain to the patient that the pro-
the tubing with I.V. solution until all of cedure will cause him no discomfort.
the air is out. Then clamp the tubing.
The steps that follow differ, depending For room-temperature injectant
on the temperature of the injectant. in a closed-delivery system
◆ Verify the presence of a PA wave-
For room-temperature injectant in a form on the cardiac monitor.
closed-delivery system ◆ Unclamp the I.V. tubing, and with-
After you clamp the tubing, connect draw exactly 10 ml of solution. Re-
the primed system to the stopcock of clamp the tubing.
the proximal injectant lumen of the ◆ Turn the stopcock at the catheter in-
thermodilution PA catheter. Next, con- jectant hub to open a fluid path be-
nect the temperature probe from the tween the injectant lumen of the ther-
CO computer to the flow-through hous- modilution PA catheter and the syringe.
ing device. Connect the CO computer ◆ Press the START button on the CO
cable to the thermistor connector on computer, or wait for an INJECT mes-
the PA catheter, and verify the blood sage to flash.
temperature reading. Finally, turn on ◆ Inject the solution smoothly within
the CO computer and enter the correct 4 seconds, making sure that it doesn’t
computation constant, as provided by leak at the connectors.
the catheter manufacturer. The con- ◆ If available, analyze the contour of
stant is determined by the volume and the thermodilution washout curve on a
temperature of the injectant as well as strip chart recorder. It should show a
the size and type of catheter. rapid upstroke and a gradual, smooth
Age alert For children, you’ll return to the baseline.
need to adjust the computation ◆ Repeat these steps until three values
constant to reflect a smaller volume are within 10% to 15% of the median
and a smaller catheter size. value. Compute the average, and
record the patient’s CO.
For iced injectant in a ◆ Return the stopcock to its original
closed-delivery system position, and make sure that the injec-
After you clamp the tubing, place the tant delivery system tubing is clamped.
coiled segment into the Styrofoam con- ◆ Verify the presence of a PA wave-
tainer, and add crushed ice and water form on the cardiac monitor.
to cover the entire coil. Let the solution ◆ Discontinue CO measurements
cool for 15 to 20 minutes. The rest of when the patient’s condition is hemo-
the steps are the same as those for dynamically stable and the patient has
room-temperature injectant in a closed- been weaned from his vasoactive and
delivery system. inotropic medications. You can leave
the PA catheter in place for pressure
Implementation measurements.
◆ Disconnect and discard the injectant
◆ Confirm the patient’s identity using delivery system and the I.V. bag. Cover
two patient identifiers. exposed stopcocks with air-occlusive
◆ Place the patient in a supine posi- caps.
tion, with the head of the bed elevated ◆ Monitor the patient for signs and
symptoms of inadequate perfusion,
including restlessness, fatigue, changes tient’s CO is better assessed by calcu-

in the level of consciousness, decreased lating his cardiac index (CI), adjusted
capillary refill time, diminished periph- for his body size.
eral pulses, oliguria, and pale, cool skin. ◆ To calculate the patient’s CI, divide
his CO by his body surface area (BSA),
For iced injectant in a which is a function of height and
closed-delivery system weight. For example, a CO of 4 L/min-
◆ Unclamp the I.V. tubing and with- ute might be adequate for a 55,
draw 5 ml of solution into the syringe. 120-lb (1.65-m, 54.4-kg) patient (nor-
Age alert With children, with- mally a BSA of 1.59 and a CI of 2.5),
draw 3 ml or less. but would be inadequate for a 62,
◆ Inject the solution to flow past the 230-lb (1.88-m, 104.3-kg) patient (nor-
temperature sensor while you observe mally a BSA of 2.26 and a CI of 1.8).
the injectant temperature that registers The normal CI for adults ranges from
on the computer. Verify that the injec- 2.5 to 4.2 L/minute/m2; for pregnant
tant temperature is between 43° and women, it is 3.5 to 6.5 L/minute/m2.
54° F (6.1° and 12.2° C). Age alert The normal CI for
◆ Verify the presence of a PA wave- infants and children is 3.5 to
form on the cardiac monitor. 4 L/minute/m2; for elderly adults, it’s
◆ Withdraw exactly 10 ml of cooled 2 to 2.5 L/minute/m2.
solution before you reclamp the tubing. ◆ Add the fluid volume injected for
◆ Turn the stopcock at the catheter in- CO determinations to the patient’s total
jectant hub to open a fluid path be- intake. Injectant delivery of 30 ml/hour
tween the injectant lumen of the PA will contribute 720 ml to the patient’s
catheter and the syringe. 24-hour intake.
◆ Press the START button on the CO ◆ After CO is measured, make sure
computer, or wait for the INJECT mes- that the clamp on the injectant bag is
sage to flash. secured to prevent inadvertent delivery
◆ Inject the solution smoothly within of the injectant to the patient.
4 seconds, making sure that it doesn’t
leak at the connectors. Documentation
◆ If available, analyze the contour of
the thermodilution washout curve. It Document your patient’s CO, CI, and
should show a rapid upstroke and a other hemodynamic values and vital
gradual, smooth return to the baseline. signs at the time of measurement. Note
◆ Wait 1 minute between injections, the patient’s position during measure-
and repeat the procedure until three ment as well as any other unusual oc-
values are within 10% to 15% of the currences, such as bradycardia or neu-
median value. Compute the average, rologic changes.
and record the patient’s CO.
◆ Return the stopcock to its original
position, and make sure that the injec- Cardiopulmonary
tant delivery system tubing is clamped. resuscitation, adult
◆ Verify the presence of a PA wave-
form on the cardiac monitor. Cardiopulmonary resuscitation (CPR)
aims to restore and maintain the
Special considerations patient’s respirations and circulation
after his heartbeat and breathing have
◆ The normal range for CO is 4 to stopped. A basic life support procedure
8 L/minute. The adequacy of a pa-
performed on patients in cardiac arrest, ◆ Call out for help, send someone to
CPR should be performed according to activate EMS, or call a code as appro-
the 2005 American Heart Association priate. Get the automated external de-
(AHA) guidelines. fibrillator (AED). If no one is available,
Most adults in sudden cardiac arrest activate EMS or call a code yourself,
develop ventricular fibrillation and re- get the AED, and return to the patient.
quire defibrillation, and CPR alone ◆ Put the patient in the supine posi-
doesn’t improve survival rates. Howev- tion on a hard, flat surface. When
er, early activation of emergency med- moving him, roll his head and torso as
ical services (EMS), CPR, and defibril- a unit. Avoid twisting or pulling his
lation as well as early advanced car- neck, shoulders, or hips.
diac life support (ACLS) all contribute ◆ Kneel near the patient’s shoulders to
to an improved survival rate. gain easy access to his head and chest.
Basic CPR consists of assessing the
patient, calling for help, and then fol- Open the airway: head-tilt, chin-lift
lowing the ABC protocol: open the air- maneuver
way, restore breathing, and restore cir-
culation. After the patient’s airway has ◆ If the patient doesn’t appear to have
been opened and his breathing and cir- a neck injury, use the head-tilt, chin-lift
culation restored, defibrillation, drug maneuver to open his airway. To do
therapy, and diagnosis by electrocardio- this, place one hand on his forehead
gram may follow. If possible, find out if and apply pressure to tilt his head
the patient has a Do Not Resuscitate or- back. Be aware that, frequently, the
der before beginning CPR. muscles controlling the patient’s
tongue will be relaxed, causing the
Equipment tongue to obstruct the airway; this ma-
neuver opens the airway.
◆ A hard surface on which to place ◆ Place the fingertips of your other
the patient ◆ optional: protective hand under the bony part of his lower
equipment such as a disposable airway jaw near his chin. Lift his chin while
device keeping his mouth partially open.
Don’t place your fingertips on the soft
Implementation tissue under his chin because this
maneuver may obstruct the airway.
◆ Follow these step-by-step CPR
guidelines as currently recommended Open the airway: jaw-thrust
by the AHA. maneuver
One-person rescue ◆ If you suspect a neck injury, use the

◆ Assess the patient to determine if jaw-thrust maneuver instead of the
he’s unconscious. To ensure you don’t head-tilt, chin-lift maneuver.
start CPR on a person who’s conscious, ◆ Kneel at the patient’s head with
shake his shoulders and shout, “Are your elbows on the ground.
you okay?” If there’s no response, ◆ Rest your thumbs on the patient’s
check whether the patient has an in- lower jaw near the corners of the
jury, particularly to the head or neck. mouth, pointing your thumbs toward
Alert If you suspect a head or his feet. Place your fingertips around
neck injury, move the patient the lower jaw.
as little as possible to reduce the risk
of paralysis.
◆ To open the airway, lift the lower Instead, do rescue breathing, giving
jaw with your fingertips. 10 to 12 breaths (one for every 5 to 6
seconds). After 2 minutes, recheck
Check for breathing the pulse. You should give each
breath over 1 second, and the breath
◆ While maintaining the open airway, should cause the chest to rise visibly.
place your ear over the patient’s mouth After 2 minutes, recheck the patient’s
and nose. Listen for air moving, and note pulse, but spend no more than 10 sec-
whether his chest rises and falls. You onds doing so.
may also feel for airflow on your cheek. ◆ If the patient has no pulse, start giv-
◆ If the patient starts to breathe, keep ing chest compressions. Make sure that
the airway open and continue checking the patient is lying on a hard surface
breathing until help arrives. and that your knees are far enough
◆ If he doesn’t start breathing within apart to provide you with a wide base
10 seconds after you open his airway, of support.
begin rescue breathing. Pinch his nos- ◆ Put the heel of one hand on the
trils shut using the hand you had on center of the patient’s chest at the nip-
his forehead. ple line. Place the other hand directly
◆ Take a regular (not deep) breath on top of the first hand, making sure
and place your mouth over his, creat- your fingers aren’t on his chest. This
ing a tight seal. position will keep the compression
◆ Give 2 full breaths that have force on the sternum and reduce the
enough volume to produce a visible risk of rib fracture, lung puncture, or
chest rise. Each ventilation should last liver laceration.
over 1 second. ◆ With elbows locked, arms straight,
◆ If your first attempt at ventilation and shoulders directly over your
isn’t successful, reposition the patient’s hands, you’re ready to give chest com-
head and try again. If you still aren’t pressions. Compress the sternum 11⁄2
successful, the patient may have a for- to 2 (3.8 to 5 cm), using your upper
eign-body obstruction. Check for den- body weight and delivering pressure
tures or another foreign-body airway through the heels of your hands.
obstruction. If you see dentures or any ◆ After each compression, release
other object blocking the airway, re- pressure completely and allow the pa-
move the object. tient’s chest to return to a normal posi-
tion so that the heart can fill with
Assess circulation blood.
Alert Don’t change hand po-
◆ Keep your hand on the patient’s fore- sition during compressions;
head so that his airway remains open. you might injure the patient.
◆ Palpate the carotid artery closest to ◆ Give 30 chest compressions at a rate
you. To do this, place your index and of about 100 per minute. Push hard
middle fingers in the groove between and fast.
the trachea and the sternocleidomas- ◆ Open the airway and give 2 ventila-
toid muscle. tions. Find the proper hand position
◆ Palpate for 10 seconds to detect a again and give 30 more compressions.
pulse, and observe for signs of circula- ◆ Continue chest compressions until
tion. EMS arrives or another rescuer arrives
Alert If you detect a pulse, with the AED.
don’t start chest compressions.
◆ Interrupt chest compressions as in- arrives, the ACLS providers take over,
frequently as possible, and make sure or the patient starts to move.
interruptions last no longer than 10
seconds, except for special interven- Special considerations
tions such as use of an AED or inser-
tion of an airway. ◆ Some health care professionals may
hesitate to give mouth-to-mouth
Two-person rescue breaths. For this reason, the AHA rec-
◆ If another rescuer arrives and the ommends that all health care profes-
EMS team hasn’t arrived, tell the sec- sionals learn how to use disposable air-
ond rescuer to repeat the call for help. way equipment.
◆ If the second rescuer isn’t a health ◆ If you’re a single rescuer activating
care professional, ask him to stand by. EMS, getting an AED, and returning to
Then, after about 2 minutes or 5 cycles the patient to perform CPR, tailor your
of compressions and ventilations, you response to take into account the cause
can switch. The switch should occur of the arrest. For instance, if you’re res-
within 5 seconds. cuing an unresponsive patient with a
◆ If the rescuer is another health care likely hypoxic arrest, perform 5 cycles
professional, you can perform two-person of CPR before activating EMS and get-
CPR. He should start assisting after ting an AED.
you’ve finished 5 cycles of 30 compres- ◆ Lay rescuers should use the head-
sions, 2 ventilations, and a pulse check. tilt, chin-lift position for all patients,
◆ The second rescuer should get into whether or not they appear injured, be-
place opposite you. While you’re cause the jaw thrust is difficult to per-
checking for a pulse, he should find form. Lay rescuers are also taught to
the proper hand placement for deliver- give 2 rescue breaths and immediately
ing chest compressions. begin 30 chest compressions without
◆ If you don’t detect a pulse, say, “No stopping to check for a pulse. This is
pulse, continue CPR,” and give 2 venti- because research has shown they can’t
lations. reliably check for a pulse within 10
◆ The second rescuer should begin giv- seconds or accurately assess for other
ing compressions at a rate of 100 per signs of circulation
minute. Compressions and ventilations Alert CPR can cause compli-
should be given at a ratio of 30 compres- cations, especially if the com-
sions to 2 ventilations. The “compressor” pressor’s hands are placed improperly
(at this point, the second rescuer) should on the sternum. Such complications
count out loud so that the “ventilator” include fractured ribs, liver lacera-
can anticipate when to give ventilations. tion, and punctured lungs. Gastric
◆ To ensure ventilations are effective, distention may result from giving too
make sure they cause a visible chest much air during ventilation.
rise.
◆ As the “ventilator,” you must check Documentation
for breathing and a pulse.
◆ The compressor role should switch Note why you initiated CPR; report
after 5 cycles of compressions and ven- whether the patient suffered cardiac or
tilations. The switch should take no respiratory arrest. Record when you
more than 5 seconds. found the patient and started CPR and
◆ Both rescuers should continue giv- how long the patient received CPR.
ing CPR until an AED or defibrillator Note the patient’s response and any
complications. Also include any inter- A peripherally inserted central

ventions taken to correct complica- catheter (PICC) usually enters at the
tions. basilic vein and terminates in the supe-
If the patient also received ACLS, rior vena cava. PICCs may be inserted
document which interventions were by a specially trained nurse, radiolo-
performed, who performed them, gist, or surgeon. New catheters have
when they were performed, and what longer needles and smaller lumens, fa-
equipment was used. Document if the cilitating this procedure. PICCs are typ-
patient was moved to an intensive care ically used for long-term I.V. antibiotic
unit. therapy and can be safely used in the
home care and long-term care settings.
They may also be used in a patient
Central venous access device who has a chest injury; neck, chest, or
insertion and removal shoulder burns; compromised respira-
tory function; or a surgical site that’s
A central venous access device close to a CV line placement site.
(CVAD), also known as a central ve- CV therapy increases the risk of cer-
nous catheter, is a sterile catheter tain life-threatening complications, such
made of polyurethane or silicone rub- as pneumothorax, sepsis, thrombus for-
ber (Silastic). It’s inserted through a mation, and perforation of blood ves-
large vein, such as the subclavian vein, sels and adjacent organs. Also, a CVAD
the jugular vein, or peripheral veins. may decrease patient mobility, is diffi-
The tip of the catheter must be placed cult to insert, and is more expensive
in the superior vena cava for the than a peripheral I.V. catheter.
catheter to be considered a CVAD. At the end of therapy or at the on-
By providing access to the central set of complications, a physician or
veins, central venous (CV) therapy of- nurse removes the CVAD. CVAD re-
fers several benefits. It allows monitor- moval is a sterile procedure. A PICC-
ing of CV pressure, which indicates trained nurse may remove a peripheral-
blood volume or pump efficiency, and ly inserted central line. If the patient
permits aspiration of blood samples for has an infection, the removal proce-
diagnostic tests. It also allows adminis- dure includes swabbing the catheter tip
tration of I.V. fluids (in large amounts, over an agar plate for culture.
if needed) when an emergency arises;
when decreased peripheral circulation Equipment and preparation
makes peripheral vein access difficult;
when prolonged I.V. therapy reduces For inserting a CVAD
the number of accessible peripheral Cap, sterile gloves, and gowns ◆ blan-
veins; when solutions must be diluted ket ◆ linen-saver pad ◆ sterile towel ◆
(for large fluid volumes or for irritating large sterile drape, marker, and labels
or hypertonic fluids such as total par- ◆ masks ◆ alcohol pad ◆ chlorhexi-
enteral nutrition solutions); and when dine swab ◆ normal saline solution ◆
a patient requires long-term venous ac- 3-ml syringe with 25G 1 needle ◆ 1%
cess. Because multiple blood samples or 2% injectable lidocaine ◆ dextrose
can be drawn without repeated veni- 5% in water (D5W) ◆ syringes for
puncture, the CVAD decreases the pa- blood sample collection ◆ suture mate-
tient’s anxiety and preserves the peri- rial ◆ two 14G or 16G CVADs ◆ I.V.
pheral veins. solution with administration set pre-
pared for use ◆ infusion pump or
Central venous access device insertion and removal 287
controller as needed ◆ transparent ◆ Wash your hands thoroughly to pre-

semipermeable dressing ◆ 1 adhesive vent the spread of microorganisms.
tape ◆ sterile scissors ◆ heparin or nor-
mal saline flushes as needed ◆ portable Inserting a CVAD
X-ray machine ◆ optional: clippers ◆ Reinforce the physician’s explana-
tion of the procedure, and answer the
For flushing a catheter patient’s questions. Make sure that the
Normal saline solution or heparin flush patient has signed a consent form, and
solution ◆ alcohol pad check his history for hypersensitivity to
iodine, latex, or the local anesthetic.
For changing an injection cap ◆ Place the patient in Trendelenburg’s
Alcohol pad ◆ injection cap ◆ padded position to dilate the veins and reduce
clamp the risk of an air embolism.
◆ For subclavian access, place a rolled
For removing a CVAD blanket lengthwise between the pa-
Clean gloves ◆ mask ◆ sterile suture tient’s shoulders to increase venous
removal set ◆ alcohol pad ◆ sterile distention. For jugular access, place a
2 2 gauze pads ◆ forceps ◆ tape rolled blanket under the opposite
◆ sterile, plastic adhesive-backed shoulder to extend the neck, making
dressing or transparent semipermeable anatomic landmarks more visible.
dressing ◆ agar plate, if needed for Place a linen-saver pad under the pa-
culture ◆ antimicrobial swab tient to prevent soiling of the bed.
The type of catheter (tunneled, im- ◆ Turn the patient’s head away from
planted, or percutaneously inserted) se- the site to prevent possible contamina-
lected depends on the type of therapy to tion from airborne pathogens and to
be used. The Centers for Disease Con- make the site more accessible. Or if
trol and Prevention recommends using dictated by facility policy, place a mask
antimicrobial-impregnated catheters in on the patient unless this increases his
adults who expect to keep the catheter anxiety or is contraindicated due to his
in place longer than 5 days to decrease respiratory status.
the risk of catheter-related bloodstream ◆ Prepare the insertion site. Make
infections. Some facilities have prepared sure that the skin is free from hair be-
trays containing most of the equipment cause hair can harbor microorganisms.
needed for catheter insertion. Before in- Clip the hair close to the skin rather
sertion of a CVAD, confirm the catheter than shaving. You may also need to
type and size with the physician; usual- wash the skin with soap and water.
ly, a 14G or 16G catheter is selected. Set ◆ Establish a sterile field on a table,
up the I.V. solution and prime the ad- using a sterile towel or the wrapping
ministration set using strict aseptic tech- from the instrument tray. Label all
nique. Recheck all connections to make medications, medication containers,
sure that they’re tight. As ordered, noti- and other solutions on and off the ster-
fy the radiology department that a chest ile field.
X-ray is required. ◆ Put on a mask and sterile gloves
and gown (maximum barrier precau-
Implementation tions). Clean the area around the inser-
tion site with a chlorhexidine swab us-
◆ Confirm the patient’s identity using ing a vigorous side-to-side motion.
two patient identifiers. ◆ After the physician puts on a cap,
mask, sterile gown, and sterile gloves
and drapes the area with a large sterile policy. If the system is being main-
drape to create a sterile field, open the tained as a heparin lock and the infu-
packaging of the 3-ml syringe and the sions are intermittent, the flushing pro-
25G 1 needle. Give the syringe to the cedure will vary according to facility
physician using sterile technique. policy, the medication administration
◆ Wipe the top of the lidocaine vial schedule, and the type of catheter.
with an alcohol pad, and invert it. The ◆ All lumens of a multilumen catheter
physician then fills the 3-ml syringe must be flushed regularly. Verify that tip
and injects the anesthetic into the site. placement is in the superior vena cava.
◆ Open the catheter package, and give Flush vigorously, using only low-pressure
the catheter to the physician using 10-ml syringes. It’s important to be able
aseptic technique. The physician then to obtain 3 to 5 ml of free-flowing blood
inserts the catheter. before each flush. If you can’t obtain
◆ During this time, prepare the I.V. ad- 3 to 5 ml of blood, follow facility policy
ministration set for immediate attach- regarding catheter occlusion or malfunc-
ment to the catheter hub. Ask the pation. Most facilities use a heparin flush
tient to perform Valsalva’s maneuver solution, available in premixed 10-ml
while the physician attaches the I.V. multidose vials. Recommended concen-
line to the catheter hub. This maneuver trations vary from 10 to 100 units of he-
increases intrathoracic pressure, reduc- parin per milliliter. Use normal saline
ing the possibility of an air embolus. solution instead of heparin to maintain
◆ After the physician attaches the I.V. patency in two-way valve devices, such
line to the catheter hub, set the flow as the Groshong type. Research suggests
rate at a keep-vein-open rate to main- that heparin isn’t always needed to keep
tain venous access. (Alternatively, the the line open.
catheter may be capped and flushed ◆ The recommended frequency for
with heparin.) The physician then su- flushing CVADs varies from once every
tures the catheter in place. 8 hours to once weekly.
◆ After an X-ray confirms correct ◆ The recommended amount of flush-
catheter placement in the superior ing solution also varies. If the volume
vena cava, set the flow rate as ordered. of the cannula and the add-on devices
◆ Use antimicrobial solution to re- is known, Infusion Nurses Society stan-
move dried blood that could harbor dards require using twice that amount.
microorganisms. Secure the catheter All catheters have the same internal
with a catheter securement device, volume of less than 1 ml. Most facili-
sterile tape, or sterile surgical strips ties recommend using 3 to 5 ml of so-
and use a transparent semipermeable lution to flush the catheter, although
dressing. some facility policies call for as much
◆ Expect some serosanguineous as 10 ml of solution.
drainage during the first 24 hours. La- ◆ Before flushing, clean the cap with
bel the dressing with the date and time an alcohol pad. Allow the cap to dry. If
of catheter insertion and the length you are using a needleless system
and gauge of the catheter. when flushing, follow manufacturer
◆ Place the patient in a comfortable guidelines.
position and reassess his status. ◆ Access the cap, and aspirate 3 to
5 ml of blood to confirm the proper
Flushing a catheter function and patency of the CVAD.
◆ To maintain patency, flush the ◆ Inject the recommended type and
catheter routinely, according to facility amount of flush solution.
Central venous access device insertion and removal 289
◆ After you flush the catheter, main- catheter, explain the procedure to the
tain positive pressure by keeping your patient.
thumb on the plunger of the syringe ◆ Place the patient in a supine posi-
while you withdraw the syringe. This tion to prevent an air embolism.
prevents blood backflow and clotting ◆ Wash your hands, and put on clean
in the line. If you are flushing a valved gloves and a mask.
catheter, close the clamp just before ◆ Turn off all infusions and prepare a
the last of the flush solution leaves the sterile field using a sterile drape.
syringe. ◆ Remove and discard the old dress-
ing, and change to sterile gloves.
Changing an injection cap ◆ Inspect the site for signs of drainage
◆ CVADs that are used for intermittent and inflammation.
infusions have needle-free injection ◆ Clip the sutures, and use forceps to
caps (short luer-lock devices similar to remove the catheter in a slow, even
the heparin lock adapters that are used motion. Have the patient perform Val-
for peripheral I.V. therapy). These caps salva’s maneuver as the catheter is
must be luer-lock types to prevent in- withdrawn to prevent an air embolism.
advertent disconnection and an air em- ◆ Apply pressure with a dry sterile
bolism. These caps contain a minimal gauze pad immediately after you re-
amount of empty space, so don’t pre- move the catheter.
flush the cap before you connect it. ◆ Apply antiseptic ointment to the
◆ The frequency of cap changes varies catheter exit site to seal the site and
according to facility policy and fre- prevent an air embolism. Cover the site
quency of use. Changing the cap once with a sterile 2 2 gauze pad, and
weekly is recommended. Use strict place a transparent semipermeable
aseptic technique when changing the dressing over the gauze. Write the date
cap. and time of removal and your initials
◆ Clean the connection site with an on the dressing with indelible ink.
alcohol pad. Keep the site covered until epithelial-
◆ Instruct the patient to perform Val- ization has occurred. Follow up with
salva’s maneuver while you quickly the patient’s family physician if the pa-
disconnect the old cap and connect the tient is discharged.
new injection cap using aseptic tech- ◆ Measure the length of the removed
nique. If he can’t perform this maneu- PICC catheter to ensure that the catheter
ver, use a padded clamp or pinch off has been completely removed. If you
the catheter to prevent air from enter- suspect that the catheter hasn’t been
ing the catheter. completely removed, notify the physi-
cian immediately and monitor the pa-
Removing a CVAD tient closely for signs of distress. If you
◆ Before starting, check the patient’s suspect an infection, swab the catheter
record for the most recent placement on a fresh agar plate and send the speci-
(confirmed by X-ray) to trace the men to the laboratory for culture.
catheter’s path as it exits the body. ◆ Dispose of the I.V. tubing and
◆ Make sure that assistance is avail- equipment properly.
able if a complication (such as uncon-
trolled bleeding) occurs during catheter Special considerations
removal. Some vessels, such as the
subclavian vein, can be difficult to ◆ While you’re awaiting chest X-ray
compress. Before you remove the confirmation of proper catheter
Key steps in changing a central venous dressing
Appropriate dressing changes and site

care are needed to remove Staphylococ-
cus epidermidis, the major organism
causing infection in central venous cath-
eters. Expect to change your patient’s cen-
tral venous dressing weekly. Many facili-
ties specify dressing changes whenever
the dressing becomes soiled, moist, or
loose. The following illustrations show the
key steps you’ll perform.
First, put on clean gloves and remove After the solution has dried, cover the
the old dressing by pulling it toward the site with a dressing such as the transpar-
exit site of a long-term catheter or toward ent semipermeable dressing shown here.
the insertion site of a short-term catheter. Write the time and date on the dressing.
This technique helps you to avoid pulling
out the line. Remove and discard your
gloves.
Next, put on sterile gloves and clean
the skin around the site, using an antimi-
crobial solution. Start at the center and
move outward, using a circular motion.
Allow the skin to dry. Use chlorhexi-
dine swabs as recommended by the Cen-
ters for Disease Control and Prevention to
clean the site using a vigorous side-to-
side motion. Don’t use circular motion.
placement, infuse an I.V. solution, such physician immediately if these signs

as D5W or normal saline solution, at a appear.
keep-vein-open rate, until correct place- ◆ If a gauze dressing is used, change
ment is assured. Alternatively, use a it at least every 48 hours. If a transpar-
heparin lock and flush the line. ent semipermeable dressing is used,
◆ Watch for signs of air embolism, in- change it every 7 days, according to fa-
cluding sudden onset of pallor, cyano- cility policy, or whenever it becomes
sis, dyspnea, coughing, and tachycar- moist or soiled. Change the tubing
dia that progresses to syncope and every 72 hours and the solution every
shock. If any of these signs occur, 24 hours. Dressing, tubing, and solu-
place the patient on his left side in tion changes for a CVAD should be per-
Trendelenburg’s position and notify the formed using aseptic technique. (See
physician. Make sure that the exit site Key steps in changing a central venous
is covered with an occlusive dressing. dressing.) Assess the site daily for
◆ After the catheter is inserted, moni- signs and symptoms of complications,
tor the patient for signs and symptoms such as discharge, inflammation, and
of pneumothorax, such as shortness of tenderness, and document your obser-
breath, uneven chest movement, tachy- vations.
cardia, and chest pain. Notify the
◆ To prevent an air embolism, close the solution infused, the physician’s

the catheter clamp or have the patient name, and the patient’s response to the
perform Valsalva’s maneuver each time procedure. Also document the time of
that the catheter hub is open to air. A the X-ray, its results, and your notifica-
Groshong catheter doesn’t require tion of the physician.
clamping because it has a closed, Finally, record the date and time of
valved-tip catheter. catheter removal and the type of an-
◆ Long-term use of a CVAD, such as a timicrobial ointment and dressing ap-
Hickman catheter, a Broviac catheter, a plied. Note the condition of the cath-
Port, or a PICC, allows patients to re- eter insertion site.
ceive all types of infusion therapies at
home. These catheters have a much
longer life than short-term devices be- Central venous pressure
cause they’re less thrombogenic and monitoring
less prone to infection.
Patient teaching tips A can- In central venous pressure (CVP) moni-
didate for home therapy may toring, the physician inserts a catheter
have a family member or friend who through a vein and advances it until its
can safely and competently adminis- tip lies in or near the right atrium. Be-
ter the I.V. fluids, a backup helper, a cause no major valves lie at the junc-
suitable home environment, trans- tion of the vena cava and the right atri-
portation, and the ability to prepare, um, pressure at end diastole reflects
handle, store, and dispose of the back to the catheter. When connected
equipment. The care procedures used to a manometer, the catheter measures
in the home are the same as those CVP, an index of right ventricular func-
used in the facility. tion.
The overall goal of home therapy CVP monitoring helps you to assess
is patient safety, so patient teaching cardiac function, evaluate venous re-
must begin well before discharge. turn to the heart, and indirectly gauge
Most patients who receive home how well the heart is pumping. The
therapy learn to care for the catheter central venous (CV) line also provides
themselves and infuse their own access to a large vessel for rapid, high-
medications and solution. volume fluid administration and allows
◆ Complications can occur at any frequent blood withdrawal for laborato-
time during infusion therapy. Traumat- ry samples.
ic complications such as pneumotho- CVP monitoring can be done inter-
rax typically occur at the time of mittently or continuously. The catheter
catheter insertion, but may not be no- is inserted percutaneously or using a
ticed until after the procedure is com- cutdown method. Typically, a single-
pleted. Systemic complications such lumen CVP line is used for intermittent
as sepsis typically occur later, during pressure readings. To measure the pa-
infusion therapy. Other complications tient’s volume status, a disposable
include thrombus formation and air plastic water manometer is attached
embolism. between the I.V. line and the central
catheter with a three- or four-way stop-
Documentation cock. CVP is recorded in centimeters of
water (cm H2O) or millimeters of mer-
Record the date and time of insertion, cury (mm Hg) and read from manome-
the length and location of the catheter, ter markings.
CVP is highly individualized but Monitoring CVP intermittently with

usually ranges from 5 to 10 cm H2O. a water manometer
Any condition that alters venous re- ◆ With the CV line in place, position
turn, circulating blood volume, or car- the patient flat. Use a leveling device to
diac performance can affect CVP. If the align the base of the disposable CVP
circulating volume increases (such as manometer with the previously deter-
with enhanced venous return to the mined zero reference point. Because
heart), CVP rises. If the circulating vol- CVP reflects right atrial pressure, you
ume decreases (such as with reduced must align the right atrium (zero refer-
venous return), CVP drops. ence point) with the zero mark on the
manometer. To find the right atrium,
Equipment locate the fourth intercostal space at
the midaxillary line; this is the phlebo-
For intermittent CVP monitoring static axis. Mark the appropriate place
Disposable CVP manometer set ◆ lev- on the patient’s chest so that all subse-
eling device (such as a rod from a quent recordings are made using the
reusable CVP pole holder or a carpen- same location.
ter’s level or rule) ◆ stopcock (to at- ◆ If the patient can’t tolerate a flat po-
tach the CVP manometer to the sition, place him in semi-Fowler’s posi-
catheter) ◆ I.V. pole ◆ I.V. solution, tion. When the head of the bed is ele-
drip chamber, and tubing vated, the phlebostatic axis remains
constant, but the midaxillary line
For continuous CVP monitoring changes. Use the same degree of eleva-
Pressure monitoring kit with dispos- tion for all subsequent measurements.
able pressure transducer ◆ leveling de- ◆ Attach the manometer to an I.V.
vice ◆ bedside pressure module ◆ pole or place it next to the patient’s
continuous I.V. flush solution ◆ chest. Make sure that the zero refer-
1 unit/1 to 2 ml of heparin flush solu- ence point is level with the right atri-
tion ◆ pressure bag um. (See Measuring CVP with a water
manometer.)
For removing a CV catheter ◆ Verify that the manometer is con-
Gloves ◆ suture removal set ◆ sterile nected to the I.V. tubing. Typically, the
gauze pads ◆ antimicrobial ointment markings on the manometer range
◆ dressing ◆ tape from 2 to 38 cm H2O. However, man-
ufacturer’s markings may differ, so
Implementation read the directions before setting up
the manometer and obtaining readings.
◆ Confirm the patient’s identity using ◆ Turn the stopcock off to the patient.
two patient identifiers. Slowly fill the manometer with I.V.
◆ Gather the necessary equipment. solution until the fluid level is 10 to
Explain the procedure to the patient to 20 cm H2O higher than the expected
reduce his anxiety. CVP value. Don’t overfill the tube be-
◆ Assist the physician as he inserts cause fluid that spills over the top can
the CV catheter. The procedure is simi- become a source of contamination.
lar to that used for pulmonary artery ◆ Turn the stopcock off to the I.V. so-
pressure monitoring, except that the lution and open to the patient. The flu-
catheter is advanced only as far as the id level in the manometer will drop.
superior vena cava. When the fluid level comes to rest, it
will fluctuate slightly with respirations.
Measuring CVP with a water manometer
To ensure accurate central venous pressure (CVP) readings, make sure that the base of
the manometer is aligned with the patient’s right atrium (the zero reference point). The
manometer set usually contains a leveling rod to allow you to determine this alignment
quickly.
After you adjust the position of the manometer, examine the typical three-way stop-
cock. By turning it to any position shown below, you can control the direction of fluid
flow. Four-way stopcocks are also available.
All openings Manometer to

blocked patient
I.V. solution
I.V. solution to I.V. solution to bottle
manometer patient
Manometer
Zero point
Three-way stopcock
Expect it to drop during inspiration and Monitoring CVP continuously with

to rise during expiration. a water manometer
◆ Record CVP at the end of expira- Follow the procedure as outlined for
tion, when intrathoracic pressure has a monitoring CVP intermittently with a
negligible effect. Depending on the water manometer, except that the CVP
type of water manometer used, note system will be continuously hooked up
the value either at the bottom of the for use.
meniscus or at the midline of the small ◆ Make sure that the stopcock is
floating ball. turned so that the I.V. solution port,
◆ After obtaining the CVP value, turn the CVP column port, and the patient
the stopcock to resume the I.V. infu- port are open. With this stopcock posi-
sion. Adjust the drip rate as needed. tion, infusion of the I.V. solution in-
◆ Place the patient in a comfortable creases CVP. Therefore, expect higher
position. readings than those taken with the
stopcock turned off to the I.V. solution.
If the I.V. solution infuses at a constant ducer. Then connect the continuous I.V.
rate, CVP will change as the patient’s flush solution to the pressure tubing.
condition changes, although the initial ◆ To obtain values, position the pa-
reading will be higher. Assess the patient flat. If he can’t tolerate this posi-
tient closely for changes. tion, use semi-Fowler’s position. Locate
the level of the right atrium by identi-
Monitoring CVP continuously with fying the phlebostatic axis. Zero the
a pressure monitoring system transducer, leveling the transducer
◆ Make sure that the CV line or the air–fluid interface stopcock with the
proximal lumen of a pulmonary artery right atrium. Read the CVP value from
catheter is attached to the system. If the digital display on the monitor, and
the patient has a CV line with multiple note the waveform. Make sure that the
lumens, one lumen may be dedicated patient is still when the reading is tak-
to continuous CVP monitoring and the en to prevent artifact. (See Identifying
other lumens used for fluid administra- hemodynamic pressure monitoring
tion. problems.) Use this position for all sub-
◆ Set up a pressure transducer system. sequent readings.
Connect noncompliant pressure tubing
from the CVP catheter hub to the trans- (Text continues on page 297.)
Identifying hemodynamic pressure monitoring problems
PROBLEM POSSIBLE CAUSES INTERVENTIONS
No ◆ Power supply turned off ◆ Check the power supply.

waveform ◆ Monitor screen pressure ◆ Raise the monitor screen pres-
range set too low sure range, if necessary.
◆ Rebalance and recalibrate the
equipment.
◆ Loose connection in the line ◆ Tighten loose connections.
◆ Transducer not connected to ◆ Check and tighten the connection.
the amplifier
◆ Stopcock off to the patient ◆ Position the stopcock correctly.
◆ Catheter occluded or out of ◆ Use the fast-flush valve to flush
the blood vessel the line, or try to aspirate blood
from the catheter. If the line remains
blocked, notify the physician and
prepare to replace the line.
Drifting ◆ Improper warmup ◆ Allow the monitor and transducer

waveforms to warm up for 10 to 15 minutes.
◆ Electrical cable kinked or ◆ Place the monitor’s cable where
compressed it can’t be stepped on or com-
pressed.
◆ Temperature change in room ◆ Routinely zero and calibrate the
air or I.V. flush solution equipment 30 minutes after setting
it up. This allows I.V. fluid to warm
to room temperature.
Identifying hemodynamic pressure monitoring problems (continued)
Line that ◆ Stopcocks positioned incor- ◆ Make sure that the stopcocks are
doesn’t flush rectly positioned correctly.
◆ Inadequate pressure from a ◆ Make sure that the pressure bag
pressure bag gauge reads 300 mm Hg.
◆ Kink in the pressure tubing ◆ Check the pressure tubing for
kinks.
◆ Blood clot in the catheter ◆ Try to aspirate the clot with a
syringe. If the line still won’t flush,
notify the physician and prepare to
replace the line, if necessary. Impor-
tant: Never use a syringe to flush a
hemodynamic line.
Artifact ◆ Patient movement ◆ Wait until the patient is quiet be-

(waveform fore taking a reading.
interference) ◆ Electrical interference ◆ Make sure that the electrical
equipment is connected and ground-
ed correctly.
◆ Catheter fling (tip of the pul- ◆ Notify the physician, who may
monary artery [PA] catheter mov- try to reposition the catheter.
ing rapidly in a large blood ves-
sel or heart chamber)
◆ Transducer balancing port po- ◆ Position the balancing port level
sitioned below the patient’s right with the patient’s right atrium.
atrium
◆ Flush solution flow rate too ◆ Check the flush solution flow
fast rate. Maintain it at 3 to 4 ml/hour.
◆ Air in the system ◆ Remove air from the lines and
the transducer.
◆ Catheter fling (tip of the PA ◆ Notify the physician, who may
catheter moving rapidly in a try to reposition the catheter.
large blood vessel or heart
chamber)
False-high ◆ Transducer balancing port po- ◆ Position the balancing port level
readings sitioned above the right atrium with the patient’s right atrium.
◆ Transducer imbalance ◆ Make sure that the flow system
of the transducer isn’t kinked or oc-
cluded, and rebalance and recali-
brate the equipment.
◆ Loose connection ◆ Tighten loose connections.
◆ Secure all connections.
(continued)
Identifying hemodynamic pressure monitoring problems (continued)
False-low ◆ Air bubbles ◆ Remove air from the lines and

readings the transducer.
◆ Blood clot in the catheter ◆ Check for and replace cracked
equipment.
◆ Blood flashback in the line ◆ Refer to “Line that doesn’t flush”
on page 295.
◆ Incorrect transducer position ◆ Make sure that the stopcock po-
sitions are correct, tighten loose con-
nections, replace cracked equipment,
flush the line with the fast-flush
valve, and replace the transducer
dome if blood backs up into it.
◆ Make sure that the transducer is
kept at the level of the right atrium
at all times. Improper levels give
false-high or false-low pressure
readings.
Damped ◆ Arterial catheter out of the ◆ Reposition the catheter if it’s

waveform blood vessel or pressed against against the vessel wall.
the vessel wall ◆ Try to aspirate blood to confirm
proper placement in the vessel. If
you can’t aspirate blood, notify the
physician and prepare to replace the
line. Note: Bloody drainage at the in-
sertion site may indicate catheter
displacement. Notify physician.
◆ Ruptured balloon ◆ Notify physician immediately for
catheter replacement.
Pulmonary ◆ Incorrect amount of air in the ◆ If you feel no resistance when in-
artery wedge balloon jecting air, or if you see blood leak-
pressure ing from the balloon inflation lu-
tracing unob- men, stop injecting air and notify
tainable the physician. If the catheter is left
in, label the inflation lumen with a
warning not to inflate.
◆ Catheter malpositioned ◆ Deflate the balloon. Check the la-
bel on the catheter for the correct
volume. Reinflate slowly with the
correct amount. To avoid rupturing
the balloon, never use more than
the stated volume.
◆ Notify the physician. Obtain a
chest X-ray.
Removing a CV access device of infection, such as redness, and note

◆ You may assist the physician in re- patient complaints of tenderness. Cover
moving a CV access device. (In some the site with a clear, transparent semi-
states, a nurse is permitted to remove permeable dressing.
the catheter when acting under a ◆ After the initial CVP reading, reeval-
physician’s order or under advanced uate readings frequently to establish a
collaborative standards of practice.) baseline for the patient. Authorities
◆ If the head of the bed is elevated, recommend obtaining readings at 15-,
minimize the risk of air embolism dur- 30-, and 60-minute intervals to estab-
ing catheter removal — for instance, by lish a baseline. If the patient’s CVP
placing the patient in Trendelenburg’s fluctuates by more than 2 cm H2O, sus-
position if the line was inserted using a pect a change in his clinical status and
superior approach. If he can’t tolerate report this finding to the physician.
this position, position him flat. ◆ Change the I.V. solution every
◆ Turn the patient’s head to the side 24 hours and the I.V. tubing every
opposite the catheter insertion site. The 96 hours, according to facility policy.
physician removes the dressing and ex- Label the I.V. solution, tubing, and
poses the insertion site. If sutures are dressing with the date, the time, and
in place, he removes them carefully. your initials.
◆ Turn the I.V. solution off. ◆ Assess the patient for complications
◆ The physician pulls the catheter out of CVP monitoring, including pneu-
in a slow, smooth motion and then ap- mothorax (which typically occurs on
plies pressure to the insertion site. catheter insertion), sepsis, thrombus,
◆ Apply pressure with a dry sterile puncture of a vessel or an adjacent or-
gauze pad immediately after the catheter gan, and air embolism.
is removed. Apply antimicrobial oint-
ment to the catheter exit site to seal the Documentation
site and prevent air embolism. Cover the
site with a sterile 2 2 gauze pad, and Document all dressing, tubing, and so-
place a transparent semipermeable dress- lution changes. Also document the pa-
ing over the gauze. Keep the site covered tient’s tolerance of the procedure, the
until epithelialization has occurred. date and time of catheter removal, and
◆ Assess the patient for signs of respi- the type of dressing applied. Note the
ratory distress, which may indicate an condition of the catheter insertion site
air embolism. and whether a culture specimen was
collected. Note any complications as
Special considerations well as actions taken.
◆ As ordered, arrange for daily chest

X-rays to check the placement of the Chest physiotherapy
catheter.
◆ Care for the insertion site according Chest physiotherapy (PT) includes pos-
to facility policy. Typically, you’ll tural drainage, coughing and deep-
change the dressing weekly. breathing exercises, and chest percussion
◆ Wash your hands before performing and vibration. Together, these techniques
dressing changes, and use aseptic tech- mobilize and eliminate secretions, reex-
nique and sterile gloves when redress- pand lung tissue, and promote efficient
ing the site. When removing the old use of the respiratory muscles. Of critical
dressing, observe the patient for signs importance to the bedridden patient,
chest PT helps to prevent or treat atelec- gown ◆ suction equipment as needed

tasis and may also help to prevent pneu- ◆ equipment for oral care ◆ trash bag
monia, two respiratory complications Gather the equipment at the bed-
that can seriously impede recovery. side. Set up suction equipment, if
Postural drainage performed with needed, and test its function.
percussion and vibration encourages pe-
ripheral pulmonary secretions to empty Implementation
by gravity into the major bronchi or tra-
chea and is accomplished by sequential ◆ Confirm the patient’s identity using
repositioning of the patient. Usually, se- two patient identifiers.
cretions drain best with the patient posi- ◆ Check the order.
tioned so that the bronchi are perpen- ◆ Explain the procedure to the pa-
dicular to the floor. Lower and middle tient, provide privacy, and wash your
lobe bronchi usually empty best with hands.
the patient in the head-down position; ◆ Put on gloves, face shield, and
upper lobe bronchi, in the head-up posi- gown, and follow standard precautions.
tion. Percussing the chest with cupped ◆ Auscultate the patient’s lungs with
hands mechanically dislodges thick, a stethoscope to determine the pa-
tenacious secretions from the bronchial tient’s baseline respiratory status.
walls. Vibration can be used with per- ◆ Position the patient as necessary us-
cussion or as an alternative to it in a pa- ing pillows. For patients with general-
tient who is frail, is in pain, or is recov- ized disease, drainage usually begins
ering from thoracic surgery or trauma. with the lower lobes, continues with
Candidates for chest PT include pa- the middle lobes, and ends with the
tients who expectorate large amounts upper lobes. For patients with localized
of sputum, such as those with bronchi- disease, drainage begins with the af-
ectasis or cystic fibrosis. The procedure fected lobes and proceeds to the other
hasn’t proved effective in treating pa- lobes to avoid spreading the disease to
tients with status asthmaticus, lobar uninvolved areas.
pneumonia, or acute exacerbations of ◆ Instruct the patient to remain in
chronic bronchitis when the patient each position for 10 to 15 minutes.
has scant secretions and is being me- During this time, perform percussion
chanically ventilated. Chest PT has and vibration as ordered. (See Perform-
little value in the treatment of patients ing percussion and vibration.)
with stable, chronic bronchitis. ◆ After you perform postural drainage,
Contraindications include active pul- percussion, or vibration, instruct the
monary bleeding with hemoptysis and patient to cough to remove loosened se-
the immediate posthemorrhage stage, cretions. First, tell him to inhale deeply
fractured ribs or an unstable chest wall, through his nose and then to exhale in
lung contusions, pulmonary tuberculo- three short huffs. Then instruct him to
sis, untreated pneumothorax, acute inhale deeply again and then to cough
asthma or bronchospasm, lung abscess through a slightly open mouth. Three
or tumor, bony metastasis, head injury, consecutive coughs are highly effective.
and recent myocardial infarction. An effective cough sounds deep, low,
and hollow; an ineffective one, high-
Equipment and preparation pitched. Have the patient exercise for
about 1 minute, then have him rest for
Stethoscope ◆ emesis basin ◆ facial 2 minutes. Gradually progress to 10-
tissues ◆ pillows or folded towels for minute exercise periods done four times
positioning ◆ gloves, face shield, and daily.
Performing percussion and vibration
To perform percussion, instruct the patient

to breathe slowly and deeply, using the di-
aphragm, to promote relaxation. Hold
your hands in a cupped shape, with your
fingers flexed and your thumbs pressed
tightly against your index fingers. Percuss
each segment for 1 to 2 minutes by alter-
nating your hands against the patient in a
rhythmic manner. Listen for a hollow
sound on percussion to verify that you’re
performing the technique correctly.
To perform vibration, ask the patient to

inhale deeply and then to exhale slowly
through pursed lips. While the patient ex-
hales, firmly press your fingers and the
palms of your hands against the chest
wall. Tense the muscles of your arms and
shoulders in an isometric contraction to
send fine vibrations through the chest
wall. Vibrate during five exhalations over
each chest segment.
◆ If coughing is ineffective, suction limited to 30 minutes or less, as tolerat-

the patient. ed. Drainage of different lobes may need
◆ Provide oral hygiene because secre- to be done during separate PT sessions.
tions may have a foul taste or a stale ◆ If the patient is receiving chest PT
odor. Dispose of secretions with suction to prevent dehydration of mucus and
equipment or tissues and a trash bag. promote easier mobilization, make sure
Provide an emesis basin if needed. that he takes in plenty of fluids. Avoid
◆ Monitor the patient’s response to performing postural drainage immedi-
treatment, and auscultate his lungs to ately before or within 11⁄2 hours after
evaluate the effectiveness of therapy. meals to avoid nausea and aspiration
of food or vomitus.
Special considerations ◆ Because chest percussion can in-
duce bronchospasm, adjunct treatment
◆ For optimal effectiveness and safety, (for example, intermittent positive-pres-
modify chest PT according to the pa- sure breathing, aerosol, or nebulizer
tient’s condition. For example, initiate or therapy) should precede chest PT.
increase the flow of supplemental oxy- ◆ Don’t perform percussion over the
gen, if indicated. Also, suction the pa- spine, liver, kidneys, or spleen to avoid
tient who has an ineffective cough re- injury to the spine or internal organs.
flex. If the patient tires quickly during Also, avoid performing percussion on
therapy, shorten the sessions. Fatigue bare skin or on a female patient’s
leads to shallow respirations and in- breasts. Percuss over soft clothing (but
creased hypoxia. Chest PT should be not over buttons, snaps, or zippers), or
place a thin towel over the chest wall. ly watery or pasty. In addition to col-
Remove jewelry that might scratch or lecting waste matter, the pouch helps
bruise the patient. to control odor and protect the stoma
Patient teaching tips Explain and peristomal skin. Most disposable
coughing and deep-breathing pouching systems can be used for 2 to
exercises preoperatively so that the 7 days; some models last even longer.
patient can practice them when he’s All pouching systems must be
pain-free and can concentrate better. changed immediately if a leak devel-
Postoperatively, splint the patient’s in- ops, and every pouch must be emptied
cision using your hands or, if possible, when it’s one-third to one-half full.
teach the patient to splint it himself to The patient with an ileostomy may
minimize pain during coughing. need to empty his pouch four or five
◆ Observe the patient for complica- times daily.
tions. During postural drainage in Naturally, the best time to change
head-down positions, pressure on the the pouching system is when the bow-
diaphragm by abdominal contents can el is least active, usually 2 to 4 hours
impair respiratory excursion and lead after meals. After a few months, most
to hypoxia or postural hypotension. patients can predict the best changing
The head-down position may also lead time.
to increased intracranial pressure, The selection of a pouching system
which precludes the use of chest PT in should take into consideration which
a patient with acute neurologic impair- system provides the best adhesive seal
ment. Vigorous percussion or vibration and skin protection for the individual
can cause rib fracture, especially if the patient. The type of pouch selected
patient has osteoporosis. In a patient also depends on the location and struc-
with emphysema and blebs, coughing ture of the stoma, the availability of
can lead to pneumothorax. supplies, the wear time, the consisten-
cy of effluent, personal preference, and
Documentation cost.
Record the date and time of chest PT. Equipment

Note the positions used to drain secre-
tions and the length of time that each Pouching system ◆ stoma measuring
position is maintained. Also record the guide ◆ stoma paste (if drainage is wa-
chest segments that are percussed or tery to pasty or stoma secretes excess
vibrated; the color, amount, odor, and mucus) ◆ scissors ◆ water or pouch-
viscosity of secretions produced and cleaning solution ◆ washcloth and
the presence of blood; complications towel ◆ closure clamp ◆ toilet or bed-
that occur and nursing actions that are pan ◆ gloves ◆ facial tissue ◆ option-
taken; and the patient’s tolerance of al: ostomy belt, paper tape, mild non-
treatment. moisturizing soap, electric clippers
◆ prepared skin barrier ◆ gauze pad
Pouching systems may be drainable
Colostomy and ileostomy care or closed-bottomed, disposable or
reusable, adhesive-backed, and one- or
A patient with an ascending or trans- two-piece. (See Comparing ostomy
verse colostomy or an ileostomy must pouching systems.)
wear an external pouch to collect
emerging fecal matter, which is typical-
Comparing ostomy pouching systems
Manufactured in many shapes and sizes, A two-piece, disposable, drainable

ostomy pouches are fashioned for comfort, pouch with a separate skin barrier (shown
safety, and easy application. For example, below) permits frequent changes and min-
a disposable, closed-end pouch may meet imizes skin breakdown. Also made of
the needs of a patient who irrigates, who transparent or opaque, odor-proof plastic,
wants added security, or who wants to this style comes with belt tabs and usually
discard the pouch after each bowel move- snaps to the skin barrier with a flange
ment. Another patient may prefer a mechanism.
reusable, drainable pouch. Some common-
ly available pouches are described below.
Disposable pouches
The patient who must empty his pouch of-
ten (because of diarrhea or a new colosto-
my or ileostomy) may prefer a one-piece,
drainable, disposable pouch with a closure
clamp attached to a skin barrier (below
left).
These transparent or opaque, odor-
proof, plastic pouches come with attached
adhesive or karaya seals. Some pouches Reusable pouches
have microporous adhesive or belt tabs. Typically manufactured from sturdy,
The bottom opening allows for easy drain- opaque, hypoallergenic plastic, the
ing. This pouch may be used permanently reusable pouch comes with a separate,
or temporarily, until the stoma size stabi- custom-made faceplate and O-ring (as
lizes. shown below). Some pouches have a pres-
Also disposable and made of transpar- sure valve for releasing gas. The device
ent or opaque, odor-proof plastic, a one- has a 1- to 2-month life span, depending
piece, disposable, closed-end pouch (be- on how frequently the patient empties the
low right) may come in a kit with an ad- pouch.
hesive seal, belt tabs, a skin barrier, or a Reusable equipment may benefit a pa-
carbon filter for gas release. A patient with tient who needs a firm faceplate or who
a regular bowel elimination pattern may wishes to minimize cost. However, many
choose this style for added security and reusable ostomy pouches aren’t odor-
confidence. proof.
Implementation additional surgery, or injures the

stoma.
◆ Provide privacy and emotional sup-
port. Applying or changing the pouch
◆ Collect all equipment.
Fitting the pouch and skin barrier ◆ Wash your hands and provide pri-
◆ For a pouch with an attached skin vacy.
barrier, measure the stoma with the ◆ Explain the procedure to the pa-
stoma-measuring guide. Select the tient. As you perform each step, ex-
opening size that matches the stoma. plain what you’re doing and why be-
◆ For an adhesive-backed pouch with cause the patient will eventually per-
a separate skin barrier, measure the form the procedure himself.
stoma with the measuring guide and ◆ Put on gloves.
select the opening that matches the ◆ Remove and discard the old pouch.
stoma. Trace the selected size opening Wipe the stoma and the peristomal
onto the paper back of the skin barrier. skin gently with a facial tissue.
Cut out the opening. (If the pouch has ◆ Carefully wash the stoma with mild
precut openings, which can be handy nonmoisturizing soap and water, and
for a round stoma, select an opening dry the peristomal skin by patting it
that’s 1⁄8 [3 mm] larger than the gently. Allow the skin to dry thorough-
stoma. If the pouch comes without an ly. Inspect the peristomal skin and
opening, cut the hole 1⁄8 wider than stoma. If necessary, clip the surround-
the measured tracing.) The cut-to-fit ing hair (in a direction away from the
system works best for an irregularly stoma) to promote a better seal and
shaped stoma. avoid skin irritation from hair pulling
◆ For a two-piece pouching system against the adhesive.
with flanges, see Applying a skin barri- ◆ If you are applying a separate skin
er and pouch. barrier, peel off the paper backing of
◆ Avoid fitting the pouch too tightly the prepared skin barrier, center the
because the stoma has no pain recep- barrier over the stoma, and press gen-
tors. A constrictive opening could in- tly to ensure adhesion.
jure the stoma or the skin without the ◆ You may want to outline the stoma
patient feeling the warning of discom- on the back of the skin barrier (de-
fort. Avoid cutting the opening too pending on the product) with a thin
big because a large opening may ex- ring of stoma paste to provide extra
pose the skin to fecal matter and skin protection. Skip this step if the pa-
moisture. tient has a sigmoid or descending
◆ A patient with a descending or sig- colostomy, formed stools, and little
moid colostomy who has formed stools mucus.
and whose ostomy doesn’t secrete ◆ Remove the paper backing from the
much mucus may choose to wear only adhesive side of the pouching system,
a pouch. In this case, make sure that and center the pouch opening over the
the pouch opening closely matches the stoma. Press gently to secure.
stoma size. ◆ For a pouching system with flanges,
◆ Between 6 weeks and 1 year after align the lip of the pouch flange with
surgery, the stoma will shrink to its the bottom edge of the skin barrier
permanent size. At that point, pattern- flange. Gently press around the circum-
making preparations won’t be needed ference of the pouch flange, beginning
unless the patient gains weight, has at the bottom, until the pouch adheres
Applying a skin barrier and pouch
Fitting a skin barrier and an ostomy pouch properly can be done in a few steps.
The commonly used, two-piece pouching system with flanges is shown below.
Measure the stoma using a measuring Remove the backing from the skin barrier
guide. and moisten it or apply barrier paste as
needed along the edge of the circular
opening.
Trace the appropriate circle carefully on

the back of the skin barrier.
Center the skin barrier over the stoma,

with the adhesive side down, and gently
press it to the skin.
Cut the circular opening in the skin barri-

er. Bevel the edges to prevent them from
irritating the patient.
Gently press the pouch opening onto the

ring until it snaps into place.
securely to the barrier flange. (The improve adherence. The patient’s body
pouch will click into its secured posi- warmth also helps to improve adher-
tion.) Hold the barrier against the skin, ence and to soften a rigid skin barrier.
and gently pull on the pouch to con- ◆ Attach an ostomy belt to secure the
firm the seal between flanges. pouch further, if desired. (Some pouch-
◆ Encourage the patient to stay quiet- es have belt loops, and others have
ly in position for about 5 minutes to plastic adapters for belts.)
◆ Leave a small amount of air in the skin sealant, if available, to give the
pouch to allow drainage to fall to the skin added protection from drainage
bottom. and adhesive irritants.
◆ Apply the closure clamp, if needed. ◆ Remove the pouching system if the
◆ If desired, apply paper tape in a pic- patient reports burning or itching be-
ture-frame fashion to the pouch edges neath it or purulent drainage around
for additional security. the stoma. Notify the physician or ther-
apist of skin irritation, breakdown,
Emptying the pouch rash, or unusual appearance of the
◆ Put on gloves. stoma or peristomal area.
◆ Tilt the bottom of the pouch up- ◆ Use commercial pouch deodorants,
ward, and remove the closure clamp. if desired. However, most pouches are
◆ Turn up a cuff on the lower end of odor-free, and odor should be evident
the pouch, and allow the pouch to only when you empty the pouch or if it
drain into the toilet or bedpan. leaks. Before the patient is discharged,
◆ Wipe the bottom of the pouch with suggest that he avoid odor-causing
a gauze pad, and reapply the closure foods, such as fish, eggs, onions, and
clamp. garlic.
◆ The bottom portion of the pouch ◆ If the patient wears a reusable
can be rinsed with cool tap water. pouching system, suggest that he ob-
Don’t aim water up near the top of the tain two or more systems so that he
pouch because the water may loosen can wear one while the other dries af-
the seal on the skin. ter it is cleaned with soap and water or
◆ A two-piece flanged system can also a commercially prepared cleaning solu-
be emptied by unsnapping the pouch. tion.
Let the drainage flow into the toilet. ◆ Failure to fit the pouch properly
◆ Release flatus through the gas re- over the stoma or improper use of a
lease valve, if the pouch has one. Oth- belt can injure the stoma. Be alert for a
erwise, release flatus by tilting the bot- possible allergic reaction to adhesives
tom of the pouch upward, releasing the or other ostomy products.
clamp, and expelling the flatus. To re-
lease flatus from a flanged system, Documentation
loosen the seal between the flanges.
◆ Never make a pinhole in a pouch to Record the date and time of the pouch-
release gas. The hole destroys the odor- ing system change, and note the char-
proof seal. acter of drainage, including color,
◆ Remove and discard gloves. amount, type, and consistency. De-
scribe the appearance of the stoma and
Special considerations the peristomal skin. Document patient
teaching, and describe the teaching
◆ After you perform the procedure content. Record the patient’s response
and explain it to the patient, encourage to self-care, and evaluate his learning
the patient’s increasing involvement in progress.
self-care.
◆ Use adhesive solvents and removers
only after patch testing of the patient’s Colostomy irrigation
skin is performed. Some products may
irritate the skin or produce hypersensi- Irrigation of a colostomy can serve two
tivity reactions. Consider using a liquid purposes: It allows a patient with a
Colostomy irrigation 305
descending or sigmoid colostomy to Fill the irrigation bag with warmed

regulate bowel function, and it cleans tap water (or normal saline solution, if
the large bowel before and after tests, the irrigation is to clean the bowel).
surgery, or other procedures. Hang the bag on the I.V. pole or a wall
Colostomy irrigation may begin as hook. The bottom of the bag should be
soon as bowel function resumes after at the patient’s shoulder level to pre-
surgery. However, most clinicians rec- vent fluid from entering the bowel too
ommend waiting until the patient’s quickly. Most irrigation sets also have
bowel movements are more pre- a clamp that regulates the flow rate.
dictable. Initially, the nurse or the pa- Prime the tubing with irrigant to
tient irrigates the colostomy at the prevent air from entering the colon and
same time every day, recording the possibly causing cramps and gas pains.
amount of output and any spillage that
occurs between irrigations. Between 4 Implementation
and 6 weeks may pass before colosto-
my irrigation establishes a predictable ◆ Confirm the patient’s identity using
pattern of elimination. two patient identifiers.
◆ Explain each step of the procedure
Equipment and preparation to the patient because he’ll probably be
irrigating the colostomy himself.
Colostomy irrigation set (contains an ◆ Provide privacy, and wash your
irrigation drain or sleeve, an ostomy hands.
belt [if needed] to secure the drain or ◆ If the patient is in bed, place a
sleeve, water-soluble lubricant, linen-saver pad under him to protect
drainage pouch clamp, and irrigation the sheets from getting soiled.
bag with clamp, tubing, and cone tip) ◆ Put on gloves.
◆ 1 L of tap water irrigant warmed to ◆ If the patient uses an ostomy
about 105° F (40.6° C) ◆ warmed nor- pouch, remove it.
mal saline solution (for cleansing ene- ◆ Place the irrigation sleeve over the
mas) ◆ I.V. pole or wall hook ◆ wash- stoma. If the sleeve doesn’t have an
cloth and towel ◆ water ◆ ostomy adhesive backing, secure the sleeve
pouching system ◆ linen-saver pad ◆ with an ostomy belt. If the patient has
gloves ◆ optional: bedpan or chair, a two-piece pouching system with
mild nonmoisturizing soap, rubber flanges, snap off the pouch and save it.
band or clip, and small dressing, ban- Snap on the irrigation sleeve.
dage, or commercial stoma cap ◆ Place the open-ended bottom of the
Depending on the patient’s condi- irrigation sleeve in the bedpan or toilet
tion, irrigation of the colostomy may to promote drainage by gravity. If nec-
be performed in bed using a bedpan or essary, cut the sleeve so that it meets
in the bathroom using the toilet or a the water level inside the bedpan or
chair. Set up the irrigation bag with toilet. Effluent may splash from a short
tubing and a cone tip. For irrigation sleeve or may not drain from a long
with the patient in bed, place the bed- sleeve.
pan beside the bed and elevate the ◆ Lubricate your gloved small finger
head of the bed to between 45 and 90 with water-soluble lubricant, and insert
degrees, if allowed. For irrigation in the the gloved finger into the stoma. If
bathroom, have the patient sit on the you’re teaching the patient, have him
toilet or on a chair facing the toilet, do this to determine the bowel angle at
whichever he finds more comfortable. which to insert the cone safely. Expect
the stoma to tighten when the finger ◆ Inspect the skin and stoma for
enters the bowel and then to relax in a changes in appearance. Although it’s
few seconds. usually dark pink to red, the color of
◆ Lubricate the cone with water- the stoma may change with the pa-
soluble lubricant to prevent it from tient’s status. Notify the physician of
irritating the mucosa. marked changes in stoma color. A pale
◆ Insert the cone into the top opening hue may result from anemia. Substan-
of the irrigation sleeve and then into tial darkening suggests a change in
the stoma. Angle the cone to match the blood flow to the stoma.
bowel angle. Insert the cone gently, but ◆ Apply a clean pouch. If the patient
snugly; never force it into place. has a regular pattern of bowel elimina-
◆ Unclamp the irrigation tubing, and tion, he may prefer a small dressing,
allow the water to flow slowly. If you bandage, or commercial stoma cap.
don’t have a clamp to control the flow ◆ If the irrigation sleeve is disposable,
rate of the irrigant, pinch the tubing discard it. If the irrigation sleeve is
to control the flow. The water should reusable, rinse it and hang it to dry
enter the colon over a period of 5 to along with the irrigation bag, tubing,
10 minutes. (If the patient reports and cone.
cramping, slow or stop the flow, keep
the cone in place, and have the patient Special considerations
take a few deep breaths until the
cramping stops.) Cramping during irri- ◆ Irrigating a colostomy to establish a
gation may result from a bowel that’s regular bowel elimination pattern isn’t
ready to empty, water that’s too cold, a successful in all patients. If the bowel
rapid flow rate, or air in the tubing. continues to move between irrigations,
◆ Have the patient remain stationary try decreasing the volume of irrigant.
for 15 to 20 minutes to allow the initial Increasing the volume of irrigant won’t
effluent to drain. help, because it only stimulates peri-
◆ If the patient is ambulatory, he can stalsis. Keep a record of results. Also
stay in the bathroom until all effluent consider irrigating every other day.
empties, or he can clamp the bottom of ◆ Irrigation may help regulate bowel
the drainage sleeve with a rubber band function in patients with a descending
or clip and return to bed. Explain that or sigmoid colostomy because this is
ambulation and activity stimulate elim- the bowel’s stool storage area. Howev-
ination. Suggest that the nonambulato- er, a patient with an ascending or
ry patient lean forward or massage his transverse colostomy won’t benefit
abdomen to stimulate elimination. from irrigation. A patient with a de-
◆ Wait about 45 minutes for the bowel scending or sigmoid colostomy who’s
to finish eliminating the irrigant and ef- missing part of the ascending or trans-
fluent. Then remove the irrigation sleeve. verse colon may not be able to irrigate
◆ If the irrigation was intended to successfully, because his ostomy may
clean the bowel, repeat the procedure function as an ascending or transverse
with warmed normal saline solution colostomy.
until the return solution appears clear. ◆ If diarrhea develops, discontinue ir-
◆ Using a washcloth, mild nonmois- rigations until stools form again. Irriga-
turizing soap, and water, gently clean tion alone won’t achieve regularity for
the area around the stoma. Rinse and the patient. He must also observe a
dry the area thoroughly with a clean complementary diet and exercise regi-
towel. men.
Defibrillation 307
◆ If the patient has a strictured stoma rent may be placed on the patient’s
that prohibits cone insertion, remove chest or, during cardiac surgery, direct-
the cone from the irrigation tubing and ly on the myocardium.
replace it with a soft silicone catheter. Because ventricular fibrillation leads
Angle the catheter gently 2 to 4 (5 to to immediate death if it isn’t corrected,
10 cm) into the bowel to instill the irri- the success of defibrillation depends on
gant. Don’t force the catheter into the early recognition and quick treatment
stoma, and don’t insert it farther than of this arrhythmia. In addition to treat-
the recommended length because you ing ventricular fibrillation, defibrilla-
may perforate the bowel. tion may be used to treat ventricular
◆ Observe the patient for complica- tachycardia that doesn’t produce a
tions. Bowel perforation may occur if a pulse.
catheter is incorrectly inserted into the Patients with a history of ventricular
stoma. Fluid and electrolyte imbal- fibrillation may be candidates for an
ances may result from using too much implantable cardioverter-defibrillator, a
irrigant. sophisticated device that automatically
discharges an electric current when it
Documentation senses a ventricular tachyarrhythmia.
(See Understanding the ICD, page 308.)
Record the date and time of irrigation
and the type and amount of irrigant Equipment
used. Note the color of the stoma and
the character of drainage, including its Defibrillator with electrocardiogram
color, consistency, and amount. Record (ECG) monitor and recorder ◆ external
patient teaching. Describe the teaching paddles ◆ conductive medium pads
content and the patient’s response to ◆ oxygen therapy equipment ◆ hand-
self-care instruction. Evaluate the pa- held resuscitation bag ◆ emergency
tient’s learning progress. cardiac medications
Implementation
Defibrillation
◆ Assess the patient to determine if
The 2005 American Heart Association he lacks a pulse. Call for help, and per-
guidelines identify defibrillation as the form cardiopulmonary resuscitation
standard treatment for ventricular fib- (CPR) until the defibrillator and other
rillation after cardiopulmonary resusci- emergency equipment arrive.
tation (CPR). CPR prolongs the time ◆ If the defibrillator has “quick look”
that defibrillation can occur, but CPR capability, place the external paddles
alone isn’t likely to correct ventricular on the patient’s chest to view his car-
fibrillation, so early defibrillation is diac rhythm quickly. Otherwise, con-
critical. nect the monitoring leads of the ECG
Defibrillation involves using elec- monitor with recorder to the patient,
trode paddles to direct an electric cur- and assess his cardiac rhythm. If ven-
rent through the patient’s heart. The tricular fibrillation or pulseless ventric-
current causes the myocardium to de- ular tachycardia occurs, prepare to de-
polarize, which in turn encourages the fibrillate the patient.
sinoatrial node to resume control of the ◆ Expose the patient’s chest, and
electrical activity of the heart. The apply conductive medium pads at
electrode paddles that deliver the cur- the paddle placement positions. For
Understanding the ICD
The implantable cardioverter-defibrillator (ICD) has a programmable pulse generator

and lead system that monitors the activity of the heart, detects ventricular bradyar-
rhythmias and tachyarrhythmias, and responds with appropriate therapies. The range of
therapies includes antitachycardia and bradycardia pacing, cardioversion, and defibrilla-
tion. Newer defibrillators can also provide dual-chamber or biventricular pacing.
Implantation of an ICD is similar to that of a permanent pacemaker. The cardiologist
positions the lead (or leads) transvenously in the endocardium of the right ventricle (and
the right atrium, if both chambers require pacing). The lead connects to a generator box,
which is implanted on the left or right side of the upper chest, near the clavicle.
Leads
anterolateral placement, place one pad- ately below the scapulae, but not un-
dle to the right of the upper sternum, der the vertebral column.
just below the right clavicle, and the Alert Never place defibrillator
other over the fifth or sixth intercostal paddles over an implanted
space at the left anterior axillary line. pacemaker.
For anteroposterior placement, place ◆ Turn on the defibrillator. For exter-
the anterior paddle directly over the nal defibrillation in an adult patient,
heart at the precordium, to the left of set the energy level to 360 joules, un-
the lower sternal border. Place the flat less using a biphasic defibrillator,
posterior paddle under the patient’s which utilizes lower energy settings.
body, beneath the heart and immedi- (See Biphasic defibrillators.)
Defibrillation 309
◆ Charge the paddles by pressing the

charge buttons, which are located ei- Biphasic defibrillators
ther on the machine or on the paddles.
◆ Place the paddles over the conduc- Most facility defibrillators are mono-
tive pads and press firmly against the phasic; they deliver a single current
patient’s chest, using 25 lb (11.3 kg) of of electricity that travels in one direc-
pressure. tion between the two pads or paddles
◆ Reassess the patient’s cardiac on the patient’s chest. To be effective,
rhythm. they require a high amount of electric
current.
◆ If the patient remains in ventricular
Recently, new biphasic defibrillators
fibrillation or pulseless ventricular
have been introduced into facilities.
tachycardia, instruct all personnel to
Placement of the pads or paddles is the
stand clear of the patient and the bed. same as with monophasic defibrillators.
◆ Discharge the current by pressing The difference is that the electric current
both paddle charge buttons simultane- discharged from the pads or paddles
ously. travels in a positive direction for a spec-
◆ Resume CPR immediately. Perform ified duration and then reverses and
five cycles of CPR and then reassess flows in a negative direction for the re-
the patient’s rhythm. maining time of the electrical discharge.
◆ If necessary, prepare to defibrillate a This type of defibrillator delivers two
second time. Instruct a colleague to set currents of electricity and lowers the de-
the energy level on the defibrillator to fibrillation threshold of the heart mus-
360 joules. Announce that you’re pre- cle, making it possible to defibrillate
paring to defibrillate, and follow the ventricular fibrillation successfully with
procedure described earlier. smaller amounts of energy. Instead of
◆ Resume CPR immediately. Perform 360 joules, an initial shock of 120 to
five cycles of CPR and reassess the pa- 200 joules is usually effective. The
tient. If defibrillation is needed again, biphasic defibrillator adjusts for differ-
ences in impedance (the resistance of
instruct a colleague to set the energy
the current through the chest). This
level to 360 joules. Then follow the
helps reduce the number of shocks
same procedure as before.
needed to terminate ventricular fibrilla-
◆ If the patient still has no pulse after tion. Biphasic technology uses lower en-
three initial defibrillations, resume ergy levels and fewer shocks. Thus, it
CPR, give supplemental oxygen, and reduces the damage to the myocardial
begin administration of appropriate muscle. Biphasic defibrillators, when
emergency cardiac medications such as used at the clinically appropriate energy
antiarrhythmics. Also, consider possi- level, may be used for defibrillation
ble causes for failure of the patient’s and — when placed in the synchronized
rhythm to convert, such as acidosis or mode — for synchronized cardioversion.
hypoxia.
◆ If defibrillation restores a normal
rhythm, check the patient’s central and
peripheral pulses and measure the pa- supplemental oxygen, ventilation, and
tient’s blood pressure, heart rate, and medications as needed. Check the pa-
respiratory rate. Assess the patient’s tient’s chest for electrical burns, and
level of consciousness, cardiac rhythm, treat them as ordered with cortico-
breath sounds, skin color, and urine steroid or lanolin-based creams. Also,
output. Obtain baseline arterial blood prepare the defibrillator for immediate
gas values and a 12-lead ECG. Provide reuse.
Special considerations Equipment
◆ Defibrillators vary from one manu- Doppler ultrasound blood flow detector
facturer to the next, so familiarize ◆ coupling or transmission gel ◆ soft
yourself with the equipment. Defibrilla- cloth ◆ antiseptic solution
tor operation should be checked at
least every 8 hours and after each use. Implementation
◆ Defibrillation can be affected by
several factors, including the size and ◆ Apply a small amount of coupling
placement of the paddles, the condition or transmission gel (not water-soluble
of the patient’s myocardium, the dura- lubricant) to the ultrasound probe.
tion of the arrhythmia, chest resis- ◆ Position the probe on the skin di-
tance, and the number of counter- rectly over the selected artery.
shocks. ◆ When using a Doppler ultrasound
◆ Remove any transdermal medica- blood flow detector model with a
tions from the chest (and back if using speaker, turn the instrument on. Mov-
anterior-posterior placement) because ing counterclockwise, set the volume
the medium may interfere with current control to the lowest setting. If your
conduction or produce a burn. model doesn’t have a speaker, plug in
◆ Defibrillation can cause accidental the earphones and slowly raise the vol-
electric shock to those providing care. ume. The Doppler ultrasound stetho-
The use of an insufficient amount of scope is basically a stethoscope fitted
conductive medium can lead to skin with an audio unit, a volume control,
burns. and a transducer, which amplifies the
movement of RBCs.
Documentation ◆ To obtain the best signals with ei-
ther device, tilt the probe 45 to 60 de-
Document the procedure, including the grees from the artery and apply gel be-
patient’s ECG rhythms before and after tween the skin and the probe. Slowly
defibrillation; the number of times that move the probe in a circular motion to
defibrillation was performed; the volt- locate the center of the artery and the
age used during each attempt; whether Doppler signal — a hissing noise at the
a pulse returned; the dosage, route, heartbeat.
and time of drug administration; ◆ Avoid moving the probe rapidly be-
whether CPR was used; the way that cause it distorts the signal.
the airway was maintained; and the ◆ Count the signals for 60 seconds to
patient’s outcome. determine the pulse rate.
◆ After you’ve measured the pulse
rate, clean the probe with an approved
Doppler use antiseptic solution. Don’t immerse the
probe or bump it against a hard sur-
More sensitive than palpation for deter- face.
mining pulse rate, the Doppler ultra-
sound blood flow detector is especially Documentation
useful when a pulse is weak. Unlike
palpation, which detects expansion and Record the location and quality of the
retraction of the arterial walls, this in- pulse, the pulse rate, and the time of
strument detects the motion of red measurement.
blood cells (RBCs).
Feeding tube insertion and removal 311
water-soluble lubricant ◆ skin prepara-

Feeding tube insertion and tion (such as tincture of benzoin) ◆ fa-
removal cial tissues ◆ penlight ◆ small cup of
water with straw, or ice chips ◆ emesis
Inserting a feeding tube nasally or orally basin ◆ 60-ml syringe ◆ pH test strip
into the stomach or duodenum provides
nourishment to a patient who can’t or For removal
won’t eat. The feeding tube also permits Linen-saver pad ◆ tube clamp ◆ bulb
administration of supplemental feedings syringe
to a patient who has very high nutri- Have a tube of the proper size avail-
tional requirements, such as an uncon- able. Usually, the physician orders the
scious patient or one with extensive smallest-bore tube that will allow free
burns. Typically, a nurse inserts the passage of the liquid feeding formula.
feeding tube as ordered. The preferred Read the instructions on the tubing
route for a feeding tube is nasal, but the package carefully because the charac-
oral route may be used for patients with teristics of feeding tubes vary accord-
such conditions as a deviated septum or ing to the manufacturer. (For example,
an injury of the head or nose. some tubes have marks at the appro-
The physician may order duodenal priate lengths for gastric, duodenal,
feeding when the patient can’t tolerate and jejunal insertion.)
gastric feeding or when he expects gas- Examine the tube to make sure that
tric feeding to produce aspiration. The it’s free from defects, such as cracks or
absence of bowel sounds or possible rough or sharp edges. Next, run water
intestinal obstruction contraindicates through the tube to check for patency,
the use of a feeding tube. activate the coating, and facilitate re-
Feeding tubes differ somewhat from moval of the guide wire.
standard nasogastric tubes. Made of sili-
cone, rubber, or polyurethane, feeding Implementation
tubes have small diameters and great
flexibility. These qualities reduce ◆ Confirm the patient’s identity using
oropharyngeal irritation, necrosis result- two patient identifiers.
ing from pressure on the tracheoesoph- ◆ Explain the procedure to the pa-
ageal wall, irritation of the distal esoph- tient, and show him the feeding tube
agus, and discomfort from swallowing. so that he knows what to expect and
To facilitate passage, some feeding tubes can cooperate more fully.
are weighted with tungsten. Some tubes ◆ Provide privacy. Wash your hands
need a guide wire to keep them from and put on gloves.
curling in the back of the throat. ◆ Assist the patient into semi-Fowler’s
These small-bore tubes usually have or high Fowler’s position.
radiopaque markings and a water- ◆ Place a linen-saver pad across the
activated coating that provides a lub- patient’s chest in case of spills.
ricated surface. ◆ To determine the tube length need-
ed to reach the stomach, extend the
Equipment and preparation distal end of the tube from the tip of
the patient’s nose to his earlobe. Coil
For insertion this portion of the tube around your
Feeding tube (#6 to #18 French, with fingers so that the end will remain
or without a guide wire) ◆ linen-saver curved until you insert it. Extend the
pad ◆ gloves ◆ hypoallergenic tape ◆ uncoiled portion from the earlobe to
the xiphoid process. Use a small piece reaches the patient’s nostril or lips.
of hypoallergenic tape to mark the total Tube placement should be confirmed
length of the two portions. by X-ray.
◆ Once each shift or before adminis-
Inserting the tube nasally tering liquids or medications, you can
◆ Using the penlight, assess nasal pa- check tube placement by measuring
tency. Inspect the nasal passages for a the exposed portion of the tube and
deviated septum, polyps, or other ob- documenting its length. Any increase
structions. Occlude one nostril, then from the original measurement may
the other, to determine which has the signal that the tube has dislodged.
better airflow. Assess the patient’s his- ◆ You may also check tube placement
tory of nasal injury or surgery. by examining the aspirate and placing
◆ Lubricate the curved tip of the tube a small amount on the pH test strip.
(and the guide wire, if appropriate) Probability of gastric placement is in-
with a small amount of water-soluble creased if the aspirate has a typical
lubricant to ease insertion and prevent gastric fluid appearance (grassy green,
tissue injury. clear and colorless with mucous
◆ Ask the patient to hold the emesis shreds, or brown) and the pH is 5.
basin and facial tissues in case he ◆ After you confirm the initial proper
needs them. tube placement, remove the tape mark-
◆ To advance the tube, insert the ing the tube length.
curved, lubricated tip into the more ◆ Tape the tube to the patient’s nose
patent nostril and direct it along the and remove the guide wire.
nasal passage toward the ear on the ◆ To advance the tube to the duode-
same side. When it passes the naso- num, especially a tungsten-weighted
pharyngeal junction, turn the tube tube, position the patient on his right
180 degrees to aim it downward, into side. This allows gravity to assist in
the esophagus. Tell the patient to lower passage of the tube through the py-
his chin to his chest to close the trachea. lorus. Move the tube forward 2 to 3
Then give him a small cup of water with (5 to 7.5 cm) hourly until X-ray studies
a straw or ice chips. Direct him to sip confirm duodenal placement. (An
the water or suck on the ice and swal- X-ray must confirm placement before
low frequently to ease passage of the feeding begins because duodenal feed-
tube. Advance the tube as he swallows. ing can cause nausea and vomiting if
it’s accidentally delivered to the stom-
Inserting the tube orally ach.)
◆ Have the patient lower his chin to ◆ Apply a skin preparation to the pa-
close his trachea, and ask him to open tient’s cheek before securing the tube
his mouth. with tape. This helps the tube to ad-
◆ Place the tip of the tube at the back here to the skin and prevents irritation.
of the patient’s tongue, give the patient ◆ Tape the tube securely to the pa-
water, and instruct him to swallow. Re- tient’s cheek to avoid excessive pres-
mind him to avoid clamping his teeth sure on his nostrils.
down on the tube. Advance the tube as
he swallows. Removing the tube
◆ Protect the patient’s chest with a
Positioning the tube linen-saver pad.
◆ Continue to pass the tube until the ◆ Flush the tube with air with the
tape marking the appropriate length bulb syringe, clamp or pinch it to
Gastric lavage 313
prevent aspiration of fluid during with- against the stomach wall. If the tube
drawal, and withdraw the tube gently, coils above the stomach, you won’t be
but quickly. able to aspirate the stomach contents.
◆ Promptly cover and discard the To rectify this situation, change the pa-
used tube. tient’s position or withdraw the tube a
few inches, readvance it, and try to as-
Special considerations pirate again. If the tube was inserted
with a guide wire, don’t use the guide
◆ Check gastric residual contents be- wire to reposition the tube. However,
fore each feeding. Withhold the feeding the physician may do so, using fluoro-
if residual volumes are greater than scopic guidance.
200 ml on two successive assessments. Patient teaching tips If the
◆ Flush the feeding tube every 4 patient will use a feeding tube
hours with 20 to 30 ml of normal at home, make appropriate nursing
saline solution or water to maintain pa- referrals for home care and teach
tency. Retape the tube at least daily the patient and his caregivers how
and as needed. Alternate taping the to use and care for a feeding tube.
tube toward the inner and the outer Teach them how to obtain equip-
side of the nose to avoid constant pres- ment, insert and remove the tube,
sure on the same nasal area. Inspect prepare and store feeding formula,
the skin for redness and breakdown. and solve problems regarding tube
◆ Provide nasal hygiene daily using position and patency.
cotton-tipped applicators and water- Teach the patient to watch for
soluble lubricant to remove crusted se- complications related to prolonged
cretions. Help the patient to brush his intubation, such as skin erosion at
teeth, gums, and tongue with mouth- the nostril, sinusitis, esophagitis,
wash or a mild salt-water solution at esophagotracheal fistula, gastric ul-
least twice daily. ceration, and pulmonary and oral
◆ If the patient can’t swallow the feed- infection.
ing tube, use a guide to aid insertion.
◆ Precise placement of the feeding tube Documentation
is especially important because small-
bore feeding tubes may slide into the For tube insertion, record the date and
trachea without causing immediate signs time, tube type and size, insertion site,
or symptoms of respiratory distress, exposed length of tube, area of place-
such as coughing, choking, gasping, or ment, and confirmation of proper
cyanosis. However, the patient will usu- placement. Also record the name of the
ally cough if the tube enters the larynx. person performing the procedure.
To make sure that the tube clears the Record flushes on the patient’s record
larynx, ask the patient to speak. If he of intake and output. For tube removal,
can’t, the tube is in the larynx. With- record the date, time, and the patient’s
draw the tube at once and reinsert it. tolerance of the procedure.
◆ When aspirating gastric contents to
check tube placement, pull gently on
the syringe plunger to prevent trauma Gastric lavage
to the stomach lining or bowel. If you
meet resistance during aspiration, stop After poisoning or drug overdose, espe-
the procedure because resistance may cially in patients who have central
result simply from the tube lying nervous system depression or an
inadequate gag reflex, gastric lavage specimen container ◆ laboratory re-

flushes the stomach and removes in- quests ◆ norepinephrine ◆ optional:
gested substances through a gastric patient restraints and charcoal
lavage tube. The procedure is also used A prepackaged, syringe-type irriga-
to empty the stomach in preparation tion kit may be used for intermittent
for endoscopic examination. For pa- lavage. For poisoning or a drug over-
tients with gastric or esophageal bleed- dose, however, the continuous lavage
ing, lavage with tepid or iced water or setup may be more appropriate be-
normal saline solution may be used to cause it’s a faster and more effective
stop bleeding. However, some contro- means of diluting and removing the
versy exists over the effectiveness of harmful substance.
iced lavage for this purpose. Set up the lavage equipment. (See
Gastric lavage can be continuous or Preparing for gastric lavage.) If iced
intermittent. Typically, this procedure lavage is ordered, chill the desired irri-
is done in the emergency department gant (water or normal saline solution)
or intensive care unit by a physician, in a basin of ice. Lubricate the end of
gastroenterologist, or nurse. A wide- the lavage tube with the water-soluble
bore lavage tube is usually inserted by lubricant or anesthetic ointment.
a gastroenterologist.
Gastric lavage is contraindicated af- Implementation
ter ingestion of a corrosive substance
(such as lye, a petroleum distillate, am- ◆ Confirm the patient’s identity using
monia, an alkali, or a mineral acid) be- two patient identifiers.
cause the lavage tube may perforate ◆ Explain the procedure to the pa-
the already compromised esophagus. tient, provide privacy, and wash your
Correct placement of the lavage hands.
tube is essential for patient safety. Ac- ◆ Put on gloves and a face shield.
cidental misplacement of the tube (in ◆ Drape the towel or linen-saver pad
the lungs, for example) followed by over the patient’s chest to protect him
lavage can be fatal. Other complica- from spills.
tions of gastric lavage include brady- ◆ The physician inserts the lavage
arrhythmias and aspiration of gastric tube nasally and advances it slowly
fluids. and gently. Forceful insertion may in-
jure tissues and cause epistaxis. He
Equipment and preparation checks the placement of the tube by in-
jecting about 30 cc of air into the tube
Lavage setup ◆ two graduated contain- with the bulb syringe and then auscul-
ers for drainage ◆ clamp or smooth tating the abdomen with a stethoscope.
hemostat ◆ 2 to 3 L of normal saline If the tube is in place, he’ll hear air en-
solution, tap water, or appropriate anti- tering the stomach.
dote as ordered ◆ basin of ice, if or- ◆ Because the patient may vomit
dered ◆ Ewald tube or any large-lumen when the lavage tube reaches the pos-
gastric or lavage tube, typically #36 to terior pharynx during insertion, be pre-
#40 French ◆ water-soluble lubricant pared to suction the airway immediate-
or anesthetic ointment ◆ stethoscope ly with a tonsillar suction device.
◆ 1⁄2 hypoallergenic tape ◆ 50-ml ◆ When the lavage tube passes the
bulb or catheter-tip syringe ◆ gloves ◆ posterior pharynx, help the patient into
face shield ◆ linen-saver pad or towel Trendelenburg’s position and turn him
◆ tonsillar suction device ◆ labeled toward his left side in a three-quarter
Gastric lavage 315
Preparing for gastric lavage
Prepare the lavage setup as follows:

◆ Connect one of the three pieces of
large-lumen tubing to the irrigant contain-
er.
◆ Insert the stem of the Y-connector in
the other end of the tubing.
◆ Connect the remaining two pieces of
tubing to the free ends of the Y-connector.
◆ Place the unattached end of one of the
tubes into one of the drainage containers.
(Later, you’ll connect the other piece of
tubing to the patient’s gastric tube.)
◆ Clamp the tube that leads to the irri-
gant.
◆ Suspend the entire setup from the I.V.
pole, hanging the irrigant container at the
highest level.
prone posture. This position minimizes the patient’s tolerance and prevent vom-
passage of gastric contents into the iting. Use water or normal saline solution,
duodenum and may prevent the patient preferably warmed to 68 F (20.2 C)
from aspirating vomitus. to avoid the risk of hypothermia.
◆ After securing the lavage tube ◆ Clamp the inflow tube with a
nasally or orally with hypoallergenic smooth hemostat, and unclamp the
tape and making sure that the irrigant outflow tube to allow the irrigant to
inflow tube on the lavage setup is flow out. If you’re using the syringe ir-
clamped, connect the unattached end rigation kit, aspirate the irrigant with
of this tube to the lavage tube. Allow the syringe and empty it into a gradu-
the stomach contents to empty into a ated container. Measure the amount of
graduated drainage container before outflow to make sure that it equals at
you instill irrigant. This confirms prop- least the amount of irrigant that you
er tube placement and decreases the instilled. This prevents accidental
risk of overfilling the stomach with irri- stomach distention and vomiting. If the
gant and inducing vomiting. If you’re drainage amount is significantly less
using a syringe irrigation kit, aspirate than the instilled amount, reposition
the stomach contents with a 50-ml the tube until sufficient solution flows
bulb or catheter-tip syringe before in- out. Gently massage the abdomen over
stilling the irrigant. the stomach to promote outflow.
◆ When you confirm proper tube ◆ Repeat the inflow–outflow cycle un-
placement, begin gastric lavage by in- til the returned fluids appear clear. This
stilling about 250 ml of irrigant to assess signals that the stomach no longer
holds harmful substances or that ◆ When you aspirate the stomach for
bleeding has stopped. ingested poisons or drugs, save the
◆ Assess the patient’s vital signs, contents in a labeled specimen contain-
urine output, and level of conscious- er to send to the laboratory for analysis
ness (LOC) every 15 minutes. Notify with the appropriate laboratory re-
the physician of any changes. quest. If ordered, after lavage to re-
◆ If ordered, remove the lavage tube. move poisons or drugs, administer
charcoal, as directed, through the naso-
Special considerations gastric (NG) tube. The charcoal will
absorb remaining toxic substances. The
◆ To control GI bleeding, the physi- tube may be clamped temporarily, al-
cian may order continuous irrigation of lowed to drain via gravity, attached to
the stomach with an irrigant and a intermittent suction, or removed.
vasoconstrictor such as norepineph- ◆ When you perform gastric lavage to
rine. After the stomach absorbs norepi- stop bleeding, keep precise records of
nephrine, the portal system delivers the intake and output to determine the
drug directly to the liver, where it’s amount of bleeding. When large vol-
metabolized. This prevents the drug umes of fluid are instilled and with-
from circulating systemically and initi- drawn, serum electrolyte and arterial
ating a hypertensive response. Alterna- blood gas levels may be measured dur-
tively, the physician may direct you to ing or at the end of lavage.
clamp the outflow tube for a prescribed ◆ Assess the patient for complica-
period after you instill the irrigant and tions during gastric lavage. Vomiting
the vasoconstrictor and before you and subsequent aspiration, the most
withdraw it. This allows the mucosa common complications of gastric
time to absorb the drug. lavage, occur more commonly in a
◆ Never leave a patient alone during groggy patient. Bradyarrhythmias may
gastric lavage. Observe him continu- also occur. Especially after iced
ously for changes in LOC, and monitor lavage, the patient’s body temperature
his vital signs frequently. The natural may drop, thereby triggering cardiac
vagal response to intubation can de- arrhythmias.
press the patient’s heart rate.
◆ If you must restrain the patient, se- Documentation
cure the restraints on the same side of
the bed or stretcher so that you can Record the date and time of lavage, the
free them quickly without moving to size and type of NG tube used, the vol-
the other side of the bed. ume and type of irrigant, and the
◆ Remember to keep tracheal suction- amount of gastric contents drained.
ing equipment nearby and to watch Document this information on the
closely for airway obstruction caused record of intake and output, and in-
by vomiting or excess oral secretions. clude your observations, including the
Throughout gastric lavage, you may color and consistency of drainage. Keep
need to suction the oral cavity fre- precise records of the patient’s vital
quently to ensure an open airway and signs and LOC, drugs instilled through
prevent aspiration. For the same rea- the tube, the time that the tube was re-
sons, and if he doesn’t exhibit an ade- moved, and the patient’s response to
quate gag reflex, the patient may re- the procedure.
quire an endotracheal tube before the
procedure.
Gastrostomy feeding button care 317
◆ Explain the insertion, reinsertion,

Gastrostomy feeding and feeding procedure to the patient.
button care Tell him that the physician will per-
form the initial insertion.
A gastrostomy feeding button is an alter- ◆ Wash your hands and put on gloves.
native feeding device for an ambulatory ◆ Check for residual with the syringe.
patient who’s receiving long-term enteral If you find more than 50 ml of resid-
feedings. Approved by the Food and ual, inform the physician and withhold
Drug Administration for 6-month implan- the feeding until reassessment.
tation, feeding buttons can be used to re- ◆ Attach the adapter and feeding
place gastrostomy tubes, if necessary. catheter to the food syringe or bag.
The feeding button has a mushroom Clamp the catheter, and fill the syringe
dome at one end and two wing tabs or bag and catheter with formula. Refill
and a flexible safety plug at the other. the syringe before it’s empty. These
When inserted into an established steps prevent air from entering the
stoma, the button lies almost flush stomach and distending the abdomen.
with the skin, with only the top of the ◆ Open the safety plug, and attach the
safety plug visible. adapter and feeding catheter to the
The button can usually be inserted gastrostomy feeding button. Elevate the
into a stoma in less than 15 minutes. In food syringe or bag above the patient’s
addition to its cosmetic appeal, the de- stomach level, and gravity-feed the for-
vice is easily maintained, reduces skin mula for 15 to 30 minutes, varying the
irritation and breakdown, and is less height as needed to alter the flow rate.
likely to become dislodged or to migrate Use a pump for continuous infusion or
than an ordinary feeding tube. A one- for feedings that last several hours.
way antireflux valve mounted just inside ◆ After the feeding, flush the button
the mushroom dome prevents accidental with 10 ml of water. Clean the inside of
leakage of gastric contents. The device the feeding catheter with a cotton-tipped
usually is replaced after 3 to 4 months applicator and water to preserve its pa-
because the antireflux valve wears out. tency and to dislodge formula or food
particles. Lower the food syringe or bag
Equipment below the patient’s stomach level to al-
low belching. Remove the adapter and
Gastrostomy feeding button of the cor- feeding catheter. The antireflux valve
rect size (all three sizes, if correct one should prevent gastric reflux. Snap the
isn’t known) ◆ gloves ◆ feeding acces- safety plug into place to keep the lumen
sories, including adapter, feeding clean and prevent leakage if the antire-
catheter, food syringe or bag, and for- flux valve fails. If the patient feels nau-
mula ◆ catheter clamp ◆ cleaning seated or vomits after the feeding, vent
equipment, including water, cotton- the button with the adapter and feeding
tipped applicator, pipe cleaner, and catheter to help control the vomiting.
mild soap or antiseptic solution ◆ op- ◆ Wash the catheter and food syringe
tional: pump to provide continuous in- or bag in mild soap, and rinse thor-
fusion over several hours oughly. Clean the catheter and adapter
with a pipe cleaner. Rinse the equip-
Implementation ment well before using it for the next
feeding. Soak the equipment once per
◆ Confirm the patient’s identity using week according to the manufacturer’s
two patient identifiers. recommendations.
How to reinsert a gastrostomy feeding button
If your patient’s gastrostomy feeding button pops out (with coughing, for instance), you
or he will need to reinsert the device. Here are some steps to follow.
Prepare the equipment ◆ Remove the obturator by gently rotat-

Collect the feeding button, an obturator, ing it as you withdraw it, to keep the an-
and water-soluble lubricant. If the button tireflux valve from adhering to it. If the
will be reinserted, wash it with soap and valve sticks, gently push the obturator
water and rinse it thoroughly. back into the button until the valve closes.
◆ After you remove the obturator, make
sure that the valve is closed. Then close
Safety plug the flexible safety plug, which should be
relatively flush with the skin surface.
Mushroom
Antireflux dome
valve
Insert the button

◆ Check the depth of the patient’s stoma
to make sure that you have a feeding but-
ton of the correct size. Then clean around ◆ If you need to administer a feeding
the stoma. right away, open the safety plug and at-
◆ Lubricate the obturator with a water- tach the feeding adapter and feeding
soluble lubricant, and distend the button tube. Deliver the feeding as ordered.
several times to ensure the patency of the
antireflux valve within the button. Feeding
◆ Lubricate the mushroom dome and the catheter
stoma. Gently push the button through Feeding
the stoma into the stomach. adapter
Obturator
Abdominal
wall Safety plug
Special considerations the amount of formula already deliv-

ered, and resume feeding.
◆ If the button pops out during feed- ◆ Once daily, clean the peristomal
ing, reinsert it (see How to reinsert a skin with mild soap and water or
gastrostomy feeding button), estimate povidone-iodine solution and let the
Incentive spirometry 319
skin air-dry for 20 minutes to minimize the amount of air that the patient pulls
skin irritation. Also clean the site through the device when he inhales.
whenever spillage from the feeding bag Patients who are at low risk for at-
occurs. electasis may use a flow incentive
Patient teaching tips Before spirometer. Patients who are at high
discharge, make sure that the risk may need a volume incentive
patient can insert and care for the gas- spirometer, which measures lung infla-
trostomy feeding button. If necessary, tion more precisely.
teach him or a family member or care- Incentive spirometry benefits the
giver how to reinsert the button by patient who requires prolonged bed
first practicing on a model. Offer writ- rest, especially the postoperative pa-
ten instructions, and answer the patient, who may regain his normal respi-
tient’s questions about obtaining re- ratory pattern slowly because of such
placement supplies. predisposing factors as abdominal or
thoracic surgery, advanced age, inactiv-
Documentation ity, obesity, smoking, and decreased
ability to cough effectively and expel
Record the feeding time and duration, lung secretions.
the amount and type of feeding formu-
la used, and patient tolerance. Main- Equipment and preparation
tain records of intake and output as
needed. Note the appearance of the Flow or volume incentive spirometer,
stoma and surrounding skin. as indicated, with sterile disposable
tube and mouthpiece (The tube and
mouthpiece are sterile on first use and
Incentive spirometry clean on subsequent uses.) ◆ stetho-
scope ◆ warm water
Incentive spirometry involves the use Assemble the ordered equipment at
of a breathing device to help the pa- the patient’s bedside. Read the manu-
tient achieve maximal ventilation. The facturer’s instructions for spirometer
device measures respiratory flow or setup and operation. Remove the ster-
respiratory volume and induces the pa- ile disposable tube and mouthpiece
tient to take a deep breath and hold it from the package, and attach them to
for several seconds. This deep breath the device. Set the flow rate or volume
increases lung volume, boosts alveolar goal, as determined by the physician or
inflation, and promotes venous return. respiratory therapist and based on the
This exercise also establishes alveolar patient’s preoperative performance.
hyperinflation for a longer time than is Turn on the machine, if necessary.
possible with a normal deep breath,
thus preventing and reversing the alve- Implementation
olar collapse that causes atelectasis
and pneumonitis. ◆ Confirm the patient’s identity using
Devices used for incentive spirome- two patient identifiers.
try provide a visual incentive to ◆ Wash your hands and follow stan-
breathe deeply. Some are activated dard precautions.
when the patient inhales a certain vol- ◆ Assess the patient’s condition.
ume of air; the device then estimates ◆ Explain the procedure to the pa-
the amount of air inhaled. Others con- tient, making sure that he understands
tain plastic floats that rise according to the importance of performing incentive
spirometry regularly to maintain alveo- ◆ Auscultate the patient’s lungs, and

lar inflation. compare the findings with those of the
◆ Help the patient into a comfortable first auscultation.
sitting position or semi-Fowler’s posi- ◆ Instruct the patient to remove the
tion to promote optimal lung expan- mouthpiece. Wash the mouthpiece in
sion. If you’re using a flow incentive warm water and shake it dry. Avoid
spirometer and the patient can’t as- immersing the spirometer itself be-
sume or maintain this position, he can cause this enhances bacterial growth
perform the procedure in any position and impairs the effectiveness of the in-
as long as the device remains upright. ternal filter in preventing inhalation of
Tilting a flow incentive spirometer de- extraneous material.
creases the required patient effort and ◆ Place the mouthpiece in a plastic
reduces the effectiveness of the exer- storage bag between exercises. Label it
cise. and the spirometer, if applicable, with
◆ Auscultate the patient’s lungs with the patient’s name so that another pa-
a stethoscope to provide a baseline for tient doesn’t inadvertently use the
comparison with posttreatment auscul- equipment.
tation.
◆ Instruct the patient to insert the Special considerations
sterile mouthpiece and to close his lips
tightly around it. A weak seal may al- ◆ If the patient is scheduled for sur-
ter flow or volume readings. gery, assess beforehand his respiratory
◆ Instruct the patient to exhale nor- pattern and his ability to meet appro-
mally and then to inhale as slowly and priate postoperative goals. Teach him
deeply as possible. If he has difficulty how to use the spirometer before
with this step, tell him to suck as he surgery so that he can concentrate on
would through a straw, but more slow- your instructions and practice the exer-
ly. Ask the patient to retain the entire cise. A preoperative evaluation will
volume of air that he inhaled for 3 sec- also help in establishing postoperative
onds or, if you’re using a device with a therapeutic goals.
light indicator, until the light turns off. ◆ Avoid exercising at mealtime, to
This deep breath creates sustained prevent nausea. If the patient has diffi-
transpulmonary pressure near the end culty breathing only through his
of inspiration and is sometimes called mouth, provide a noseclip to measure
a sustained maximal inspiration. each breath fully. Provide paper and a
◆ Tell the patient to remove the pencil so that the patient can note ex-
mouthpiece and exhale normally. Al- ercise times. Exercise frequency varies
low him to relax and take several nor- with the patient’s condition and ability.
mal breaths before attempting another ◆ Immediately after surgery, monitor
breath with the spirometer. Repeat this the patient’s exercise frequently to en-
sequence 5 to 10 times during every sure compliance and assess achieve-
waking hour. Note tidal volumes. ment.
◆ Evaluate the patient’s ability to
cough effectively. Encourage him to Documentation
cough after each effort because deep
lung inflation may loosen secretions Record preoperative teaching. Docu-
and facilitate their removal. Examine ment preoperative flow or volume lev-
the expectorated secretions. els, the date and time of the procedure,
the type of spirometer used, the flow
or volume levels achieved, and the For people with latex allergy, latex
number of breaths taken. Note the pa- becomes a hazard when the protein in
tient’s condition before and after the latex comes in direct contact with the
procedure, his tolerance of the proce- mucous membranes or is inhaled, as
dure, and the results of both ausculta- occurs when powdered latex surgical
tions. gloves are used. People with asthma
If you used a flow incentive spirom- are at greater risk for worsening symp-
eter, compute the volume by multiply- toms from airborne latex.
ing the setting by the duration that the The diagnosis of latex allergy is
patient kept the ball (or balls) suspend- based on the patient’s history and find-
ed, as follows. If the patient suspended ings on physical examination. Labora-
the ball for 3 seconds at a setting of tory testing should be performed to
500 cc during each of 10 breaths, multi- confirm or exclude the diagnosis. Skin
ply 500 cc by 3 seconds and then record testing can be done. The radioaller-
this total (1,500 cc) and the number of gosorbent test measures the serum lev-
breaths, as follows: 1,500 cc 10 el of latex-specific immunoglobulin E
breaths. If you used a volume incentive in the blood. Other blood tests include
spirometer, take the volume reading the AlaSTAT test, Hycor assay, and
directly from the spirometer. For exam- Pharmacia Cap test.
ple, record 1,000 cc 5 breaths. Latex allergy can produce various
signs and symptoms, including general-
ized itching (on the hands and arms,
Latex allergy protocol for example); itchy, watery, or burning
eyes; sneezing and coughing (hay
Latex, a natural product of the rubber fever–type signs and symptoms); rash;
tree, is commonly used in barrier pro- hives; bronchial asthma, scratchy
tection products and medical equip- throat, or difficulty breathing; edema of
ment — and more and more nurses and the face, hands, or neck; and anaphy-
patients are becoming hypersensitive to laxis.
it. Those who are at increased risk for To help identify people who are at
latex allergy include people who have risk, ask specific questions about latex
had or will undergo multiple surgical allergy during the health history. (See
procedures (especially those with a his- Latex allergy screening, page 322.) If
tory of spina bifida), health care work- the patient’s history shows a latex sen-
ers (especially those in the emergency sitivity, the physician assigns him to
department and operating room), one of three categories based on the
workers who manufacture latex and la- extent of his sensitization. Group 1 pa-
tex-containing products, and people tients have a history of anaphylaxis or
with a genetic predisposition to latex a systemic reaction when exposed to a
allergy. natural latex product. Group 2 patients
People who are allergic to certain have a clear history of a nonsystemic
cross-reactive foods — including apri- allergic reaction. Group 3 patients
cots, cherries, grapes, kiwis, passion don’t have a history of latex hypersen-
fruit, bananas, avocados, chestnuts, sitivity, but are considered high risk
tomatoes, and peaches — may also be because of an associated medical con-
allergic to latex. Exposure to latex elic- dition, occupation, or crossover allergy.
its an allergic response similar to the If you determine that the patient is
response elicited by these foods. sensitive to latex, make sure that he
doesn’t come in contact with it
Latex allergy screening
To determine if your patient has a latex ◆ Do you have any congenital abnormal-
sensitivity or allergy, ask the following ities? If yes, explain.
screening questions: ◆ Do you have any food allergies? If so,
◆ What is your occupation? what specific allergies do you have? De-
◆ Have you experienced an allergic reac- scribe your reaction.
tion, local sensitivity, or itching after ex- ◆ If you experience shortness of breath
posure to any latex products, such as bal- or wheezing when blowing up latex bal-
loons or condoms? loons, describe your reaction.
◆ Do you have shortness of breath or ◆ Have you had any previous surgical
wheezing after blowing up balloons or af- procedures? Did you experience associat-
ter a dental visit? Do you have itching in ed complications? If so, describe them.
or around your mouth after eating a ba- ◆ Have you had previous dental proce-
nana? dures? Did you have any complications? If
If your patient answers “yes” to any of so, describe them.
these questions, proceed with the follow- ◆ Are you exposed to latex in your occu-
ing questions: pation? Do you experience a reaction to
◆ Do you have a history of allergies, der- latex products at work? If so, describe
matitis, or asthma? If so, what type of re- your reaction.
action do you have?
because such contact could result in a Implementation

life-threatening hypersensitivity reac-
tion. Creating a latex-free environment For all patients in groups 1 and 2
is the only way to safeguard the pa- ◆ Assess all patients who are being
tient. Many facilities now designate la- admitted to the delivery room or short
tex-free equipment that’s usually kept procedure unit or having a surgical
on a cart that can be moved into the procedure for latex allergy.
patient’s room. ◆ If the patient has a confirmed latex
allergy, bring a cart with latex-free
Equipment and preparation equipment into his room.
◆ Document in the patient’s chart
Latex allergy patient identification (according to facility policy) that the
wristband ◆ latex-free equipment, inpatient has a latex allergy. If policy
cluding room contents requires that the patient wear a latex
After you’ve determined that the allergy patient identification wristband,
patient has a latex allergy or is sensi- place it on the patient.
tive to latex, arrange for him to be ◆ Post a LATEX ALLERGY sign in the pa-
placed in a private room. If that isn’t tient’s room.
possible, make the room latex-free, ◆ If the patient will be receiving anes-
even if his roommate hasn’t been des- thesia, make sure that LATEX ALLERGY is
ignated as hypersensitive to latex, to clearly visible on the front of his chart.
prevent the spread of airborne particles (See Anesthesia induction and latex al-
from latex products used on the other lergy.) Notify the circulating nurse in
patient. the surgical unit, the nurses in the
postanesthesia care unit, and all other
Anesthesia induction and latex allergy
CAUSES OF SIGNS AND SYMPTOMS SIGNS AND SYMPTOMS

INTRAOPERATIVE IN A CONSCIOUS IN AN ANESTHETIZED
REACTION PATIENT PATIENT
◆ Latex contact with ◆ Abnormal cramping ◆ Bronchospasm

mucous membranes ◆ Anxiety ◆ Cardiopulmonary arrest
◆ Latex contact with the ◆ Bronchoconstriction ◆ Facial edema
intraperitoneal serosal ◆ Diarrhea ◆ Flushing
lining ◆ Faintness ◆ Hypotension
◆ Inhalation of airborne ◆ Generalized pruritus ◆ Laryngeal edema
latex particles during ◆ Itchy eyes ◆ Tachycardia
anesthesia ◆ Nausea ◆ Urticaria
◆ Injection of antibiotics ◆ Shortness of breath ◆ Wheezing
and anesthetic agents ◆ Swelling of soft tissue
through latex ports (hands, face, and tongue)
◆ Vomiting
◆ Wheezing
team members that the patient has a gram wires with a nonlatex product to
latex allergy. protect the patient from latex contact.
◆ If the patient must be transported to ◆ Wrap a transparent semipermeable
another area of the facility, make sure dressing over the patient’s finger before
that the latex-free cart accompanies using pulse oximetry.
him and that all health care workers ◆ Use latex-free syringes when admin-
who come in contact with him are istering medication.
wearing nonlatex gloves. The patient ◆ If the patient has an allergic reaction
should wear a mask with cloth ties to latex, act immediately. (See Manag-
when leaving his room to protect him ing a latex allergy reaction, page 324.)
from inhaling airborne latex particles.
◆ Notify central supply, dietary ser- Special considerations
vices, and the pharmacy about the pa-
tient’s allergy. ◆ The signs and symptoms of latex al-
◆ If the patient will have an I.V. line, lergy usually occur within 30 minutes
make sure that only latex-free products after anesthesia is induced. However,
are used to establish I.V. access. the time of onset can range from
◆ Be sure that you use only latex-free 10 minutes to several hours.
I.V. products and supplies. ◆ As a health care worker, you’re in a
◆ Use a nonlatex tourniquet. If none position to develop latex hypersensitiv-
are available, use a latex tourniquet ity. If you suspect that you’re sensitive
over clothing. to latex, contact the employee health
◆ Use latex-free equipment for oxygen services department about facility pro-
administration. Remove the elastic and tocol for latex-sensitive employees. Use
tie the equipment on with gauze. latex-free products whenever possible
◆ Wrap your stethoscope, blood pres- to help reduce your exposure to latex.
sure cuff and tubing, and electrocardio- ◆ Patients who do not have a history
of latex hypersensitivity but have an
Managing a latex allergy reaction
If you determine that your patient is hav- ◆ Administer epinephrine according to

ing an allergic reaction to a latex product, the patient’s symptoms.
act immediately. Make sure that you per- ◆ Administer famotidine, as ordered.
form emergency interventions using latex- ◆ If bronchospasm is evident, treat it
free equipment. If the latex product that with nebulized albuterol, as ordered.
caused the reaction is known, remove it ◆ Secondary treatment for latex allergy
and perform the following measures: reaction is aimed at treating the swelling
◆ If the allergic reaction develops during and tissue reaction to the latex as well as
medication administration or during a breaking the chain of events associated
procedure, stop the medication or proce- with the allergic reaction. It includes:
dure immediately. – diphenhydramine
◆ Assess the patient’s airway, breathing, – methylprednisolone
and circulation. – famotidine.
◆ Administer 100% oxygen with continu- ◆ Document the event and the exact
ous pulse oximetry. cause (if known). If latex particles have
◆ Start I.V. volume expanders with lac- entered the I.V. line, insert a new I.V. line
tated Ringer’s solution or normal saline with a new catheter, new tubing, and new
solution. infusion attachments as soon as possible.
associated medical condition, occupa- administer drugs or anesthetics and to

tion, or crossover allergy should be relieve ICP by removing CSF.
aware of the potential for latex hyper- Performed by a physician or an ad-
sensitivity. vanced practice nurse, lumbar punc-
Alert Don’t assume that if ture requires sterile technique and
something doesn’t look like careful patient positioning. This proce-
rubber it isn’t latex. Latex is found in dure is contraindicated in patients with
various types of equipment, including a lumbar deformity or an infection at
electrocardiograph leads, oral and the puncture site. Lumbar puncture
nasal airway tubing, tourniquets, isn’t recommended if the patient has
nerve stimulation pads, temperature an intracranial mass lesion because the
strips, and blood pressure cuffs. rapid reduction in pressure that follows
lumbar puncture can lead to tonsillar
herniation and medullary compression.
Lumbar puncture
Equipment and preparation
Lumbar puncture involves inserting a
sterile needle into the subarachnoid Overbed table ◆ two pairs of sterile
space of the spinal canal, usually be- gloves ◆ antiseptic solution ◆ sterile
tween the third and fourth lumbar ver- gauze pads ◆ alcohol pad ◆ sterile
tebrae. This procedure is used to detect fenestrated drape ◆ 3-ml syringe for lo-
the presence of blood in the cerebro- cal anesthetic ◆ 25G 3⁄4 sterile needle
spinal fluid (CSF), to obtain CSF speci- for injecting anesthetic ◆ local anes-
mens for laboratory analysis, and to thetic (usually 1% lidocaine) ◆18G or
inject dyes or gases for contrast in radi- 20G 31⁄2 spinal needle with stylet
ologic studies. It’s also used to
Lumbar puncture 325
(22G needle for children) ◆ three-way

stopcock ◆ manometer ◆ small adhe- Positioning for lumbar
sive bandage ◆ three sterile collection puncture
tubes with stoppers ◆ laboratory re-
quests ◆ labels ◆ light source such as To position a patient for a lumbar
a gooseneck lamp ◆ sterile marker and puncture, have him lie on his side at
labels ◆ optional: patient-care re- the edge of the bed, with his chin
minder tucked to his chest and his knees
Disposable lumbar puncture trays drawn up to his abdomen. Make sure
contain most of the needed sterile that the patient’s spine is curved and
his back is at the edge of the bed (as
equipment.
shown below). This position widens
the spaces between the vertebrae,
Implementation easing insertion of the needle.
To help the patient maintain this
◆ Confirm the patient’s identity using position, place one of your hands be-
two patient identifiers. hind his neck and the other hand be-
◆ Explain the procedure to the patient hind his knees, and pull gently. Hold
to ease his anxiety and ensure his co- the patient firmly in this position
operation. Make sure that he has throughout the procedure to prevent
signed a consent form. accidental displacement of the needle.
◆ Inform the patient that he may ex-
perience a headache after lumbar Patient positioning
puncture, but reassure him that his co-
operation during the procedure mini-
mizes this effect.
◆ Check the patient’s history for hy-
persensitivity to local anesthetic.
◆ Immediately before the procedure,
provide privacy and instruct the patient
to void.
◆ Wash your hands thoroughly.
◆ Open the disposable lumbar punc-
ture tray on an overbed table, being
Typically, the physician inserts the
careful not to contaminate the sterile needle between the third and fourth
field when you open the wrapper. La- lumbar vertebrae (as shown below).
bel all medications, medication con-
tainers, and other solutions on and off Needle positioning
the sterile field.
◆ Provide an adequate light source at Third
lumbar
the puncture site, and adjust the height vertebra Fourth
of the patient’s bed to allow the proce- lumbar
dure to be performed comfortably. vertebra
◆ Position the patient, and reempha-
size the importance of remaining as Subarachnoid
still as possible to minimize discomfort space
and trauma. (See Positioning for lum-
bar puncture.)
◆ The physician cleans the puncture help the patient extend his legs to pro-
site with sterile gauze pads soaked vide a more accurate pressure reading.
in antiseptic solution, wiping in a ◆ The physician detaches the manom-
circular motion away from the punc- eter and allows CSF to drain from the
ture site. He uses three different pads needle hub into the collection tubes.
to prevent contamination of spinal tis- When he has collected 2 to 3 ml in
sues by normal skin flora. Next, he each tube, mark the tubes in sequence,
drapes the area with the sterile fenes- insert stoppers to secure them, and
trated drape to provide a sterile field. label them.
(If the physician uses povidone-iodine ◆ If the physician suspects an obstruc-
pads instead of sterile gauze pads, he tion in the spinal subarachnoid space,
may remove his sterile gloves and put he may check for Queckenstedt’s sign.
on another pair to avoid introducing After he takes an initial CSF pressure
antiseptic solution into the subarach- reading, compress the patient’s jugular
noid space with the lumbar puncture vein for 10 seconds, as ordered. This
needle.) increases ICP and — if no subarachnoid
◆ If no ampule of anesthetic is in- block is present — causes the CSF pres-
cluded on the equipment tray, clean sure to rise. The physician takes pres-
the injection port of a multidose vial of sure readings every 10 seconds until
anesthetic with an alcohol pad. Invert the pressure stabilizes.
the vial 45 degrees so that the physi- ◆ After the physician collects the spe-
cian can insert a 25G needle and sy- cimens and removes the spinal needle,
ringe and withdraw the anesthetic for clean the puncture site with antiseptic
injection. solution and apply a small adhesive
◆ Before the physician injects the bandage.
anesthetic, tell the patient that he’ll ex- ◆ Send the CSF specimens to the lab-
perience a transient burning sensation oratory immediately, with the complet-
and local pain. Ask him to report other ed laboratory request.
persistent pain or sensations because
they may indicate irritation or puncture Special considerations
of a nerve root, requiring repositioning
of the needle. ◆ During lumbar puncture, watch the
◆ When the physician inserts the patient closely for signs of an adverse
spinal needle with stylet into the sub- reaction: elevated pulse rate, pallor,
arachnoid space, instruct the patient to and clammy skin. Alert the physician
remain still and to breathe normally. If immediately if any significant changes
necessary, hold the patient firmly in occur.
position to prevent sudden movement ◆ The patient may be ordered to lie
that may displace the needle. flat for 8 to 12 hours after the proce-
◆ If the lumbar puncture is being dure. If necessary, place a patient-care
performed to administer contrast media reminder on his bed.
for radiologic studies or spinal anes- ◆ Collected CSF specimens must be
thetic, the physician injects the dye or sent to the laboratory immediately;
anesthetic at this time. they can’t be refrigerated for later
◆ When the needle is in place, the transport.
physician attaches a manometer with a ◆ If ordered, encourage the patient to
three-way stopcock to the needle hub drink fluids after the procedure to re-
to read the CSF pressure. If ordered, duce the risk of spinal headache.
Manual ventilation 327
◆ Check the puncture site for redness, citation bag maintains ventilation. Ad-
swelling, and drainage every hour for ministration of oxygen with a resuscita-
the first 4 hours and then every 4 hours tion bag can help improve a compro-
for the next 24 hours. mised cardiorespiratory system.
◆ Assess the patient for complications
after lumbar puncture. Headache is the Equipment and preparation
most common adverse effect. Others
include a reaction to the anesthetic, Handheld resuscitation bag ◆ mask ◆
meningitis, epidural and subdural ab- oxygen source (wall unit or tank) ◆
scess, bleeding into the spinal canal, oxygen tubing ◆ nipple adapter at-
leakage of CSF through the dural defect tached to oxygen flowmeter ◆ gloves
that remains after the needle is with- ◆ goggles or face shield (if needed) ◆
drawn, local pain caused by irritation optional: oxygen accumulator and posi-
of the nerve root, edema and hema- tive end-expiratory pressure (PEEP)
toma at the puncture site, transient dif- valve ◆ optional: oropharyngeal air-
ficulty voiding, and fever. The most se- way or nasopharyngeal airway
rious complications (tonsillar hernia- Unless the patient is intubated or
tion and medullary compression) are has a tracheostomy, select a mask that
rare. fits snugly over the patient’s mouth
and nose. Attach the mask to the re-
Documentation suscitation bag. If oxygen is readily
available, connect the handheld resus-
Record the initiation and completion citation bag to the oxygen source. At-
times of the procedure, the patient’s re- tach one end of the oxygen tubing to
sponse, the drugs administered, the the bottom of the bag and the other
number of specimen tubes collected, end to the nipple adapter on the
the time at which specimens were flowmeter of the oxygen source.
transported to the laboratory, and the Turn on the oxygen, and adjust the
color, consistency, and any other char- flow rate according to the patient’s
acteristics of the collected specimens. condition. For example, if the patient
has a low partial pressure of arterial
oxygen, he’ll need a higher fraction of
Manual ventilation inspired oxygen (FIO2). To increase the
concentration of inspired oxygen, you
Manual ventilation involves using a can add an oxygen accumulator (also
handheld resuscitation bag, which is called an oxygen reservoir). This de-
an inflatable device that can be at- vice, which attaches to an adapter on
tached to a face mask or directly to an the bottom of the bag, permits an FIO2
endotracheal (ET) or tracheostomy of up to 100%. If time allows, set up
tube to allow manual delivery of oxy- suction equipment.
gen or room air to the lungs of a pa-
tient who can’t breathe by himself. Implementation
Usually used in an emergency, manual
ventilation can also be performed ◆ Put on gloves and other personal
while the patient is disconnected tem- protective equipment and follow stan-
porarily from a mechanical ventilator, dard precautions.
such as during a tubing change, during ◆ Turn the oxygen flow rate to
transport, or before suctioning. In 15 L/minute.
these cases, use of the handheld resus-
◆ Before you use the handheld resus-

How to apply a handheld citation bag, remove any objects from
resuscitation bag and mask the patient’s upper airway. Also, suc-
tion the patient to remove secretions
Circle the edges of the mask with the that may obstruct the airway. If neces-
index and first finger of one hand
sary, insert an oropharyngeal or na-
while lifting the jaw with the other
sopharyngeal airway to maintain air-
fingers. Make sure there’s a tight seal.
way patency. If the patient has a tra-
cheostomy or an ET tube in place,
suction the tube.
◆ If appropriate, remove the head-
board and stand at the head of the bed
to help keep the patient’s neck extend-
ed and to free space at the side of the
bed for other activities such as car-
diopulmonary resuscitation.
◆ Tilt the patient’s head backward, if
not contraindicated, and pull his jaw
Make sure that the patient’s mouth re-
mains open underneath the mask. At- forward to move the tongue away from
tach the bag to the mask and to the the base of the pharynx and prevent
tubing that leads to the oxygen source. obstruction of the airway. (See How to
apply a handheld resuscitation bag and
mask.)
◆ Keeping your nondominant hand on
the patient’s mask, exert downward
pressure to seal the mask against his
face. For an adult patient, use your
dominant hand to compress the bag to
deliver 500 to 600 cc of air over 1 sec-
ond.
Age alert For infants and chil-
dren, use a pediatric handheld
If the patient has a tracheostomy tube resuscitation bag. For a child, deliver
or an endotracheal tube in place, re- 15 breaths/minute, or one compres-
move the mask from the bag and at-
sion of the bag every 4 seconds; for an
tach the handheld resuscitation bag
infant, 20 breaths/minute, or one com-
directly to the tube.
pression every 3 seconds. Infants and
children should receive 250 to 500 cc
of air with each compression.
◆ Deliver breaths with the patient’s
own inspiratory effort, if any is pre-
sent. Don’t attempt to deliver a breath
as the patient exhales.
◆ Observe the patient’s chest to en-
sure that it rises and falls with each
compression. If ventilation doesn’t
occur, check the fit of the mask and
the patency of the patient’s airway. If
necessary, reposition the patient’s head occurred and the nursing action taken,
and ensure patency with an oral air- and the patient’s response to treat-
way. ment, according to facility protocol for
respiratory arrest.
Special considerations In a nonemergency situation, record
the date and time of the procedure, the
◆ Add PEEP to manual ventilation by reason and the length of time that the
attaching a PEEP valve to the resuscita- patient was disconnected from me-
tion bag. This may improve oxygena- chanical ventilation and received man-
tion if the patient hasn’t responded to ual ventilation, complications that oc-
an increased fraction of inspired oxy- curred and nursing actions taken, and
gen levels. Always use a PEEP valve to the patient’s tolerance of the proce-
manually ventilate a patient who has dure.
been receiving PEEP on the ventilator.
◆ If the patient has a possible cervical
injury, avoid neck hyperextension; in- Mechanical ventilation
stead, use the jaw-thrust technique to
open the airway. If you need both Mechanical ventilation involves using a
hands to keep the patient’s mask in mechanical ventilator that moves air
place and maintain hyperextension, into and out of the patient’s lungs.
use the lower part of your arm to com- Although the equipment serves to ven-
press the bag against your side. tilate the patient, it doesn’t ensure ade-
◆ Observe the patient for vomiting quate gas exchange. Mechanical venti-
through the clear part of the mask. If lators may use either positive or nega-
vomiting occurs, stop the procedure tive pressure to ventilate patients.
immediately, lift the mask, wipe and Positive-pressure ventilators exert a
suction the vomitus, and resume resus- positive pressure on the airway, which
citation. causes inspiration while increasing
◆ Underventilation commonly occurs tidal volume (VT). The inspiratory cy-
because it’s difficult to keep the hand- cles of these ventilators may vary in
held resuscitation bag positioned tight- volume, pressure, or time. For example,
ly on the patient’s face while ensuring a volume-cycle ventilator — the type
an open airway. In addition, the vol- most commonly used — delivers a pre-
ume of air delivered to the patient set volume of air each time, regardless
varies with the type of bag used and of lung resistance. A pressure-cycle
the hand size of the person who is ventilator generates flow until the ma-
compressing the bag. For these rea- chine reaches a preset pressure, regard-
sons, have someone assist with the less of the volume delivered or the
procedure, if possible. time required to achieve the pressure.
◆ Aspiration of vomitus can result in A time-cycle ventilator generates flow
pneumonia, and gastric distention may for a preset amount of time. A high-
occur if air is forced into the patient’s frequency ventilator uses high respira-
stomach. tory rates and low VT to maintain alve-
olar ventilation.
Documentation Negative-pressure ventilators act by
creating negative pressure, which pulls
In an emergency, record the date and the thorax outward and allows air to
time of the procedure, the manual ven- flow into the lungs. Examples of such
tilation efforts, complications that ventilators are the iron lung, the
cuirass (chest shell), and the body help reduce anxiety and fear. Assure
wrap. Negative-pressure ventilators are the patient and his family that staff
used mainly to treat neuromuscular members are nearby to provide care.
disorders, such as Guillain-Barré syn- ◆ Perform a complete physical assess-
drome, myasthenia gravis, and polio- ment, and draw blood for ABG analysis
myelitis. to establish a baseline.
Other indications for ventilator use ◆ Suction the patient, if necessary.
include central nervous system disor- ◆ Plug the mechanical ventilator into
ders, such as cerebral hemorrhage and an uninterruptable, emergency power,
spinal cord transsection, adult respira- electrical outlet, connect it to the oxy-
tory distress syndrome, pulmonary ede- gen source, and turn it on. Adjust the
ma, chronic obstructive pulmonary dis- settings on the ventilator as ordered.
ease, flail chest, and acute hypoventila- (See Ventilator modes and settings).
tion. Make sure that the alarms are set as
ordered and that the humidifier is filled
Equipment and preparation with sterile distilled water. Attach a
capnographic device that measures car-
Oxygen source ◆ air source that can bon dioxide levels to confirm endotra-
supply 50 psi ◆ mechanical ventilator cheal tube placement, detect discon-
◆ humidifier ◆ ventilator circuit tub- nection from the ventilator, and allow
ing, connectors, and adapters ◆ con- early detection of complications.
densation collection trap ◆ spirometer, ◆ Put on gloves if you haven’t done
respirometer, or electronic device to so already. Connect the endotracheal
measure flow and volume ◆ in-line tube to the ventilator. Observe the pa-
thermometer ◆ probe for gas sampling tient for chest expansion, and auscul-
and measuring airway pressure ◆ tate for bilateral breath sounds to veri-
gloves ◆ handheld resuscitation bag fy that the patient is being ventilated.
with reservoir ◆ suction equipment ◆ ◆ Monitor the patient’s ABG values
sterile distilled water ◆ equipment for after the initial ventilator setup (usual-
arterial blood gas (ABG) analysis ◆ ly 20 to 30 minutes), after changes in
soft restraints, if indicated ◆ optional: the ventilator settings, and as the pa-
oximeter tient’s clinical condition indicates to
In most facilities, respiratory thera- determine if the patient is being venti-
pists assume responsibility for setting lated adequately and to prevent oxygen
up the ventilator. If necessary, check toxicity. Be prepared to adjust the ven-
the manufacturer’s instructions for set- tilator settings based on the ABG
ting it up. In most cases, you’ll need to analysis.
add sterile distilled water to the humid- ◆ Check the ventilator circuit tubing
ifier and connect the ventilator to the frequently for condensation, which can
appropriate gas source. cause airflow resistance and infection if
the patient aspirates it. As needed,
Implementation drain the condensate into a collection
trap or briefly disconnect the patient
◆ Verify the physician’s order for ven- from the ventilator (ventilating him
tilator support. If the patient isn’t al- with a handheld resuscitation bag, if
ready intubated, prepare him for intu- necessary), and empty the water into a
bation. receptacle. Don’t drain the condensate
◆ When possible, explain the proce- into the humidifier because the
dure to the patient and his family to
Ventilator modes and settings
Although a respiratory therapist usually initiates mechanical ventilation and adjusts the
ventilator modes or settings based on the physician’s orders, you should understand all
of the following terms.
MODE OR SETTING FUNCTION
Assist-control (A/C) ◆ Delivers a breath at a preset tidal volume (VT) if patient

ventilation fails to initiate a breath within a preset time period
◆ Ventilator triggered to deliver a breath at a preset VT if
patient initiates a breath
Continuous positive air- ◆ Can only be used with patients who are breathing sponta-
way pressure (CPAP) neously and effectively
◆ Maintains a preset positive pressure in the airways to de-
crease resistance
Control ventilation (CV) ◆ Delivers a preset VT at a fixed rate, regardless of whether

patient initiates any breaths
◆ Used for apneic patients
High-frequency ventila- ◆ Delivers a small amount of gas at a rapid rate, ranging

tion (HFV) from 60 to100 breaths/minute
◆ Requires sedation and drug-induced paralysis
◆ Used for hemodynamically unstable patients during short-
term procedures or for patients at risk for pneumothorax
Independent lung venti- ◆ Uses two ventilators to ventilate each lung separately
lation (ILV) ◆ Uses a double-lumen endotracheal tube and requires
sedation and drug-induced paralysis
◆ Useful for patients with different disease processes in
each lung
Inverse ratio ventilation ◆ Reverses normal inspiratory-expiratory (I:E) ratio of 1:2, de-
(IRV) livering an I:E ratio of 2:1 or greater to allow longer inspiration
◆ Requires sedation and drug-induced paralysis
◆ Helps improve oxygenation in patient who’s hypoxic even
while on positive end-expiratory pressure
Positive end-expiratory ◆ Setting triggers ventilator to apply positive pressure at

pressure (PEEP) the end of each expiration to keep alveoli open and increase
area for oxygen exchange
Pressure support ventila- ◆ Allows ventilator to apply a preset amount of positive

tion (PSV) pressure when patient inspires spontaneously
◆ Increases VT while decreasing patient’s breathing workload
Synchronous intermittent ◆ Delivers a preset number of breaths at a specific VT.

mandatory ventilation ◆ Allows patient to supplement mechanical ventilations with
(SIMV) his own breaths; VT and rate determined by patient’s own in-
spiratory ability
condensate may be contaminated with the ventilator tubing, make sure that
the patient’s secretions. condensation in the tubing doesn’t
◆ Check the in-line thermometer to flow into the lungs. Aspiration of this
make sure that the temperature of the contaminated moisture can cause infec-
air delivered to the patient is close to tion. Provide care for the artificial air-
body temperature. Monitor flow vol- way as needed.
ume and airway pressure according to ◆ Assess the patient’s peripheral cir-
facility policy. culation, and monitor his urine output
◆ When monitoring the patient’s vital for signs of decreased cardiac output
signs, count spontaneous breaths as (CO). Watch for signs and symptoms
well as ventilator-delivered breaths. of excess fluid volume or dehydration.
◆ Change, clean, or dispose of the ◆ Place the call light within the pa-
ventilator tubing and equipment ac- tient’s reach, and establish a method
cording to facility policy, to reduce the of communication, such as a commu-
risk of bacterial contamination. Typi- nication board, because intubation and
cally, the ventilator tubing is changed mechanical ventilation impair the pa-
every 48 to 72 hours and sometimes tient’s ability to speak. An artificial air-
more often. way may help the patient to speak by
◆ When ordered, begin to wean the allowing air to pass through his vocal
patient from the ventilator. cords.
◆ Administer a sedative or a neuro-
Special considerations muscular blocker as ordered to relax
the patient or to eliminate spontaneous
◆ Provide the patient with emotional breathing efforts that can interfere with
support during all phases of mechani- the action of the ventilator. A patient
cal ventilation to reduce his anxiety who’s receiving a neuromuscular
and promote successful treatment. blocker requires close observation be-
Even if the patient is unresponsive, cause he can’t breathe or communi-
continue to explain all procedures and cate.
treatments to him. ◆ If the patient is receiving a neuro-
◆ Make sure that the ventilator alarms muscular blocker, make sure that he
are on at all times. These alarms alert also receives a sedative. Neuromuscu-
nursing staff to potentially hazardous lar blockers cause paralysis without al-
conditions and changes in patient sta- tering the patient’s level of conscious-
tus. If an alarm sounds and the prob- ness (LOC). Reassure the patient and
lem can’t be identified easily, discon- his family that the paralysis is tempo-
nect the patient from the ventilator and rary. Make sure that emergency equip-
use a handheld resuscitation bag to ment is readily available in case the
ventilate him. ventilator malfunctions or the patient
◆ Unless contraindicated, turn the pa- is accidentally extubated. Continue to
tient from side to side every 1 to 2 explain all procedures to the patient,
hours to facilitate lung expansion and and take additional steps to ensure his
removal of secretions. Perform active safety, such as raising the side rails of
or passive range-of-motion exercises his bed while turning him and covering
for all extremities to reduce the haz- and lubricating his eyes.
ards of immobility. If the patient’s con- ◆ Make sure that the patient gets ade-
dition permits, position him upright at quate rest and sleep because fatigue
regular intervals to increase lung ex- can delay weaning from the ventilator.
pansion. When moving the patient or Provide subdued lighting, safely muffle
equipment noises, and restrict staff ac- ◆ Assess the patient for complica-
cess to the area to promote quiet dur- tions. Mechanical ventilation can
ing rest periods. cause tension pneumothorax, de-
◆ When weaning the patient, watch creased CO, oxygen toxicity, excess flu-
him for signs of hypoxia. Schedule id volume caused by humidification,
weaning to fit comfortably and realisti- infection, and GI complications, such
cally within the patient’s daily regi- as distention or bleeding from stress
men. Avoid scheduling sessions after ulcers.
meals, baths, or lengthy therapeutic or
diagnostic procedures. Have the patient Documentation
help you set up the schedule to give
him some sense of control over the Document the date and time that me-
procedure. As the patient’s tolerance chanical ventilation is initiated. Note
for weaning increases, help him sit up the type of ventilator used as well as
while out of bed to improve his breath- its settings. Describe the patient’s
ing and sense of well-being. Suggest di- subjective and objective responses
versionary activities to take his mind to mechanical ventilation, including
off his breathing. vital signs, breath sounds, use of ac-
Patient teaching tips If the cessory muscles, intake and output,
patient will be discharged while and weight. List complications that
using a ventilator, evaluate the fami- occurred and nursing actions taken.
ly’s or the caregiver’s ability and mo- Record all pertinent laboratory data,
tivation to provide such care. Well be- including the results of ABG analysis
fore discharge, develop a teaching and oxygen saturation levels.
plan to address the patient’s needs. During weaning, record the date
For example, teaching should include and time of each session, the weaning
information about ventilator care and method used, and the baseline and
settings, artificial airway care, suc- subsequent vital signs, oxygen satura-
tioning, respiratory therapy, commu- tion levels, and ABG values. Describe
nication, nutrition, therapeutic exer- the patient’s subjective and objective
cise, the signs and symptoms of infec- responses, including LOC, respiratory
tion, and ways to troubleshoot minor effort, arrhythmias, skin color, and
equipment malfunctions. need for suctioning.
◆ Evaluate the patient’s need for List all complications and nursing
adaptive equipment, such as a hospital actions taken. If the patient was receiv-
bed, a wheelchair or walker with a ing pressure support ventilation or us-
ventilator tray, a patient lift, and a bed- ing a T-piece or tracheostomy collar,
side commode. Determine whether the note the duration of spontaneous
patient needs to travel; if so, select ap- breathing and the patient’s ability to
propriate portable and backup equip- maintain the weaning schedule. If in-
ment. termittent mandatory ventilation was
◆ Before discharge, have the patient’s used, with or without pressure support
caregiver demonstrate his ability to use ventilation, record the control breath
the equipment. At discharge, contact a rate, the time of each breath reduction,
durable medical equipment vendor and and the rate of spontaneous respira-
a home health nurse to follow up with tions.
the patient. Refer the patient to com-
munity resources, if available.
Moss tube, which has a triple lumen, is

Nasogastric tube insertion usually inserted during surgery. (See
and removal Types of NG tubes.)
Usually inserted to decompress the Equipment and preparation

stomach, a nasogastric (NG) tube can
prevent vomiting after major surgery. An For inserting an NG tube
NG tube is typically in place for 48 to 72 NG tube (usually #12, #14, #16, or #18
hours after surgery, by which time peri- French for a normal adult) ◆ towel or
stalsis usually resumes. However, the linen-saver pad ◆ facial tissues ◆ eme-
tube may remain in place for shorter or sis basin ◆ penlight ◆ 1 or 2 hypoal-
longer periods, depending on its use. lergenic tape ◆ gloves ◆ water-soluble
The NG tube has other diagnostic lubricant ◆ cup of water with straw (if
and therapeutic applications, especially appropriate) ◆ pH test strip ◆ tongue
in assessing and treating upper GI blade ◆ catheter-tip or bulb syringe or
bleeding, collecting gastric contents for irrigation set ◆ safety pin ◆ ordered
analysis, performing gastric lavage, as- suction equipment ◆ optional: ice, al-
pirating gastric secretions, and admin- cohol pad, warm water, and rubber
istering medications and nutrients. band
Inserting an NG tube requires close
observation of the patient and verifica- For removing an NG tube
tion of proper placement. An NG tube Gloves ◆ catheter-tip syringe ◆ normal
must be inserted with extra care in saline solution ◆ towel or linen-saver
pregnant patients and in those with an pad ◆ adhesive remover ◆ optional:
increased risk of complications. For ex- clamp
ample, a physician will order an NG Inspect the NG tube for defects,
tube for a patient with aortic aneur- such as rough edges or partially closed
ysm, myocardial infarction, gastric lumens. Check the patency of the tube
hemorrhage, or esophageal varices by flushing it with water. To ease inser-
only if he believes that the benefits tion, increase the flexibility of a stiff
outweigh the risks. The tube must be tube by coiling it around your gloved
removed carefully to prevent injury or fingers for a few seconds or by dipping
aspiration. it into warm water. Stiffen a limp rub-
Most NG tubes have a radiopaque ber tube by briefly chilling it in ice.
marker or strip at the distal end to al-
low the position of the tube to be veri- Implementation
fied by X-ray. If an X-ray doesn’t con-
firm placement, the physician may or- ◆ Whether you’re inserting or remov-
der fluoroscopy. ing an NG tube, provide privacy, wash
The most common types of NG your hands, and put on gloves before
tubes are the Levin tube, which has inserting the tube. Check the physi-
one lumen, and the Salem sump tube, cian’s order to determine the type of
which has two lumens, one for suction tube that should be inserted.
and drainage and a smaller one for
ventilation. Air flows through the vent Inserting an NG tube
lumen continuously. This protects the ◆ Confirm the physician’s order for
delicate gastric mucosa by preventing a the type of tube to be inserted.
vacuum from forming should the tube ◆ Confirm the patient’s identity using
adhere to the stomach lining. The two patient identifiers.
Types of NG tubes
The physician will choose the type and diameter of the nasogastric (NG) tube that best
suits the patient’s needs, including lavage, aspiration, enteral therapy, or stomach de-
compression. Choices may include the Levin tube and the Salem sump tube.
Levin tube Salem sump tube

The Levin tube is a rubber or plastic tube The Salem sump tube is a double-lumen
that has a single lumen, a length of 42 to tube that’s made of clear plastic and has a
50 (106.5 to 127 cm), and holes at the blue sump port (pigtail) that allows at-
tip and along the side. mospheric air to enter the patient’s stom-
ach. Thus, the tube floats freely and does-
n’t adhere to or damage the gastric mu-
cosa. The larger port of this 48 (122-cm)
tube serves as the main suction conduit.
The tube has openings at 45, 55, 65, and
75 cm as well as a radiopaque line to ver-
ify placement.
◆ Explain the procedure to the patient ◆ Put on gloves and drape the towel
to ease her anxiety and promote coop- or linen-saver pad over the patient’s
eration. Explain that she may have chest to protect her gown and bed
some nasal discomfort, that she may linens from spills.
gag, and that her eyes may water. Tell ◆ Have the patient blow her nose gen-
her that swallowing will ease advance- tly to clear her nostrils.
ment of the tube. ◆ Place the facial tissues and emesis
◆ Agree on a signal that the patient basin within the patient’s reach.
can use if she wants you to stop briefly ◆ Help the patient to face forward,
during the procedure. with her neck in a neutral position.
◆ Gather and prepare all necessary ◆ To determine how long the NG tube
equipment. must be to reach the patient’s stomach,
◆ Help the patient into high Fowler’s hold the end of the tube at the tip of
position, unless contraindicated. her nose, then extend the tube to
her earlobe and then down to the xi- ◆ Aim the tube downward and toward
phoid process. the ear closer to the chosen nostril. Ad-
◆ Mark this distance on the tubing vance it slowly to avoid pressure on
with the tape. (Average measurements the turbinates and resultant pain and
for an adult range from 22 to 26 [56 bleeding.
to 66 cm].) You may need to add 2 ◆ When the tube reaches the na-
(5 cm) to this measurement for tall pa- sopharynx, you’ll feel resistance. In-
tients, to ensure entry into the stom- struct the patient to lower her head
ach. slightly to close the trachea and open
◆ To determine which nostril will al- the esophagus. Rotate the tube 180 de-
low easier access, use a penlight and grees toward the opposite nostril to
inspect for a deviated septum or other redirect it so that it won’t enter the pa-
abnormalities. Ask the patient if she tient’s mouth.
has had nasal surgery or a nasal in- ◆ Unless contraindicated, offer the pa-
jury. Assess airflow in both nostrils tient a cup of water with a straw. Di-
by occluding one nostril at a time rect her to sip and swallow as you
while the patient breathes through slowly advance the tube (as shown be-
her nose. Choose the nostril with bet- low). This helps the tube to pass to the
ter airflow. esophagus. If you aren’t using water,
◆ Lubricate the first 3 (7.6 cm) of the ask the patient to swallow.
tube with a water-soluble lubricant to
minimize injury to the nasal passages.
Using a water-soluble lubricant pre-
vents lipoid pneumonia, which may re-
sult from aspiration of an oil-based lu-
bricant or from accidental slippage of
the tube into the trachea.
◆ Instruct the patient to hold her head
straight and upright.
◆ Grasp the tube with the end point-
ing downward, curve it, if necessary,
and carefully insert it into the more
patent nostril (as shown below).
Ensuring proper tube placement

◆ Use a tongue blade and penlight to
examine the patient’s mouth and throat
for signs of a coiled section of tubing
(especially in an unconscious patient).
Coiling indicates an obstruction.
◆ Keep an emesis basin and facial tis-
sues readily available for the patient.
◆ As you carefully advance the tube from the tip of her nose. Crisscross the
and the patient swallows, watch for tabbed ends around the tube (as
signs of respiratory distress, which shown below). Apply another piece of
may indicate that the tube is in the tape over the bridge of the nose to se-
bronchus and must be removed im- cure the tube.
mediately.
◆ Stop advancing the tube when the
tape mark reaches the patient’s nostril.
◆ Attach a catheter-tip or bulb syringe
to the tube, and try to aspirate the
stomach contents. If you don’t obtain
stomach contents, position the patient
on her left side to move the tube into
the greater curvature of the stomach,
and aspirate again.
Alert When confirming tube
placement, never place the end
of the tube in a container of water. If
the tube is mispositioned in the tra-
chea, the patient may aspirate water.
Furthermore, water without bubbles
doesn’t confirm proper placement. In-
stead, the tube may be coiled in the
trachea or the esophagus. ◆ Alternatively, stabilize the tube with
◆ If you still can’t aspirate the stom- a prepackaged product that secures
ach contents, advance the tube 1 to 2 and cushions it at the nose.
(2.5 to 5 cm) and try to asirate again. ◆ To reduce discomfort from the
Examine the aspirate and place a small weight of the tube, tie a slipknot
amount on the pH test strip. If the as- around the tube with a rubber band.
pirate has a gastric fluid appearance Secure the rubber band to the patient’s
(grassy green, clear and colorless with gown with a safety pin, or wrap anoth-
mucous shreds, or brown), and the pH er piece of tape around the end of the
is 5, probability of gastric placement tube and leave a tab. Fasten the tape
is increased. tab to the patient’s gown.
◆ If possible, have tube placement ◆ Attach the tube to suction equip-
confirmed by X-ray. ment, if ordered, and set the designat-
◆ Secure the NG tube to the patient’s ed suction pressure.
nose with hypoallergenic tape (or an- ◆ Provide frequent nose and mouth
other designated tube holder). If the care while the tube is in place.
patient’s skin is oily, wipe the bridge of
her nose with an alcohol pad, and al- Removing an NG tube
low it to dry. You’ll need about 4 ◆ Explain the procedure to the pa-
(10.2 cm) of 1 tape. Split one end of tient, informing her that it may cause
the tape up the center about 11⁄2 some nasal discomfort and sneezing or
(3.8 cm). Make tabs on the split ends gagging.
by folding the sticky sides together. ◆ Assess the patient’s bowel function
Stick the uncut end of the tape on the by auscultating for peristalsis or flatus.
patient’s nose so that the split in the ◆ Help the patient into semi-Fowler’s
tape starts about 1⁄2 (1.3 cm) to 11⁄2 position. Drape a towel or linen-saver
pad across her chest to protect her ◆ While advancing the tube in an un-
gown and bed linens from spills. conscious patient or in a patient who
◆ Wash your hands and put on gloves. can’t swallow, stroke the patient’s neck
◆ Using a catheter-tip syringe, flush to encourage the swallowing reflex and
the tube with 10 ml of normal saline facilitate passage down the esophagus.
solution to make sure that the tube ◆ While advancing the tube, watch
doesn’t contain stomach contents that for signs that it has entered the tra-
could irritate tissues during tube re- chea, such as choking or breathing dif-
moval. ficulties in a conscious patient and cy-
◆ Untape the tube from the patient’s anosis in an unconscious patient or a
nose, and unpin it from her gown. patient without a cough reflex. If these
◆ Clamp the tube by folding it in your signs occur, remove the tube immedi-
hand. ately. Allow the patient time to rest;
◆ Ask the patient to hold her breath then try to reinsert the tube.
to close the epiglottis. Withdraw the ◆ Vomiting after tube placement sug-
tube gently and steadily. When the dis- gests tubal obstruction or incorrect po-
tal end of the tube reaches the na- sition. Assess the patient immediately
sopharynx, you can pull it quickly. to determine the cause.
◆ As soon as possible, cover and re- ◆ An NG tube may be inserted or re-
move the tube. Its sight and odor may moved at home. Indications for inser-
nauseate the patient. tion include gastric decompression and
◆ Assist the patient with thorough short-term feeding. A home care nurse
mouth care, and clean the tape residue or the patient may insert the tube, de-
from her nose with adhesive remover. liver the feeding, and remove the tube.
◆ For the next 48 hours, monitor the ◆ Assess the patient for potential
patient for signs and symptoms of GI complications of prolonged intubation,
dysfunction, including nausea, vomit- such as skin erosion at the nostril, si-
ing, abdominal distention, and food in- nusitis, esophagitis, esophagotracheal
tolerance. GI dysfunction may necessi- fistula, gastric ulceration, and pul-
tate reinsertion of the tube. monary and oral infection. Additional
complications that may result from
Special considerations suction include electrolyte imbalances
and dehydration.
◆ If the patient has a deviated septum
or other nasal condition that prevents Documentation
nasal insertion, pass the tube orally,
after removing dentures if necessary. Record the type and size of the NG
Slide the tube over the tongue; proceed tube and the date, time, and route of
as you would for nasal insertion. insertion. Note the type and amount of
◆ When using the oral route, coil the suction, if used, and describe the
end of the tube around your hand. drainage, including the amount, color,
This helps to curve and direct the tube character, consistency, and odor. Note
downward at the pharynx. the patient’s tolerance of the proce-
◆ If the patient is unconscious, tilt her dure.
chin toward her chest to close the tra- When you remove the tube, record
chea. Advance the tube between respi- the date and time. Describe the color,
rations to make sure that it doesn’t en- consistency, and amount of gastric
ter the trachea. drainage. Note the patient’s tolerance
of the procedure.
Obstructed airway, adult 339
Implementation
Obstructed airway, adult
Conscious adult
Sudden obstructed airway can occur ◆ Determine the patient’s level of con-
when a foreign body lodges in the sciousness by tapping his shoulder and
throat or bronchus; when the patient asking, “Are you choking? Can you
aspirates blood, mucus, or vomitus; speak?” If he has complete airway ob-
when the tongue blocks the pharynx; struction, he won’t be able to answer.
or when the patient experiences trau- If he makes crowing sounds, his air-
matic injury, bronchoconstriction, or way is partially blocked and you
bronchospasm. The patient will display should encourage him to cough. This
such symptoms as grabbing his throat will either clear the airway or make the
with his hand, being unable to speak, obstruction complete. Intervene for a
coughing weakly and ineffectively, or complete obstruction.
making high-pitched sounds while in- ◆ Tell the patient that you’ll try to dis-
haling. lodge the foreign body.
A completely obstructed airway ◆ Stand behind the patient and wrap
causes anoxia, which leads to brain your arms around his waist. Make a fist
damage and death in 4 to 6 minutes. with one hand, and place the thumb
An upper-abdominal thrust creates di- side of your fist against his abdomen, at
aphragmatic pressure in the static lung the midline, slightly above the umbili-
below the foreign body sufficient to ex- cus and well below the xiphoid process.
pel the obstruction. Grasp your fist with the other hand.
Use abdominal thrusts on a con- ◆ Press your fist into the patient’s ab-
scious adult patient who can’t speak, domen with quick inward and upward
cough, or breathe; if the patient is un- thrusts five times. Each thrust should
conscious, instead start cardiopul- be a separate and distinct movement;
monary resuscitation (CPR) immediate- each should be forceful enough to cre-
ly. For a pregnant or markedly obese ate an artificial cough that will dis-
patient or for a patient who has recent- lodge the object.
ly undergone abdominal surgery, use a ◆ Repeat thrusts until the object is ex-
chest thrust instead of an abdominal pelled from the airway or the patient
thrust. The chest thrust forces air out becomes unresponsive. Make sure you
of the lungs to create an artificial have a firm grasp on the patient be-
cough. cause he may lose consciousness and
These maneuvers are contraindicat- need to be lowered to the floor.
ed in a patient with incomplete or par- ◆ If the patient loses consciousness,
tial airway obstruction or when the pa- lower him to the floor, support his head
tient can maintain adequate ventilation and neck to prevent injury, and place
to dislodge the foreign body by effec- him in the supine position. Call for
tive coughing. However, a patient who help, activate emergency medical ser-
can’t speak, cough, or breathe requires vices (EMS), begin CPR, and follow the
immediate action to dislodge the ob- interventions for relieving an obstructed
struction. airway in an unconscious person.
Equipment Obese or pregnant conscious adult

◆ If the patient is conscious, stand be-
◆ No specific equipment needed hind the patient and place your arms
under the armpits and around the chest.
◆ Place the thumb side of your to prevent additional obstruction and

clenched fist against the middle of the resume the maneuver as necessary.
sternum, avoiding the margins of the ◆ Even if efforts to clear the airway
ribs and the xiphoid process. Grasp don’t seem to be effective, keep trying.
your fist with your other hand, and As oxygen deprivation increases, smooth
perform a chest thrust with enough and skeletal muscles relax, making your
force to expel the foreign body. Contin- maneuvers more likely to succeed.
ue until the patient expels the obstruc- ◆ Explain what you’re doing as need-
tion or loses consciousness. ed to gain the patient’s cooperation.
◆ If the patient loses consciousness, ◆ Complications such as nausea, regur-
carefully lower the patient to the floor gitation, and achiness may develop after
and place in a supine position. Estab- the patient regains consciousness and
lish unresponsiveness, call for help, ac- can breathe independently. Assess the
tivate EMS, and begin CPR. patient for injuries such as ruptured or
lacerated abdominal or thoracic viscera,
Unconscious adult which may result from improper place-
◆ If you come upon an unconscious ment of the rescuer’s hands or because
patient, establish unresponsiveness. of osteoporosis or metastatic lesions.
Call for help or activate EMS.
◆ If you are rescuing a conscious pa- Documentation
tient with an obstructed airway and the
patient loses consciousness, lower the Record the date and time of the proce-
patient to the ground and immediately dure. Note the patient’s actions before
activate EMS. Place the patient in a the obstruction, document the approxi-
supine position and begin CPR. mate length of time it took to clear the
◆ Each time the airway is opened us- airway, and record the type and size of
ing the head-tilt, chin-lift maneuver, object removed.
look for an object in the patient’s Note the patient’s vital signs after
mouth. Remove the object if present. the procedure and his tolerance of the
◆ Attempt to ventilate the patient and procedure. Document any complications
follow with 30 chest compressions. that occurred and nursing actions taken.
Alert The blind finger-sweep is
no longer taught by the Ameri-
can Heart Association. A finger-sweep Peripheral I.V. catheter
should only be used when a foreign insertion
body can be seen in the mouth. Stud-
ies have shown that blind finger- Peripheral I.V. catheter insertion involves
sweeps may result in injury to the pa- selection of a venipuncture device and
tient’s mouth and throat or to the res- an insertion site, application of a tourni-
cuer’s fingers, and there’s no evidence quet, preparation of the site, and
of its effectiveness. In addition, the venipuncture. Selection of a venipunc-
tongue-jaw lift is no longer used. The ture device and site depends on the type
patient’s mouth should be opened us- of solution to be used; the frequency
ing a head-tilt, chin-lift maneuver. and duration of infusion; the patency
and location of accessible veins; the pa-
Special considerations tient’s age, size, and condition; and,
when possible, the patient’s preference.
◆ If the patient vomits during chest or If possible, choose a vein in the
abdominal thrusts, wipe out the mouth nondominant arm or hand. The pre-
ferred venipuncture sites are the
cephalic and basilic veins in the lower that’s appropriate for the infusion (un-
arm and the veins in the dorsum of the less subsequent therapy will require a
hand. The least favorable sites are the larger one). Smaller gauges cause less
veins in the leg and the foot because of trauma to the veins, allow greater
the increased risk of thrombophlebitis. blood flow around their tips, and re-
Antecubital veins can be used if no duce the risk of phlebitis.
other venous access is available. If you’re using a winged infusion
A peripheral catheter allows admin- set, connect the adapter to the admin-
istration of fluids, medication, blood, istration set and unclamp the line until
and blood components and maintains fluid flows from the open end of the
I.V. access to the patient. Insertion is needle cover. Then close the clamp and
contraindicated in a sclerotic vein, an place the needle on a sterile surface,
edematous or impaired arm or hand, or such as the inside of its packaging.
a postmastectomy arm with axillary Take the catheter device and open
node dissection and in patients with a its package to allow easy access.
mastectomy, burns, or an arteriovenous
fistula. Subsequent venipunctures Implementation
should be performed proximal to a pre-
viously used or injured vein. ◆ Confirm the patient’s identity using
two patient identifiers.
Equipment and preparation ◆ Place the I.V. pole in the proper slot
in the patient’s bed frame. If you’re us-
Alcohol pads or other approved antimi- ing a portable I.V. pole, position it
crobial solution such as chlorhexidine close to the patient.
swabs ◆ gloves ◆ disposable tourniquet ◆ Hang the I.V. solution with the at-
(latex-free tubing) ◆ I.V. access devices tached primed administration set on
◆ I.V. solution with attached and the I.V. pole.
primed administration set ◆ I.V. pole ◆ ◆ Verify the patient’s identity by com-
sharps container ◆ transparent semiper- paring the information on the solution
meable dressing ◆ commercial catheter- container with the two patient identi-
securement device, sterile 1 hypoaller- iers on the patient’s wristband.
genic gauze tape, or sterile surgical ◆ Wash your hands thoroughly. Explain
strips ◆ 1 hypoallergenic tape ◆ op- the procedure to the patient to ensure
tional: arm board, roller gauze, and his cooperation and reduce anxiety. Anx-
warm packs ◆ adhesive bandage iety can cause a vasomotor response
Commercial venipuncture kits come that results in venous constriction.
with or without an I.V. access device. In
many facilities, venipuncture equipment Selecting the site
is kept on a tray or cart, allowing a ◆ Select the puncture site. If long-term
choice of the correct access devices and therapy is anticipated, start distal on
easy replacement of contaminated items. the selected vein so that you can move
Check the information on the label proximally, as needed, for subsequent
of the I.V. solution container, including I.V. insertion sites. For infusion of an ir-
the patient’s name and room number, ritating medication, choose a large vein.
the type of solution, the date and time Make sure that the intended vein can
of its preparation, the preparer’s name, accommodate the I.V. access device.
and the ordered infusion rate. Compare ◆ Place the patient in a comfortable,
the physician’s orders with the solution reclining position, leaving the arm in a
label to verify that the solution is cor- dependent position to increase venous
rect. Select the smallest-gauge device fill of the lower arms and hands. If the
patient’s skin is cold, warm it by rub- short edges of the wings (with the bev-
bing and stroking the arm, covering el of the needle facing upward) be-
the entire arm with warm packs, or tween the thumb and forefinger of
submerging it in warm water for 5 to your dominant hand. Squeeze the
10 minutes. wings together. If you’re using an over-
the-needle cannula, grasp the plastic
Applying the tourniquet hub with your dominant hand, remove
◆ Apply a tourniquet above the ante- the cover, and examine the cannula tip.
cubital fossa to dilate the vein. Check If the edge isn’t smooth, discard and
for a radial pulse. If it isn’t present, re- replace the device.
lease the tourniquet and reapply it ◆ Use the thumb of your nondomi-
with less tension to prevent arterial oc- nant hand to stretch the skin taut be-
clusion. low the puncture site to stabilize the
◆ To locate veins, lower the arm be- vein (as shown below).
low heart level. Have the patient pump
his fist. Tap gently over the vein.
◆ Lightly palpate the vein with the in-
dex and middle fingers of your non-
dominant hand. Once the vein is iden-
tified and secure, stretch the skin to
anchor the vein. If the vein feels hard
or ropelike, select another vein.
◆ Leave the tourniquet in place for no
longer than 3 minutes. If you can’t find
a suitable vein and prepare the site in
that time, release the tourniquet for a
few minutes. Then reapply it and con-
tinue the procedure.
Preparing the site ◆ Tell the patient that you’re about to

◆ Put on gloves. Clip the hair around insert the device.
the insertion site, if needed. Clean the ◆ Hold the needle with the bevel up,
site with a chlorhexidine swab using a and enter the skin directly over the
vigorous side-to-side motion to remove vein at a 0- to 15-degree angle (as
flora that would otherwise be intro- shown below).
duced into the vascular system with
the venipuncture. Allow the antimicro-
bial solution to dry.
◆ If ordered, administer a local anes-
thetic. Make sure that the patient isn’t
sensitive to lidocaine.
◆ Lightly press the vein with the
thumb of your nondominant hand
about 11⁄2 (3.8 cm) from the intended
insertion site. The vein should feel
round, firm, fully engorged, and re-
silient.
◆ Grasp the access cannula. If you’re
using a winged infusion set, hold the
◆ Aggressively push the needle directly quickly attach the I.V. tubing. This
through the skin about 1⁄3 (1 cm) and method typically results in less blood
into the vein in one motion. Check the being spilled.
flashback chamber behind the hub for
blood return, signifying that the vein
has been properly accessed. You may
not see blood return in a small vein.
◆ Level the insertion device slightly
by lifting its tip to prevent puncturing
the back wall of the vein with the ac-
cess device.
◆ If you’re using a winged infusion
set, advance the needle fully, if possi-
ble, and hold it in place. Release the
tourniquet, open the administration set
clamp slightly, and check for free flow
or infiltration.
◆ If you’re using an over-the-needle
cannula, advance the device to at least Dressing the site
half its length to ensure that the can- ◆ After the venous access device has
nula itself — not just the introducer been inserted, clean the skin complete-
needle — has entered the vein. Remove ly. If necessary, dispose of the stylet in a
the tourniquet. sharps container. Regulate the flow rate.
◆ Grasp the cannula hub to hold it in ◆ If possible, use a commercial
the vein, and withdraw the needle. As catheter-securement device to secure
you withdraw it, press lightly on the the catheter. Or use sterile 1 hypoaller-
catheter tip to prevent bleeding. genic tape or sterile surgical strips to
◆ Advance the cannula up to the hub secure the device.
or until you meet resistance. ◆ Apply a transparent semipermeable
◆ To advance the cannula while infus- dressing to the site.
ing I.V. solution, release the tourniquet ◆ Loop the I.V. tubing on the patient’s
and remove the inner needle. Using limb, and secure the tubing with hy-
aseptic technique, attach the I.V. tubing poallergenic tape. The loop allows
and begin the infusion. Stabilize the some slack to prevent dislodgment of
vein with one hand, and use the other the cannula because of tension on the
to advance the catheter into the vein. line. (See Methods of taping a venous
When the catheter is advanced, decrease access site, page 344.)
the I.V. flow rate. This method reduces ◆ Label the last piece of tape with the
the risk of puncturing the opposite wall type and gauge of the needle and the
of the vein because the catheter is ad- length of the cannula; the date and
vanced without the steel needle and be- time of insertion; and your initials. Ad-
cause the rapid flow dilates the vein. just the flow rate as ordered.
◆ To advance the cannula before start- ◆ If needed, place an arm board un-
ing the infusion, release the tourniquet. der the joint and secure it with roller
Stabilize the vein with one hand, and gauze or tape to provide stability. Make
use the other hand to advance the sure that the insertion site is visible
catheter up to the hub (as shown at and that the tape isn’t constricting the
top of next column). Remove the inner patient’s circulation. Check frequently
needle and, using aseptic technique,
Methods of taping a venous access site
When using tape to secure the venous access device to the insertion site, use one of the
basic methods described below. Only sterile tape should be used under a transparent
semipermeable dressing.
Chevron method H method
◆ Cut a long strip of 1⁄2 tape. With the ◆ Cut three strips of 1 tape.
sticky side up, place it under the cannula. ◆ Place one strip of tape over each wing,
◆ Cross the ends of the tape over the keeping the tape parallel to the cannula
cannula so that the tape sticks to the pa- (as shown).
tient’s skin (as shown). ◆ Place the other strip of tape perpendic-
◆ Apply a piece of 1 tape across the two ular to the first two strips. Put it either di-
wings of the chevron. rectly on top of the wings or just below
◆ Loop the tubing, and secure it with an- the wings, directly on top of the tubing.
other piece of 1 tape. When the dressing ◆ Make sure that the cannula is secure.
is secured, apply a label. On the label, Then apply a dressing and a label. On the
write the date and time of insertion, the label, write the date and time of insertion,
type and gauge of the needle, and your the type and gauge of the needle or can-
initials. nula, and your initials.
U method
◆ Cut a 2 (5-cm) strip of 1⁄2 tape. With
the sticky side up, place the tape under
the hub of the cannula.
◆ Bring each side of the tape up, folding
it over the wings of the cannula in a U
shape (as shown). Press it down parallel
to the hub.
◆ Apply tape to stabilize the catheter.
◆ When a dressing is secured, apply a la-
bel. On the label, write the date and time
of insertion, the type and gauge of the
needle or cannula, and your initials.
for impaired circulation distal to the in- skin. If necessary, apply it over the pa-
fusion site. tient’s gown. Make sure that skin
preparation materials are at room tem-
Removing a peripheral I.V. catheter perature to avoid vasoconstriction be-
◆ A peripheral I.V. catheter is removed cause of lower temperatures.
at the completion of therapy, for cannu- ◆ If the patient is allergic to chlorhexi-
la site changes, and for suspected infec- dine, clean the skin with alcohol.
tion or infiltration. The procedure usu- ◆ If you don’t see blood flashback, re-
ally requires gloves, a sterile gauze pad, move the cannula and try again or pro-
and an adhesive bandage. ceed according to facility policy.
◆ To remove the I.V. catheter, clamp ◆ Change a gauze or transparent
the I.V. tubing to stop the flow of solu- dressing whenever you change the ad-
tion. Gently remove the transparent ministration set (every 48 hours or ac-
dressing and all tape from the skin. cording to your facility’s policy).
◆ Using aseptic technique, open the ◆ Rotate the I.V. site every 72 hours or
gauze pad and adhesive bandage and according to facility policy.
place them within reach. Put on Patient teaching tips Many
gloves. Hold the sterile gauze pad over patients who receive I.V. therapy
the puncture site with one hand, and at home have a central venous line. If
use your other hand to withdraw the you’re caring for a patient who’s going
cannula slowly and smoothly, keeping home with a peripheral line, teach him
it parallel to the skin. Inspect the tip of how to care for the I.V. site and how to
the cannula; if it isn’t smooth, assess identify certain complications. If the
the patient immediately and notify the patient has movement restrictions,
physician. make sure that he understands them.
◆ Using the gauze pad, apply firm ◆ Teach the patient how to examine
pressure over the puncture site for 1 to the site. Instruct him to notify the
2 minutes after removal or until bleed- physician or home care nurse if he has
ing has stopped. redness, swelling, or discomfort, or if
◆ Clean the site and apply the adhe- the dressing becomes moist.
sive bandage or, if blood oozes, apply ◆ Tell the patient to report all problems
a pressure bandage. with the I.V. line (for instance, if the so-
◆ If drainage appears at the puncture lution stops infusing or if an alarm goes
site, swab the tip across an agar plate off on an infusion pump). Explain that
and send it to the laboratory to be cul- a home care nurse will change the I.V.
tured, according to facility policy. site at established intervals.
Clean the area, apply a sterile dressing, ◆ If the patient is using an intermit-
and notify the physician. tent infusion device, teach him how
◆ Instruct the patient to restrict activi- and when to flush it.
ty for about 10 minutes and to leave ◆ Teach the patient about possible
the dressing in place for at least 1 complications related to peripheral
hour. If the patient has lingering ten- lines. Complications can result from the
derness at the site, apply warm packs needle or the catheter (infection and
and notify the physician. phlebitis) or from the solution (circula-
tory overload, infiltration, sepsis, and al-
Special considerations lergic reaction). (See Risks of peripheral
I.V. therapy, pages 346 to 353.)
Age alert Apply the tourniquet
carefully to avoid pinching the (Text continues on page 352.)
Risks of peripheral I.V. therapy

COMPLICATIONS SIGNS AND SYMPTOMS
Local complications
Cannula dislodgment ◆ Cannula partially backed out of vein
◆ Solution infiltrating
Hematoma ◆ Tenderness at the venipuncture site

◆ Bruised area around the site
◆ Inability to advance or flush the I.V. line
Infiltration ◆ Swelling at and above the I.V. site (may extend along the en-
tire limb)
◆ Discomfort, burning, or pain at the site (may be painless)
◆ Tight feeling at the site
◆ Skin cool to the touch around the I.V. site
◆ Blanching at the site
◆ Continuing fluid infusion, even when the vein is occluded, al-
though the rate may decrease
Nerve, tendon, or liga- ◆ Extreme pain (similar to electrical shock when the nerve is
ment damage punctured)
◆ Numbness and muscle contraction
◆ Delayed effects, including paralysis, numbness, and deformity
Occlusion ◆ Infusion that doesn’t flow

◆ Pump alarms indicating occlusion
◆ Discomfort at infusion site
POSSIBLE CAUSES NURSING INTERVENTIONS
◆ Loosened tape, or tubing ◆ If no infiltration occurs, retape without pushing the

snagged in the bed linens, result- cannula back into the vein. If it has pulled out, apply
ing in partial retraction of the pressure to the I.V. site with a sterile dressing.
cannula; cannula pulled out by a Prevention
confused patient ◆ Tape the venipuncture device securely on insertion.
◆ Puncture of the vein through ◆ Remove the venous access device.

the opposite wall at the time of ◆ Apply pressure and warm soaks to the affected area.
insertion ◆ Recheck for bleeding.
◆ Leakage of blood as a result ◆ Document the patient’s condition and your interventions.
of needle displacement Prevention
◆ Application of inadequate ◆ Choose a vein that can accommodate the size of the
pressure when the cannula is dis- venous access device.
continued ◆ Release the tourniquet as soon as insertion is successful.
◆ Venous access device dis- ◆ Stop the infusion and infiltrate the site with antidote, if
lodged from the vein, or perfora- ordered.
tion of the vein ◆ Check the patient’s pulse and capillary refill periodical-
ly to assess circulation.
◆ Apply ice (early) or warm soaks (later) to aid absorp-
tion, and elevate the patient’s limb.
◆ Restart the infusion above the infiltration site or in an-
other limb.
◆ Document the patient’s condition and your interventions.
Prevention
◆ Check the I.V. site frequently.
◆ Don’t obscure the area above the site with tape.
◆ Teach the patient to observe the I.V. site and to report
pain or swelling.
◆ Improper venipuncture tech- ◆ Stop the procedure.

nique that causes injury to the Prevention
surrounding nerves, tendons, or ◆ Don’t penetrate the tissues repeatedly with the venous
ligaments access device.
◆ Tight taping or improper ◆ Don’t apply excessive pressure when taping; don’t
splinting with an arm board encircle the limb with tape.
◆ Pad the arm boards and secure them with tape, if
possible.
◆ Interruption of the I.V. flow ◆ Use a mild flush injection. Don’t force it. If it’s unsuc-
◆ Failure to flush the saline lock cessful, remove the I.V. line and insert a new one.
◆ Backflow of blood in the line Prevention
when the patient walks ◆ Maintain the I.V. flow rate.
◆ Line clamped for too long ◆ Flush promptly after intermittent piggyback adminis-
tration.
◆ Have the patient walk with his arm bent at the elbow
to reduce the risk of blood backflow.
(continued)
Risks of peripheral I.V. therapy (continued)
Local complications (Continued)

Phlebitis ◆ Tenderness proximal to the venous access device
◆ Redness at the tip of the cannula and along the vein
◆ Vein that’s hard on palpation
◆ Pain during infusion
◆ Possible blanching if vasospasm occurs
◆ Elevated temperature
◆ Puffy area over vein
Severed cannula ◆ Leakage from the shaft of the cannula
Thrombophlebitis ◆ Severe discomfort

◆ Reddened, swollen, and hardened vein
Thrombosis ◆ Painful, reddened, and swollen vein

◆ Sluggish or stopped I.V. flow
◆ Poor blood flow around the ◆ Remove the venous access device.
venous access device ◆ Apply warm soaks.
◆ Friction from movement of the ◆ Notify the physician if the patient has a fever.
cannula along the vein wall ◆ Document the patient’s condition and your interven-
◆ Venous access device left in tions.
the vein for too long Prevention
◆ Drug or solution with high or ◆ Restart the infusion using a larger vein for an irritating
low pH or high osmolarity, such solution, or restart it with a smaller-gauge device to en-
as phenytoin and some antibi- sure adequate blood flow.
otics (erythromycin, nafcillin, and ◆ Tape the device securely to prevent motion.
vancomycin)
◆ Inadvertent cutting of the can- ◆ If the broken part is visible, attempt to retrieve it. If
nula by scissors you’re unsuccessful, notify the physician.
◆ Reinsertion of the needle into ◆ If a portion of the cannula enters the bloodstream,
the cannula place a tourniquet above the I.V. site to prevent progres-
sion of the broken part.
◆ Notify the physician and the radiology department.
◆ Document the patient’s condition and your interven-
tions.
Prevention
◆ Don’t use scissors near the I.V. site.
◆ Never reinsert the needle into the cannula.
◆ Remove the unsuccessfully inserted cannula and the
needle together.
◆ Thrombosis and inflammation ◆ Remove the device; restart the infusion in the opposite
limb if possible.
◆ Apply warm soaks.
◆ Notify the physician.
◆ Watch for I.V. therapy–related infection (thrombi pro-
vide an excellent environment for bacterial growth).
Prevention
◆ Check the site frequently. Remove the venous access
device at the first sign of redness and tenderness.
◆ Injury to the endothelial cells ◆ Remove the venous access device; restart infusion in
of the vein wall, allowing the opposite limb, if possible.
platelets to adhere and thrombi ◆ Apply warm soaks.
to form ◆ Watch for I.V. therapy–related infection (thrombi pro-
vide an excellent environment for bacterial growth).
Prevention
◆ Use proper venipuncture techniques to reduce injury to
the vein.
(continued)
Local complications (Continued)

Vasovagal reaction ◆ Sudden pallor, sweating, faintness, dizziness, and nausea
◆ Decreased blood pressure
Venous spasm ◆ Pain along the vein

◆ Sluggish flow rate when the clamp is completely open
◆ Blanched skin over the vein
Systemic complications
Air embolism ◆ Respiratory distress
◆ Unequal breath sounds
◆ Weak pulse
◆ Increased central venous pressure
◆ Decreased blood pressure
◆ Confusion, disorientation, loss of consciousness
Allergic reaction ◆ Itching

◆ Watery eyes and nose
◆ Bronchospasm
◆ Wheezing
◆ Urticarial rash
◆ Edema at I.V. site
◆ Anaphylactic reaction (flushing, chills, anxiety, itching, palpita-
tions, paresthesia, wheezing, seizures, cardiac arrest) within
minutes or up to 1 hour after exposure
◆ Vasospasm as a result of anx- ◆ Lower the head of the bed.

iety or pain ◆ Instruct the patient to take deep breaths.
◆ Check the patient’s vital signs.
Prevention
◆ Prepare the patient for therapy to relieve his anxiety.
◆ Use a local anesthetic to prevent pain.
◆ Severe irritation of the vein ◆ Apply warm soaks over the vein and the surrounding
from irritating drugs or fluids area.
◆ Administration of cold fluids ◆ Decrease the flow rate.
or blood Prevention
◆ Very rapid flow rate (with flu- ◆ Use a blood warmer for blood or packed red blood
ids at room temperature) cells.
◆ Solution container that’s ◆ Discontinue the infusion.

empty ◆ Place the patient on his left side in Trendelenburg’s
◆ Solution container that’s emp- position to allow air to enter the right atrium and dis-
tying, and an added container perse by way of the pulmonary artery.
that’s pushing air down the line ◆ Administer oxygen.
(if the line isn’t purged first) ◆ Notify the physician.
◆ Tubing that’s disconnected ◆ Document the patient’s condition and your interven-
tions.
Prevention
◆ Purge the tubing of air completely before starting the
infusion.
◆ Use an air-detection device on the pump or an air-
eliminating filter proximal to the I.V. site.
◆ Secure the connections.
◆ Allergens such as medications ◆ If a reaction occurs, stop the infusion immediately.

◆ Maintain a patent airway.
◆ Notify the physician.
◆ Administer an antihistaminic steroid, an anti-inflam-
matory, and an antipyretic as prescribed.
◆ Give 0.2 to 0.5 ml of 1:1,000 aqueous epinephrine
S.C. as prescribed. Repeat at 3-minute intervals and as
needed and prescribed.
Prevention
◆ Obtain the patient’s allergy history. Be aware of cross-
allergies.
◆ Assist with test dosing, and document any new aller-
gies.
◆ Monitor the patient carefully during the first 15 min-
utes of administration of a new drug.
(continued)
Systemic complications (Continued)

Circulatory overload ◆ Discomfort
◆ Engorgement of the jugular veins
◆ Respiratory distress
◆ Increased blood pressure
◆ Crackles
◆ Increased difference between fluid intake and output
Systemic infection (sep- ◆ Fever, chills, and malaise for no apparent reason
ticemia or bacteremia) ◆ Contaminated I.V. site, usually with no visible signs of infec-
tion at the site
Documentation
Peripheral I.V. line
In your notes or on the appropriate I.V. maintenance
sheets, record the date and time of the
venipuncture; the type, gauge, and Routine maintenance of I.V. sites and
length of the cannula; the anatomic lo- systems includes regular assessment
cation of the insertion site; and the rea- and rotation of the site and periodic
son the site was changed. changes of the dressing, tubing, and
Document the number of attempts solution. These measures help to pre-
at venipuncture, the type and flow rate vent complications, such as thrombo-
of I.V. solution, the name and amount phlebitis and infection. They should be
of medication in the solution (if any), performed according to facility policy.
all adverse reactions and the actions Typically, gauze I.V. dressings are
taken to correct them, patient teaching changed every 48 hours or when the
and evidence of patient understanding, dressing becomes wet, soiled, or
and your initials. nonocclusive. Transparent semiperme-
able dressings are changed whenever
I.V. tubing is changed. I.V. tubing is
changed every 72 hours or according to
Peripheral I.V. line maintenance 353
◆ Loosening of the roller clamp ◆ Raise the head of the bed.

to allow run-on infusion ◆ Administer oxygen as needed.
◆ Flow rate that’s too rapid ◆ Notify the physician.
◆ Miscalculation of fluid require- ◆ Administer medications (probably furosemide) as pre-
ments scribed.
Prevention
◆ Use a pump, volume-control set, controller, or rate
minder for elderly or compromised patients.
◆ Recheck calculations of the fluid requirements.
◆ Monitor the infusion frequently.
◆ Failure to maintain aseptic ◆ Notify the physician.

technique during insertion of the ◆ Administer medications as prescribed.
device or site care ◆ Culture the site and the device.
◆ Severe phlebitis, which can ◆ Monitor the patient’s vital signs.
set up ideal conditions for the Prevention
growth of organisms ◆ Use aseptic technique when handling solutions and
◆ Poor taping that permits the tubing, inserting the venous access device, and discontin-
venous access device to move, uing infusion.
which can introduce organisms ◆ Secure all connections.
into the bloodstream ◆ Change the I.V. solutions, tubing, and venous access
◆ Prolonged indwelling time of device at the recommended times.
the device ◆ Use I.V. filters.
◆ Weak immune system
facility policy, and I.V. solution is For tubing changes

changed every 24 hours or as needed. I.V. administration set ◆ gloves ◆ ster-
The site should be assessed every 2 ile 2 2 gauze pad ◆ adhesive tape
hours if a transparent semipermeable for labeling ◆ hypoallergenic tape
dressing is used. Otherwise, the site is
assessed with every dressing change For I.V. site changes
and should be rotated every 72 hours. Commercial kits containing the equip-
ment for dressing changes are available.
Equipment and preparation If the facility keeps I.V. equipment
and dressings in a tray or cart, have it
For dressing changes nearby, if possible, because you may
Gloves ◆ chlorhexidine swab ◆ adhe- need to select a new venipuncture site,
sive bandage, sterile 2 2 gauze depending on the condition of the
pad, or transparent semipermeable current site. If you’re changing the so-
dressing ◆ 1 adhesive tape lution and tubing, attach and prime the
I.V. administration set before you enter
For solution changes the patient’s room.
Solution container as ordered (bag or
bottle) ◆ alcohol pad
Implementation halfway up the cannula. Label the

dressing with the date and time of the
◆ Confirm the patient’s identity using procedure.
◆ Wash your hands thoroughly to pre- Changing the solution
vent the spread of microorganisms. ◆ Wash your hands.
Wear gloves whenever you are working ◆ Inspect the new solution container
near the venipuncture site. for cracks, leaks, and other damage.
◆ Explain the procedure to the patient Check the solution for discoloration,
to allay his fears and ensure coopera- turbidity, and particulates. Note the
tion. date and time that the solution was
mixed as well as its expiration date.
Changing the dressing ◆ When inverting the tubing, clamp it
◆ Remove the old dressing, open all to prevent air from entering it. Keep
supply packages, and put on gloves. the drip chamber half full.
◆ Hold the cannula in place with your ◆ If you’re replacing a bag, remove
nondominant hand to prevent acciden- the seal or tab from the new bag and
tal movement or dislodgment, which remove the old bag from the pole. Re-
could puncture the vein and cause in- move the spike, insert it into the new
filtration. bag, and adjust the flow rate.
◆ Assess the venipuncture site for ◆ If you’re replacing a bottle, remove
signs and symptoms of infection (red- the cap and seal from the new bottle
ness and pain), infiltration (coolness, and wipe the rubber port with an alco-
blanching, and edema), and phlebitis hol pad. Clamp the line, remove the
(redness, firmness, pain along the spike from the old bottle, and insert
path of the vein, and edema). If such the spike into the new bottle. Then
signs and symptoms are present, cover hang the new bottle, and adjust the
the area with a sterile 2 2 gauze flow rate.
pad and remove the catheter or nee-
dle. Apply pressure to the area until Changing the tubing
the bleeding stops, and apply an ad- ◆ Reduce the I.V. flow rate, remove
hesive bandage. Using fresh equip- the old spike from the container, and
ment, start the I.V. line in another ap- hang it on the I.V. pole. Place the cover
propriate site, preferably on the oppo- of the new spike loosely over the old
site extremity. one.
◆ If the venipuncture site is without ◆ Keeping the old spike in an upright
complications, stabilize the cannula position above the patient’s heart level,
and carefully clean around the punc- insert the new spike into the I.V. con-
ture site with a chlorhexidine swab, us- tainer.
ing a circular motion outward from the ◆ Prime the system. Hang the new
site to avoid introducing bacteria into I.V. container and the primed set on
the clean area. Allow the area to dry the pole, and grasp the new adapter in
completely. one hand. Stop the flow rate in the old
◆ Cover the site with a transparent tubing.
semipermeable dressing. This type of ◆ Put on sterile gloves.
dressing allows visibility of the inser- ◆ Place a sterile gauze pad under the
tion site and maintains sterility. It’s needle or cannula hub to create a ster-
placed over the insertion site to
ile field. Press one finger over the can- Special considerations
nula to prevent bleeding.
◆ Gently disconnect the old tubing Check the prescribed I.V. flow rate be-
(as shown below), taking care to fore each solution change to prevent
avoid dislodging or moving the I.V. errors. If you crack the adapter or hub
device. If you have trouble disconnect- or if you accidentally dislodge the can-
ing the old tubing, use a hemostat to nula from the vein, remove the cannu-
hold the hub securely while you twist la. Apply pressure and an adhesive
the tubing to remove it. Alternatively, bandage to stop bleeding. Perform a
use one hemostat on the venipuncture venipuncture at another site, and
device and another on the hard plastic restart the I.V. line.
end of the tubing. Pull the hemostats
in opposite directions. Don’t clamp Documentation
the hemostats shut; this could crack
the tubing adapter or the venipunc- Record the time, date, and the rate and
ture device. type of solution (and any additives) in
the I.V. flowchart. Also record dressing
or tubing changes and the appearance
of the site in your notes.
Peritoneal dialysis, continuous

ambulatory
Continuous ambulatory peritoneal dial-
ysis (CAPD) requires insertion of a per-
manent peritoneal catheter (such as a
Tenckhoff catheter) to constantly circu-
late dialysate in the peritoneal cavity.
Inserted under local anesthetic, the
◆ Remove the protective cap from the catheter is sutured in place and its dis-
new tubing, and connect the new tal portion is tunneled subcutaneously
adapter to the cannula. Hold the hub to the skin surface. There it serves as a
securely to prevent dislodging the nee- port for the dialysate, which flows into
dle or the cannula tip. and out of the peritoneal cavity by
◆ Observe for blood backflow into the gravity.
new tubing to verify that the needle or CAPD is usually used for patients
cannula is still in place. (You may not with end-stage renal disease. CAPD can
be able to do this with small-gauge be a welcome alternative to hemodialy-
cannulas.) sis because it gives the patient more in-
◆ Adjust the clamp to maintain the dependence and requires less travel for
appropriate flow rate. treatments. It also provides more stable
◆ Retape the cannula hub and I.V. fluid and electrolyte levels than con-
tubing, and recheck the I.V. flow rate ventional hemodialysis.
because taping may alter it. Patients or family members can
◆ Label the new tubing and container usually learn to perform CAPD after
with the date and time. Label the solu- only 2 weeks of training. Because the
tion container with a time strip. patient can resume normal daily activi-
ties between solution changes, CAPD
helps to promote independence and a To minimize the risk of contaminat-

return to a near-normal lifestyle. It also ing the port, leave the wrapper of the
costs less than hemodialysis. dialysate container in place. This also
Conditions that may prohibit CAPD keeps the bag dry, which makes it easi-
include recent abdominal surgery, aber to examine for leakage after the
dominal adhesions, an infected abdom- wrapper is removed.
inal wall, diaphragmatic tears, ileus, Wash your hands, and put on a sur-
and respiratory insufficiency. gical mask. Remove the dialysate con-
tainer from the warming setup, and re-
Equipment move its protective wrapper. Squeeze
the bag firmly to check for leaks.
To infuse dialysate If ordered, use a syringe to add any
Prescribed amount of dialysate (usually prescribed medication to the dialysate,
in 2-L bags) ◆ basin of hot water or using sterile technique to avoid con-
commercial warmer ◆ three surgical tamination. (The ideal approach is to
masks ◆ 42 (106.7-cm) connective tub- add medication under a laminar flow
ing with drain clamp ◆ six to eight hood.) Disinfect multiple-dose vials in
packages of sterile 4 4 gauze pads a 5-minute povidone-iodine soak. In-
◆ medication, if ordered ◆ antiseptic sert the connective tubing into the
pads ◆ hypoallergenic tape ◆ plastic dialysate container. Open the drain
snap-top container ◆ antiseptic solution clamp to prime the tube, and close the
◆ sterile basin ◆ container of alcohol ◆ clamp.
sterile gloves ◆ belt or small fabric Place an antiseptic pad on the port
pouch ◆ two sterile waterproof paper of the dialysate container. Cover the
drapes (one fenestrated) ◆ optional: sy- port with a dry gauze pad, and secure
ringes and labeled specimen container the pad with hypoallergenic tape. Re-
move and discard the surgical mask.
To temporarily discontinue dialysis Tear the tape so that it will be ready to
Three sterile waterproof paper drapes secure the new dressing. Commercial
(two fenestrated) ◆ 4 4 gauze pads devices with antiseptic pads are avail-
(for cleaning and dressing the catheter) able for covering the dialysate contain-
◆ two surgical masks ◆ sterile basin ◆ er and tubing connection.
hypoallergenic tape ◆ antiseptic solu-
tion ◆ sterile gloves ◆ sterile rubber Implementation
catheter cap
All equipment for infusing the ◆ Weigh the patient to establish a
dialysate and discontinuing the proce- baseline level. Weigh him at the same
dure must be sterile. Commercially pre- time each day to help monitor fluid
pared sterile CAPD kits are available. balance.
Check the concentration of the dialy-
sate against the physician’s order. Also Infusing dialysate
check the expiration date and the ap- ◆ Assemble all equipment at the pa-
pearance of the solution. It should be tient’s bedside, and explain the proce-
clear, not cloudy. Warm the solution to dure to him. Prepare the sterile field by
body temperature with a heating pad placing a sterile waterproof paper
or a commercial warmer, if one is drape on a dry surface near the pa-
available. Don’t warm the solution in a tient. Take care to maintain the sterility
microwave oven because the tempera- of the drape.
ture is unpredictable.
◆ Fill the plastic snap-top container maining pads soaked with antiseptic
with antiseptic solution, and place it solution.
on the sterile field. Place the basin of ◆ Remove the antiseptic solution pad
hot water on the sterile field. Place on the catheter cap, remove the cap,
four pairs of sterile gauze pads in the and use the remaining antiseptic pad to
sterile basin, and saturate them with clean the end of the catheter hub. At-
the antiseptic solution. Drop the re- tach the connective tubing from the
maining gauze pads on the sterile field. dialysate container to the catheter.
Loosen the cap on the alcohol contain- Make sure to secure the luer-lock con-
er, and place it next to the sterile field. nector tightly.
◆ Put on a surgical mask, and provide ◆ Open the drain clamp on the dialy-
one for the patient. sate container to allow the solution to
◆ Carefully remove the dressing cover- enter the peritoneal cavity by gravity
ing the peritoneal catheter, and discard over a period of 5 to 10 minutes. Leave
it. Avoid touching the catheter or the a small amount of fluid in the bag to
skin. Check the integrity of the skin at make the bag easier to fold. Close the
the catheter site, and look for signs of drain clamp.
infection such as purulent drainage. If ◆ Fold the bag and secure it with a
drainage is present, obtain a specimen, belt, or tuck it into the patient’s cloth-
put it in a labeled specimen container, ing or a small fabric pouch.
and notify the physician. ◆ After the prescribed dwell time (usu-
◆ Put on the sterile gloves, and pal- ally 4 to 6 hours), unfold the bag, open
pate the insertion site and the subcuta- the clamp, and allow peritoneal fluid to
neous tunnel route for tenderness or drain back into the bag by gravity.
pain. If these symptoms occur, notify ◆ When drainage is complete, attach a
the physician. new bag of dialysate. Repeat the infu-
Alert If the patient has sion.
drainage, tenderness, or pain, ◆ Discard the used supplies appropri-
don’t proceed with the infusion with- ately.
out specific orders.
◆ Wrap one gauze pad saturated with Discontinuing dialysis temporarily
antiseptic solution around the distal ◆ Wash your hands, put on a surgical
end of the catheter, and leave it in mask, and provide a mask for the pa-
place for 5 minutes. Clean the catheter tient. Explain the procedure to him.
and the insertion site with the rest of ◆ Using sterile gloves, remove and
the gauze pads, moving in concentric discard the dressing over the peritoneal
circles away from the insertion site. catheter.
Use straight strokes to clean the ◆ Set up a sterile field next to the pa-
catheter, beginning at the insertion site tient by covering a clean, dry surface
and moving outward. Use a clean area with a sterile waterproof paper drape.
of the pad for each stroke. Loosen the Take care to maintain the sterility of
catheter cap one notch, and clean the the drape. Place all equipment on the
exposed area. Place each used pad at sterile field, and place the 4 4
the base of the catheter to help support gauze pads in the sterile basin. Satu-
it. After you use the third pair of pads, rate them with the antiseptic solution.
place the sterile waterproof, fenestrated Open the 4 4 gauze pads to be
paper drape around the base of the used as the dressing, and drop them
catheter. Continue to clean the catheter onto the sterile field. Tear pieces of hy-
for another minute with one of the re- poallergenic tape as needed.
◆ Tape the dialysate tubing to the side ◆ Make sure that the patient keeps an
rail of the bed to keep the catheter and accurate record of fluid intake and out-
tubing off the patient’s abdomen. put. Excessive fluid loss may result
◆ Change to another pair of sterile from a concentrated (4.25%) dialysate
gloves. Place one of the fenestrated solution, improper or inaccurate moni-
drapes around the base of the catheter. toring of inflow and outflow, or inade-
◆ Use a pair of antiseptic pads to quate oral fluid intake. Excessive fluid
clean about 6 (15 cm) of the dialysis retention may result from improper or
tubing. Clean the tubing for 1 minute, inaccurate monitoring of inflow and
moving in one direction only, away outflow or excessive salt or oral fluid
from the catheter. Then clean the intake.
catheter, moving from the insertion site Patient teaching tips Teach
to the junction of the catheter and the the patient and his family how
dialysis tubing. Place used pads at the to use sterile technique throughout the
base of the catheter to prop it up. Use procedure, especially for cleaning the
two more pairs of pads to clean the insertion site and changing the dress-
junction for a total of 3 minutes. ing, to prevent complications such as
◆ Place the second fenestrated drape peritonitis. Also teach them the signs
over the first at the base of the cathe- and symptoms of peritonitis — cloudy
ter. With the fourth pair of pads, clean fluid, fever, abdominal pain, and ten-
the junction of the catheter and 6 of derness — and emphasize the impor-
the dialysate tubing for another tance of notifying the physician imme-
minute. diately if such signs and symptoms
◆ Disconnect the dialysate tubing arise. Encourage them to call the
from the catheter. Pick up the sterile physician immediately if redness and
rubber catheter cap and fasten it to the drainage occur; these are also signs of
catheter, making sure that it fits secure- infection. Peritonitis is the most com-
ly over both notches of the hard plastic mon complication of CAPD. Although
tip of the catheter. it’s treatable, it can permanently scar
◆ Clean the insertion site and a 2 the peritoneal membrane, decreasing
(5 cm) radius around it with antiseptic its permeability and reducing the effi-
pads, working from the insertion site ciency of dialysis. Untreated peritonitis
outward. Let the skin air-dry before ap- can cause septicemia and death. In-
plying the dressing. form the patient about the advantages
◆ Properly dispose of the used sup- of an automated continuous cycler sys-
plies. tem for home use. (See Continuous-
cycle peritoneal dialysis.) Instruct the
Special considerations patient to record his weight and blood
pressure daily and to check regularly
◆ If inflow and outflow are slow or for swelling of the extremities.
absent, check the tubing for kinks. You
can also try raising the solution or Documentation
repositioning the patient to increase
the inflow rate. Repositioning the pa- Record the type and amount of fluid
tient or applying manual pressure to instilled and returned for each ex-
the lateral aspects of the patient’s ab- change, the time and duration of the
domen may also help to increase exchange, and any medications added
drainage. to the dialysate. Note the color and
clarity of the returned exchange fluid,
Pulse oximetry 359
Continuous-cycle peritoneal dialysis
Continuous-cycle peritoneal dialysis or in a health care facility. The patient

(CCPD) is an easy method for the patient typically initiates CCPD at bedtime and
who uses an automated continuous cycler undergoes three to seven exchanges, de-
system. When set up, this system runs the pending on individual prescriptions. On
dialysis treatment automatically until all awakening, the patient infuses the pre-
of the dialysate is infused. The system re- scribed dialysis volume, disconnects him-
mains closed throughout the treatment, self from the unit, and carries the
which reduces the risk of contamination. dialysate in his peritoneal cavity during
CCPD can be performed while the patient the day.
is awake or asleep. The system’s alarms The continuous cycler requires the
warn about general system, dialysate, and same aseptic care and maintenance pro-
patient problems. cedures as the manual method.
The cycler can be set to an intermittent
or continuous dialysate schedule at home
and check it for mucus, pus, and sorbed by the arterial blood, and calcu-
blood. Also note any discrepancy in lates the exact mixed venous oxygen
the balance of fluid intake and output saturation without interference from
as well as any signs of fluid imbalance, surrounding venous blood, skin, con-
such as weight changes, decreased nective tissue, or bone. Ear oximetry
breath sounds, peripheral edema, as- works by monitoring the transmission
cites, and changes in skin turgor. of light waves through the vascular bed
Record the patient’s weight, blood of a patient’s earlobe. The results will
pressure, and pulse rate after his last be inaccurate if the patient’s earlobe is
fluid exchange for the day. poorly perfused, as from low cardiac
output.
Pulse oximetry Equipment
Performed intermittently or continu- Oximeter ◆ transducer (photodetector)

ously, oximetry is a relatively simple for finger or ear probe ◆ alcohol pads
procedure that’s used to monitor arteri- ◆ nail polish remover, if needed
al oxygen saturation noninvasively.
Pulse oximeters usually denote arterial Implementation
oxygen saturation values with the sym-
bol SpO2. Invasively measured arterial ◆ Explain the procedure to the pa-
oxygen saturation values are denoted tient.
by the symbol SaO2.
Two diodes send red and infrared Finger pulse oximetry
light through a pulsating arterial vascu- ◆ Select a finger for the test. Although
lar bed such as the one in the fingertip. the index finger is commonly used, a
A photodetector that’s slipped over the smaller finger may be selected if the
finger measures the transmitted light as patient’s fingers are too large for the
it passes through the vascular bed, de- equipment. Make sure that the patient
tects the relative amount of color ab- isn’t wearing false fingernails, and
remove any nail polish from the test revascularizing the patient’s earlobe
finger with nail polish remover. Place each time.
the transducer (photodetector) finger ◆ After the procedure, remove the
probe over the patient’s finger so that probe, turn off and unplug the unit,
light beams and sensors oppose each and clean the probe by gently rubbing
other and attach to the oximeter. If the it with an alcohol pad.
patient has long fingernails, position
the probe perpendicular to the finger, if Special considerations
possible, or clip the fingernail. Always
position the patient’s hand at heart lev- ◆ If oximetry has been performed
el to eliminate venous pulsations and properly, the readings are typically ac-
to promote accurate readings. curate. However, certain factors may
Age alert If you’re testing a interfere with accuracy. For example,
neonate or a small infant, wrap elevated carboxyhemoglobin or methe-
the probe around the foot so that light moglobin levels, such as occur in
beams and detectors oppose each oth- heavy smokers and urban dwellers, can
er. For a large infant, use a probe that cause a falsely elevated SpO2 reading.
fits on the great toe, and secure it to (See Diagnosing pulse oximeter prob-
the foot. lems.)
◆ Turn on the power switch. If the de- ◆ Certain intravascular substances,
vice is working properly, a beep will such as lipid emulsions and dyes, can
sound, a display will light momentari- also prevent accurate readings. Other
ly, and the pulse searchlight will flash. factors that may interfere with accurate
The SpO2 and pulse rate displays will results include excessive light (for ex-
show stationary zeros. After four to six ample, from phototherapy, surgical
heartbeats, the SpO2 and pulse rate dis- lamps, direct sunlight, and excessive
plays will supply information with ambient lighting), excessive patient
each beat, and the pulse amplitude in- movement, excessive ear pigment, hy-
dicator will begin to track the pulse. pothermia, hypotension, and vasocon-
striction.
Ear pulse oximetry ◆ If the patient has compromised cir-
◆ Using an alcohol pad, massage the culation in his extremities, you can
patient’s earlobe for 10 to 20 seconds. place a photodetector across the bridge
Mild erythema indicates adequate vas- of his nose.
cularization. Following the manufactur- ◆ If SpO2 is used to guide weaning of
er’s instructions, attach the ear probe the patient from forced inspiratory oxy-
to the patient’s earlobe or pinna. Use gen, obtain arterial blood gas analysis
the ear probe stabilizer for prolonged occasionally to correlate SpO2 readings
or exercise testing. Be sure to establish with SaO2 levels.
good contact on the ear; an unstable ◆ If an automatic blood pressure cuff is
probe may set off the low-perfusion used on the same extremity that’s used
alarm. After the probe has been at- to measure SpO2, the cuff will interfere
tached for a few seconds, a saturation with SpO2 readings during inflation.
reading and pulse waveform will ap- ◆ If light is a problem, cover the
pear on the screen. probes; if patient movement is a prob-
◆ Leave the ear probe in place for 3 lem, move the probe or select a differ-
minutes or more, until readings stabi- ent probe; and if ear pigment is a prob-
lize at the highest point, or take three lem, reposition the probe, revascularize
separate readings and average them, the site, or use a finger probe.
Diagnosing pulse oximeter problems
To maintain a continuous display of arteri- securely fastened and that the pulse
al oxygen saturation levels, you’ll need to oximeter is plugged into a power source.
keep the monitoring site clean and dry.
Make sure that the skin doesn’t become Inadequate or intermittent blood
irritated from adhesives used to keep dis- flow to the site
posable probes in place. You may need to Check the patient’s pulse rate and capil-
change the site if this happens. Dispos- lary refill time, and take corrective action
able probes that irritate the skin can be if blood flow to the site is decreased. This
replaced by nondisposable models that may mean loosening restraints, removing
don’t need tape. tight-fitting clothes, taking off a blood
Another common problem with pulse pressure cuff, or checking arterial and I.V.
oximeters is the failure of the devices to lines. If none of these interventions works,
obtain a signal. If this happens, your first you may need to find an alternate site.
reaction should be to check the patient’s Finding a site with proper circulation may
vital signs. If they’re sufficient to produce prove challenging when a patient is re-
a signal, check for the following problems. ceiving a vasoconstrictor.
Venous pulsations Equipment malfunction

Erroneous readings may result if the pulse Remove the pulse oximeter from the pa-
oximeter detects venous pulsations. These tient, set the alarm limits according to
may occur in patients with tricuspid regur- your facility’s policy, and try the instru-
gitation or pulmonary hypertension, or if ment on yourself or another healthy per-
a finger probe is taped on too tightly. son. This will tell you if the equipment is
working correctly.
Poor connection
See if the sensors are properly aligned.
Make sure that the wires are intact and
◆ Normal SpO2 levels for ear and pulse oximetric measurement; and the ac-
oximetry are 90% to 100% for adults tions taken. Record the reading in ap-
and 93.8% to 100% by 1 hour after propriate flowcharts, if indicated.
birth for healthy, full-term neonates.
Lower levels may indicate hypoxemia
that warrants intervention. For such pa- Seizure management
tients, follow facility policy or the
physician’s orders, which may include Seizures are paroxysmal events that are
increasing oxygen therapy. If SaO2 lev- associated with abnormal electrical dis-
els decrease suddenly, you may need to charges of neurons in the brain. Partial
resuscitate the patient immediately. No- seizures are usually unilateral, involv-
tify the physician of any significant ing a localized, or focal, area of the
change in the patient’s condition. brain. Generalized seizures involve the
entire brain. When a patient has a gen-
Documentation eralized seizure, the goal of nursing
care is to protect him from injury and
Document the procedure, including the prevent serious complications. Appro-
date, time, and type of procedure; the priate care also includes observation of
Precautions for generalized seizures
By taking appropriate precautions, you zures who’s being admitted for a change
can help to protect a patient from injury, in medication, treatment of an infection,
aspiration, and airway obstruction in case or detoxification may have an increased
he has a seizure. Plan your precautions risk of seizures.
using information obtained from the pa- ◆ Explain the reasons for the precautions
tient’s history. What kind of seizure has to the patient.
the patient previously had? Is he aware of ◆ To protect the patient’s limbs, head,
exacerbating factors? Sleep deprivation, and feet from injury if he has a seizure
missed doses of an anticonvulsant, and while in bed, cover the side rails, head-
even upper respiratory tract infections can board, and footboard with side rail pads
increase seizure frequency in some people or bath blankets. If you use blankets,
who have had seizures. Was his previous keep them in place with adhesive tape.
seizure an acute episode, or did it result Be sure to keep the side rails raised while
from a chronic condition? the patient is in bed to prevent falls. Keep
the bed in a low position to minimize in-
Gather the equipment juries that may occur if the patient climbs
Based on answers provided in the pa- over the side rails.
tient’s history, you can tailor your precau- ◆ Place an airway at the patient’s bed-
tions to his needs. Start by gathering the side, or tape it to the wall above the bed
appropriate equipment, including a hospi- according to facility policy. Keep suction
tal bed with full-length side rails, com- equipment nearby in case you need to es-
mercial side rail pads or six bath blankets tablish a patent airway. Explain to the pa-
(four for a crib), adhesive tape, an oral tient how the airway will be used.
airway, and oral or nasal suction equip- ◆ If the patient has frequent or pro-
ment. longed seizures, prepare an I.V. heparin
lock to facilitate the administration of
Bedside preparations emergency medications.
Carry out the precautions that you think
are appropriate for the patient. Remem-
ber that a patient with preexisting sei-
the characteristics of the seizure to ins, such as mercury, lead, or carbon

help determine the area of the brain in- monoxide; genetic abnormalities, such
volved. as tuberous sclerosis and phenylke-
Patients who are considered at risk tonuria; perinatal injuries; and stroke.
for seizures are those with a history of Patients at risk for seizures need pre-
seizures and those with conditions that cautionary measures to help prevent
predispose them to seizures. These injury if a seizure occurs. (See Precau-
conditions include metabolic abnormal- tions for generalized seizures.)
ities, such as hypocalcemia, hypoglyce-
mia, and pyridoxine deficiency; brain Equipment
tumors or other space-occupying le-
sions; infections, such as meningitis, Oral airway ◆ suction equipment ◆
encephalitis, and brain abscess; trau- side rail pads ◆ seizure activity record
matic injury, especially if the dura ◆ optional: I.V. line and normal saline
mater was penetrated; ingestion of tox- solution, oxygen as ordered, endotra-
Understanding status epilepticus
Status epilepticus is a continuous seizure drawal of an anticonvulsant, hypoxic or

state, unless it’s interrupted by emergency metabolic encephalopathy, acute head
interventions. It can occur with all types of trauma, or septicemia as a result of en-
seizures. The most life-threatening exam- cephalitis or meningitis.
ple is generalized tonic-clonic status Emergency treatment of status epilepti-
epilepticus, which is a continuous general- cus usually consists of phenobarbital, di-
ized tonic-clonic seizure without interven- azepam, lorazepam, or phenytoin; I.V.
ing return of consciousness. dextrose 50% (when seizures are caused
Status epilepticus, which is always an by hypoglycemia); and I.V. thiamine (in
emergency, is accompanied by respiratory patients with chronic alcoholism or with-
distress. It can result from abrupt withdrawal).
cheal intubation, dextrose 50% in wa- ◆ Don’t forcibly restrain the patient or
ter, thiamine restrict his movements during the
seizure. The force of his movements
Implementation against restraints could cause muscle
strain or even joint dislocation.
◆ If you’re with a patient when he ex- ◆ Time the seizure activity from be-
periences an aura, help him get into ginning to end, and continually assess
bed, raise the side rails, and adjust the the patient during the seizure. Observe
bed flat. Use side rail pads and blan- the earliest sign, such as head or eye
kets to pad the rails securely. If he’s deviation, as well as how the seizure
away from his room, lower him to the progresses, what form it takes, and
floor and place a pillow, blanket, or how long it lasts. Document the
other soft material under his head to seizure on the hospital seizure activity
keep it from hitting the floor. record. Your description may help de-
◆ Stay with the patient during the termine the type and cause of the
seizure, and be ready to intervene if seizure.
complications such as airway obstruc- ◆ If this is the patient’s first seizure,
tion develop. If necessary, have anoth- notify the physician immediately. If the
er staff member obtain the appropriate patient has had seizures before, notify
equipment and notify the physician of the physician only if the seizure activi-
the obstruction. ty is prolonged or if the patient doesn’t
◆ Provide privacy, if possible. regain consciousness. (See Understand-
Alert During a seizure don’t ing status epilepticus.)
try to hold the patient’s mouth ◆ If ordered, establish an I.V. line and
open or place your hands inside his infuse normal saline solution at a keep-
mouth because he may bite you. After vein-open rate.
the patient’s jaw becomes rigid, don’t ◆ If the seizure is prolonged and the
force an airway into place because you patient becomes hypoxemic, administer
could break his teeth or cause another oxygen, as ordered. Some patients may
injury. If needed, insert an oral airway require endotracheal intubation.
after the seizure subsides. ◆ If the patient has diabetes and hy-
◆ Move hard or sharp objects out of the poglycemia, administer dextrose 50%
patient’s way, and loosen his clothing. in water by I.V. push, if ordered. If the
patient has alcoholism, a bolus of thi- perience a postictal period of de-

amine may be ordered to stop the creased mental status lasting 30 min-
seizure. utes to 24 hours. Reassure the patient
◆ After the seizure, turn the patient that this doesn’t indicate incipient
on his side and apply suction, if need- brain damage.
ed, to facilitate drainage of secretions
and maintain a patent airway. Insert an Documentation
oral airway, if needed.
◆ Check the patient for injuries. Document that the patient requires
◆ Reorient and reassure the patient, seizure precautions, and record all pre-
as needed. cautions taken. Record the date and
◆ When the patient is comfortable the time that the seizure began as well
and safe, document what happened as its duration and any precipitating
during the seizure. factors. Identify any sensation that may
◆ After the seizure, monitor the pa- be considered an aura. If the seizure
tient’s vital signs and mental status was preceded by an aura, have the pa-
every 15 to 20 minutes for 2 hours. tient describe what he experienced.
◆ Ask the patient about his aura and Record any involuntary behavior
activities preceding the seizure. The that occurred at the onset of the
type of aura (auditory, visual, olfacto- seizure, such as lip smacking, chewing
ry, gustatory, or somatic) helps to pin- movements, or hand and eye move-
point the site in the brain where the ments. Describe where the movement
seizure originated. began and the parts of the body in-
volved. Note if the activity showed any
Special considerations progression or pattern. Document
whether the patient’s eyes deviated to
◆ Because a seizure commonly indi- one side and whether the pupils
cates an underlying disorder, such as changed in size, shape, equality, or re-
meningitis or a metabolic or electrolyte action to light. Note if the patient’s
imbalance, a complete diagnostic teeth were clenched or open. Record
workup will be ordered if the cause of incontinence, vomiting, or salivation
the seizure isn’t evident. that occurred during the seizure.
◆ The patient who has a seizure may Note the patient’s response to the
experience an injury, respiratory diffi- seizure. Was the patient aware of what
culty, and decreased mental capability. happened? Did he fall into a deep sleep
Common injuries include scrapes and after the seizure? Was he upset or
bruises that occur when the patient hits ashamed? Document all medications
objects during the seizure and traumat- given, all complications experienced
ic injury to the tongue caused by biting. during the seizure, and all interven-
If you suspect a serious injury, such as tions performed. Record the patient’s
a fracture or deep laceration, notify the mental status after the seizure.
physician and arrange for appropriate
evaluation and treatment.
◆ Changes in respiratory function in- Sequential compression
clude aspiration, airway obstruction, therapy
and hypoxemia. After the seizure,
complete a respiratory assessment and Safe, effective, and noninvasive, se-
notify the physician if you suspect a quential compression therapy helps pre-
problem. Expect most patients to ex- vent deep vein thrombosis (DVT) in
Sequential compression therapy 365
surgical patients. This therapy massages Determining proper sleeve size

the legs in a wavelike, milking motion ◆ Before applying the compression
that promotes blood flow and deters sleeve, determine the proper size of
thrombosis. sleeve that you need. Wash your hands.
Typically, sequential compression ◆ Measure the circumference of the
therapy complements other preventive patient’s upper thigh while she rests in
measures, such as antiembolism stock- bed. Do this by placing the measuring
ings and anticoagulant therapy. Al- tape under the thigh at the gluteal fur-
though patients who are at low risk for row (as shown below).
DVT may require only antiembolism
stockings, those who are at moderate
to high risk may require both antiem-
bolism stockings and sequential com-
pression therapy. These preventive
measures are continued for as long as
the patient remains at risk.
Both antiembolism stockings and
sequential compression sleeves are
commonly used preoperatively and
postoperatively because blood clots
tend to form during surgery. About
20% of blood clots form in the femoral
vein. Sequential compression therapy
counteracts blood stasis and coagula-
tion changes, two of the three major
factors that promote DVT. It reduces ◆ Hold the tape snugly, but not tight-
stasis by increasing peak blood flow ly, around the patient’s leg. Note the
velocity, helping to empty the femoral exact circumference.
vein’s valve cusps of pooled or static ◆ Find the patient’s thigh measurement
blood. The compressions cause an anti- on the sizing chart, and locate the corre-
clotting effect by increasing fibrinolytic sponding size of the compression sleeve.
activity, which stimulates the release of ◆ Remove the compression sleeves
a plasminogen activator. from the package and unfold them.
◆ Lay the unfolded sleeves on a flat
Equipment surface with the cotton lining facing up
(as shown below).
Measuring tape and sizing chart for
brand of sleeves being used ◆ pair of
compression sleeves in correct size ◆
connecting tubing ◆ compression con-
troller
Implementation
◆ Explain the procedure to the patient

to increase his cooperation.
◆ Wash your hands.
◆ Notice the markings on the lining ends together. Listen for a click, which
denoting the ankle and the area behind signals a firm connection. Make sure
the knee at the popliteal pulse point. that the tubing isn’t kinked.
Use these markings to position the ◆ Plug the compression controller into
sleeves at the appropriate landmarks. the proper wall outlet. Turn on the
power.
Applying the sleeves ◆ The controller automatically sets the
◆ Place the patient’s leg on the lining compression sleeve pressure at 45 mm
of one of the sleeves. Position the back Hg, which is the midpoint of the nor-
of the knee over the popliteal opening. mal range (35 to 55 mm Hg).
◆ Make sure that the back of the an- ◆ Observe the patient to see how well
kle is over the ankle marking. he tolerates the therapy and the con-
◆ Starting at the side opposite the troller as the system completes its first
clear plastic tubing, wrap the sleeve cycle.
snugly around the patient’s leg. ◆ Check the AUDIBLE ALARM key. The
◆ Fasten the sleeve securely with the green light should be lit, indicating that
Velcro fasteners. For the best fit, secure the alarm is working.
the ankle and calf sections, followed by ◆ The compression sleeves should
the thigh section. function continuously (24 hours/day)
◆ The sleeve should fit snugly, but until the patient is fully ambulatory.
not tightly. Check the fit by inserting Check the sleeves at least once each
two fingers between the sleeve and the shift to ensure proper fit and inflation.
patient’s leg at the knee opening.
Loosen or tighten the sleeve by read- Removing the sleeves
justing the Velcro fastener. ◆ You may remove the sleeves when
◆ Using the same procedure, apply the patient is walking, bathing, or leav-
the second sleeve (as shown below). ing the room for tests or other proce-
dures, as long as you reapply the
sleeves immediately after the tests and
procedures are over. To disconnect the
sleeves from the tubing, press the
latches on each side of the connectors
and pull the connectors apart.
◆ Store the tubing and the compres-
sion controller according to facility pol-
icy. This equipment isn’t disposable.
◆ Remove the sleeves and assess and

document skin integrity every 8 hours
Operating the system to avoid skin breakdown.
◆ Connect each sleeve to the tubing ◆ The compression controller also has
leading to the controller. Both sleeves a mechanism to help cool the patient.
must be connected to the compression ◆ If you’re applying only one sleeve —
controller for the system to operate. for example, if the patient has a cast —
Line up the blue arrows on the sleeve leave the unused sleeve folded in the
connector with the arrows on the tub- plastic bag. Cut a small hole in the
ing connectors, and firmly push the sealed bottom edge of the bag, and
Surgical site verification 367
pull the sleeve connector (the part that cluding inadequate assessment of the
holds the connecting tubing) through patient, inadequate review of the med-
the hole. Then you can join both ical records, inaccurate communication
sleeves to the compression controller. among members of the health team,
◆ If a malfunction triggers the instru- the involvement of multiple surgeons
ment alarm, you’ll hear beeping. The in the procedure, failure to include the
system shuts off whenever the alarm is patient in the site-identification pro-
activated. cess, and the practice of relying solely
◆ To respond to the alarm, remove the on the physician for site identification.
operator’s card from the slot on the top Because serious consequences may
of the compression controller. Follow result from wrong-site surgery, the
the instructions printed on the card nurse must confirm that the correct site
next to the matching code. has been identified before surgery be-
◆ Don’t use this therapy in patients gins.
with any of the following conditions:
– acute DVT or DVT diagnosed within Equipment
the last 6 months
– severe peripheral arterial occlusive Surgical consent ◆ medical record ◆
disease procedure schedule ◆ hypoallergenic,
– lower extremity bypass nonlatex permanent marker
– massive edema of the legs because
of pulmonary edema or heart failure Implementation
– any local condition that would like-
ly be aggravated by the compression ◆ Confirm the patient’s identity using
sleeves, such as dermatitis, vein liga- two patient identifiers.
tion, gangrene, and recent skin graft- ◆ Before the procedure, check the pa-
ing. A patient with a pronounced leg tient’s chart for documentation. Com-
deformity would also be unlikely to pare the information on the chart with
benefit from the compression sleeves. the history and physical examination
form, the nursing assessment, the pre-
Documentation procedure verification checklist, the
signed informed consent form with the
Document the procedure, the patient’s exact procedure site identified, the pro-
understanding of the procedure, the pa- cedure schedule, and the patient’s ver-
tient’s response, and the status of the bal confirmation of the correct site.
alarm and cooling settings. ◆ After you verbally confirm the site
with the patient, the person performing
the surgery or a member of the surgical
Surgical site verification team who is fully informed about the
patient and the procedure marks the
Wrong-site surgery is a general term site with a permanent marker. The
that refers to a surgical procedure mark needs to be visible after the pa-
that’s performed on the wrong body tient has been prepped and draped.
part or side of the body, or even the ◆ Make sure that the surgical team
wrong patient. This error may occur in (surgeon, operating room or procedure
the operating room or in other settings, staff, and anesthesia personnel) identi-
such as during ambulatory care or in- fies the patient and verifies the correct
terventional radiology. procedure and the correct site before
Several factors may contribute to an they begin the surgery.
increased risk of wrong-site surgery, in-
Special considerations how well the patient tolerates the ar-

rhythmia. For example, if the patient is
If the patient’s condition prevents him hemodynamically unstable, he requires
from verifying the correct site, the sur- urgent cardioversion. When preparing
geon will identify and mark the site us- for cardioversion, the patient’s condi-
ing history and physical examination tion can deteriorate quickly, necessitat-
forms, signed informed consent form, ing immediate defibrillation.
preprocedure verification checklist, Indications for cardioversion include
procedure schedule, X-rays, and other stable paroxysmal atrial tachycardia,
imaging studies. unstable paroxysmal supraventricular
tachycardia, atrial fibrillation, atrial
Documentation flutter, and ventricular tachycardia with
a pulse.
Complete the preprocedure verification
checklist used by the facility. Record Equipment
that the correct site was verified, and
note who marked the correct site with Cardioverter-defibrillator ◆ conductive
a permanent marker. medium pads ◆ anterior, posterior, or
transverse paddles ◆ electrocardiogram
(ECG) monitor with recorder ◆ seda-
Synchronized cardioversion tive ◆ oxygen therapy equipment ◆
airway ◆ handheld resuscitation bag ◆
Used to treat tachyarrhythmias, car- emergency cardiac medication ◆ auto-
dioversion delivers an electric charge to matic blood pressure cuff (if available)
the myocardium at the peak of the ◆ pulse oximeter (if available)
R wave. This charge causes immediate
depolarization, interrupting reentry cir- Implementation
cuits and allowing the sinoatrial node
to resume control. Synchronizing the ◆ Confirm the patient’s identity using
electric charge with the R wave en- two patient identifiers.
sures that the current won’t be deliv- ◆ Explain the procedure to the pa-
ered on the vulnerable T wave and tient, and make sure that he has signed
thus won’t disrupt repolarization. a consent form.
Synchronized cardioversion is the ◆ Check the patient’s recent serum
treatment of choice for arrhythmias potassium and magnesium levels and
that don’t respond to vagal massage or arterial blood gas values. Also check
drug therapy, such as atrial tachycar- his recent digoxin levels. Although pa-
dia, atrial flutter, atrial fibrillation, and tients receiving digoxin may undergo
symptomatic ventricular tachycardia. cardioversion, they tend to require low-
Cardioversion should be performed er energy levels to convert. If ordered,
according to the 2005 American Heart withhold the dose on the day of the
Association guidelines and should be procedure.
preceded by an assessment of the pa- ◆ Withhold all food and fluids for 6 to
tient’s cardiac and metabolic status if 12 hours before the procedure. If the
possible. This assessment should in- cardioversion is urgent, withhold the
clude electrolyte values and renal func- previous meal.
tion tests. ◆ Obtain a 12-lead ECG to serve as a
Cardioversion may be an elective or baseline.
an urgent procedure, depending on
Synchronized cardioversion 369
◆ Check to see if the physician has or- tient with atrial flutter, and 100 joules
dered the administration of any cardiac for a patient who has monomorphic
drugs before the procedure. Verify that ventricular tachycardia with a pulse.
the patient has a patent I.V. site in case ◆ Remove the paddles from the ma-
drug administration becomes neces- chine, and prepare them as you would
sary. if you were defibrillating the patient.
◆ Connect the patient to a pulse Place the conductive medium pads or
oximeter and an automatic blood pres- the appropriate paddles in the same
sure cuff, if available. positions as you would to defibrillate.
◆ Consider administering oxygen for 5 ◆ Make sure that everyone stands
to 10 minutes before the cardioversion away from the bed; then push the dis-
to promote myocardial oxygenation. If charge buttons. Hold the paddles in
the patient wears dentures, evaluate place and wait for the energy to be dis-
whether they support his airway or charged — the machine must synchro-
might cause an airway obstruction. If nize the discharge with the QRS com-
they might cause an obstruction, re- plex.
move them. ◆ Check the waveform on the moni-
◆ Place the patient in the supine posi- tor. If the arrhythmia doesn’t convert,
tion, and assess his vital signs, level of repeat the procedure two or three more
consciousness (LOC), cardiac rhythm, times at 3-minute intervals. Gradually
and peripheral pulses. increase the energy level with each ad-
◆ Remove any oxygen delivery device ditional countershock.
just before cardioversion to avoid pos- ◆ After the cardioversion, frequently
sible combustion. assess the patient’s LOC and respirato-
◆ Have emergency cardiac medication ry status, including airway patency,
at the patient’s bedside. respiratory rate and depth, and the
◆ Administer a sedative as ordered. need for supplemental oxygen. Because
The patient should be heavily sedated, the patient will be heavily sedated, he
but still able to breathe adequately. may require airway support with a
◆ Carefully monitor the patient’s handheld resuscitation bag.
blood pressure and respiratory rate un- ◆ Record a postcardioversion 12-lead
til he recovers. ECG, and monitor the patient’s ECG
◆ Apply the ECG monitor with recor- rhythm for 2 hours. Check the patient’s
der, and press the POWER button to turn chest for electrical burns.
on the cardioverter-defibrillator. Push
the SYNC button to synchronize the ma- Special considerations
chine with the patient’s QRS complex-
es. Make sure that the SYNC button ◆ If the patient is attached to a bed-
flashes with each of the patient’s QRS side or telemetry monitor, disconnect
complexes. You should also see a the unit before cardioversion. The elec-
bright green flag flash on the ECG tric current that it generates could
monitor. damage the equipment.
◆ Turn the ENERGY SELECT dial to the ◆ Improper synchronization may re-
ordered amount of energy. Advanced sult if the patient’s ECG tracing con-
cardiac life support protocols call for tains artifact-like spikes, such as
50 to 100 joules for a patient with un- peaked T waves or bundle-branch
stable supraventricular tachycardia, 100 blocks when the R wave may be taller
to 200 joules for a patient with atrial than the R wave.
fibrillation, 50 to 100 joules for a pa-
◆ Although the electric shock of car- by way of two electrodes, which are
dioversion won’t usually damage an placed on the front and back of the pa-
implanted pacemaker, avoid placing the tient’s chest. Transcutaneous pacing is
paddles directly over the pacemaker. quick and effective, but it’s used only
◆ Remove any patches with metallic until the physician can institute trans-
backings such as nitroglycerin patches. venous pacing.
This backing may cause a ring during Transcutaneous pacing is recom-
cardioversion. mended by the 2005 American Heart
◆ Reset the synchronization mode af- Association guidelines for cardiopul-
ter each cardioversion because many monary resuscitation (CPR) and emer-
defibrillators automatically default back gency cardiovascular care for sympto-
to the unsynchronized mode. matic bradycardia when a pulse is pres-
◆ Common complications after cardio- ent. If transcutaneous pacing doesn’t
version include transient, harmless ar- correct the problem, transvenous pac-
rhythmias, such as atrial, ventricular, ing is indicated. Transvenous pacing
and junctional premature beats. Seri- involves threading an electrode catheter
ous ventricular arrhythmias, such as through a vein into the patient’s right
ventricular fibrillation, may also occur. atrium or right ventricle. The electrode
However, this type of arrhythmia is attaches to an external pulse generator.
more likely to result from digoxin toxi- As a result, the pulse generator can
city, high amounts of electrical energy, provide an electrical stimulus directly
severe heart disease, electrolyte imbal- to the endocardium. This is the most
ance, or improper synchronization with common type of pacemaker.
the R wave. However, the physician may choose
to insert a transthoracic pacemaker as
Documentation an elective surgical procedure or as an
emergency measure during CPR. To in-
Document the procedure, including the sert this type of pacemaker, the physi-
voltage delivered with each attempt, cian performs a procedure similar to
the rhythm strips obtained before and pericardiocentesis, in which he uses a
after the procedure, and the patient’s cardiac needle to pass an electrode
tolerance of the procedure. through the chest wall and into the
right ventricle. This procedure carries a
significant risk of coronary artery lacer-
Temporary pacemaker ation and cardiac tamponade.
insertion and care During cardiac surgery, the surgeon
may insert electrodes through the epi-
Usually inserted in an emergency, a cardium of the right ventricle and, if he
temporary pacemaker consists of an wants to institute atrioventricular se-
external, battery-powered pulse genera- quential pacing, the right atrium. From
tor and a lead or electrode system. The there, the electrodes pass through the
four types of temporary pacemakers in- chest wall, where they remain avail-
clude transcutaneous, transvenous, able if temporary pacing becomes nec-
transthoracic, and epicardial. essary. This is called epicardial pacing.
In a life-threatening situation, when In addition to helping to correct
time is critical, a transcutaneous pace- conduction disturbances, a temporary
maker is the best choice. This device pacemaker may help to diagnose
sends an electrical impulse from the conduction abnormalities. For example,
pulse generator to the patient’s heart during a cardiac catheterization or
electrophysiology study, a physician For epicardial pacing

may use a temporary pacemaker to All equipment listed for temporary pac-
localize conduction defects. In the ing ◆ atrial epicardial wires ◆ ventric-
process, he may also learn whether the ular epicardial wires ◆ sterile rubber
patient is at risk for an arrhythmia. finger cot ◆ sterile dressing materials
Contraindications to pacemaker (if the wires won’t be connected to a
therapy include electromechanical dis- pulse generator)
sociation and ventricular fibrillation.
Implementation
Equipment
◆ Confirm the patient’s identity using
For transcutaneous pacing two patient identifiers.
Transcutaneous pacing generator ◆ ◆ If applicable, explain the procedure
transcutaneous pacing electrodes ◆ to the patient.
cardiac monitor ◆ clippers
For transcutaneous pacing
For all other types of temporary ◆ If necessary, clip the patient’s hair
pacing over the areas of electrode placement.
Temporary pacemaker generator with Don’t shave the areas. If you nick the
new battery ◆ guide wire or introducer skin, the current from the pulse gener-
◆ electrode catheter ◆ sterile gloves ◆ ator could cause discomfort and the
sterile dressings ◆ adhesive tape ◆ an- nicks could become irritated or infect-
tiseptic solution ◆ sterile marker and ed after the electrodes are applied.
labels ◆ nonconducting tape or rubber ◆ Attach monitoring electrodes to the
surgical glove ◆ pouch for external patient in the lead I, II, or III position.
pulse generator ◆ emergency cardiac Do this even if the patient is already
drugs ◆ intubation equipment ◆ defib- on a bedside or telemetry monitor be-
rillator ◆ cardiac monitor with strip- cause you’ll need to connect the elec-
chart recorder ◆ equipment to start a trodes to the pacemaker. If you select
peripheral I.V. line, if appropriate ◆ the lead II position, adjust the LL elec-
I.V. fluids ◆ sedative ◆ optional: elas- trode placement to accommodate the
tic bandage or gauze strips, restraints anterior pacing electrode and the pa-
tient’s anatomy.
For transvenous pacing ◆ Plug the patient cable into the elec-
All equipment listed for temporary pac- trocardiogram (ECG) input connection
ing ◆ bridging cable ◆ percutaneous on the front of the pacing generator.
introducer tray or venous cutdown tray Set the selector switch to the MONITOR
◆ sterile gowns ◆ linen-saver pad ◆ ON position.
antimicrobial soap ◆ alcohol pads ◆ ◆ You should see the ECG waveform
vial of 1% lidocaine ◆ 5-ml syringe ◆ on the monitor. Adjust the R-wave
fluoroscopy equipment, if needed ◆ beeper volume to a suitable level, and
fenestrated drape ◆ prepackaged cut- activate the alarm by pressing the
down tray (for antecubital vein place- ALARM ON button. Set the alarm for
ment only) ◆ sutures ◆ receptacle for 10 to 20 beats lower and 20 to 30 beats
infectious wastes higher than the intrinsic rate.
◆ Press the START/STOP button to ob-
For transthoracic pacing tain a printout of the waveform.
All equipment listed for temporary pac- ◆ Now you’re ready to apply the two
ing ◆ transthoracic or cardiac needle pacing electrodes. First, make sure that
the patient’s skin is clean and dry to ◆ With full capture, the patient’s heart
ensure good skin contact. rate should be approximately the same
◆ Pull off the protective strip from the as the pacemaker rate set on the ma-
posterior electrode (marked BACK), and chine. The usual pacing threshold is
apply the electrode on the left side of between 40 and 80 mA.
the back, just below the scapula and to
the left of the spine. For transvenous pacing
◆ The anterior pacing electrode ◆ Check the patient’s history for hy-
(marked FRONT) has two protective persensitivity to local anesthetics. At-
strips — one covering the jellied area tach the cardiac monitor to the patient
and one covering the outer rim. Expose and obtain a baseline assessment, in-
the jellied area and apply it to the skin cluding the patient’s vital signs, skin
in the anterior position — to the left color, level of consciousness (LOC),
side of the precordium in the usual V2 heart rate and rhythm, and emotional
to V5 position. Move this electrode state. Insert a peripheral I.V. line if the
around to obtain the best waveform. patient doesn’t already have one. Begin
Then expose the outer rim of the elec- an I.V. infusion of dextrose 5% in wa-
trode and firmly press it to the skin. ter at a keep-vein-open rate.
◆ Now you’re ready to pace the heart. ◆ Insert a new battery into the exter-
After making sure that the energy out- nal pacemaker generator, and test it to
put in milliamperes (mA) is 0, connect make sure that it has a strong charge.
the electrode cable to the monitor out- Connect the bridging cable to the gen-
put cable. erator, and align the positive and nega-
◆ Check the waveform, looking for a tive poles. This cable allows slack be-
tall QRS complex in lead II. tween the electrode catheter and the
◆ Turn the selector switch to PACER generator, reducing the risk of acciden-
ON. Tell the patient that he may feel a tal displacement of the catheter.
thumping or twitching sensation. Reas- ◆ Place the patient in the supine posi-
sure him that you’ll give him medication. If necessary, clip the hair around
tion if he can’t tolerate the discomfort. the insertion site. Open the supply tray
◆ Set the rate dial to 10 to 20 beats while maintaining a sterile field. Label
higher than the patient’s intrinsic all medications, medication containers,
rhythm. Look for pacer artifact or and other solutions on and off the ster-
spikes, which will appear as you in- ile field. Using sterile technique, clean
crease the rate. If the patient doesn’t the insertion site with antimicrobial
have an intrinsic rhythm, set the rate soap and then wipe the area with anti-
at 60. septic solution. Cover the insertion site
◆ Slowly increase the amount of ener- with a fenestrated drape. Because fluo-
gy delivered to the heart by adjusting roscopy may be used during the place-
the OUTPUT mA dial. Do this until cap- ment of lead wires, put on a protective
ture is achieved — you’ll see a pacer apron.
spike followed by a widened QRS com- ◆ Provide the physician with the local
plex that resembles a premature ven- anesthetic.
tricular contraction. This is the pacing ◆ After anesthetizing the insertion
threshold. To ensure consistent cap- site, the physician will puncture the
ture, increase the output by 10%. Don’t brachial, femoral, subclavian, or jugu-
go any higher because you could cause lar vein. Then he’ll insert a guide wire
the patient needless discomfort. or an introducer and advance the elec-
trode catheter.
◆ As the catheter advances, watch the ◆ Connect the electrode catheter to

cardiac monitor. When the electrode the generator, lining up the positive
catheter reaches the right atrium, you’ll and negative poles. Watch the cardiac
notice large P waves and small QRS monitor for signs of ventricular pacing
complexes. Then, as the catheter reaches and capture.
the right ventricle, the P waves will be- ◆ After the physician sutures the elec-
come smaller while the QRS complexes trode catheter into place, use sterile
enlarge. When the catheter touches the technique to apply a sterile 4 4
right ventricular endocardium, expect to gauze dressing to the site. Tape the
see elevated ST segments, premature dressing securely, and label it with the
ventricular contractions, or both. date and time of application.
◆ When the electrode catheter is in ◆ Check the patient’s peripheral puls-
the right ventricle, it will send an im- es and vital signs to assess cardiac out-
pulse to the myocardium, causing de- put. If you can’t palpate a pulse, con-
polarization. If the patient needs atrial tinue to perform CPR.
pacing, alone or with ventricular pac- ◆ If the patient has a palpable pulse,
ing, the physician may place an elec- assess his vital signs, ECG reading, and
trode in the right atrium. LOC.
◆ Meanwhile, continuously monitor
the patient’s cardiac status and treat For epicardial pacing
any arrhythmias, as appropriate. Assess ◆ During preoperative teaching, in-
the patient for jaw pain and earache; form the patient that epicardial pace-
these symptoms indicate that the elec- maker wires may be placed during car-
trode catheter has missed the superior diac surgery.
vena cava and has moved into the ◆ Just before the end of cardiac sur-
neck instead. gery, the physician will hook epicardial
◆ When the electrode catheter is in wires into the epicardium. Depending
place, attach the catheter leads to the on the patient’s condition, the physi-
bridging cable, lining up the positive cian may insert atrial wires, ventricular
and negative poles. wires, or both.
◆ Set the pacemaker as ordered. ◆ If indicated, connect the electrode
◆ The physician will then suture the catheter to the generator, lining up the
catheter to the insertion site. After- positive and negative poles. Set the
ward, put on sterile gloves and apply a pacemaker as ordered.
sterile dressing to the site. Label the ◆ If the wires won’t be connected to
dressing with the date and time of ap- an external pulse generator, place them
plication. in a sterile rubber finger cot. Cover
both the wires and the insertion site
For transthoracic pacing with a sterile, occlusive dressing to
◆ Clean the skin to the left of the help protect the patient from micro-
xiphoid process with povidone-iodine shock and infection.
solution. Work quickly, because CPR
must be interrupted for the procedure. Special considerations
◆ After interrupting CPR, the physi-
cian will insert a transthoracic needle ◆ Take care to prevent microshock.
through the patient’s chest wall to the Warn the patient not to use any electri-
left of the xiphoid process and into the cal equipment that isn’t grounded,
right ventricle. He’ll follow this needle such as telephones, electric shavers,
with the electrode catheter. televisions, or lamps.
◆ Other safety measures include plac- ◆ Record the date and time of pace-
ing a plastic cover (supplied by the maker insertion, the type of pacemak-
manufacturer) over the pacemaker con- er, the reason for insertion, and the pa-
trols to avoid an accidental setting tient’s response. Note the pacemaker
change. Insulate the pacemaker by cov- settings. Document all complications
ering all exposed metal parts, such as and the interventions taken.
the electrode connections and pacemak- ◆ If the patient has epicardial pacing
er terminals, with nonconducting tape, wires in place, clean the insertion site
or place the pacing unit in a dry rubber with antiseptic solution and change the
surgical glove. If the patient is disorient- dressing daily. At the same time, moni-
ed or uncooperative, use restraints to tor the site for signs of infection. Keep
prevent accidental removal of the pace- the pulse generator nearby in case pac-
maker wires. If the patient needs emer- ing becomes necessary.
gency defibrillation, make sure that the
pacemaker can withstand the proce- Complications
dure. If you’re unsure, disconnect the Complications associated with pace-
pulse generator to avoid damage. maker therapy include microshock,
◆ When using a transcutaneous pace- equipment failure, and competitive or
maker, don’t place the electrodes over fatal arrhythmias. Transcutaneous
a bony area because bone conducts pacemakers may also cause skin break-
current poorly. With female patients, down and muscle pain and twitching
place the anterior electrode under the when the pacemaker fires. Transvenous
patient’s breast, but not over the di- pacemakers may cause such complica-
aphragm. If the physician inserts the tions as pneumothorax or hemothorax,
electrode through the brachial or cardiac perforation and tamponade, di-
femoral vein, immobilize the patient’s aphragmatic stimulation, pulmonary
arm or leg to avoid putting stress on embolism, thrombophlebitis, and infec-
the pacing wires. tion. Also, if the physician threads the
◆ After insertion of any temporary electrode through the antecubital or
pacemaker, assess the patient’s vital femoral vein, venous spasm, throm-
signs, skin color, LOC, and peripheral bophlebitis, or lead displacement may
pulses to determine the effectiveness of result.
the paced rhythm. Perform a 12-lead Complications associated with
ECG to serve as a baseline, and per- transthoracic pacemakers include pneu-
form additional ECGs daily or with mothorax, cardiac tamponade, emboli,
clinical changes. If possible, obtain a sepsis, lacerations of the myocardium
rhythm strip before, during, and after or coronary artery, and perforation of a
pacemaker placement; whenever the cardiac chamber. Epicardial pacemak-
pacemaker settings are changed; and ers carry a risk of infection, cardiac ar-
whenever the patient receives treat- rest, and diaphragmatic stimulation.
ment because of a complication related
to the pacemaker. Documentation
◆ Continuously monitor the ECG read-
ing, noting the capture, sensing, rate, Record the reason for pacing, the time
intrinsic beats, and competition of it started, and the locations of the elec-
paced and intrinsic rhythms. If the trodes. For a transvenous or transtho-
pacemaker is sensing correctly, the racic pacemaker, note the date, the
sense indicator on the pulse generator time, and the reason for the temporary
should flash with each beat. pacemaker.
For any temporary pacemaker, re- Check the physician’s order to de-
cord the pacemaker settings. Note the termine the type of drainage system to
patient’s response to the procedure be used and the specific procedural de-
along with all complications and the tails. If appropriate, request the drain-
interventions taken. If possible, obtain age and suction systems from the cen-
rhythm strips before, during, and after tral supply department. Collect the ap-
pacemaker placement; whenever pace- propriate equipment, and take it to the
maker settings are changed; and when patient’s bedside.
the patient is treated for a complication
caused by the pacemaker. As you mon- Implementation
itor the patient, record his response
to temporary pacing and note changes ◆ Explain the procedure to the pa-
in his condition. tient, and wash your hands.
◆ Maintain sterile technique through-
out the procedure and whenever you
Thoracic drainage make changes in the system or alter
any of the connections, to avoid intro-
Thoracic drainage uses gravity and ducing pathogens into the pleural
possibly suction to restore negative space.
pressure and remove material that col-
lects in the pleural cavity. An underwa- Setting up a commercially prepared
ter seal in the drainage system allows disposable system
air and fluid to escape from the pleural ◆ Open the thoracic drainage system.
cavity, but doesn’t allow air to reenter. Place it on the floor in the rack that
The system combines drainage collec- the manufacturer supplied, to avoid ac-
tion, a water seal, and suction control cidentally knocking it over or dislodg-
into a single unit. (See Disposable ing the components. After the system
drainage systems, page 376.) is prepared, it may be hung from the
Specifically, thoracic drainage may side of the patient’s bed.
be ordered to remove accumulated air, ◆ Remove the plastic connector from
fluids (blood, pus, chyle, serous fluids), the short tube that’s attached to the
or solids (blood clots) from the pleural water-seal chamber. Using a sterile
cavity; to restore negative pressure in 50-ml catheter-tip syringe, instill sterile
the pleural cavity; or to reexpand a par- distilled water into the water-seal
tially or totally collapsed lung. chamber until it reaches the 2-cm mark
or the mark specified by the manufac-
Equipment and preparation turer. The Ohio and Thora-Klex sys-
tems are ready to use, but with the
Thoracic drainage system (Pleur-evac, Pleur-evac and Thora-Klex systems,
Argyle, Ohio, or Thora-Klex systems, 15 ml of sterile water may be added to
which may function as gravity draining help detect air leaks. Replace the plas-
systems or may be connected to suc- tic connector.
tion to enhance chest drainage) ◆ ster- ◆ If suction is ordered, remove the
ile distilled water (usually 1 L) ◆ adhe- cap (also called the muffler, or the at-
sive tape ◆ sterile clear plastic tubing mosphere vent cover) on the suction-
◆ two rubber-tipped Kelly clamps ◆ control chamber to open the vent. In-
sterile 50-ml catheter-tip syringe ◆ suc- still sterile distilled water until it reach-
tion source, if ordered ◆ optional: alco- es the 20 cm mark or the ordered level,
hol pad, lotion and recap the suction-control chamber.
Disposable drainage systems
Commercially prepared disposable drainage systems combine drainage collection, water

seal, and suction control in one unit (as shown here). These systems ensure patient safe-
ty with positive- and negative-pressure relief valves and have a prominent air-leak indi-
cator. Some systems produce no bubbling sound.
To drainage To suction
system source or air
From Vent to
patient room air
20 cm
250 ml
Drainage
collection
chamber
2 cm
◆ Using the long tube, connect the pa- ◆ Mark the drainage level in the
tient’s chest tube to the closed drain- drainage collection chamber by noting
age collection chamber. Secure the con- the date and time at the drainage level
nection with adhesive tape. on the chamber every 8 hours (or more
◆ Using the sterile clear plastic tub- often if there is a large amount of
ing, connect the short tube on the drainage).
drainage system to the suction source, ◆ Check the water level in the water-
and turn on the suction. Gentle bub- seal chamber every 8 hours. If neces-
bling should begin in the suction sary, carefully add sterile distilled wa-
chamber, indicating that the correct ter until the level reaches the 2-cm
level of suction has been reached. mark indicated on the water-seal
chamber of the commercial system.
Managing closed-chest underwater ◆ Check for fluctuation in the water-
seal drainage seal chamber as the patient breathes.
◆ Monitor the patient every 2 hours. Normal fluctuations of 2 to 4 (5 to
◆ Monitor the character, consistency, 10 cm) reflect changes in pressure in
and amount of drainage in the drain- the pleural space during respiration. To
age collection chamber. check for fluctuation when a suction
system is being used, momentarily
disconnect the suction system so that insertion site while coughing, to mini-
the air vent is opened, and observe for mize pain.
fluctuation. ◆ Check the rate and quality of the
◆ Check for intermittent bubbling in patient’s respirations, and auscultate
the water-seal chamber. This occurs his lungs periodically to assess air ex-
normally when the system is removing change in the affected lung. Dimin-
air from the pleural cavity. If bubbling ished or absent breath sounds may in-
isn’t readily apparent during quiet dicate that the lung hasn’t reexpanded.
breathing, have the patient cough or ◆ Tell the patient to report breathing
take a deep breath. Absence of bub- difficulty immediately. Notify the phy-
bling indicates that the pleural space sician immediately if the patient has
has sealed. cyanosis, rapid or shallow breathing,
◆ Check the water level in the subcutaneous emphysema, chest pain,
suction-control chamber. Detach the or excessive bleeding.
chamber or bottle from the suction ◆ When clots are visible, you may be
source; when bubbling ceases, observe able to strip (or milk) the tubing, de-
the water level. If necessary, add sterile pending on facility policy. This proce-
distilled water to bring the level to the dure is controversial because it creates
20-cm line, or as ordered. high negative pressure that could suck
◆ Check for gentle bubbling in the viable lung tissue into the drainage
suction-control chamber because it in- ports of the tube, with subsequent rup-
dicates that the proper level of suction tured alveoli and pleural air leak. Strip
has been reached. Vigorous bubbling the tubing only when clots are visible.
in this chamber increases the rate of Use an alcohol pad or lotion as a lubri-
water evaporation. cant on the tube, and pinch the tube
◆ Periodically check that the air vent between your thumb and index finger
in the system is working properly. Oc- about 2 (5 cm) from the insertion site.
clusion of the air vent results in a Using your other thumb and index fin-
buildup of pressure in the system that ger, compress the tubing as you slide
could cause the patient to have tension your fingers down the tube or use a
pneumothorax. mechanical stripper. After the tube has
◆ Coil the tubing, and secure it to the been stripped, release your thumb and
edge of the bed with a rubber band or index finger and pinch the tube near
tape. Avoid creating dependent loops or the insertion site.
kinks or placing pressure on the tubing. ◆ Check the chest tube dressing at
Avoid lifting the drainage system above least every 8 hours. Palpate the area
the patient’s chest because fluid may surrounding the dressing for crepitus or
flow back into the pleural space. subcutaneous emphysema, which indi-
◆ Keep two rubber-tipped Kelly cates that air is leaking into the subcu-
clamps at the patient’s bedside to taneous tissue surrounding the inser-
clamp the chest tube in case the com- tion site. Change the dressing, if neces-
mercially prepared system cracks or to sary, or according to facility policy.
locate an air leak. ◆ Encourage active or passive range-
◆ Encourage the patient to cough fre- of-motion (ROM) exercises for the pa-
quently and to breathe deeply to help tient’s arm on the affected side if he
drain the pleural space and expand the has been splinting the arm. Usually, a
lungs. patient who has undergone thoracoto-
◆ Tell him to sit upright to allow opti- my will splint his arm to decrease his
mal lung expansion and to splint the discomfort.
◆ Give ordered pain medication as ◆ If a commercially prepared system

needed to provide comfort and to help cracks, clamp the chest tube momen-
with deep breathing, coughing, and tarily with the two rubber-tipped
ROM exercises. clamps at the bedside (placed there at
◆ Remind the ambulatory patient to the time of tube insertion). Place the
keep the drainage system below chest clamps close to each other near the in-
level and to be careful not to discon- sertion site; they should face in oppo-
nect the tubing to maintain the water site directions to provide a more com-
seal. With a suction system, the patient plete seal. Observe the patient for al-
must stay within range of the length of tered respirations while the tube is
tubing attached to a wall outlet or clamped. Replace the damaged equip-
portable pump. ment. (Prepare the new unit before you
clamp the tube.)
Special considerations ◆ Instead of clamping the tube, you
can submerge the distal end of the
◆ Instruct staff and visitors to avoid tube in a container of normal saline so-
touching the equipment to prevent com- lution to create a temporary water seal
plications from separated connections. while you replace the drainage system.
◆ If excessive continuous bubbling is Check facility policy for the proper pro-
present in the water-seal chamber, es- cedure.
pecially if suction is being used, make ◆ Tension pneumothorax may result
sure that there isn’t a leak in the drain- from excessive accumulation of air,
age system. Try to locate a leak by drainage, or both. Eventually, it may
clamping the tube momentarily at vari- exert pressure on the heart and aorta,
ous points along its length. Begin causing a precipitous fall in cardiac
clamping at the proximal end of the output.
tube, and work down toward the drain-
age system, paying special attention to Documentation
the seal around the connections. If any
connection is loose, push it back to- Record the date and time that thoracic
gether and tape it securely. The bub- drainage began, the type of system
bling will stop when a clamp is placed used, the amount of suction applied to
between the air leak and the water the pleural cavity, the presence or ab-
seal. If you clamp along the entire sence of bubbling or fluctuation in the
length of the tube and the bubbling water-seal chamber, the initial amount
doesn’t stop, the drainage unit may be and type of drainage, and the patient’s
cracked and need replacement. respiratory status.
◆ If a commercially prepared drainage At the end of each shift, record how
collection chamber fills, replace it. frequently the system is inspected and
Double-clamp the tube close to the in- the chest tubes are milked or stripped
sertion site (use two clamps facing in as well as the amount, color, and con-
opposite directions), exchange the sys- sistency of drainage; the presence or
tem, remove the clamps, and retape absence of bubbling or fluctuation in
the connection. the water-seal chamber; the patient’s
Alert Never leave the tubes respiratory status; the condition of the
clamped for longer than 1 chest dressings; any pain medication
minute, to prevent tension pneumotho- given; and all complications and the
rax, which may occur when clamping nursing action taken.
stops air and fluid from escaping.
tion the table or stand on your pre-

Tracheal suction ferred side of the bed to facilitate suc-
tioning.
Tracheal suction involves the removal Attach the collection container to
of secretions from the trachea or bron- the suction unit and the connecting
chi by means of a catheter inserted tube to the collection container. Label
through the mouth or nose, a tracheal and date the normal saline solution or
stoma, a tracheostomy tube, or an en- sterile water. Open the waterproof
dotracheal (ET) tube. In addition to re- trash bag.
moving secretions, tracheal suctioning
stimulates the cough reflex. This proce- Implementation
dure helps maintain a patent airway to
promote optimal exchange of oxygen ◆ Before suctioning, determine
and carbon dioxide and to prevent whether the facility requires a physi-
pneumonia that results from pooling of cian’s order, and obtain one, if neces-
secretions. Performed as frequently as sary.
the patient’s condition warrants, tra- ◆ Assess the patient’s vital signs,
cheal suction calls for strict aseptic breath sounds, and general appearance
technique. to establish a baseline for comparison
after suctioning. Review the patient’s
Equipment and preparation arterial blood gas values and oxygen
saturation levels if they’re available.
Supplemental oxygen source (wall or Evaluate the patient’s ability to cough
portable unit, such as nasal cannula or and deep-breathe because they’ll help
aerosol source, and handheld resuscita- to move secretions up the tracheo-
tion bag with mask, 15-mm adapter, or bronchial tree. If you’ll be performing
positive end–expiratory pressure nasotracheal suctioning, check the pa-
[PEEP] valve, if indicated) ◆ wall or tient’s history for a deviated septum,
portable suction apparatus ◆ collection nasal polyps, nasal obstruction, nasal
container ◆ connecting tube ◆ suction trauma, epistaxis, or mucosal swelling.
catheter kit (or sterile suction catheter, ◆ Wash your hands. Put on personal
one sterile glove, one clean glove, and protective equipment. Explain the pro-
disposable sterile solution container) ◆ cedure to the patient, even if he’s unre-
1-L bottle of sterile water or normal sponsive. Tell him that suctioning usu-
saline solution ◆ sterile water-soluble ally causes transient coughing or gag-
lubricant (for nasal insertion) ◆ sy- ging, but that coughing helps to
ringe for deflating cuff of ET or tra- remove the secretions. If the patient
cheostomy tube ◆ waterproof trash has been suctioned previously, summa-
bag ◆ goggles and face mask or face rize the reasons for suctioning. Contin-
shield ◆ optional: sterile towel ue to reassure the patient throughout
Choose a suction catheter of the ap- the procedure to minimize anxiety, pro-
propriate size. The diameter should be mote relaxation, and decrease oxygen
no larger than half of the inside diame- demand.
ter of the tracheostomy or ET tube, to ◆ Assemble all equipment, making
minimize hypoxia during suctioning. sure that the suction apparatus is con-
(A #12 or #14 French catheter may be nected to a collection container and
used for an 8-mm or larger tube.) Place connecting tube.
the suction apparatus on the patient’s ◆ Unless contraindicated, place the
overbed table or bedside stand. Posi- patient in semi-Fowler’s or high
Fowler’s position to promote lung ex-

pansion and productive coughing.
◆ Remove the top from the normal
saline solution or sterile water bottle.
◆ Open the package containing the
disposable sterile solution container.
◆ Using strictly aseptic technique, open
the suction catheter kit and put on the
gloves. If you are using individual sup-
plies, open the suction catheter and the
gloves, placing the clean glove on your
nondominant hand and then the sterile
glove on your dominant hand.
◆ Using your nondominant (nonsterile) ◆ Dip the tip of the catheter in the
hand, pour the normal saline solution or saline solution to lubricate the outside
sterile water into the solution container. of the catheter and reduce tissue trau-
◆ Place a small amount of sterile ma during insertion.
water-soluble lubricant on the sterile ◆ With the catheter tip in the sterile
area. Lubricant may be used to facili- solution, occlude the control valve
tate passage of the catheter during na- with the thumb of your nondominant
sotracheal suctioning. hand. Suction a small amount of solu-
◆ Place a sterile towel over the pation to lubricate the inside of the cath-
tient’s chest, if desired, to provide an eter, facilitating the passage of secre-
additional sterile area. tions through it (as shown below).
◆ Using your dominant (sterile) hand,
remove the catheter from its wrapper.
Keep it coiled so that it can’t touch a
nonsterile object. Using your other
hand to manipulate the connecting
tubing, attach the catheter to the tub-
ing (as shown below).
◆ For nasal insertion of the catheter,

◆ With your nondominant hand, set lubricate the tip of the catheter with
the suction pressure according to facility the sterile, water-soluble lubricant to
policy. Typically, the pressure is set be- reduce tissue trauma during insertion.
tween 80 and 120 mm Hg. Higher pres- ◆ If the patient isn’t intubated or is
sures don’t enhance secretion removal intubated but isn’t receiving a supple-
and may cause traumatic injury. Occlude mental oxygen source or aerosol, in-
the suction port to assess suction pres- struct him to take three to six deep
sure (as shown at top of next column).
breaths to help minimize or prevent Nasotracheal insertion in a

hypoxia during suctioning. nonintubated patient
◆ If the patient isn’t intubated, but is ◆ Disconnect the oxygen from the pa-
receiving oxygen, evaluate his need for tient, if applicable.
preoxygenation. If indicated, instruct ◆ Using your nondominant hand,
him to take three to six deep breaths raise the tip of the patient’s nose to
while using his supplemental oxygen straighten the passageway and facili-
source. (If needed, the patient may con- tate insertion of the catheter.
tinue to receive supplemental oxygen ◆ Insert the catheter into the patient’s
during suctioning by leaving his nasal nostril while you gently roll it between
cannula in one nostril or by keeping your fingers to help advance it through
the oxygen mask over his mouth.) the turbinates.
◆ If the patient is being mechanically ◆ As the patient inhales, quickly ad-
ventilated, preoxygenate him with a vance the catheter as far as possible.
handheld resuscitation bag or the sigh To avoid oxygen loss and tissue
mode on the ventilator. To use the re- trauma, don’t apply suction during in-
suscitation bag, set the oxygen flow sertion.
meter at 15 L/minute, disconnect the ◆ If the patient coughs as the catheter
patient from the ventilator, and deliver passes through the larynx, briefly hold
three to six breaths with the resuscita- the catheter still. Continue to advance
tion bag (as shown below). the catheter when the patient inhales.
Nasotracheal insertion in an
intubated patient
◆ If you’re using a closed system, see
Closed tracheal suctioning, page 382.
◆ Using your nonsterile hand, discon-
nect the patient from the ventilator.
◆ With your sterile hand, gently insert
the suction catheter into the artificial
airway (as shown below). Advance the
catheter, without applying suction, un-
til you meet resistance. If the patient
coughs, pause briefly and then resume
advancement.
◆ If the patient is being maintained

on PEEP, evaluate the need to use a re-
suscitation bag with a PEEP valve.
◆ To preoxygenate the patient using
the ventilator, first adjust the fraction
of inspired oxygen (FIO2) and the tidal
volume according to facility policy and
patient need. Then, use the sigh mode
on the ventilator or manually deliver
three to six breaths. If you have an as-
sistant for the procedure, the assistant
can manage the patient’s oxygen needs
while you perform the suctioning.
Closed tracheal suctioning
The closed tracheal suction system can T-piece to the patient’s endotracheal or
ease removal of secretions and reduce pa- tracheostomy tube (as shown below).
tient complications. Consisting of a sterile
suction catheter in a clear plastic sleeve,
the system permits the patient to remain
connected to the ventilator during
suctioning.
Catheter sleeve
T-piece
◆ Use one hand to keep the T-piece par-

allel to the patient’s chin, and use the
thumb and index finger of the other hand
Suction catheter
to advance the catheter through the tube
and into the patient’s tracheobronchial
As a result, the patient can maintain tree (as shown below). You may need to
the tidal volume, oxygen concentration, retract the catheter sleeve gently as you
and positive end-expiratory pressure de- advance the catheter.
livered by the ventilator while being suc-
tioned. In turn, this reduces the occurrence
of suction-induced hypoxemia.
Another advantage of this system is a
reduced risk of infection, even when the
same catheter is used many times. Be-
cause the catheter remains in a protective
sleeve, gloves aren’t required but are still
recommended. The caregiver doesn’t need
to touch the catheter, and the ventilator
circuit remains closed.
◆ While continuing to hold the T-piece
Implementation and control valve, apply intermittent suc-
To perform the procedure, gather a closed tion and withdraw the catheter until it
suction control valve, a T-piece to connect reaches its fully extended length in the
the artificial airway to the ventilator sleeve. Repeat the procedure as necessary.
breathing circuit, and a catheter sleeve ◆ After you’ve finished suctioning, flush
that encloses the catheter and has connec- the catheter by maintaining suction while
tions at each end for the control valve and slowly introducing normal saline solution
the T-piece. Then follow these steps: or sterile water into the irrigation port.
◆ Remove the closed suction system from ◆ Place the thumb control valve in the
its wrapping. Attach the control valve to OFF position.
the connecting tubing. ◆ Dispose of and replace the suction
◆ Depress the thumb suction control equipment and supplies according to facil-
valve, and keep it depressed while setting ity policy.
the suction pressure to the desired level. ◆ Remove your gloves and wash your
◆ Connect the T-piece to the ventilator hands.
breathing circuit, making sure that the irri- ◆ Change the closed suction system every
gation port is closed. Then connect the 24 hours to minimize the risk of infection.
Suctioning the patient When the sputum contains blood, note

◆ After inserting the catheter, apply whether it’s streaked or well mixed.
suction intermittently by removing Also, indicate how often blood appears
and replacing the thumb of your nonin the sputum. If the patient’s heart
dominant hand over the control valve. rate and rhythm are being monitored,
Simultaneously use your dominant observe him for arrhythmias. If they
hand to withdraw the catheter as you occur, stop suctioning and ventilate the
roll it between your thumb and fore- patient.
finger. This rotating motion prevents ◆ Patients who can’t mobilize secre-
the catheter from pulling tissue into tions effectively may need to perform
the tube as it exits, thus avoiding tis- tracheal suctioning after discharge.
sue trauma. Never suction for longer
than 10 seconds at a time to prevent After suctioning
hypoxia. ◆ After suctioning, hyperoxygenate
◆ If the patient is intubated, use your the patient who’s being maintained on
nondominant hand to stabilize the tip a ventilator using the handheld resusci-
of the ET tube as you withdraw the tation bag or the ventilator’s sigh
catheter to prevent accidental extuba- mode, as described earlier.
tion or irritation of the mucous mem- ◆ Readjust the FIO2 and, for ventilated
branes. patients, the tidal volume to the or-
◆ If applicable, resume oxygen deliv- dered settings.
ery by reconnecting the source of oxy- ◆ After suctioning the lower airway,
gen or ventilation and hyperoxygenat- assess the patient’s need for upper-
ing the patient’s lungs before you con- airway suctioning. If the cuff of the
tinue, to prevent or relieve hypoxia. ET or tracheostomy tube is inflated,
◆ Observe the patient, and allow him suction the upper airway before deflat-
to rest for a few minutes before the ing the cuff with a syringe. Always
next suctioning. The timing of each change the catheter and sterile glove
suctioning and the length of each rest before resuctioning the lower airway,
period depend on the patient’s toler- to avoid introducing microorganisms
ance of the procedure and the absence into the lower airway.
of complications. To enhance the re- ◆ Discard the gloves and catheter in
moval of secretions, encourage the pa- the waterproof trash bag. Clear the
tient to cough between suctioning at- connecting tubing by aspirating the re-
tempts. maining saline solution or water. Dis-
◆ Look at the secretions. If they’re card and replace the suction equipment
thick, clear the catheter periodically by and supplies according to facility poli-
dipping the tip in the saline solution cy. Wash your hands.
and applying suction. Normally, spu- ◆ Auscultate the lungs bilaterally and
tum is watery and tends to be sticky. take the patient’s vital signs, if indicat-
Tenacious or thick sputum usually indi- ed, to assess the effectiveness of the
cates dehydration. Watch for color vari- procedure.
ations. Sputum that’s white or translu-
cent is normal; yellow indicates pus; Special considerations
green indicates retained secretions or
Pseudomonas infection; brown usually ◆ Raising the patient’s nose into the
indicates old blood; red indicates fresh sniffing position helps to align the lar-
blood; and a red currant jelly appear- ynx and pharynx and may facilitate pas-
ance indicates Klebsiella infection. sage of the catheter during nasotracheal
suctioning. If the patient’s condition ◆ Patients with compromised cardio-

permits, have an assistant extend the vascular or pulmonary status are at
patient’s head and neck above his risk for hypoxemia, arrhythmias, hy-
shoulders. The patient’s lower jaw may pertension, or hypotension. Patients
need to be moved up and forward. If with a history of nasopharyngeal
the patient is responsive, ask him to bleeding, those who are taking an anti-
stick out his tongue so that he doesn’t coagulant, those who recently have un-
swallow the catheter during insertion. dergone a tracheostomy, and those
◆ During suctioning, the catheter typi- who have a blood dyscrasia are at in-
cally is advanced as far as the main- creased risk for bleeding because of
stem bronchi. However, because of the suctioning.
tracheobronchial anatomy, the catheter ◆ Use caution when suctioning pa-
tends to enter the right mainstem tients who have increased intracranial
bronchus instead of the left. Using an pressure because suction may further
angled catheter (such as a coudé) may increase pressure.
help you to guide the catheter into the ◆ If the patient has laryngospasm or
left mainstem bronchus. Rotating the bronchospasm (rare complications)
patient’s head to the right seems to during suctioning, disconnect the suc-
have a limited effect. tion catheter from the connecting tub-
◆ Studies show that instilling normal ing and allow the catheter to act as an
saline solution into the trachea before airway. Discuss with the patient’s
suctioning may stimulate the patient’s physician the use of a bronchodilator
cough, but doesn’t liquefy his secre- or lidocaine to reduce the risk of this
tions. Keeping the patient adequately complication.
hydrated and using bronchial hygiene
techniques seem to have a greater ef- Documentation
fect on mobilizing secretions.
◆ In addition to the closed tracheal Record the date and time of the proce-
method, oxygen insufflation offers a dure; the technique used; the reason
new approach to suctioning. This for suctioning; the amount, color, con-
method uses a double-lumen catheter sistency, and odor (if any) of the secre-
that allows oxygen insufflation during tions; any complications and the nurs-
suctioning. ing action taken; and the patient’s re-
◆ Don’t allow the collection container sponse to the procedure.
on the suction machine to become
more than three-quarters full, to avoid
damaging the machine. Transfusion of blood and
◆ Assess the patient for complica- blood products
tions. Because oxygen is removed
along with secretions, the patient may Whole blood transfusion replenishes
have hypoxemia and dyspnea. In addi- the volume and the oxygen-carrying
tion, anxiety may alter respiratory pat- capacity of the circulatory system by
terns. Cardiac arrhythmias can result increasing the mass of circulating red
from hypoxia and stimulation of the blood cells (RBCs). Transfusion of
vagus nerve in the tracheobronchial packed RBCs, from which 80% of the
tree. Tracheal or bronchial trauma can plasma has been removed, restores
result from traumatic or prolonged suc- only the oxygen-carrying capacity. Af-
tioning. ter plasma is removed, the resulting
component has a hematocrit of 65%
to 80% and a usual volume of 300 to ◆ optional: ice bag and warm com-
350 ml. (Whole blood without the plas- presses
ma removed has a hematocrit of about Straight-line and Y-type blood admin-
38%.) Each unit of whole blood or istration sets are commonly used. Al-
RBCs contains enough hemoglobin though filters come in both mesh and
to raise the hemoglobin level in an microaggregate types, the latter is pre-
average-sized adult 1 g/L, or by 3%. ferred especially when transfusing multi-
Both types of transfusion treat de- ple units of blood. Highly effective leuko-
creased hemoglobin levels and hemat- cyte removal filters are available for use
ocrit. Whole blood is rarely used and when transfusing blood and packed
only when decreased levels result from RBCs. The use of these filters can post-
hemorrhage; packed RBCs, the most pone sensitization to transfusion therapy.
commonly transfused, are used when Administer packed RBCs with a
depressed levels accompany normal Y-type set. Using a straight-line set
blood volume, to avoid possible fluid forces you to piggyback the tubing so
and circulatory overload. (See Transfus- that you can stop the transfusion, if
ing blood and selected components, necessary, but still keep the vein open.
pages 386 to 391.) Whole blood and Piggybacking increases the chance that
packed RBCs contain cellular debris harmful microorganisms will enter the
and require in-line filtration during ad- tubing as you’re connecting the blood
ministration. (Washed packed RBCs, line to the established line.
commonly used for patients who were Multiple-lead tubing minimizes the
previously sensitized to transfusions, risk of contamination, especially when
are rinsed with a special solution that multiple units of blood are transfused.
removes white blood cells and plate- (A straight-line set would require mul-
lets, thus decreasing the chance of a tiple piggybacking.) A Y-type set gives
transfusion reaction.) you the option of adding normal saline
Alert Depending on facility solution to packed cells — decreasing
policy, two licensed profession- their viscosity — if the patient can tol-
als need to identify the patient and erate the added fluid volume.
blood products at the patient’s bedside Avoid obtaining either whole blood or
before administering a transfusion, to packed RBCs until you’re ready to begin
prevent errors and a potentially fatal the transfusion. Prepare the equipment
reaction. when you’re ready to start the infusion.
Alert If the patient is a Jeho-
vah’s Witness, a transfusion re- Implementation
quires special written permission.
◆ Verify the written order in the pa-
Equipment and preparation tient’s medical record. Confirm that the
order and the medical record are la-
Blood administration set (170- to 260- beled with the patient’s name and
micron filter and tubing with drip identification number.
chamber for blood, or combined set) ◆ ◆ Confirm the patient’s identity using
I.V. pole ◆ gloves ◆ gown ◆ face two patient identifiers.
shield ◆ whole blood or packed RBCs ◆ Explain the procedure to the pa-
◆ 250 ml of normal saline solution ◆ tient. Make sure that he has signed an
venipuncture equipment, if needed informed consent form before any
(should include 20G or larger catheter) blood is transfused.
Transfusing blood and selected components

BLOOD COMPONENT INDICATIONS
Packed red blood cells ◆ Inadequate circulating red cell mass

(RBCs) ◆ Symptomatic deficiency of oxygen-carrying capac-
Same RBC mass as whole blood, ity
but with 80% of the plasma re- ◆ Symptomatic chronic anemia
moved ◆ Hemoglobin < 7 g/dl or hematocrit < 21%
Volume: 250 ml ◆ Sickle cell disease (red cell exchange)
Whole blood ◆ Massive blood loss

Complete (pure) blood ◆ Deficiency of oxygen carrying capability and vol-
Volume: 500 ml ume expansion
White blood cells (WBCs ◆ Sepsis unresponsive to antibiotics (especially if

or leukocytes) patient has positive blood cultures or a persistent
Whole blood with all of the RBCs fever > 101º F [38.3º C]) and granulocytopenia
and about 80% of the supernatant (granulocyte count usually < 500/µl)
plasma removed
Volume: usually 150 ml
Leukocyte-poor RBCs ◆ Same as for packed RBCs

Same as packed RBCs, with about ◆ Prevention of febrile reactions from leukocyte an-
95% of the leukocytes removed tibodies
Volume: 200 ml ◆ Immunocompromised patients
COMPATIBILITY NURSING CONSIDERATIONS
◆ Type A receives A or O. ◆ Use a blood administration set to infuse blood within

◆ Type B receives B or O. four hours.
◆ Type AB receives AB, A, B, ◆ Administer only with 0.9% normal saline solution.
or O. ◆ A RBC transfusion isn’t appropriate for anemias treat-
◆ Type O receives O. able by nutritional or drug therapies.
◆ Rh match is necessary.
◆ ABO identical: Type A receives ◆ Whole blood is seldom administered.

A; type B receives B; type AB re- ◆ Use a blood administration set to infuse blood within
ceives AB; type O receives O. four hours.
◆ Rh match is necessary. ◆ Administer only with 0.9% normal saline solution.
◆ Closely monitor patient volume status during adminis-
tration for risk of volume overload.
◆ Same as for packed RBCs ◆ Use a blood administration set to provide 1 unit daily
◆ Compatibility with human for 5 days or until the infection resolves.
leukocyte antigen (HLA) is prefer- ◆ As prescribed, premedicate with diphenhydramine.
able, but not necessary unless ◆ Because a WBC infusion induces fever and chills, ad-
the patient is sensitized to HLA minister an antipyretic if fever occurs. Don’t discontinue
as a result of previous transfu- the transfusion; instead, reduce the flow rate as ordered
sions. for patient comfort.
◆ Rh match is necessary. ◆ Agitate the container to prevent the WBCs from set-
tling, thus preventing the delivery of a bolus infusion of
WBCs.
◆ Same as for packed RBCs ◆ Use a blood administration set to infuse blood within
◆ Rh match is necessary. 4 hours.
◆ Other considerations are the same as those for packed
RBCs.
(continued)
Transfusing blood and selected components (continued)
Platelets ◆ Bleeding resulting from critically decreased circu-

Platelet sediment from RBCs or lating platelet counts or functionally abnormal
plasma platelets
Volume: 35 to 50 ml/unit; 1 unit ◆ Prevention of bleeding caused by thrombocytope-
of platelets = 7 107 platelets nia
◆ Platelet count < 50,000/microliter before surgery
or a major invasive procedure
Fresh frozen plasma ◆ Bleeding

(FFP) ◆ Coagulation factor deficiencies
Uncoagulated plasma separated ◆ Warfarin reversal
from RBCs and rich in coagulation ◆ Thrombotic thrombocytopenic purpura
factors V, VIII, and IX
Volume: 200 to 250 ml
Albumin 5% (buffered ◆ Volume lost because of shock from burns, trauma,

saline); albumin 25% surgery, or infections
(salt poor) ◆ Hypoproteinemia (with or without edema)
A small plasma protein prepared
by fractionating pooled plasma
Volume: 5% = 12.5 g/250 ml;
25% = 12.5 g/50 ml
◆ ABO identical when possible ◆ Use a filtered component drip administration set to in-
◆ Rh match is preferred. fuse 100 ml over 15 minutes.
◆ As prescribed, premedicate with antipyretics and anti-
histamines if the patient’s history includes a platelet
transfusion reaction.
◆ Avoid administering platelets when the patient has a
fever.
◆ Prepare to draw blood for a platelet count as ordered,
1 hour after the platelet transfusion, to determine the in-
crements for platelet transfusion.
◆ Keep in mind that the physician seldom orders a
platelet transfusion for conditions in which platelet de-
struction is accelerated, such as idiopathic thrombocy-
topenic purpura and drug-induced thrombocytopenia.
◆ ABO is required. ◆ Use a straight-line I.V. set, and administer the infusion
◆ Rh match not required. rapidly.
◆ Keep in mind that large-volume transfusions of FFP
may require correction for hypocalcemia because citric
acid in FFP binds calcium.
◆ Unnecessary ◆ Use a the administration set supplied by the manufac-

turer, with the rate and volume dictated by the patient’s
condition and response.
◆ Remember that reactions to albumin (fever, chills, nau-
sea) are rare.
◆ Avoid mixing albumin with protein hydrolysates and
alcohol solutions.
◆ Consider delivering albumin as a volume expander un-
til the laboratory completes crossmatching for a whole
blood transfusion.
◆ Keep in mind that albumin is contraindicated in severe
anemia and administered cautiously in cardiac and pul-
monary disease because heart failure may result from cir-
culatory overload.
(continued)
Transfusing blood and selected components (continued)
cryoprecipitate ◆ Bleeding associated with hypofibrinogenemia or

Insoluble portion of plasma recov- dysfibrinogenemia
ered from FFP containing fibrino- ◆ Significant factor XIII deficiency (prevention or
gen, Factor VIII:c, Factor VIII: vwf, treatment)
Factor XIII, and fibrovectin.
Volume: about 30 ml (freeze-
dried)
Immune globulin ◆ Primary immune deficiencies

Processed human plasma from ◆ Secondary immune deficiencies
multiple donors that contains 95% ◆ Kawasaki syndrome
IgG, < 2.5% IgA, and a fraction of ◆ Idiopathic thrombocytopenia purpura
IgM. ◆ Neurologic disorders (Guillain-Barré syndrome,
dermatomyositis, myasthenia gravis)
◆ Record the patient’s baseline vital tient’s blood bank identification num-
signs. ber, if present, with the number on the
◆ If the patient doesn’t have an I.V. blood bag. Identification of blood and
line in place, perform a venipuncture, blood products is performed at the pa-
using a catheter with a diameter of tient’s bedside by two licensed profes-
20G or larger. Avoid using an existing sionals, according to facility policy.
line if the needle or catheter lumen is ◆ Put on gloves, a gown, and a face
smaller than 20G. Central venous ac- shield. Use a Y-type set, and close all
cess devices may also be used for of the clamps on the set. Insert the
transfusion therapy. spike of the line that you’re using for
◆ Obtain whole blood or packed RBCs the normal saline solution into the bag
from the blood bank within 30 minutes of saline solution. Open the port on the
of the transfusion start time. Check the blood bag, and insert the spike of the
expiration date on the blood bag, and line that you’re using to administer the
observe the bag for abnormal color, blood or cellular component into the
RBC clumping, gas bubbles, and extra- port. Hang the bag of normal saline so-
neous material. Return outdated or ab- lution and blood or cellular component
normal blood to the blood bank. on the I.V. pole, open the clamp on the
◆ Compare the name and identifica- line of saline solution, and squeeze the
tion number on the patient’s wristband drip chamber until it’s half full. Re-
with the information on the label of the move the adapter cover at the tip of
blood bag. Check the blood bag identi- the blood administration set, open the
fication number, the ABO blood group, main flow clamp, and prime the tubing
and Rh compatibility. Compare the pa- with saline solution.
◆ ABO compatible. ◆ Use a blood administration set.

◆ Rh compatability not required. ◆ Add 0.9% normal saline solution to each bag of cryo-
precipitate as needed to facilitate transfusion.
◆ Cryoprecipitate must be administered within six hours
of thawing.
◆ Before administering, check lab study results to con-
firm a deficiency of one of the specific clotting factors in
cryoprecipitate.
◆ Patients with hemophilia A or von Willebrand’s disease
should only be treated with cryoprecipitate when appro-
priate factor VIII concentrates are not available.
◆ ABO compatibility and Rh ◆ Use the administration set supplied by the manufactur-
match are unnecessary. er.
◆ Reconstitute the lyophilized powder with 0.9% sodium
chloride injection, 5% dextrose, or sterile water.
◆ Administer at the minimal concentration available and
at the slowest practical rate.
◆ If you’re administering packed RBCs ◆ If signs of a transfusion reaction de-

with a Y-type set, you can add saline velop, record the patient’s vital signs
solution to the bag to dilute the cells and stop the transfusion. Infuse saline
by closing the clamp between the pa- solution at a moderately slow infusion
tient and the drip chamber and open- rate, and notify the physician at once.
ing the clamp from the blood. Lower If no signs of a reaction appear within
the blood bag below the saline contain- 15 minutes, adjust the flow clamp to
er and let 30 to 50 ml of saline solution the ordered infusion rate. A unit of
flow into the packed cells. Close the RBCs may be given over 1 to 4 hours,
clamp to the blood bag, rehang the as ordered.
bag, rotate it gently to mix the cells ◆ Recheck vital signs, including tem-
and saline solution, and close the perature, every 15 minutes for the first
clamp to the saline container. 30 minutes after beginning the transfu-
◆ Attach the prepared blood adminis- sion, and then according to facility
tration set to the venipuncture device, policy.
and flush it with normal saline solu- ◆ After completing the transfusion,
tion. Close the clamp to the saline put on gloves and remove and discard
solution, and open the clamp between the used infusion equipment. Recon-
the blood bag and the patient. Adjust nect the original I.V. fluid, if necessary,
the flow rate to no greater than 5 ml/ or discontinue the I.V. infusion.
minute for the first 15 minutes of the ◆ Return the empty blood bag to the
transfusion so that you can observe blood bank. Discard the tubing and
the patient for a possible transfusion filter.
reaction. ◆ Record the patient’s vital signs.
Special considerations – If the blood bag empties before the

next one arrives, administer normal
◆ Although some microaggregate fil- saline solution slowly. If you’re using a
ters can be used for up to 10 units of Y-type set, close the blood line clamp,
blood, replace the filter and tubing if open the saline clamp, and let the sa-
more than 1 hour elapses between line run slowly until the new blood ar-
transfusions. When administering mul- rives. Decrease the flow rate or clamp
tiple units of blood under pressure, use the line before attaching the new unit
a blood warmer to avoid hypothermia. of blood.
Blood components may be warmed to ◆ Despite improvements in cross-
no more than 107.6° F (42° C). matching precautions, transfusion reac-
◆ For rapid blood replacement, you tions can still occur. Unlike a transfu-
may need to use a pressure bag. Exces- sion reaction, an infectious disease
sive pressure may develop, leading to that’s transmitted during a transfusion
broken blood vessels and extravasa- may go undetected until days, weeks,
tion, with hematoma and hemolysis of or even months later, when it produces
the infusing RBCs. signs and symptoms. Measures to pre-
◆ If the transfusion stops, take the fol- vent disease transmission include labo-
lowing steps, as needed: ratory testing of blood products and
– Check that the I.V. container is at careful screening of potential donors,
least 3 (0.9 m) above the level of the neither of which is guaranteed.
I.V. site. ◆ Hepatitis C accounts for most cases
– Make sure that the flow clamp is of posttransfusion hepatitis. The tests
open and that the blood completely that detect hepatitis B and hepatitis C
covers the filter. If it doesn’t, squeeze can produce false-negative results and
the drip chamber until it does. may allow some cases of hepatitis to
– Gently rock the bag back and forth, go undetected.
agitating blood cells that may have set- ◆ When testing for antibodies to hu-
tled. man immunodeficiency virus (HIV), re-
– Untape the dressing over the I.V. member that antibodies don’t appear
site to check cannula placement. Repo- until 6 to 12 weeks after exposure. Ac-
sition the cannula, if necessary. cording to the American Association of
– Flush the line with saline solution, Blood Banks, the estimated risk of ac-
and restart the transfusion. Using a quiring HIV from a single transfusion
Y-type set, close the flow clamp to the of blood products varies from 1 in
patient and lower the blood bag. Open 40,000 to 1 in 153,000.
the saline clamp and allow some saline ◆ Many blood banks screen blood for
solution to flow into the blood bag. Re- cytomegalovirus (CMV). Blood with
hang the blood bag, open the flow CMV is especially dangerous for an im-
clamp to the patient, and reset the flow munosuppressed, seronegative patient.
rate. Blood banks also test blood for syph-
– If a hematoma develops at the I.V. ilis, but refrigerating blood virtually
site, stop the infusion immediately. Re- eliminates the risk of transfusion-
move the I.V. cannula. Notify the phy- related syphilis.
sician, and expect to place ice on the ◆ Circulatory overload and hemolytic,
site intermittently for 8 hours; then ap- allergic, febrile, and pyogenic reactions
ply warm compresses. Follow facility can result from any transfusion. Coagu-
policy. lation disturbances, citrate intoxication,
hyperkalemia, acid-base imbalance,
Tube feedings 393
loss of 2,3-diphosphoglycerate, ammo- Equipment and preparation

nia intoxication, and hypothermia can
result from massive transfusion. For gastric feedings
Feeding formula ◆ 120 ml of water ◆
Documentation gavage bag with tubing and flow regu-
lator clamp ◆ towel or linen-saver pad
Record the date and time of the trans- ◆ 60-ml syringe or barrel syringe ◆ pH
fusion, the type and amount of transfu- test strip ◆ optional: infusion con-
sion product, the patient’s vital signs, troller and gavage bag tubing set (for
your check of all identification data, continuous administration) and adapter
and the patient’s response. Document to connect gavage tubing to feeding
any transfusion reaction and treatment. tube
For duodenal or jejunal feedings

Tube feedings Feeding formula ◆ enteral administra-
tion set, containing gavage container,
Tube feedings involve delivery of a liq- drip chamber, roller clamp or flow reg-
uid feeding formula directly to the ulator, and tube connector ◆ I.V. pole
stomach (known as gastric gavage), ◆ 60-ml syringe with adapter tip ◆
duodenum, or jejunum. Gastric gavage water ◆ optional: volumetric pump ad-
is typically indicated for a patient who ministration set (for enteral infusion
can’t eat normally because of dyspha- pump) and Y-connector
gia or oral or esophageal obstruction or A bulb syringe or large catheter-tip
injury. Gastric feedings may also be syringe may be substituted for a gav-
given to an unconscious or intubated age bag after the patient shows toler-
patient or to a patient who’s recovering ance for a gravity drip infusion. The
from GI tract surgery and can’t ingest physician may order an infusion pump
food orally. to ensure accurate delivery of the pre-
Duodenal or jejunal feedings described formula.
crease the risk of aspiration because Refrigerate formulas that are pre-
the formula bypasses the pylorus. Jeju- pared in the dietary department or
nal feedings result in reduced pancreat- pharmacy. Refrigerate commercial for-
ic stimulation; thus, the patient may re- mulas only after they have been
quire an elemental diet. opened. Check the date on all formula
Patients usually receive gastric feed- containers. Discard expired commercial
ings on an intermittent schedule. For formula. Use powdered formula within
duodenal or jejunal feedings, most pa- 24 hours of mixing. Shake the contain-
tients seem to better tolerate a continu- er vigorously to mix the solution thor-
ous slow drip. oughly.
Liquid nutrient solutions come in Allow the formula to warm to room
various formulas for administration temperature before administering it.
through a nasogastric tube, a small- Cold formula can increase the chance
bore feeding tube, a gastrostomy or je- of diarrhea. Never warm formula over
junostomy tube, a percutaneous endo- direct heat or in a microwave. Heat
scopic gastrostomy or jejunostomy may curdle the formula or change its
tube, or a gastrostomy feeding button. chemical composition, and hot formula
Tube feeding is contraindicated in pa- may injure the patient.
tients who have no bowel sounds or Pour 60 ml of water into the gradu-
have a suspected intestinal obstruction. ated container. After you close the flow
clamp on the administration set, pour colorless with mucous shreds, or

the appropriate amount of formula into brown) and the pH is ≤ 5.
the gavage bag. Hang no more than a ◆ To assess gastric emptying, aspirate
4- to 6-hour supply at one time to pre- and measure the residual gastric con-
vent bacterial growth. tents. Hold feedings if the residual vol-
Open the flow clamp on the admin- ume is greater than the predetermined
istration set to remove air from the amount specified in the physician’s or-
lines. This keeps air from entering the der (usually 50 to 100 ml). Reinstill any
patient’s stomach and causing disten- aspirate obtained.
tion and discomfort. ◆ Connect the gavage bag tubing to
the feeding tube. Depending on the
Implementation type of tube used, you may need to
use an adapter to connect the two.
◆ Confirm the patient’s identity using ◆ If you’re using a bulb or catheter-tip
two patient identifiers, provide privacy, syringe, remove the bulb or plunger.
and wash your hands. Attach the syringe to the pinched-off
◆ Tell the patient that he’ll receive feeding tube to prevent excess air from
nourishment through the tube, and ex- entering the patient’s stomach, causing
plain the procedure to him. distention. If you’re using an infusion
◆ If the patient has a nasal or an oral controller, thread the tube from the for-
tube, cover his chest with a towel or mula container through the controller,
linen-saver pad to protect him and the according to manufacturer directions.
bed linens from spills. Blue food dye can be added to the
◆ Assess the patient’s abdomen for feeding to allow you to identify aspira-
bowel sounds and distention. tion quickly. Purge the tubing of air,
and attach it to the feeding tube.
Delivering a gastric feeding ◆ Open the flow regulator clamp on
◆ Elevate the bed to semi-Fowler’s or the gavage bag tubing, and adjust the
high Fowler’s position to prevent aspi- flow rate, as appropriate. When using a
ration by gastroesophageal reflux and bulb syringe, fill the syringe with for-
to promote digestion. mula and release the feeding tube to
Alert Check the placement of allow formula to flow through it. The
the feeding tube to ensure that it height at which you hold the syringe
hasn’t slipped out since the last feed- determines the flow rate. When the sy-
ing. Never give a tube feeding until ringe is three-quarters empty, pour
you’re certain that the tube is properly more formula into it.
positioned in the patient’s stomach. ◆ To prevent air from entering the
Administering a feeding through a mis- tube and the patient’s stomach, never
placed tube can cause the feeding for- allow the syringe to empty completely.
mula to enter the patient’s lungs. If you’re using an infusion controller,
◆ To check the patency and position set the flow rate according to manufac-
of the tube, remove the cap or plug turer directions. Always administer a
from the feeding tube and use the sy- tube feeding slowly — typically, 200 to
ringe to aspirate stomach contents. Ex- 350 ml over a period of 15 to 30 min-
amine the aspirate and place a small utes, depending on the patient’s toler-
amount on the pH test strip. Probabili- ance and the physician’s order — to
ty of gastric placement is increased if prevent sudden stomach distention,
the aspirate has a typical gastric fluid which can cause nausea, vomiting,
appearance (grassy green, clear and cramps, or diarrhea.
Tube feedings 395
◆ After administering the appropriate with volumes increasing gradually once

amount of formula, flush the tubing by tolerance is established.
adding about 60 ml of water to the ◆ Flush the tube with water every 4
gavage bag or bulb syringe, or manual- hours to maintain patency and provide
ly flush it with a barrel syringe. This hydration. A needle catheter jejunosto-
maintains the patency of the tube by my tube may need to be flushed every
removing excess formula, which could 2 hours to prevent buildup of formula
occlude the tube. inside the tube. A Y-connector may be
◆ If you’re administering a continuous useful for frequent flushing. Attach the
feeding, flush the feeding tube every continuous feeding tube to the main
4 hours to help prevent occlusion of port, and use the side port for flushes.
the tube. Monitor gastric emptying ◆ Change the equipment every 24
every 4 hours. hours or according to facility policy.
◆ To discontinue gastric feeding (de-
pending on the equipment you’re us- Special considerations
ing), close the regulator clamp on the
gavage bag tubing, disconnect the sy- ◆ If the feeding solution doesn’t ini-
ringe from the feeding tube, or turn off tially flow through a bulb syringe, at-
the infusion controller. tach the bulb and squeeze it gently to
◆ Cover the end of the feeding tube start the flow. Then remove the bulb.
with its plug or cap to prevent leakage Never use the bulb to force the formula
and contamination. through the tube.
◆ Leave the patient in semi-Fowler’s ◆ If the patient becomes nauseated or
or high Fowler’s position for at least vomits, stop the feeding immediately.
30 minutes. He may vomit if his stomach becomes
◆ Rinse all reusable equipment with distended because of overfeeding or
warm water. Dry it and store it in a delayed gastric emptying.
convenient place for the next feeding. ◆ To reduce oropharyngeal discomfort
Change the equipment every 24 hours from the tube, allow the patient to
or according to facility policy. brush his teeth or care for his dentures
regularly, and encourage frequent gar-
Delivering a duodenal or gling. If the patient is unconscious, ad-
jejunal feeding minister oral care swabs every 4 hours.
◆ Elevate the head of the bed, and Use petroleum jelly on dry, cracked
place the patient in low Fowler’s posi- lips.
tion. Alert Dry mucous membranes
◆ Open the enteral administration set, may indicate dehydration,
and hang the gavage container on the which requires increased fluid intake.
I.V. pole. Clean the patient’s nostrils with cot-
◆ If you’re using a nasoduodenal ton-tipped applicators, apply lubricant
tube, measure its length to check tube along the mucosa, and assess the
placement. You may not obtain any skin for signs of breakdown.
residual when you aspirate the tube. ◆ During continuous feedings, assess
◆ Open the roller clamp, and regulate the patient frequently for abdominal
the flow to the desired rate. To regulate distention. Flush the tubing by adding
the rate with a volumetric infusion about 50 ml of water to the gavage bag
pump, follow manufacturer directions or bulb syringe. This maintains the pa-
for setting up the equipment. Most patency of the tube by removing excess
tients receive small amounts initially, formula, which could occlude the tube.
◆ If the patient has diarrhea, give him which could lead to fatal hyperosmotic
small, frequent, less concentrated feed- dehydration. Monitor blood glucose
ings, or administer bolus feedings over levels to assess glucose tolerance. (A
a longer period. Also, make sure that serum glucose level of less than 170
the formula isn’t cold and that proper mg/dl is considered stable.) Also moni-
storage and sanitation practices have tor serum levels of electrolytes, blood
been followed. The loose stools associ- urea nitrogen, and glucose as well as
ated with tube feedings make extra serum osmolality and other pertinent
perineal skin care necessary. Giving findings to determine the patient’s re-
paregoric, tincture of opium, or di- sponse to therapy and assess his hydra-
phenoxylate hydrochloride may im- tion status.
prove the condition. Changing to a for- ◆ Special pulmonary formulas are
mula with more fiber may eliminate available for patients who are prone to
liquid stools. carbon dioxide retention.
◆ If the patient becomes constipated, ◆ Check the flow rate hourly to en-
the physician may increase the fruit, sure correct infusion. (With an impro-
vegetable, or sugar content of the for- vised administration set, use a time
mula. Assess the patient’s hydration tape to record the rate because it’s dif-
status because dehydration may pro- ficult to obtain precise readings from
duce constipation. Increase fluid in- an irrigation container or enema bag.)
take, as needed. If the condition per- ◆ For duodenal or jejunal feeding,
sists, administer an appropriate drug or most patients tolerate a continuous
enema, as ordered. drip better than bolus feedings. Bolus
◆ Drugs can be administered through feedings can cause such complications
the feeding tube. Except for enteric- as hyperglycemia and diarrhea.
coated, time-released, or sustained- ◆ Until the patient acquires a toler-
release medications, crush tablets or ance for the formula, you may need to
open and dilute capsules in water be- dilute it to one-half or three-quarters
fore administering them. Make sure strength to start, and increase it gradu-
that you flush the tubing afterward to ally. Patients who are under stress or
ensure full instillation of medication. who are receiving a steroid may experi-
Some drugs may change the osmolarity ence a pseudodiabetic state. Assess
of the feeding formula and cause diar- these patients frequently to determine
rhea. the need for insulin.
◆ Small-bore feeding tubes may kink, Patient teaching tips Patient
making instillation impossible. If you education for home tube feeding
suspect this problem, try changing the includes instructions on an infusion
patient’s position, or withdraw the control device to maintain accuracy,
tube a few inches and restart. Never use of the syringe or bag and tubing,
use a guide wire to reposition the tube. care of the tube and insertion site, and
◆ Constantly monitor the flow rate of formula mixing. Formula may be
a blended or high-residue formula to mixed in an electric blender according
determine if the formula is clogging the to package directions. Formula that
tubing as it settles. To prevent such isn’t used within 24 hours must be dis-
clogging, squeeze the bag frequently to carded. If the formula must hang
agitate the solution. longer than 8 hours, advise the patient
◆ Collect blood samples, as ordered. or caregiver to use a gavage or pump
Hyperglycemia and diuresis may indi- administration set with an ice pouch to
cate an excessive carbohydrate level, decrease the incidence of bacterial
Tube feedings 397
Managing tube feeding problems
COMPLICATIONS INTERVENTIONS
Aspiration of gastric secretions ◆ Discontinue feeding immediately.

◆ Perform tracheal suction of the aspirated contents, if
possible.
◆ Notify the physician. Prophylactic antibiotics and
chest physiotherapy may be ordered.
◆ Check tube placement before feeding to prevent
complications.
Tube obstruction ◆ Flush the tube with warm water. If necessary, re-
place the tube.
◆ Flush the tube with 50 ml of water after each feed-
ing to remove excess sticky formula, which could oc-
clude the tube.
◆ When possible, use liquid forms of medications. Oth-
erwise, and if not contraindicated, crush well.
Oral, nasal, or pharyngeal irri- ◆ Provide frequent oral hygiene using mouthwash or
tation or necrosis lemon-glycerin swabs. Use petroleum jelly on cracked
lips.
◆ Change the position of the tube. If necessary, replace
the tube.
Vomiting, bloating, diarrhea, ◆ Reduce the flow rate.

or cramps ◆ Administer metoclopramide to increase GI motility.
◆ Warm the formula to prevent GI distress.
◆ For 30 minutes after feeding, position the patient on
his right side with his head elevated to facilitate gastric
emptying.
◆ Notify the physician. He may want to reduce the
amount of formula being given during each feeding.
Constipation ◆ Provide additional fluids if the patient can tolerate

them.
◆ Administer a bulk-forming laxative.
◆ Increase the fruit, vegetable, or sugar content of the
feeding.
Electrolyte imbalance ◆ Monitor serum electrolyte levels.

◆ Notify the physician. He may want to adjust the for-
mula content to correct the deficiency.
Hyperglycemia ◆ Monitor blood glucose levels.

◆ Notify the physician of elevated levels.
◆ Administer insulin, if ordered.
◆ The physician may adjust the sugar content of the
formula.
growth. Tell him to use a new bag dai- ment; the amount, type, and time of
ly. Teach family members which signs feeding; and verification of tube paten-
and symptoms to report to the physi- cy. Discuss the patient’s tolerance of
cian or home care nurse as well as the feeding, including nausea, vomit-
what measures to take in an emer- ing, cramping, diarrhea, and disten-
gency. tion.
◆ Erosion of the esophageal, tracheal, Note the result of blood and urine
nasal, and oropharyngeal mucosa can tests, hydration status, and any drugs
result if tubes are left in place for a given through the tube. Include the
long time. If possible, use smaller- date and time of administration set
lumen tubes to prevent such irritation. changes, the oral and nasal hygiene
Check facility policy regarding the fre- performed, and the results of specimen
quency of changing feeding tubes to collections.
prevent complications.
◆ With the gastric route, frequent or
large-volume feedings can cause bloat- Venipuncture
ing and retention. Dehydration, diar-
rhea, and vomiting can cause metabol- Performed to obtain a venous blood
ic disturbances. Cramping and abdomi- sample, venipuncture involves piercing
nal distention usually indicate a vein with a needle and collecting
intolerance. blood in a syringe or an evacuated
◆ With the duodenal or jejunal route, tube. Typically, venipuncture is per-
clogging of the feeding tube is com- formed using the antecubital fossa
mon. The patient may have metabolic, (median cubital veins). If necessary,
fluid, and electrolyte abnormalities, in- however, it can be performed on a vein
cluding hyperglycemia, hyperosmolar in the wrist, the dorsum of the hand,
dehydration, coma, edema, hypernatre- or another accessible location.
mia, and essential fatty acid deficiency.
◆ The patient may also experience Equipment and preparation
dumping syndrome, in which a large
amount of hyperosmotic solution in the Disposable tourniquet ◆ gloves ◆ sy-
duodenum causes excessive diffusion ringe or evacuated tubes and needle
of fluid through the semipermeable holder ◆ chlorhexidine swab ◆ 21G
membrane and results in diarrhea. In a needle for the forearm or 23G needle
patient with low serum albumin levels, for the wrist, hand, and ankle, and for
these signs and symptoms may result children and infants ◆ color-coded col-
from low oncotic pressure in the duo- lection tubes containing appropriate
denal mucosa. (See Managing tube additives ◆ labels ◆ laboratory re-
feeding problems, page 397.) quests ◆ laboratory transport bag ◆
2 2 gauze pads ◆ adhesive ban-
Documentation dage ◆ optional: cold compresses
If you’re using evacuated tubes,
On the intake and output sheet, record open the needle packet, attach the nee-
the date, volume of formula, and vol- dle to its holder, and select the appro-
ume of water. In your notes, document priate tubes. If you’re using a syringe,
the findings of abdominal assessment attach the appropriate needle to it.
(including the tube exit site, if appro- Make sure that you choose a syringe
priate); the amount of residual gastric that’s large enough to hold all of the
contents; verification of tube place- blood required for the test. Label all
Venipuncture 399
Common venipuncture sites
The illustrations below show the anatomic locations of veins commonly used for
venipuncture sites. The most commonly used sites are on the forearm, followed by those
on the hand.
Cephalic vein Median cubital vein
Basilic vein Median vein of forearm
Dorsal Metacarpal plexus

venous arch
collection tubes with the patient’s ◆ If the patient is on bed rest, ask him
name and room number, the physi- to lie in a supine position, with his
cian’s name, and the date and time of head slightly elevated and his arms at
collection. his sides. Ask the ambulatory patient
to sit in a chair and to support his arm
Implementation securely on an armrest or a table.
◆ Assess the patient’s veins to deter-
◆ Confirm the patient’s identity using mine the best puncture site. (See Com-
two patient identifiers. mon venipuncture sites.) Observe the
◆ Wash your hands thoroughly, and skin for the blue color of the vein, or
put on gloves. palpate the vein for a firm rebound
◆ Tell the patient that you’re about to sensation.
collect a blood sample, and explain the ◆ Tie a tourniquet 2 (5 cm) above the
procedure to ease his anxiety. Ask him antecubital fossa. By impeding venous
if he has ever felt faint, sweaty, or nau- return to the heart while allowing arter-
seated when having blood drawn. ial flow, a tourniquet produces venous
dilation. If arterial perfusion remains
adequate, you’ll be able to feel the evacuated tube, remove the last tube
radial pulse. (If the tourniquet doesn’t from the needle holder to release the
dilate the vein, have the patient open vacuum before withdrawing the needle
and close his fist repeatedly.) from the vein.
◆ Clean the venipuncture site with a ◆ Apply gentle dry pressure to the
chlorhexidine swab. Wipe vigorously in puncture site for 2 to 3 minutes or un-
a side-to-side motion to avoid introduc- til bleeding stops. This prevents ex-
ing potentially infectious skin flora into travasation of blood into the surround-
the vessel during the procedure. Allow ing tissue, which can cause a hema-
the skin to dry before performing toma.
venipuncture. ◆ After bleeding stops, apply an adhe-
◆ Immobilize the vein by pressing just sive bandage.
below the venipuncture site with your ◆ If you’ve used a syringe, transfer
thumb and drawing the skin taut. the sample to a collection tube. Place
◆ Position the needle holder or sy- all specimen tubes inside the biohazard
ringe with the needle bevel up and the transport bag, being careful to avoid
shaft parallel to the path of the vein foaming, which can cause hemolysis.
and at a 0- to 15-degree angle to the ◆ Check the venipuncture site to see
arm. Insert the needle into the vein. If if a hematoma has developed. If it has,
you’re using a syringe, venous blood apply cold compresses for the first
will appear in the hub; withdraw the 24 hours.
blood slowly, pulling the plunger of the ◆ Discard the tourniquet, syringes,
syringe gently to create steady suction needles, and used gloves in appropriate
until you obtain the required sample. containers.
Pulling the plunger too forcibly may ◆ Label all specimen tubes with the
collapse the vein. If you’re using a patient’s name and identification num-
needle holder and an evacuated tube, ber, date, and time of collection.
grasp the holder securely to stabilize ◆ Place all specimen tubes in a labo-
it in the vein, and push down on the ratory transport bag and send them to
color-coded collection tube until the the laboratory with a properly complet-
needle punctures the rubber stopper. ed request form.
Blood will flow into the tube automati-
cally. Special considerations
◆ Remove the tourniquet as soon as
blood flows adequately to prevent sta- ◆ Several manufacturers make safety-
sis and hemoconcentration, which can engineered blood collection sets; their
impair test results. If the flow is slug- use is recommended to help prevent
gish, leave the tourniquet in place needle sticks.
longer, but always remove it before ◆ Never collect a venous sample from
withdrawing the needle. an arm that’s already being used for
◆ Continue to fill the required tubes, I.V. therapy or blood administration,
removing one and inserting another. because this may affect test results.
Gently rotate each tube as you remove Don’t collect a venous sample from an
it to help mix the additive with the infection site, because this may intro-
sample. duce pathogens into the vascular sys-
◆ After you’ve drawn the last sample, tem. Likewise, avoid collecting blood
place a gauze pad over the puncture from edematous areas, arteriovenous
site, and slowly and gently remove the shunts, and sites of previous hemato-
needle from the vein. When using an mas or vascular injury.
Venipuncture 401
◆ If the patient has a clotting disorder

or is receiving anticoagulant therapy,
maintain firm pressure on the veni-
puncture site until the bleeding stops,
to prevent hematoma formation.
◆ Avoid using veins in the patient’s
legs for venipuncture, because this in-
creases the risk of thrombophlebitis.
◆ Assess the patient for complica-
tions. A hematoma at the needle inser-
tion site is the most common complica-
tion of venipuncture. Nerve compres-
sion injury and infection may result
from poor technique.
Documentation
Record the date, time, and site of the

venipuncture; the name of the test; the
time that the sample was sent to the
laboratory; the amount of blood col-
lected; the size of the needle used; and
any adverse reactions.
7 Surgical patient care

Reviewing the techniques
Preoperative care 403

Assessing the preoperative patient 403
Preoperative care for the bariatric
surgery patient 404
Teaching the preoperative patient 406
Identifying hazardous drugs 409
Reviewing care on the day of surgery 413
Preparing the bowel for surgery 413
Preparing the skin for surgery 413
Reviewing common general anesthetics 414
Reviewing common neuromuscular blockers 420
Postoperative care 421
Monitoring the postoperative patient 421
Postoperative care for the bariatric
surgery patient 422
Preventing postoperative complications 423
Managing postoperative complications 424
Caring for surgical wounds 428
Draining closed wounds 430
Managing dehiscence and evisceration 431
Planning for discharge 433
402
Head and neck

Preoperative care ◆ Check the patient’s scalp for lesions
or a parasitic infection.
Assessing the preoperative patient ◆ Check the jugular veins for disten-
tion.
A thorough preoperative assessment is ◆ Note the color of the sclerae; a
the foundation of good surgical care, yellowish color suggests jaundice; a
providing a baseline for comparison red-pink color suggests bacterial in-
throughout a patient’s treatment and fection.
recovery. This assessment also helps to ◆ Evert the lower eyelid, and note the
identify conditions that impair the pa- color of the conjunctiva. Pale tissue
tient’s ability to tolerate the stress of suggests anemia.
surgery or to comply with postopera- ◆ Check the nose and throat for signs
tive routines. (See Preoperative care for of respiratory tract infection.
the bariatric surgery patient, pages 404 ◆ Assess the mouth for sores, ulcera-
and 405.) tions, or bleeding of the tongue, gums,
or cheeks. Check for loose teeth, caps,
Initial steps partial plates, or dentures. Check the
Begin your preoperative assessment by lips for bluish or gray color, which may
focusing on problem areas suggested suggest cyanosis.
by the patient’s history and on any ◆ Check the neck for stiffness or cer-
body system that’s directly affected by vical node enlargement.
the surgical procedure:
◆ Note the patient’s general appear- Neurologic system
ance. Does he look healthy and well ◆ Assess the patient’s level of con-
nourished, or does he appear ill? sciousness. Note whether his pupils are
◆ Record the patient’s height, weight, uniform in size and shape.
and vital signs. Compare his blood ◆ Assess the patient’s gross and fine
pressure bilaterally, using a cuff that’s motor movements.
two-thirds the length of the patient’s ◆ Inform the physician of any behav-
arm. Document his position during this ioral changes (for instance, from
procedure. lethargy to agitation). Such changes
◆ In most cases, the patient is admit- may indicate increased intracranial
ted on the morning of surgery, so base- pressure.
line vital signs are extremely impor- ◆ Look for neurologic abnormalities
tant. Compare these values with pre- such as slurred speech. If you know or
hospital data, if available. suspect that the patient has a problem,
◆ For an inpatient, measure his vital conduct a complete neurologic exami-
signs at least every 8 hours or as or- nation.
dered throughout the preoperative peri-
od. Use these measurements to estab- Extremities and skin
lish a baseline. Document any drug or ◆ Look for changes in skin color or
food allergies. temperature that suggest impaired cir-
culation. Check for cyanotic nail beds
Systematic examination and clubbing of the fingers.
Examine the patient thoroughly from ◆ Note any skin lesions.
head to toe, using these procedures as ◆ Assess skin turgor for signs of dehy-
a guide. dration.
Preoperative care for the bariatric surgery patient
Bariatric surgery serves as a last resort in lower the risks of surgery. Many pro-
the treatment of morbid obesity. Such grams won’t accept a patient as a candi-
surgery requires significant preoperative date if he can’t ambulate a short distance
assessment and care. or is on continuous oxygen therapy.
Three types of bariatric surgery are Examples of additional criteria a pa-
performed: tient must meet include:
◆ Restrictive surgery decreases the size of ◆ quitting smoking if the patient smokes
the stomach, limiting how much the pa- ◆ losing at least 10% of the patient’s
tient can eat and slowing stomach current weight if the patient is at his
emptying. heaviest weight to lower the risk of post-
◆ Malabsorptive surgery bypasses operative complications
7 to 9 feet of small intestine, leaving ◆ agreeing to use two forms of birth
only 1.5 feet of intestine for absorbing control for the first 18 to 24 months after
nutrients. surgery if the patient is a woman of child-
◆ Combined restrictive and malab- bearing age because pregnancy requires
sorptive surgery both decreases the pa- increasing caloric intake and limits weight
tient’s stomach size and bypasses much loss.
of the small intestine; however, combined
surgery may give the patient symptoms Preoperative evaluation
of dumping syndrome. To help determine if a patient is a candi-
Although all three types of surgery date for bariatric surgery, psychological
may be performed either laparoscopically and nutritional counseling should take
or as open surgery, most are now per- place. A psychologist will discuss the pa-
formed laparoscopically because of the tient’s previous efforts to lose weight as
decreased pain, fewer wound complica- well as factors that contributed to the pa-
tions, shorter hospital stays, and faster tient’s success or failure. The psychologist
recovery time associated with laparoscop- will also assess the patient’s understand-
ic procedures. ing of the surgery, including the risks and
necessary lifestyle and dietary changes.
Selecting patients The patient and psychologist should iden-
In 1991, the National Institutes of Health tify and deal with any potential or actual
established guidelines for the surgical obstacles to successful weight loss. Devel-
treatment of obesity. To be a candidate oping the relationship before surgery will
for surgery, the patient must be: make it easier for the psychologist and
◆ 100 pounds overweight or have a patient to respond to any emotional
body mass index (BMI) greater than or stress that may develop after surgery. A
equal to 40 kg/m2 or have a BMI greater dietitian will also obtain a nutritional his-
than 35 kg/m2 accompanied by obesity- tory and assessment.
related medical conditions Depending on the patient’s medical
◆ able to demonstrate a failure to lose history, he may also need evaluation and
weight with a supervised diet and exer- surgical clearance from other medical
cise program specialists. He may need diagnostic tests
◆ evaluated by an experienced bariatric as well, possibly including:
surgeon. ◆ a two-dimensional echocardiogram to
Many bariatric surgery programs also determine cardiac function
have their own, additional criteria that ◆ a Persantine thallium stress test to de-
encourage patient responsibility and tect underlying cardiovascular disease
Preoperative care for the bariatric surgery patient (continued)
◆ a sleep study to determine if the pa- ◆ diet

tient has sleep apnea
◆ reading food labels
◆ an abdominal ultrasound to check for ◆ vitamin and mineral supplements
gallstones if the patient still has his gall-
◆ exercise
bladder; if the patient does have gall-
◆ realistic weight-loss expectations
stones, he may also have his gallbladder
◆ possible improvements in preexisting
removed during surgery.
medical conditions.
Patient teaching
Patient teaching should start preopera-
tively and continue after surgery. Topics
should include:
◆ Check the extremities for edema. sounds. Note dyspnea on exertion or

Ask the patient if his feet, ankles, or resting.
fingers ever swell. ◆ Ask the patient if he has a history
◆ Note the distribution of hair on the of respiratory disorders, such as asth-
patient’s extremities. A line of demar- ma or sleep apnea. If he reports sleep
cation of hair on the lower extremities apnea, determine whether he uses a
may indicate poor peripheral circula- continous positive airway pressure or
tion. bilevel positive airway pressure ma-
◆ Check all peripheral pulses (radial, chine at home.
pedal, femoral, and popliteal) bilateral- ◆ Ask the patient whether he smokes.
ly. Note any differences in their quality, If he does, ask how many packs per
rate, or rhythm. day he smokes and whether he has re-
◆ Mark pedal pulses for reference if cently tried to quit or cut down in an-
the patient is having a lower extremity ticipation of surgery. His physician
procedure or if positioning devices may should have advised him to stop smok-
be used on the lower extremities. ing 4 to 6 weeks before surgery.
Patient teaching tips Al-
Respiratory system though the immediate preopera-
◆ Document the patient’s respiratory tive period isn’t the time to have a
rate and pattern. A patient with ques- lengthy discussion about smoking ces-
tionable pulmonary status may require sation, information can be placed with
an alternative to inhalation anesthesia the patient’s belongings and discussed
such as a spinal block. postoperatively.
◆ Assess the patient’s breathing pat-
tern. Check for asymmetrical chest ex- Cardiovascular system
pansion and the use of accessory mus- ◆ Inspect the patient’s chest for ab-
cles. normal pulsations. Auscultate at the
◆ Auscultate the anterior and posteri- fifth intercostal space over the left mid-
or chest for breath sounds. Listen for clavicular line. If you can’t hear an api-
normal, abnormal, and adventitious cal pulse, ask the patient to turn onto
his left side; this movement may cause the last several days as well as daily
the heart to shift closer to the chest weight measurements.
wall. Note the rate and quality of the ◆ Note any discharge or odor from the
apical pulse. patient’s genitalia.
◆ Auscultate heart sounds. If you ◆ If the patient is female, ask when
hear thrills, suspect mitral valve re- her last menstrual period occurred and
gurgitation or stenosis. Murmurs that find out whether her cycle is regular.
you hear on the right side of the heart Also ask if she could be pregnant. If
are more likely to change with respi- pregnancy is suspected, suggest that a
ration than those you hear on the left pregnancy test be ordered.
side.
◆ Palpate the chest to find the point Psychological status
of maximal impulse. ◆ Set aside time to allow the patient
to discuss his feelings about the im-
GI system pending surgery. This step is important
◆ Note the contour and symmetry of because depression and anxiety can
the abdomen. Check for distention. significantly affect recovery. Offer the
◆ Note the position and color of the patient the option of seeing a member
umbilicus. Look for herniation. of the clergy.
◆ Auscultate bowel sounds in each ◆ Expect the patient to exhibit some
quadrant. Ask the patient if his bowel anxiety. If he seems inappropriately re-
movements are regular. Note the date laxed or unconcerned, consider
of the patient’s last bowel movement. whether he’s suppressing his fears. A
◆ Percuss the abdomen for air and patient who suppresses his fears may
fluid. cope poorly with surgical stress, and
◆ Palpate the abdomen for softness, it’s important to encourage him to seek
firmness, and bladder height. Note ten- support from his family or friends. If
derness. possible, allow the patient’s family and
◆ Assess the six f’s: fat, fluids, flatus, friends to visit him preoperatively. Also
feces, fetus (if the patient is pregnant), include them in your nursing care
and fibroid tissue (or any unusual plan.
mass).
Teaching the preoperative patient
Genitourinary system
◆ Ask the patient if he ever has Your teaching can help the patient to
pain, burning, or bleeding during cope with the physical and psychologi-
urination. cal stress of surgery. Because of the ris-
◆ Ask about urinary frequency and in- ing number of shorter hospital stays
continence. Can he empty his bladder and same-day surgeries, preadmission
completely? Does he awaken at night and preoperative teaching have become
to urinate? more important than ever.
◆ If indicated, monitor urine output
and try to correlate excess or deficient Explaining preoperative measures
output with the blood urea nitrogen or Include in your teaching strategy an
creatinine levels. If urine output falls, evaluation of the patient’s understand-
first assess the patency of the catheter ing of his upcoming surgery so that
and urinary drainage system, if applic- you can correct misconceptions. Plan
able. Compare intake and output over the teaching to be brief because time is
limited. Use the following teaching tips they want to visit the patient preopera-
as a guide. tively, tell them to arrive 2 hours be-
◆ Urge the patient to read the surgical fore surgery is scheduled.
consent form carefully and to ask ques- Age alert When the patient is
tions of the surgeon before signing the a child, you can help to make
form. the surgical experience less threaten-
◆ Explain that the results of chest ing by using therapeutic play. Follow
X-rays, a complete blood count, urine these guidelines:
studies, an electrocardiogram, and oth- – Allow the parent or designee to re-
er preoperative tests will determine main with the child as much as possi-
whether the patient is ready for ble. Some facilities allow the parent to
surgery. accompany the child into the operat-
◆ Discuss the rationale behind hair re- ing room.
moval, if ordered — that is, to prevent – Allow the child to bring a familiar
infection of the surgical wound by toy or comfort object that can accom-
cleaning the skin of microorganisms pany him while he’s in the operating
found in body hair. room and the postanesthesia care unit
◆ Stress the importance of withhold- (PACU).
ing food and fluids for a specified time – Allow the child to choose play arti-
before surgery. cles.
Alert Tell the patient to – Provide materials specific to the
avoid taking aspirin and non- child’s experiences, such as a nasogas-
steroidal anti-inflammatory drugs for tric tube, a syringe, or bandages.
several days before surgery because – Allow the child to participate in un-
these drugs increase the risk of structured play.
bleeding. – Provide supervision to prevent acci-
◆ Inform the patient that after he has dental injury.
completed all preoperative routines, in-
cluding dressing in a surgical cap and Previewing operating room
gown, he’ll receive preanesthetic med- procedures
ication. Tell the patient that this med- Educate the patient on operating room
ication will help him to relax, although procedures:
he probably won’t fall asleep. ◆ Warn the patient that he may need
◆ Tell the patient that he’ll receive an to wait a short time in the holding
I.V. line either before or after he goes area, a special area designated for use
into the operating room. by patients who are awaiting surgery,
◆ Help the patient to deal with his to allow the anesthetic to take effect.
fears about anesthesia. Assure him Explain that the physicians and nurses
that the anesthesiologist will monitor will wear surgical attire and will ob-
his condition throughout surgery and serve him closely.
provide the right amount of anesthet- ◆ Explain to the patient that he’ll be
ic. In most cases, an anesthesiologist repeatedly asked his name, the name
will meet with the patient before hos- of his surgeon, and the type of surgery
pitalization or on the morning of he’s having. Reassure him that this is a
surgery. safety precaution used at most facili-
◆ Show the patient’s family where ties.
they can wait during the operation. If
◆ When discussing transfer proce- so he won’t be alarmed by these rou-

dures and techniques, describe sensa- tine procedures.
tions that the patient will experience. ◆ Reduce the patient’s anxiety about
Advise the patient that he’ll be taken postoperative pain by telling him
to the operating room on a stretcher about the pain-control measures
and then transferred from the stretcher you’ll be using. Explain that the
to the operating table. For his own physician will order pain medication
safety, he’ll be strapped securely to the to be given according to the patient’s
table. The nurses in the operating needs.
room will check his vital signs fre- Patient teaching tips Teach
quently. the patient how to use the
◆ Tell the patient that the operating 0-to-10 pain scale to rate his pain
room may feel cool and that electrodes (with 0 indicating no pain and 10 de-
may be placed on his chest to monitor scribing unbearable pain). Tell the pa-
his heart rate during surgery. tient to describe his pain in terms of
◆ Explain to the patient that he’ll its quality and location. Encourage
have a blood pressure cuff placed on him to let you know as soon as he
his arm and a clip placed on one of his feels pain, instead of waiting until it
fingers to monitor his blood pressure becomes intense.
and oxygen levels. ◆ Discuss the type of medication that
◆ Describe the drowsy, floating sensa- the patient will receive, including how
tion that occurs as the anesthetic takes it works and the route of administra-
effect. Tell the patient that it’s impor- tion that will be used. Describe other
tant for him to relax when he feels this measures you’ll take to relieve his pain
sensation. and promote comfort, such as posi-
tioning, diversionary activities, and
Getting ready for recovery splinting.
Prepare the patient for his stay in the ◆ Teach the patient coughing exer-
PACU. Briefly describe the sensations cises, unless he’s scheduled for neu-
that the patient will experience when rosurgery or eye surgery. If he’s
the anesthetic wears off. Tell him that scheduled for chest or abdominal
the PACU nurse will call his name surgery, teach him how to splint his
and then ask him to answer ques- incision before he coughs. Instruct
tions and follow simple commands the patient to take a slow, deep
such as wiggling his toes. He may breath and then to breathe out
feel pain at the surgical site, but through his mouth. Tell him to take a
medications can be given to mini- second breath in the same manner.
mize the pain. Next, tell him to take a third deep
◆ Describe the oxygen delivery device, breath and hold it. He should then
such as the nasal cannula, that he’ll cough two or three times to clear his
need after surgery. breathing passages. Have him take
◆ Tell the patient that after he’s three to five normal breaths,
recovered from the anesthesia, he’ll re- exhaling slowly and relaxing after
turn to his room. He’ll be able to see each breath.
his family, but he’ll probably feel ◆ Teach the patient how to perform
drowsy. deep-breathing exercises. Instruct the
◆ Tell the patient that you’ll be taking patient to lie on his back in a comfort-
his blood pressure and pulse frequently
able position, with one hand placed on sequential compression devices, until
his chest and the other hand placed he’s ambulatory. These devices com-
over his upper abdomen. Instruct him press the calf muscles to simulate
to exhale normally, close his mouth, walking.
and inhale deeply through his nose. ◆ Demonstrate how to use an incen-
His chest shouldn’t expand. Ask him to tive spirometer, and have the patient
hold his breath and slowly count to perform a return demonstration. Ex-
five. Next, ask him to purse his lips plain that this device will provide
and exhale completely through his feedback when he’s performing deep-
mouth, without letting his cheeks ex- breathing exercises. Explain how
pand. Tell the patient to repeat the ex- simple leg exercises, such as alter-
ercise 5 to 10 times. nately contracting the calf muscles,
◆ Teach the patient the techniques of will prevent venous pooling after
early mobility and ambulation. surgery.
◆ Explain that postoperative exercis-
es help to prevent complications,
such as atelectasis, thrombophlebitis,
constipation, and loss of muscle tone.
Explain to the patient that he may
need to wear leg wraps, called (Text continues on page 413.)
Identifying hazardous drugs
Some drugs may cause hazardous complications or interactions during or after surgery.
Always review the patient’s medication record carefully before he undergoes surgery.
Use this chart to identify common drugs that can be hazardous to the patient undergo-
ing surgery.
DRUG POSSIBLE EFFECT
Antianxiety drugs
diazepam ◆ Excessive sedation
Valium ◆ Preoperative or postoperative nausea and vomiting
◆ Local tissue irritation (with I.V. administration)
hydroxyzine ◆ Drowsiness and dry mouth

hydrochloride
Vistaril
midazolam ◆ Respiratory depression (with high doses)

hydrochloride
(continued)
Identifying hazardous drugs (continued)
Antiarrhythmics
All types ◆ Laryngospasm
◆ Intensified cardiac depression and reduced cardiac output
procainamide ◆ Prolonged or enhanced effects of neuromuscular blockers

◆ Hypotension
propranolol ◆ Prolonged or enhanced effects of neuromuscular blockers

Inderal ◆ Depressed myocardial function
◆ Hypotension
◆ Laryngospasm
Antibiotics
All types ◆ Masked symptoms of infection
Aminoglycosides ◆ Increased risk of neuromuscular blockade and respiratory

amikacin, gentamicin, paralysis
kanamycin, neomycin,
streptomycin,
tobramycin
erythromycin ◆ Prolonged action of opiates

Erythrocin, E-Mycin
Anticholinergics
atropine sulfate ◆ Excessive dryness of the mouth, tachycardia, flushing, and
decreased sweating
◆ Increased intraocular pressure (IOP), blurred vision, and
dilated pupils
◆ Urine retention
◆ Agitation and delirium (in elderly patients)
glycopyrrolate ◆ Excessive dryness of the mouth, tachycardia, flushing, and

Robinul decreased sweating
◆ Increased IOP, blurred vision, and dilated pupils
◆ Urine retention
scopolamine bromide ◆ Excessive dryness of the mouth, tachycardia, and flushing

◆ Increased IOP, blurred vision, and dilated pupils
◆ Urine retention
◆ Excessive drowsiness
◆ Agitation and delirium (in elderly patients)
Anticoagulants
heparin sodium ◆ Increased risk of hemorrhage
warfarin
Coumadin
Anticonvulsants
magnesium sulfate ◆ Increased risk of neuromuscular blockade
Antidiabetics
insulin ◆ Increased insulin requirement during stress and healing
◆ Decreased insulin requirement during fasting
Antihypertensives
All types ◆ Worsened hypotension
Central nervous system depressants
Alcohol, sedative hyp- ◆ If given with general anesthetics, increased risk of respira-
notics tory depression, apnea, or hypotension
Corticosteroids
betamethasone, ◆ Delayed wound healing
cortisone, ◆ Risk of acute adrenal insufficiency
dexamethasone, ◆ Increased risk of infection
hydrocortisone, ◆ Masked symptoms of infection
methylprednisolone, ◆ Increased risk of hemorrhage
prednisolone,
prednisone,
triamcinolone
Diuretics
furosemide ◆ If given with certain anesthetics, increased risk of hypoten-
Lasix sion
Potassium-wasting ◆ Increased risk of complications associated with hypo-
diuretics kalemia
Histamine-2 receptor antagonists

cimetidine ◆ Decreased clearance of all drugs, especially diazepam, li-
Tagamet docaine, and propranolol
ranitidine
Zantac
(continued)
Myotics
demecarium, ◆ If given with succinylcholine, increased risk of neuromus-
echothiophate, cular blockade, cardiovascular collapse, prolonged respiratory
isoflurophate depression, or apnea (effects may occur up to a few months
after the patient stops taking the drug)
Nonsteroidal anti-inflammatory drugs

celecoxib, ◆ Increased risk of bleeding or hemorrhage
ibuprofen,
meloxicam,
naproxen,
rofecoxib
Opiates
All types ◆ If given with certain I.V. anesthetics (such as midazolam,
propofol, thiopental, and droperidol), increased risk of respi-
ratory depression, apnea, or hypotension
Opioids
meperidine ◆ Depressed respiration, circulation, and gastric motility
hydrochloride ◆ Dizziness, tachycardia, and sweating
morphine ◆ Hypotension, restlessness, and excitement
Demerol ◆ Preoperative or postoperative nausea and vomiting
Sedative-hypnotics
pentobarbital ◆ Confusion or excitement, especially in elderly patients or
sodium patients with severe pain
Nembutal
Thyroid hormones
All types ◆ If given with ketamine, increased risk of hypertension and
tachycardia
Tranquilizers
promethazine ◆ Postoperative hypotension
hydrochloride
Phenergan
Reviewing care on the day for several days of postoperative bed

of surgery rest and hasn’t had a recent bowel
movement may receive a mild laxative
Early on the day of surgery, follow or an enema. However, a patient who’s
these procedures: scheduled for GI, pelvic, perianal, or
◆ Verify that the patient has had noth- rectal surgery will undergo more exten-
ing by mouth since midnight. sive preparation.
◆ Verify that the patient took all pre- Preoperative enemas or an osmotic
scribed medications as instructed. cathartic solution, such as magnesium
◆ Make sure the patient hasn’t taken citrate, may help to empty the intes-
any medications that have been pro- tine, thereby minimizing injury to the
hibited, such as aspirin. colon and improving visualization of
◆ Make sure that the diagnostic test the operative site.
results appear on the chart. Expect to perform extensive prepa-
◆ Verify that all documentation, in- ration for the patient undergoing elec-
cluding informed consent, has been tive colon surgery. During surgical
signed and completed. opening of the colon, escaping bacteria
◆ Ask the patient to remove jewelry, may invade the adjacent tissue, leading
makeup, and nail polish, if applicable; to infection. Perform a mechanical
to shower with antimicrobial soap, if preparation and administer antimicro-
ordered; and to perform mouth care. bials, as ordered. Mechanical bowel
◆ Instruct the patient to remove den- preparation removes gross stool; oral
tures or partial plates. Note on the antimicrobials suppress potent mi-
chart whether he has dental crowns, croflora without encouraging resistant
caps, or braces. Also instruct him to re- strains.
move contact lenses, glasses, prosthe- If enemas are ordered to clear the
ses, and hearing aids, if applicable. bowel, and the third enema still hasn’t
Policies for the removal of hearing aids removed all the stool, notify the physi-
vary among health care facilities. Some cian. Repeated enemas may cause fluid
facilities allow the patient to leave in and electrolyte imbalances.
the hearing aid if it helps him to follow Age alert The elderly patient
instructions. Document whether the who’s allowed nothing by
patient is wearing a hearing aid into mouth and hasn’t received I.V. fluids
the operating room. is at increased risk for fluid and elec-
◆ Tell the patient to void and to put trolyte imbalances.
on a surgical cap and gown.
◆ Take and record the patient’s vital Preparing the skin for surgery
signs.
◆ Reassure the patient, and answer Before surgery, the patient’s skin must
any last-minute questions he may be as free from microorganisms as pos-
have. sible to reduce the risk of infection at
◆ Give preoperative medication, if or- the incision site.
dered. Hair removal should be done as
close as possible to the time of surgery,
Preparing the bowel for surgery such as while the patient is in the
holding area, and should be performed
The extent of bowel preparation de- with a clipper.
pends on the type and site of surgery.
For example, a patient who’s scheduled (Text continues on page 421.)
Reviewing common general anesthetics

DRUG INDICATIONS ADVANTAGES
Inhalation agents
Nitrous oxide ◆ Maintains anesthesia ◆ Has little effect on heart rate, myocardial
◆ May provide an ad- contractility, respiration, blood pressure, liver,
junct for inducing gen- kidneys, or metabolism in the absence of hy-
eral anesthesia poxia
◆ Produces excellent analgesia
◆ Allows for rapid induction and recovery
◆ Doesn’t increase capillary bleeding
◆ Doesn’t sensitize the myocardium to epi-
nephrine
halothane ◆ Maintains general ◆ Is easy to administer

anesthesia ◆ Allows for rapid, smooth induction and re-
covery
◆ Has a relatively pleasant odor and is nonir-
ritating
◆ Decreases salivary and bronchial secretions
◆ Causes bronchodilation
◆ Easily suppresses pharyngeal and laryngeal
reflexes
enflurane ◆ Maintains anesthesia ◆ Allows for rapid induction and recovery

Ethrane ◆ Occasionally used to ◆ Is nonirritating and eliminates secretions
induce anesthesia ◆ Causes bronchodilation
◆ Provides good muscle relaxation
◆ Allows cardiac rhythm to remain stable
isoflurane ◆ Maintains general ◆ Allows for rapid induction and recovery

Forane anesthesia ◆ Causes bronchodilation
◆ Occasionally used to ◆ Provides excellent muscle relaxation
induce general anesthe- ◆ Allows for an extremely stable cardiac
sia rhythm
DISADVANTAGES NURSING INTERVENTIONS
◆ Excessive amounts may cause hypoxia ◆ Monitor the patient for signs of hypoxia.
◆ Doesn’t relax muscles (procedures requir- (Always give with oxygen to prevent hypox-
ing muscular relaxation require the addition ia.)
of a neuromuscular blocker)
◆ Soluble gas can diffuse into air-contain-
ing cavities, such as the chest or bowel
◆ May cause myocardial depression, lead- ◆ Watch for arrhythmias, hypotension, and
ing to arrhythmias respiratory depression.
◆ Sensitizes the heart to the action of cate- ◆ Monitor the patient for a decrease in
cholamine body temperature; he may shiver after pro-
◆ May cause circulatory or respiratory de- longed use. Shivering increases oxygen con-
pression, depending on the dose sumption.
◆ Has no analgesic property
◆ Causes myocardial depression ◆ Monitor the patient for decreased heart

◆ Lowers the seizure threshold and respiratory rates and hypotension.
◆ Increases hypotension as the depth of ◆ Watch for shivering, which increases oxy-
anesthesia increases gen consumption.
◆ May cause shivering during recovery
◆ May cause circulatory or respiratory
depression, depending on the dose
◆ May increase intracranial pressure
◆ May cause circulatory or respiratory de- ◆ Watch for respiratory depression and hy-
pression, depending on the dose potension.
◆ Potentiates the action of nondepolarizing ◆ Watch for shivering, which increases oxy-
muscle relaxants gen consumption.
◆ May cause shivering
◆ Tends to lower blood pressure as the
depth of anesthesia increases; pulse remains
somewhat elevated
(continued)
Reviewing common general anesthetics (continued)
Inhalation agents (continued)

desflurane ◆ Induces and main- ◆ Can use decreased doses for neuromuscular
Suprane tains general anesthesia blockers
◆ Increased doses for maintenance anesthesia
may produce dose-dependent hypotension
sevoflurane ◆ Induces and main- ◆ Nonpungent odor

Ultane tains general anesthesia ◆ No respiratory irritability
in adults and children ◆ Suitable for use with mask induction
I.V. barbiturates
thiopental ◆ Used primarily to in- ◆ Promotes rapid, smooth, and pleasant in-
sodium duce general anesthesia duction and quick recovery
◆ Rarely causes complications
◆ Doesn’t sensitize the autonomic tissues of
the heart to catecholamines
I.V. benzodiazepines
diazepam ◆ Induces general ◆ Minimally affects the cardiovascular system
Valium anesthesia ◆ Acts as a potent anticonvulsant
◆ Provides amnesia ◆ Produces amnesia
during balanced anes-
thesia
midazolam ◆ Induces general ◆ Minimally affects the cardiovascular system

hydrochloride anesthesia ◆ Acts as a potent anticonvulsant
◆ Provides amnesia ◆ Produces amnesia
during balanced anes-
thesia
◆ May increase heart rate ◆ Monitor the patient’s vital signs, especial-
◆ Respiratory irritant effect is more likely in ly heart rate and blood pressure.
an adult during induction of anesthesia via ◆ Watch for shivering, which increases oxy-
mask gen consumption.
◆ Not recommended for induction of general
anesthesia in infants or children because of
high incidence of laryngospasm or other ad-
verse respiratory effects (after anesthesia is
induced and tracheal intubation is achieved,
it can be used for maintenance anesthesia)
◆ Not indicated for patients with coronary
artery disease or in those who will be ad-
versely affected by increases in heart rate
◆ Dose-related cardiac depressant ◆ Monitor the patient’s vital signs.

◆ Watch for shivering, which increases oxy-
gen consumption.
◆ Is associated with airway obstruction, res- ◆ Watch for signs and symptoms of hypox-
piratory depression, and laryngospasm, pos- ia, airway obstruction, and cardiovascular
sibly leading to hypoxia and respiratory depression.
◆ Doesn’t provide muscle relaxation and
produces little analgesia
◆ May cause cardiovascular depression, es-
pecially in hypovolemic or debilitated pa-
tients
◆ May cause irritation when injected into a ◆ Monitor the patient’s vital signs, respira-
peripheral vein tory rate, and volume.
◆ Has a long elimination half-life
◆ Can cause respiratory depression ◆ Monitor the patient’s vital signs, especial-
ly respiratory rate and volume.
(continued)
Reviewing common general anesthetics (continued)
I.V. nonbarbiturates
propofol ◆ Used for induction ◆ Allows for rapid, smooth induction
Diprivan and maintenance of ◆ Permits rapid awakening and recovery
anesthesia; particularly ◆ Causes less vomiting than other anesthetics
useful for short proce-
dures and outpatient
surgery
ketamine ◆ Produces a dissocia- ◆ Produces rapid anesthesia and profound

hydrochloride tive state of conscious- analgesia
Ketalar ness; induces anesthesia ◆ Doesn’t irritate the veins or tissues
when a barbiturate is ◆ Maintains a patent airway without endotra-
contraindicated; sole cheal intubation because it suppresses laryn-
anesthetic agent for geal and pharyngeal reflexes
short diagnostic and
surgical procedures that
don’t require relaxation
of the skeletal muscles
I.V. tranquilizers
droperidol ◆ Used preoperatively ◆ Allows for rapid, smooth induction and
Inapsine and during induction recovery
and maintenance of ◆ Produces sleepiness and mental detach-
anesthesia as an adjunct ment for several hours
to general or regional
anesthesia
Opioids
fentanyl ◆ Used preoperatively ◆ Promotes rapid, smooth induction and re-
citrate for minor and major covery
Sublimaze surgery, urologic proce- ◆ Doesn’t cause histamine release
dures, and gastroscopy; ◆ Minimally affects the cardiovascular system
also used as an adjunct ◆ Can be reversed by a opioid antagonist
to regional anesthesia (naloxone)
and to induce and main-
tain general anesthesia
◆ Can cause hypotension ◆ Monitor the patient for hypotension.

◆ Can cause pain if injected into small veins ◆ Prepare the patient for rapid emergence.
◆ May cause clonic or myoclonic movements
on emergence
◆ May interact with benzodiazepines, in-
creasing the effects of propofol
◆ Doesn’t cause profound analgesia
◆ May cause unpleasant dreams, hallucina- ◆ Protect the patient from visual, tactile,
tions, and delirium during recovery and auditory stimuli during recovery.
◆ Increases heart rate, blood pressure, and ◆ Monitor the patient’s vital signs.
intraocular pressure
◆ Preserves muscle tone, leading to poor re-
laxation during surgery
◆ May cause hypotension because it’s a pe- ◆ Monitor the patient for increased pulse
ripheral vasodilator rate, hypotension, and prolonged QT inter-
◆ Contraindicated in patients with known or val.
suspected prolonged QT interval
◆ May cause respiratory depression, eupho- ◆ Observe the patient for respiratory de-
ria, bradycardia, bronchoconstriction, nausea, pression.
vomiting, and miosis ◆ Watch for nausea and vomiting. If vomit-
◆ May cause rigidity of the skeletal muscles ing occurs, position the patient to prevent
and chest wall aspiration.
◆ Monitor the patient’s blood pressure.
◆ Decrease postoperative opioids to one-
third or one-fourth the usual dose.
Reviewing common neuromuscular blockers
DRUG ADVERSE EFFECTS SPECIAL CONSIDERATIONS
Nondepolarizing neuromuscular blockers

atracurium ◆ Slight hypotension ◆ Acts for 20 to 30 minutes
besylate in a few patients ◆ May cause slight histamine release
◆ Doesn’t accumulate with repeated doses
◆ Is useful for a patient with underlying
hepatic, renal, or cardiac disease
pancuronium ◆ Tachycardia ◆ Acts for 35 to 45 minutes

bromide ◆ Transient rash and a ◆ Is five times more potent than curare
burning sensation at ◆ Doesn’t cause ganglion blockage, so it
the injection site usually doesn’t lead to hypotension
◆ Has a vagolytic action that increases
heart rate
vecuronium ◆ Minimal and tran- ◆ Acts for 25 to 40 minutes

bromide sient cardiovascular ef- ◆ Is probably metabolized mostly in the
fects liver
◆ Weakness or paraly- ◆ Has a short duration of action and caus-
sis of the skeletal mus- es fewer cardiovascular effects than other
cles; respiratory insuffi- nondepolarizing neuromuscular blockers
ciency; respiratory
paralysis; prolonged,
dose-related apnea
Depolarizing neuromuscular blockers

succinylcholine ◆ Respiratory depres- ◆ Acts for 5 to 10 minutes
chloride sion ◆ Is metabolized mostly in the plasma by
Anectine, ◆ Bradycardia pseudocholinesterase; therefore, it’s con-
Quelicin ◆ Excessive salivation traindicated in the patient with a deficiency
◆ Hypotension of plasma cholinesterase as a result of a
◆ Arrhythmias genetic variant defect, liver disease, ure-
◆ Tachycardia mia, or malnutrition
◆ Hypertension ◆ Is used cautiously in patients with glau-
◆ Increased intraocu- coma or penetrating wounds of the eye;
lar and intragastric those undergoing eye surgery; those with
pressure burns, severe trauma, spinal cord injuries,
◆ Fasciculations or muscular dystrophy; and those with car-
◆ Muscle pain diovascular, hepatic, pulmonary, metabolic,
◆ Malignant hyper- or renal disorders; may cause sudden hy-
thermia perkalemia and consequent cardiac arrest
◆ Can cause pregnant patients who also
receive magnesium sulfate to experience
increased neuromuscular blockade because
of decreased pseudocholinesterase levels
◆ Monitor the patient’s postoperative

Postoperative care pulse rate, which should be within
20% of the preoperative rate.
Monitoring the postoperative ◆ Compare the patient’s postoperative
patient blood pressure with his preoperative
blood pressure. It should be within
The goal of monitoring the postopera- 20% of the preoperative level unless
tive patient is to minimize complica- the patient had a hypotensive episode
tions through early detection and during surgery.
prompt treatment. (See Postoperative ◆ Assess the patient’s ability to wiggle
care for the bariatric surgery patient, his toes. Assess the level of sensation if
pages 422 and 423.) he received spinal anesthesia.
◆ Assess the patient’s body tempera-
Equipment ture. If it’s lower than 95.6º F
Thermometer ◆ watch with a second (35.3º C), apply blankets and notify
hand ◆ stethoscope ◆ sphygmo- the physician. Lowered body tempera-
manometer or automated blood pres- ture causes shivering, which increases
sure machine ◆ postoperative flow- the body’s consumption of oxygen and
chart or other documentation tool may strain the heart’s normal function.
◆ Assess the patient’s infusion sites
Implementation for redness, pain, swelling, and
◆ Obtain the patient’s record from the drainage.
nurse in the postanesthesia care unit ◆ Assess the surgical wound dress-
(PACU). ings. If they’re soiled, assess the
◆ Transfer the patient from the PACU drainage and outline the soiled area.
stretcher to the bed. Position him Note the date and time of assessment
properly. Keep transfer movements on the dressing. Check the soiled area
smooth to minimize pain and compli- often; if it enlarges, reinforce the dress-
cations. ing and alert the physician.
◆ If the patient has had orthopedic ◆ Note the presence and condition of
surgery, have a coworker move the af- drains and tubes. Note the color, type,
fected extremity as you transfer the pa- odor, and amount of drainage as well
tient. as any sediment. Make sure that all
◆ If the patient is in skeletal traction, drains are properly connected and free
have a coworker move the weights as from kinks and obstructions.
you and another coworker transfer the ◆ If the patient had vascular or ortho-
patient. pedic surgery, assess the appropriate
◆ Ensure the patient’s comfort and extremities. Notify the physician of ab-
raise the side rails of the bed to ensure normalities. Make sure that any special
his safety. positioning requirements, such as no
◆ Assess the patient’s level of con- hip adduction, are clearly posted for all
sciousness. patient caregivers to see.
◆ Monitor the patient’s respiratory ◆ As the patient recovers from anes-
status by assessing his airway. Note his thesia, monitor his respiratory and car-
breathing rate and depth; auscultate diovascular status closely. Watch for
breath sounds. If ordered, administer airway obstruction and hypoventilation
oxygen and initiate oximetry. caused by laryngospasm. Also watch
Postoperative care for the bariatric surgery patient
Postoperative care plays a crucial role in Respiratory care

recovery from bariatric surgery. Follow- In the morbidly obese patient, abdominal
ing surgery, the patient is typically adipose tissue raises the diaphragm,
transferred to a medical-surgical unit. which prevents its full movement when
Once there, the patient typically needs the patient breathes and leads to the col-
extra attention because obesity leaves lapse of the alveoli in the base of the
little reserve to cope with postoperative lungs. This decrease in lung movement
complications. Specialized materials that leads to the retention of carbon dioxide.
may be needed for such care include As a result, the patient may feel sleepy,
bariatric equipment and transfer aid de- become apneic for short periods, and de-
vices, larger gowns, extra-large blood velop hypoxemia. Anesthetics during
pressure cuffs, appropriately sized bed surgery and pain medication postopera-
and support surfaces, and floor-mount- tively may worsen these conditions, mak-
ed toilets. ing postoperative respiratory care even
Postoperative care focuses on prevent- more important.
ing cardiovascular complications, particu- Postoperative measures to prevent
larly venous thromboembolism; providing such respiratory complications as atelec-
respiratory care; meeting nutritional and tasis or pneumonia include:
hydration needs; and caring for the pa- ◆ elevating the head of the bed to 30 to
tient’s skin. 45 degrees
◆ promoting coughing and deep-breath-
Cardiovascular care ing exercises
Because obesity increases intra-abdomi- ◆ providing incentive spirometry as or-
nal pressure, the patient recovering from dered
bariatric surgery is at increased risk for ◆ encouraging early ambulation
venous thromboembolism; anesthesia ◆ using continuous positive airway pres-
during surgery may add to that risk by sure or bilevel positive airway pressure
further increasing abdominal pressure. (for the patient with a history of sleep ap-
Other factors that increase the risk in- nea who uses one of these interventions
clude immobility after surgery and ve- at home).
nous stasis.
Postoperative care can help prevent Nutrition and hydration
the development of a pulmonary embo- Before receiving any fluids or food post-
lus—a life-threatening postoperative operatively, the bariatric surgery patient
complication—and deep venous throm- must undergo a limited upper GI X-ray to
boembolus of the lower extremities. If the look for any anastomotic leak or obstruc-
patient is at particular risk, he may also tion. If the test is negative, the patient can
have an inferior vena cava filter placed begin drinking water and advance to a
before surgery. liquid or pureed diet for the first 2 weeks
Specific postoperative measures in- after surgery. He can progress to soft
clude: foods 1 month after surgery, and after 6
◆ early ambulation months, he can begin to eat foods of nor-
◆ use of sequential compression devices mal texture. For the first 3 to 6 months,
◆ use of compression stockings the patient must eat at specified times be-
◆ prophylaxis with anticoagulants. cause he won’t feel hungry.
Postoperative care for the bariatric surgery patient (continued)
The main goal at each of these stages hydration. If he can’t maintain adequate
is to take in sufficient protein. Once the hydration on his own after discharge, he
patient can tolerate 3 to 4 oz (85 to may need to go to an outpatient clinic to
113 g) of protein-rich foods at a meal, he receive I.V. fluids.
should add fruits and vegetables to his
diet. The dietary goal is a minimum of Skin care
60 g (2 oz) of protein daily. The obese patient has many skin folds,
Because the gastric pouch is swollen which can harbor moisture and microor-
and stiff for the first month after ganisms. As a result, the patient recovering
surgery, the patient can drink only small from bariatric surgery is at higher risk for
sips of liquid, increasing the risk of de- skin breakdown. The poor blood supply to
hydration. The patient may only be able adipose tissue may also lead to poor
to drink an average of 1 oz (29 ml) of wound healing.
liquid over 15 minutes. This restriction Preventive measures include:
may make it physically impossible for ◆ inspecting the skin every 8 hours (more
the patient to meet the goal of 64 oz frequently if needed), with special attention
(2 L) of liquid daily. paid to areas of increased pressure and
Nausea, an early sign of dehydra- skin folds
tion, may cause the patient to drink ◆ frequent turning (at least every 2 hours)
even less, further complicating the situ- ◆ early ambulation
ation. To combat this, the patient ◆ positioning of catheters and drainage
should be encouraged to “drink tubes so that they don’t become trapped in
through” the nausea. If he can do that, skin folds
the nausea should subside and he may ◆ not using powders.
be able to drink enough to prevent de-
for sedation, which can lead to hypox- status closely. The respiratory rate
emia. and quality, along with oxygen satu-
◆ Encourage coughing and deep- ration levels, should be assessed
breathing exercises, unless the patient every hour for at least the first 24
had nasal, ophthalmic, or neurologic hours.
surgery.
◆ Administer postoperative medica- Preventing postoperative
tions, as ordered. complications
◆ Remove all fluids from the patient’s
bedside until he’s alert enough to eat After surgery, take these steps to avoid
and drink. Before giving liquids, assess complications.
his gag reflex.
Turn and reposition the patient
Special considerations Turning and repositioning the patient
◆ If the patient had epidural anesthe- every 2 hours promotes circulation,
sia or a postoperative continuous epi- thereby reducing the risk of skin
dural opioid, monitor his respiratory breakdown, especially over bony
prominences. When the patient is in a Promote exercise and ambulation

lateral recumbent position, tuck pillows Early postoperative exercise and ambu-
under bony prominences to reduce fric- lation can significantly reduce the risk
tion and promote comfort. Each time of thromboembolism and improve ven-
you turn him, inspect the skin carefully tilation. To encourage compliance, as-
to detect redness or other signs of break- sess the patient’s pain level before
down. these activities and administer anal-
Turning and repositioning may be gesics, as ordered.
contraindicated in some cases, such as Perform passive range-of-motion ex-
the patient who underwent neurologic ercises to prevent joint contractures
or musculoskeletal surgery that re- and muscle atrophy and promote circu-
quires postoperative immobilization. lation. These exercises can also help
you to assess the patient’s strength and
Encourage coughing and deep tolerance.
breathing Before encouraging ambulation, ask
Deep breathing promotes lung expan- the patient to dangle his legs over the
sion, which helps to clear anesthetics side of the bed and perform deep-
from the body. Coughing and deep breathing exercises. How well a patient
breathing also lower the risk of pulmo- tolerates this step is commonly a key
nary and fat emboli and of hypostatic predictor of out-of-bed tolerance.
pneumonia associated with the buildup Begin ambulation by helping the
of secretions in the airways. patient to walk a few feet from his
Encourage the patient to perform bed to a sturdy chair. Then have him
deep-breathing exercises at least every gradually progress each day from am-
2 hours and also to cough. Show the bulating in his room to ambulating in
patient how to splint his incision with the hallway, with or without assis-
his hands or a pillow to reduce pain. tance, as necessary. Document the fre-
Also show him how to use an incen- quency of ambulation and the pa-
tive spirometer. Because deep breath- tient’s tolerance, including the use of
ing doesn’t increase intracranial pres- an analgesic.
sure, it’s safe to do after most neuro-
surgical procedures. Managing postoperative
complications
Monitor nutrition and fluids
Adequate nutrition and fluid intake are Despite your best efforts, complications
essential to ensure proper hydration, can occur. By knowing how to recog-
promote healing, and provide the ener- nize and manage them, you can limit
gy needed to accommodate the in- their effects.
creased basal metabolism associated The following is a list of complica-
with surgery. If the patient has a pro- tions. Some complications are more
tein deficiency or compromised im- likely to produce acute changes,
mune function preoperatively, expect whereas others produce symptoms
to deliver supplemental protein by par- slowly. Also, some complications occur
enteral nutrition to promote healing. If in the immediate postoperative period,
he has renal failure, this treatment is and others are more prominent 2 or
contraindicated because his inability to 3 days after surgery.
break down protein could lead to dan-
gerously high blood nitrogen levels.
Abdominal distention, paralytic Atelectasis and pneumonia

ileus, and constipation After surgery, atelectasis may occur as
Sluggish peristalsis and paralytic ileus a result of hypoventilation and exces-
usually last for 24 to 72 hours after sive retained secretions. This provides
surgery and cause abdominal disten- a medium for bacterial growth and sets
tion. Paralytic ileus occurs whenever the stage for stasis pneumonia.
autonomic innervation of the GI tract
is disrupted. Causes include intraop- Assessment
erative manipulation of the intestinal ◆ To detect atelectasis, auscultate for
organs, hypokalemia, wound infec- diminished or absent breath sounds
tion, and the use of codeine, mor- over the affected area and note dull-
phine, or atropine. Postoperative con- ness on percussion.
stipation usually stems from colonic ◆ Assess the patient for decreased
ileus caused by diminished GI motili- chest expansion, mediastinal shift to-
ty and impaired perception of rectal ward the side of collapse, fever, rest-
fullness. lessness or confusion, worsening dys-
pnea, and elevated blood pressure,
Assessment pulse rate, and respiratory rate.
◆ To detect abdominal distention, ◆ To detect pneumonia, watch for
monitor the patient’s abdominal girth sudden onset of shaking chills with
and ask him if he feels bloated. high fever and headache.
◆ To assess the patient for paralytic ◆ Auscultate for diminished breath
ileus, auscultate for bowel sounds in sounds or for telltale crackles over the
all four quadrants. Notify the physi- affected area of the lung.
cian of decreased or absent bowel ◆ Assess the patient for dyspnea,
sounds. tachypnea, sharp chest pain exacerbat-
◆ Monitor abdominal distention and ed by inspiration, productive cough
the passage of flatus or stool. with pinkish or rust-colored sputum,
◆ Ask the patient about feelings of and cyanosis with hypoxemia that’s
nausea or abdominal fullness. confirmed by arterial blood gas mea-
surement.
Interventions ◆ Chest X-rays show patchy infiltrates
◆ To treat abdominal distention, en- or areas of consolidation.
courage ambulation and give nothing
by mouth until bowel sounds return. Interventions
◆ Insert a rectal or nasogastric (NG) ◆ Encourage the patient to perform
tube, as ordered. Keep the NG tube deep-breathing exercises and cough
patent and functioning properly. every hour while he’s awake.
◆ To treat paralytic ileus, encourage Alert Coughing is contra-
ambulation and administer medica- indicated in the patient who
tions, as ordered. If it doesn’t resolve underwent neurosurgery or eye
within 24 to 48 hours, insert an NG surgery.
tube, as ordered. Keep the NG tube ◆ Demonstrate how to use an incen-
patent and functioning properly. tive spirometer.
◆ To treat constipation, encourage am- ◆ As ordered, perform chest physio-
bulation and administer a stool soften- therapy, give an antibiotic, and admin-
er, laxative, or nonnarcotic analgesic, ister humidified air or oxygen.
as ordered. ◆ Reposition the patient every 2
hours. Elevate the head of the bed.
Hypovolemia sits up and leans forward. You also

A total blood volume loss of 15% to may hear a pericardial friction rub.
25% may result from blood loss and
severe dehydration, third-space fluid Interventions
sequestration (as in burns, peritonitis, ◆ Keep the patient on complete bed
intestinal obstruction, or acute pancre- rest in an upright position.
atitis), and fluid loss (as in excessive ◆ Provide an analgesic and oxygen, as
vomiting or diarrhea). ordered.
◆ Assess the patient’s pain in relation
Assessment to respiration and body position to dis-
◆ Check for hypotension and a rapid, tinguish pericardial pain from pain re-
weak pulse. lated to myocardial ischemia.
◆ Note cool, clammy and, perhaps, ◆ Monitor the patient for signs of car-
mottled skin. diac compression or cardiac tampon-
◆ Check for rapid, shallow respira- ade. Signs include decreased blood
tions. pressure, increased central venous
◆ Assess the patient for oliguria or pressure, and paradoxical pulse. Be-
anuria and lethargy. cause cardiac tamponade requires im-
mediate treatment, keep a pericardio-
Interventions centesis set at the patient’s bedside
◆ To increase blood pressure, adminis- whenever pericardial effusion is sus-
ter an I.V. crystalloid, such as normal pected.
saline solution or lactated Ringer’s
solution. Postoperative psychosis
◆ To restore urine output and fluid Mental aberrations typically stem from
volume, give a colloid, such as plasma, physiologic causes (cerebral anoxia,
albumin, or dextran. fluid and electrolyte imbalance, malnu-
trition, and such drugs as tranquilizers,
Pericarditis sedatives, and opioids). However, psy-
Pericarditis is an acute or chronic in- chological causes (fear, pain, and dis-
flammation of the pericardium — the fi- orientation) can also contribute.
broserous sac that envelops, supports,
and protects the heart. After surgery, Assessment
pericarditis may result from bacterial, ◆ Assess the patient’s mental status
fungal, or viral infection or from post- and compare it with the preoperative
cardiac injury that leaves the pericardi- baseline.
um intact but causes blood to leak into
the pericardial cavity. Interventions
◆ Reorient the patient frequently to
Assessment time, place, and person. Call him by
◆ To detect pericarditis, assess the pa- his preferred name and encourage him
tient for sharp, sudden pain that starts to move about.
over the sternum and radiates to the ◆ Provide clean eyeglasses and a
neck, shoulders, back, and arms. working hearing aid, if appropriate.
◆ Ask the patient to take a deep Use sedatives and restraints only if
breath and then to sit up and lean for- needed.
ward. Pericardial pain is commonly
pleuritic, increasing with deep inspira-
tion and decreasing when the patient
Septicemia and septic shock Thrombophlebitis and pulmonary

Septicemia may stem from a break in embolism
asepsis during surgery or wound care Postoperative venous stasis associated
or from peritonitis (as in ruptured ap- with immobility may lead to throm-
pendix or ectopic pregnancy). The bophlebitis — an inflammation of a
most common cause of postoperative vein, usually in the leg, accompanied
septicemia is Escherichia coli. Septic by formation of a clot. If a clot breaks
shock occurs when bacteria release en- away, it may become lodged in the
dotoxins into the bloodstream, decreas- lung, causing a pulmonary embolism.
ing vascular resistance and causing
dramatic hypotension. Assessment
◆ To detect thrombophlebitis, ask the
Assessment high-risk patient about leg pain, func-
◆ To detect septicemia, check for tional impairment, and edema.
fever, chills, rash, abdominal disten- ◆ Inspect the patient’s legs from feet
tion, prostration, pain, headache, nau- to groin and record calf circumference.
sea, and diarrhea. Note engorgement of the cavity be-
◆ Early indicators of septic shock in- hind the medial malleolus and in-
clude fever and chills; warm, dry, creased temperature in the affected
flushed skin; slightly altered mental leg. Identify areas of cordlike venous
status; increased pulse and respiratory segments.
rates; decreased or normal blood pres- ◆ To detect a pulmonary embolism,
sure; and reduced urine output. assess the patient for sudden anginal
◆ Late indicators include pale, moist, or pleuritic chest pain; dyspnea;
cold skin as well as decreased mental rapid, shallow respirations; cyanosis;
status, pulse and respiratory rates, restlessness; and possibly a thready
blood pressure, and urine output. pulse.
◆ Auscultate for fine to coarse crack-
Interventions les over the affected lung.
◆ To treat septicemia, obtain a urine
specimen and blood and wound sam- Interventions
ples for culture and sensitivity tests. ◆ To treat thrombophlebitis, elevate
◆ Administer an antibiotic, if ordered. the affected leg and apply warm com-
◆ Monitor the patient’s vital signs and presses.
level of consciousness. ◆ Administer medications, as ordered.
◆ To treat septic shock, administer an ◆ Monitor laboratory values, such as
I.V. antibiotic, if ordered. prothrombin and partial thromboplas-
◆ Monitor serum peak and trough lev- tin times, daily.
els. ◆ To treat a pulmonary embolism, ad-
◆ Give I.V. fluids and blood or blood minister oxygen and medications, as
products to restore circulating blood ordered. Elevate the head of the bed.
volume.
Alert Keep in mind that Urine retention
prompt identification and inter- The patient may not be able to void
vention is the key to helping the pa- spontaneously within 12 hours after
tient survive septicemia and septic surgery. Urine retention is usually tran-
shock. sient and reversible.
Assessment Caring for surgical wounds

◆ Monitor the patient’s intake and
output. Proper care of surgical wounds helps to
◆ Assess the patient for bladder dis- prevent infection, protects the skin
tention above the level of the symph- from maceration and excoriation, al-
ysis pubis as well as for discomfort and lows removal and measurement of
pain. Note restlessness, anxiety, di- wound drainage, and promotes patient
aphoresis, and hypertension. comfort. When a surgical incision is
closed primarily, it’s covered with a
Interventions sterile dressing for 24 to 48 hours. Af-
◆ To treat urine retention, help the pa- ter 48 hours, the incision can be cov-
tient to ambulate as soon as possible ered by a dressing or left open to air.
after surgery, unless contraindicated. Managing a draining wound in-
◆ Assist the patient to a normal void- volves two techniques: dressing and
ing position and, if possible, leave him pouching. Dressing is indicated when
alone. drainage doesn’t compromise the in-
◆ Turn the water on so that the pa- tegrity of the skin. Lightly seeping
tient can hear it, and pour warm water wounds with drains and wounds with
over his perineum. minimal purulent drainage can usually
◆ If these interventions aren’t success- be managed with packing and gauze
ful, prepare the patient for urinary dressings. Surgical incisions that are
catheterization. left open at the skin level for a few
days before closure by the physician
Wound infection (delayed primary closure) are managed
The most common wound complica- by packing with a sterile dressing. Inci-
tion, wound infection is also a major sions that are left open to heal by pri-
factor in wound dehiscence. Complete mary intention are packed with sterile
dehiscence leads to evisceration. moist gauze and covered with a sterile
dressing.
Assessment Wounds that drain more than 100
◆ To detect infection, assess surgical ml in 24 hours and those with excoriat-
wounds for increased tenderness, deep ing drainage require pouching.
pain, and edema, especially from the
third to the fifth day after the operation. Equipment and preparation
◆ Monitor the patient for increased Waterproof trash bag or trash can ◆
pulse rate and temperature and an ele- clean gloves ◆ sterile gloves ◆ gown,
vated white blood cell count. if indicated ◆ sterile 4⬙ ⫻ 4⬙ gauze
◆ Note a temperature pattern of pads ◆ abdominal bandage dressing
spikes in the afternoon or evening, pads, if needed ◆ sterile cotton-tipped
with a return to normal by morning. applicators ◆ topical medication or
ointment, if ordered ◆ prescribed
Interventions cleaning agent, if ordered ◆ sterile
◆ As ordered, obtain a wound culture container ◆ adhesive or other tape ◆
and sensitivity test, administer antibi- soap and water ◆ optional: skin pro-
otics, and irrigate the wound with an tectant, acetone-free adhesive remover
appropriate solution, if ordered. or baby oil, sterile normal saline solu-
◆ Monitor wound drainage.
tion, a graduated container, and Mont- ◆ If ordered, obtain a wound culture.

gomery straps or a T-binder
Caring for the wound or incision
For a wound with a drain ◆ Establish a sterile field for equip-
Precut sterile 4⬙ ⫻ 4⬙ gauze pads ◆ ad- ment and supplies. Squeeze the needed
hesive tape amount of ordered ointment onto the
sterile field. Pour the ordered cleaning
For pouching agent into a sterile container. Put on
Pouch with or without a drainage port sterile gloves.
◆ skin protectant ◆ sterile gauze pad ◆ If you aren’t using prepackaged
Determine the type of dressing swabs, saturate sterile gauze pads with
needed and assemble all equipment in the prescribed cleaning agent. Avoid
the patient’s room. Check the expira- using cotton balls because they may
tion date on each sterile package and shed particles in the wound.
inspect the package for tears. Place the ◆ Squeeze excess solution from the
trash bag or trash can so that you can pad or swab. Wipe once from the top
avoid carrying articles across the sterile to the bottom of the incision; then dis-
field or the wound when disposing of card the pad or swab. With a second
them. pad, wipe from top to bottom in a ver-
tical path next to the incision; then dis-
Implementation card the pad.
◆ Check the physician’s order for ◆ Continue to work outward from the
wound care instructions. Some physi- incision in lines running parallel to it.
cians prefer to not use cleaning agents Always wipe from the clean area to-
on surgical incisions unless the area is ward the less-clean area. Use each pad
soiled. or swab for only one stroke. Use sterile
◆ Note the location of drains to avoid cotton-tipped applicators to clean tight-
dislodging them during the procedure. fitting wire sutures, deep wounds, or
◆ Explain the procedure to the patient wounds with pockets.
and position him properly. Expose only ◆ If the patient has a surgical drain,
the wound site. clean the surface of the drain last.
◆ Wash your hands. Put on a gown, if Clean the surrounding skin by wiping
necessary, and clean gloves. in half or full circles from the drain site
outward.
Removing the old dressing ◆ Clean to at least 1⬙ (2.5 cm) beyond
◆ Hold the skin and pull the tape or the new dressing or 2⬙ (5 cm) beyond
dressing toward the wound. This pro- the incision.
tects newly formed tissue. Use acetone- ◆ Check for signs of infection, dehis-
free adhesive remover or baby oil, if cence, or evisceration. If you observe
needed. Don’t apply solvents to the in- such signs or if the patient reports
cision. pain, notify the physician.
◆ Remove the soiled dressing. If need- ◆ Wash the surrounding skin with
ed, loosen gauze with sterile normal soap and water, and pat dry. Apply
saline solution. prescribed topical medication and a
◆ Check the dressing to determine the skin protectant, if warranted.
amount, type, color, and odor of ◆ Pack an open wound with sterile
drainage. Discard the dressing and moist gauze using the wet-to-damp
gloves in the waterproof trash bag.
method. Avoid using cotton-lined ◆ To empty the pouch, put on gloves,

gauze pads. insert the bottom half of the pouch
into a graduated container, and open
Apply a fresh gauze dressing the drainage port. Note the color, con-
◆ Place a sterile 4⬙ ⫻ 4⬙ gauze pad at sistency, odor, and amount of fluid.
the center of the wound, and move the ◆ Wipe the bottom of the pouch and
pad outward to the edges of the wound the drainage port with a sterile gauze
site. Extend the gauze at least 1⬙ be- pad and reseal the port. Change the
yond the incision in each direction. pouch if it leaks or comes loose.
Use enough sterile dressings to absorb
all of the drainage until the next dress- Special considerations
ing change. ◆ Because many physicians prefer to
◆ When the dressing is in place, re- change the first postoperative dressing,
move and discard the gloves. Secure avoid changing it unless ordered. If
the dressing with strips of tape, a you have no such order and drainage is
T-binder, or Montgomery straps. seeping through the dressing, reinforce
◆ For a patient who recently under- the dressing with fresh sterile gauze.
went surgery or a patient with compli- To prevent bacterial growth, don’t
cations, check the dressing every 30 leave a reinforced dressing in place for
minutes or as ordered. If the wound is longer than 24 hours. Immediately re-
healing properly, check it at least every place a dressing that becomes wet from
8 hours. the outside.
◆ Consider all dressings and drains in-
Dressing a wound with a drain fectious.
◆ Use a precut sterile 4⬙ ⫻ 4⬙ gauze ◆ If the patient has two wounds in
pad. the same area, cover each separately
◆ Place the pad close to the skin with layers of sterile 4⬙ ⫻ 4⬙ gauze
around the drain so that the tubing fits pads. Then cover both sites with an
into the slit. Press a second pad around abdominal bandage dressing pad se-
the drain from the opposite direction to cured to the skin with tape.
encircle the tubing.
◆ Layer as many uncut sterile pads Draining closed wounds
around the tubing as needed to absorb
the drainage. Secure the dressing with Inserted during surgery, a closed-
tape, a T-binder, or Montgomery straps. wound drain promotes healing and
prevents swelling by suctioning
Pouching a wound serosanguineous fluid at the wound
◆ To create a pouch, measure the site. By removing this fluid, the drain
wound and cut an opening in the fac- helps to reduce the risk of infection
ing of the collection pouch that is 1⁄8⬙ and skin breakdown and the number
(0.3 cm) larger than the wound. of dressing changes.
◆ Make sure that the surrounding skin A closed-wound drain consists of
is clean and dry. Apply a skin protec- perforated tubing connected to a
tant. portable vacuum unit. The distal end
◆ Make sure that the drainage port at of the tubing lies within the wound
the bottom of the pouch is closed. and usually leaves the body from a site
Press the contoured pouch opening other than the primary suture line, to
around the wound, beginning at its preserve the integrity of the surgical
lower edge.
wound. The tubing exit site is treated Patient teaching tips If you
as an additional surgical wound; the anticipate that the patient will
drain is usually sutured to the skin. be discharged with the drain, teach
The drain may be left in place for the patient how to empty and recon-
longer than 1 week to accommodate stitute the drain at each session.
heavy drainage. ◆ Secure the vacuum unit to the pa-
tient’s bedding or, if he’s ambulatory,
Equipment to his gown. Fasten it below the level
Graduated cylinder ◆ sterile laboratory of the wound to promote drainage. To
container, if needed ◆ alcohol pad ◆ prevent possible dislodgment, don’t ap-
sterile gloves ◆ clean gloves ◆ sterile ply tension on the drainage tubing. Re-
gauze pads ◆ antiseptic cleaning agent move and discard gloves and wash
◆ prepackaged antimicrobial swabs your hands thoroughly.
◆ waterproof trash bag or trash can ◆ Put on the sterile gloves. Check for
signs of pulling or tearing of the su-
Implementation tures and for swelling or infection of
◆ Check the physician’s order and as- the surrounding skin. Gently clean the
sess the patient’s condition. Explain sutures with an antimicrobial swab or
the procedure to the patient. Provide with sterile gauze pads soaked in an
privacy. Wash your hands and put on antiseptic cleaning agent.
clean gloves. ◆ Properly dispose of drainage, solu-
◆ Unclip the vacuum unit. Using tions, and the waterproof trash bag and
aseptic technique, remove the spout clean or dispose of soiled equipment
plug to release the vacuum. and supplies.
◆ Empty the contents of the unit into
a graduated cylinder. Note the amount Special considerations
and appearance of the drainage. If or- ◆ Empty the system and measure the
dered, empty the drainage into a sterile contents once during each shift if
laboratory container and send it to the drainage has accumulated; do so more
laboratory for diagnostic testing. often if drainage is excessive.
◆ Maintaining aseptic technique, ◆ If the patient has more than one
clean the spout and plug it with an closed drain, number the drains so that
alcohol pad. you can record the amount of drainage
◆ To reestablish the vacuum that cre- from each site.
ates the suction power of the drain, Alert Don’t mistake chest
fully compress the vacuum unit. Keep tubes for closed-wound drains.
the unit compressed as you replace the The vacuum of a chest tube should
spout plug. never be released.
◆ Check the patency of the equip-
ment. Make sure that the tubing has Managing dehiscence and
no twists, kinks, or leaks. The drainage evisceration
system must be airtight to work prop-
erly. Keep the vacuum unit compressed Occasionally, the edges of a wound
when you release manual pressure; may not join, or they may separate af-
rapid reinflation indicates an air leak. ter they seem to be healing normally.
If this occurs, recompress the unit and This abnormality, called wound dehis-
secure the spout plug. cence, may lead to a more serious
complication known as evisceration, in may cause a protruding organ to be-

which a portion of the viscera pro- come ischemic and necrotic.
trudes through the incision. In turn, ◆ Keep the patient on strict bed rest
this can lead to peritonitis and septic in low Fowler’s position (elevated no
shock. more than 20 degrees), with his knees
flexed.
Equipment ◆ Monitor the patient’s vital signs
Two sterile towels ◆ 1 L of sterile nor- every 15 minutes to detect shock. Pre-
mal saline solution ◆ sterile irrigation pare him to return to the operating
set, including a basin, a solution con- room.
tainer, and a 50-ml catheter-tip syringe ◆ Prepare for insertion of an NG tube
◆ several large abdominal dressings ◆ and an I.V. line, if ordered. Connect the
sterile waterproof drape ◆ linen-saver NG tube to the suction apparatus. NG
pads ◆ sterile gloves intubation may make the patient gag,
causing further evisceration. For this
For the patient who will return to reason, the tube may be inserted in the
the operating room operating room.
I.V. administration set and I.V. fluids ◆ ◆ Administer a preoperative sedative,
nasogastric (NG) intubation equipment as ordered.
◆ sedative, as ordered ◆ suction appa-
ratus Special considerations
◆ To help prevent dehiscence and
Implementation evisceration, inspect the incision with
◆ Tell the patient to stay in bed. If each dressing change.
possible, stay with him while someone Patient teaching tips By the
else notifies the physician and collects fifth to the ninth postoperative
the equipment. day, teach the patient to feel for a
◆ Place a linen-saver pad under the healing ridge, which forms directly
patient and create a sterile field. Place under the suture line. The lack of a
the basin, solution container, and 50- healing ridge may indicate that the pa-
ml syringe on the sterile field. tient is at risk for dehiscence and evis-
◆ Open the bottle of sterile normal ceration.
saline solution and pour 400 ml into ◆ Treat early signs of infection imme-
the solution container and 200 ml into diately. Make sure that the bandages
the basin. aren’t so tight that they limit the blood
◆ Place several large abdominal dress- supply to the wound.
ings on the sterile field. Wearing sterile ◆ If the patient has weak abdominal
gloves, place one or two dressings into walls, apply an abdominal binder. En-
the basin. courage a high-risk patient to splint his
◆ Place the moistened dressings over abdomen with a pillow during strain-
the exposed viscera. Cover with sterile ing, coughing, or sneezing.
towels and a sterile waterproof drape. ◆ If a postoperative patient detects a
◆ Keep the dressings moist by gently sudden gush of pinkish serous drain-
moistening them with the saline solu- age on his wound dressing, inspect the
tion frequently. If the viscera appear incision for dehiscence. If the wound
dusky or black, notify the physician seems to be separating slowly and evis-
immediately. Interrupted blood supply
ceration hasn’t developed, place the Activity

patient in a supine position and call After surgery, the patient may be ad-
the physician. vised not to lift heavy objects. Restric-
tions usually last 4 to 6 weeks after
Planning for discharge surgery. Discuss how these limitations
will affect his daily routine. Let him
Begin planning for discharge during know when he can return to work,
your first contact with the patient. The drive, and resume sexual activity. If the
initial nursing history and preoperative patient seems unlikely to comply, dis-
assessment as well as subsequent as- cuss compromises.
sessments can provide useful informa-
tion. Home care procedures
Recognizing potential problems early Use nontechnical language and include
will help your discharge plan to suc- caregivers when teaching about home
ceed. Assess the strengths and limita- care. After the patient watches you
tions of the patient and his family. demonstrate a procedure, have him
Consider physiologic factors (such as repeat the demonstration.
the patient’s general physical and func- Explain to the patient that he may
tional abilities, current medications, not need to use the same equipment
and general nutritional status), psycho- that he used in the facility; discuss
logical factors (such as self-concept, what’s available to him at home. If the
motivation, and learning abilities), and patient needs to rent or purchase
social factors (such as the duration of equipment, such as a hospital bed or
care needed, the types of services walker, arrange for delivery before
available, and the family’s involvement discharge.
in the patient’s care).
Wound care
Medication Teach the patient how to change his
Explain the purpose of the drug thera- wound dressing. Tell him to keep the
py, the duration of the regimen, the incision clean and dry, and teach prop-
proper dosages and routes, any special er hand-washing technique. Specify
instructions, and potential adverse ef- whether and when he should shower
fects as well as when to notify the or bathe. If necessary, tell him where
physician. Try to establish a medica- he can obtain the ordered wound-
tion schedule that fits the patient’s dressing supplies.
lifestyle.
Potential complications
Diet Teach the patient to recognize wound
Discuss dietary restrictions with the pa- infection and other potential complica-
tient and, if appropriate, the person tions. Provide written instructions
who will prepare his meals. Assess the about reportable signs and symptoms,
patient’s usual dietary intake. If appro- such as bleeding or discharge from the
priate, discuss how much the diet will incision and acute pain. Advise the
cost and how the patient’s dietary re- patient to call the physician with any
strictions may affect other family mem- questions.
bers. Refer the patient to a dietitian, if
appropriate.
Return appointments
Stress the importance of scheduling
and keeping follow-up appointments,
and make sure that the patient has the
physician’s office telephone number. If
the patient has no transportation, refer
him to an appropriate community re-
source.
Referrals
Reassess whether the patient needs re-
ferral to a home care agency or another
community resource. Discuss with the
family how they’ll handle the patient’s
return home. In some facilities, a home
care coordinator or discharge planning
nurse is responsible for making refer-
rals.
8 Pain management
Assessing pain and using medications
Differentiating acute and chronic pain 436

Pain assessment 437
PQRST: The alphabet of pain assessment 437
Visual analog scale 438
Numeric rating scale 438
Wong-Baker FACES pain rating scale 438
Pain behavior checklist 439
Pharmacologic pain management 439
Pain management drugs 440
Selected nonopioid analgesic combination
products 444
Selected opioid analgesic combination
products 446
435
436 Pain management
Differentiating acute and chronic pain
Acute pain may cause certain physiologic and behavioral changes that you won’t ob-
serve in a patient with chronic pain.
TYPE OF PAIN PHYSIOLOGIC EVIDENCE BEHAVIORAL EVIDENCE
Acute ◆ Increased respirations ◆ Restlessness

◆ Increased pulse ◆ Distraction
◆ Increased blood pressure ◆ Worry
◆ Dilated pupils ◆ Distress
◆ Diaphoresis
Chronic ◆ Normal respirations, pulse, ◆ Reduced or absent physical activity

blood pressure, and pupil size ◆ Despair or depression
◆ No diaphoresis ◆ Hopelessness
Achieving adequate pain control de- (increased blood pressure and heart
pends on effectively assessing, treating, rate) in addition to self-reporting.
and monitoring pain. Pain is referred to Age alert Children metabolize
as the fifth vital sign alongside temper- drugs differently from adults
ature, pulse, blood pressure, and respi- and may experience the effects of
ration. To provide the best care possi- analgesics differently. When assessing
ble, work with physicians and other pain in a child, use verbal, numeric,
members of the health care team to de- or picture scales to help determine the
velop an individualized pain manage- child’s pain level in addition to direct
ment program for each patient. questions. Also watch for behavioral
Pain has a sensory component and cues (facial expressions, crying) and
a reaction component. The sensory physiologic changes (increased blood
component involves an electrical im- pressure and heart rate) to help deter-
pulse that travels to the central ner- mine the child’s pain level.
vous system, where it’s perceived as During the course of an illness, a
pain. The response to this perception is patient may experience acute pain,
the reaction component. chronic pain, or both.
Pain is highly subjective and unique Acute pain is caused by tissue dam-
to the person experiencing it. Any report age from injury or disease. It varies in
of pain must be assessed and addressed. intensity from mild to severe and lasts
Pain also manifests differently ac- briefly. It’s considered a protective
cording to each patient’s beliefs, cul- mechanism because it warns of current
ture, and age. or potential damage or organ disease.
Age alert An older adult may It may result from a traumatic injury,
not report pain and may metab- from surgical or diagnostic procedures,
olize and experience the effects of or from a medical disorder.
analgesic drugs differently than a Chronic pain is pain that has lasted
younger patient. To assess pain in an 6 months or longer and is ongoing. Al-
older patient with cognitive dysfunc- though it may be as intense as acute
tion, use such cues as behavior pain, it isn’t a warning of tissue dam-
(motor responses, facial expressions, age. (See Differentiating acute and
crying) and physiologic changes chronic pain.)
Pain assessment 437
PQRST: The alphabet of pain assessment
Use the PQRST mnemonic device to obtain more information about the patient’s pain.
Asking these questions elicits important details about his pain.
P rovocative or palliative
Ask the patient:
◆ What provokes or worsens your pain?
◆ What relieves your pain or causes it to subside?
Q uality or quantity
Ask the patient:
◆ What does the pain feel like? For example, is it aching, intense, knifelike, burning,
or cramping?
◆ Are you having pain right now? If so, is it more or less severe than usual?
◆ To what degree does the pain affect your normal activities?
◆ Do you have other symptoms along with the pain, such as nausea or vomiting?
R egion and radiation

Ask the patient:
◆ Where is your pain?
◆ Does the pain radiate to other parts of your body?
S everity
Ask the patient:
◆ How severe is your pain? How would you rate it on a scale of 0 to 10, with 0
being no pain and 10 being the worst pain imaginable?
◆ How would you describe the intensity of your pain at its best? At its worst? Right now?
T iming
Ask the patient:
◆ When did your pain begin?
◆ At what time of day is your pain best? At what time of day is it worst?
◆ Is the onset sudden or gradual?
◆ Is the pain constant or intermittent?
speaking the same language when ad-

Pain assessment dressing the patient’s pain.
The three most common pain as-
It’s important for the nurse to have sessment tools used by clinicians are
good pain assessment skills. The most the visual analog scale (see Visual ana-
valid assessment of pain comes from log scale, page 438), the numeric rating
the patient’s own reports of his pain. scale (see Numeric rating scale, page
(See PQRST: The alphabet of pain as- 438), and the FACES scale (see Wong-
sessment.) Baker FACES pain rating scale, page
Many pain assessment tools are 438). The patient may exhibit many
available. Whichever you choose, make physiologic and psychological respons-
sure that it’s used consistently so that es to pain, and the nurse should watch
everyone on the health care team is for these during a pain assessment.
(See Pain behavior checklist, page 439.)
438 Pain management
Visual analog scale
To use the visual analog scale, ask the patient to place a mark on the scale to indicate
his current level of pain, as shown here.
X
No Pain as
pain bad as it
can be
Numeric rating scale
A numeric rating scale can help the patient to quantify his pain. To use this scale, ask the
patient to choose a number from 0 (indicating no pain) to 10 (indicating the worst pain
imaginable) to reflect his current level of pain. He can either circle the number on the
scale or state the number that best describes his pain.
No 0 1 2 3 4 5 6 7 8 9 10 Pain as
pain bad as it
can be
Wong-Baker FACES pain rating scale
A child or an adult with language difficulties may not be able to express the pain he’s
feeling. In such instances, you can use the pain intensity scale below. To use this scale,
ask the patient to choose the face that best represents the severity of his pain on a scale
from 0 to 10.
0 1 2 3 4 5
No Hurts Hurts Hurts Hurts Hurts
hurt little bit little more even more whole lot worst
Alternate 0 2 4 6 8 10
coding
From Hockenberry, M.J., Wilson, D.: Wong’s Essentials of Pediatric Nursing, 8th ed. St. Louis, 2009,
Mosby. Used with permission. Copyright Mosby.
Pain behavior checklist
A pain behavior is something that a patient uses to communicate pain, distress, or suf-
fering. Place a check in the box next to each behavior that you observe or infer while
talking with the patient.
Grimacing Using a cane, a cervical collar, or an-

Moaning other prosthetic device
Sighing Walking with an abnormal gait
Clenching the teeth Requesting help with walking
Holding or supporting the painful Stopping frequently while walking
body area Lying down during the day
Sitting rigidly Avoiding physical activity
Frequently shifting posture or position Being irritable
Moving in a guarded or protective Asking such questions as, “Why did
manner this happen to me?”
Moving very slowly Asking to be relieved from tasks or
Limping activities
Taking medication
Some of the most common pain

Pharmacologic pain management agents are discussed here.
management (See Pain management drugs, pages
440 to 445.)
Two classes of medications are com- Many nonopioids and opioids are
monly used for pain management: used in combination with other drugs
◆ nonopioids to produce useful analgesics. (See Se-
◆ opioids. lected analgesic combination products,
Nonopioids are the first choice for pages 444 to 448.)
managing mild pain. They decrease
pain by inhibiting inflammation at the
injury site. Examples of nonopioids
are:
◆ acetaminophen
◆ nonsteroidal anti-inflammatory
drugs
◆ salicylates such as aspirin.
Opioids are narcotics that contain a
derivative of the opium plant and other
synthetic drugs that imitate natural
narcotics. Opioids work by blocking
the release of neurotransmitters that
are involved in transmitting pain sig-
nals to the brain.
440 Pain management
Pain management drugs
DRUG INDICATIONS ADVERSE EFFECTS
acetaminophen ◆ Mild pain ◆ Neutropenia, leukopenia, pancy-

Acephen, Anacin ◆ Fever topenia, thrombocytopenia
Aspirin Free, Tylenol ◆ Severe liver damage
◆ Hypoglycemia
aspirin ◆ Mild pain ◆ Tinnitus, hearing loss

ASA, Ascriptin, ◆ Fever ◆ Nausea, GI distress, occult bleed-
Bufferin ◆ Transient ischemic attacks ing, dyspepsia, GI bleeding
and thromboembolic disor- ◆ Acute renal insufficiency
ders ◆ Leukopenia, thrombocytopenia,
◆ Treatment or reduction of prolonged bleeding time
the risk of myocardial infarc- ◆ Liver dysfunction, hepatitis
tion (MI) in the patient with ◆ Rash
previous MI or unstable ◆ Hypersensitivity reactions (ana-
angina phylaxis, asthma), Reye’s syndrome,
◆ Pericarditis after acute MI angioedema
◆ Prevention of reocclusion
in coronary revascularization
procedures
◆ Stent implantation
codeine ◆ Mild to moderate pain ◆ Sedation, clouded sensorium, eu-

phosphate, ◆ Nonproductive cough phoria, dizziness, light-headedness
codeine sulfate ◆ Hypotension, bradycardia
◆ Nausea, vomiting, constipation,
dry mouth, ileus
◆ Urine retention
◆ Respiratory depression
◆ Diaphoresis
SPECIAL CONSIDERATIONS
◆ Use cautiously in patients with a history of chronic alcohol abuse because hepatotoxicity
has occurred after therapeutic doses. Also use cautiously in patients with hepatic or cardio-
vascular disease, impaired renal function, or viral infection.
◆ Know the patient’s total daily acetaminophen intake, especially if he’s taking other pre-
scribed drugs containing the compound such as Percocet (acetaminophen/oxycodone). Toxicity
can occur.
◆ Monitor the prothrombin time (PT) and International Normalized Ratio values in patients
who are receiving oral anticoagulants and long-term acetaminophen therapy.
◆ Contraindicated in patients with glucose-6-phosphate dehydrogenase deficiency or bleed-

ing disorders, such as hemophilia, von Willebrand’s disease, or telangiectasia. Also contraindi-
cated in patients with nonsteroidal anti-inflammatory drug (NSAID)-induced sensitivity reac-
tions.
◆ Use cautiously in patients with GI lesions, impaired renal function, hypoprothrombinemia,
vitamin K deficiency, thrombotic thrombocytopenic purpura, or hepatic impairment.
◆ Use cautiously in patients with a history of GI disease (especially peptic ulcer disease), in-
creased risk of GI bleeding, or decreased renal function.
◆ Don’t give oral or rectal aspirin products to children or teenagers because of the risk of
developing Reye’s syndrome.
◆ Give 8 oz (237 ml) of water or milk with salicylates to ensure passage into the stomach.
Have the patient sit up for 15 to 30 minutes after taking salicylates to prevent lodging in the
esophagus.
◆ Monitor the patient’s vital signs frequently, especially temperature.
◆ Salicylates may mask the signs and symptoms of acute infection (fever, myalgia, erythe-
ma); carefully evaluate patients who are at risk for infection such as those with diabetes.
◆ Monitor the complete blood count, platelet count, PT, blood urea nitrogen level, serum cre-
atinine level, and the results of liver function studies periodically during salicylate therapy to
detect abnormalities.
◆ Assess the patient for signs and symptoms of hemorrhage, such as petechiae, bruising,
coffee-ground vomitus, and black, tarry stools.
◆ Use cautiously in elderly or debilitated patients and in those with impaired renal or hepat-
ic function, head injuries, increased intracranial pressure (ICP), increased cerebrospinal fluid
(CSF) pressure, hypothyroidism, Addison’s disease, acute alcoholism, central nervous system
depression, bronchial asthma, chronic obstructive pulmonary disease (COPD), respiratory de-
pression, or shock.
◆ Because the safe use of codeine in pregnancy hasn’t been established, codeine shouldn’t
be given to pregnant women unless the potential benefits outweigh the possible hazards.
◆ Don’t mix with other solutions because codeine phosphate is incompatible with many
drugs.
◆ Patients who become physically dependent on the drug may experience acute withdrawal
syndrome if given an opioid antagonist.
◆ The drug may delay gastric emptying, increase biliary tract pressure resulting from con-
traction of the sphincter of Oddi, and interfere with hepatobiliary imaging studies.
(continued)
442 Pain management
Pain management drugs (continued)
fentanyl citrate ◆ Preoperative analgesic ◆ Sedation, somnolence, clouded

Sublimaze; Fentanyl ◆ Adjunct to general anes- sensorium, confusion, asthenia
Transdermal System thetic; low-dose regimen for ◆ Arrhythmias
(Duragesic-12, minor procedures; moderate- ◆ Nausea, vomiting, constipation,
Duragesic-25, dose regimen for major pro- dry mouth
Duragesic-50, cedures; high-dose regimen ◆ Urine retention
Duragesic-75, for complicated procedures ◆ Respiratory depression, apnea
Duragesic-100) ◆ Postoperative analgesic
◆ Management of chronic
pain in the patient who can’t
be managed by lesser means
◆ Management of break-
through cancer pain
hydromorphone ◆ Moderate to severe pain ◆ Sedation, somnolence, clouded

hydrochloride ◆ Cough sensorium, dizziness, euphoria
Dilaudid ◆ Hypotension, bradycardia
◆ Nausea, vomiting, constipation
◆ Urine retention
◆ Respiratory depression, bron-
chospasm
ibuprofen ◆ Arthritis, gout ◆ Acute renal failure

Advil, Motrin, ◆ Mild to moderate pain, ◆ Neutropenia, pancytopenia,
Motrin IB, Nuprin headache, backache, minor thrombocytopenia, aplastic anemia,
aches associated with the leukopenia, agranulocytosis
common cold ◆ Bronchospasm
◆ Fever reduction ◆ Stevens-Johnson syndrome
◆ Use cautiously in elderly or debilitated patients and in those with head injuries, increased
CSF pressure, COPD, decreased respiratory reserve, compromised respirations, arrhythmias,
or hepatic, renal, or cardiac disease.
◆ Safety and efficacy in children under 2 years of age and in pregnant women hasn’t been
established.
◆ Give an anticholinergic, such as atropine or glycopyrrolate, to minimize the possible
bradycardic effect of fentanyl.
◆ Gradually adjust the dosage in patients using the transdermal system. Reaching steady-
state levels of a new dose may take up to 6 days; delay dose adjustment until after at least
two applications.
◆ When reducing opiate therapy or switching to a different analgesic, expect to withdraw
the transdermal system gradually. Because the serum level of fentanyl decreases very gradu-
ally after removal, give half of the equianalgesic dose of the new analgesic 12 to 18 hours
after removal.
◆ Fentanyl Citrate Injection is a schedule II controlled substance that can produce drug de-
pendence and has the potential for abuse.
◆ Contraindicated in patients with intracranial lesions caused by increased ICP, and whenev-
er ventilator function is depressed, such as in status asthmaticus, COPD, cor pulmonale, em-
physema, and kyphoscoliosis.
◆ Use cautiously in elderly or debilitated patients and in those with hepatic or renal disease,
Addison’s disease, hypothyroidism, prostatic hyperplasia, or urethral strictures.
◆ For a better analgesic effect, give the drug before the patient has intense pain.
◆ Give by direct injection over no less than 2 minutes, and monitor the patient constantly.
Keep resuscitation equipment available. Respiratory depression and hypotension can occur
with I.V. administration.
◆ Drug may worsen or mask gallbladder pain. Increased biliary tract pressure resulting
from contraction of the sphincter of Oddi may interfere with hepatobiliary imaging studies.
◆ May be harmful to fetus and may cause addiction or withdrawal symptoms in a newborn.
Women taking the drug shouldn’t breast-feed because the drug is excreted in breast milk.
◆ Contraindicated in patients who have the syndrome of nasal polyps, angioedema, and
bronchospastic reaction to aspirin or other NSAIDs. Contraindicated during the last trimester
of pregnancy because it may cause problems with the fetus or complications during delivery.
◆ Use cautiously in patients with impaired renal or hepatic function, GI disorders, peptic ul-
cer disease, cardiac decompensation, hypertension, or coagulation defects. Because chewable
tablets contain aspartame, use cautiously in patients with phenylketonuria.
◆ Contraindicated right before and right after coronary artery bypass surgery because of the
risk of heart attack or stroke.
◆ Monitor auditory and ophthalmic functions periodically during ibuprofen therapy.
◆ Observe the patient for possible fluid retention.
◆ Patients older than age 60 may be more susceptible to the toxic effects of ibuprofen, es-
pecially adverse GI reactions. Use the lowest possible effective dose. The effect of the drug
on renal prostaglandins may cause fluid retention and edema, a significant drawback for el-
derly patients, especially those with heart failure.
(continued)
444 Pain management
Pain management drugs (continued)
ketorolac ◆ Short-term manage- ◆ Drowsiness, sedation, dizziness,

tromethamine ment of severe, acute pain headache
◆ Short-term manage- ◆ Arrhythmias
ment of moderately se- ◆ Nausea, dyspepsia, GI pain
vere, acute pain when ◆ Renal failure
switching from parenteral ◆ Thrombocytopenia
to oral administration
morphine ◆ Severe pain ◆ Seizures (with large doses), dizziness,

Astramorph PF, ◆ Severe, chronic pain re- nightmares (with long-acting oral forms),
Avinza, Duramorph, lated to cancer light-headedness
Infumorph, Kadian, ◆ Preoperative sedation ◆ Hypotension, bradycardia, shock, car-
MS Contin, and adjunct to anesthesia diac arrest
Oramorph SR ◆ Postoperative analgesia ◆ Nausea, vomiting, constipation, ileus,
◆ Control of pain caused dry mouth, biliary tract spasms, anorexia
by acute MI ◆ Urine retention
◆ Control of angina pain ◆ Thrombocytopenia
◆ Adjunctive treatment of ◆ Respiratory depression, apnea, respi-
acute pulmonary edema ratory arrest
◆ Diaphoresis, edema
◆ Physical dependence, decreased libido
Selected nonopioid analgesic combination products
Many common analgesics are combinations of two or more generic drugs. This table
lists the components of common nonopioid analgesics.
TRADE NAME GENERIC DRUGS
Anacin, P-A-C Analgesic Tablets ◆ aspirin 400 mg

◆ caffeine 32 mg
Ascriptin, Magnaprin ◆ aspirin 325 mg

◆ magnesium hydroxide 50 mg
◆ aluminum hydroxide 50 mg
◆ calcium carbonate 50 mg
Ascriptin A/D, Magnaprin Arthritis ◆ aspirin 325 mg

Strength Caplets ◆ magnesium hydroxide 75 mg
◆ calcium carbonate 75 mg
Aspirin Free Anacin PM, Extra Strength ◆ acetaminophen 500 mg

Tylenol PM, Sominex Pain Relief ◆ diphenhydramine 25 mg
◆ Contraindicated in patients with active peptic ulcer disease, recent GI bleeding or perfora-
tion, advanced renal impairment, risk of renal impairment as a result of volume depletion,
suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemo-
stasis, or an increased risk of bleeding.
◆ Use cautiously in patients with impaired renal or hepatic function.
◆ The combined duration of ketorolac therapy (I.M., I.V., oral) shouldn’t exceed 5 days.
Oral use is only for continuation of I.V. or I.M. therapy.
◆ Contraindicated in patients with conditions that would preclude administration of opioids

by the I.V. route, such as acute bronchial asthma and upper airway obstruction.
◆ Use cautiously in elderly or debilitated patients and in those with head injury, increased
ICP, seizures, pulmonary disease, prostatic hyperplasia, hepatic or renal disease, acute ab-
dominal conditions, hypothyroidism, Addison’s disease, or urethral strictures.
◆ Long-term therapy in patients with advanced renal disease may lead to toxicity as a result
of accumulation of the active metabolite.
◆ Taper gradually when stopping therapy to avoid withdrawal symptoms.
Selected nonopioid analgesic combination products (continued)
Esgic-Plus ◆ acetaminophen 500 mg

◆ caffeine 40 mg
◆ butalbital 50 mg
Excedrin Extra Strength, Excedrin Migraine ◆ aspirin 250 mg

◆ acetaminophen 250 mg
◆ caffeine 65 mg
Excedrin P.M. Caplets ◆ acetaminophen 500 mg

◆ diphenhydramine citrate 38 mg
Fiorinal†, Fiortal† ◆ aspirin 325 mg

◆ caffeine 40 mg
Sinutab Regular* ◆ acetaminophen 325 mg

◆ chlorpheniramine 2 mg
◆ pseudoephedrine hydrochloride 30 mg
(continued)
446 Pain management
Selected nonopioid analgesic combination products (continued)
Tecnal* ◆ aspirin 330 mg

◆ caffeine 40 mg
Vanquish ◆ aspirin 227 mg

◆ acetaminophen 194 mg
◆ caffeine 33 mg
◆ magnesium hydroxide 50 mg
*Available in Canada only. † Controlled substance schedule III.
Selected opioid analgesic combination products
Many common analgesics are combinations of two or more generic drugs. This table
lists the components of common opioid analgesics and their controlled substance
schedule classification.
TRADE NAME CONTROLLED GENERIC DRUGS

SUBSTANCE
SCHEDULE
Aceta with Codeine III ◆ acetaminophen 300 mg

◆ codeine phosphate 30 mg
Anexsia 7.5/650, Lorcet III ◆ acetaminophen 650 mg

Plus ◆ hydrocodone bitartrate 7.5 mg
Capital with Codeine, V ◆ acetaminophen 120 mg

Tylenol with Codeine Elixir ◆ codeine phosphate 12 mg/5 ml
Darvocet-N 50 IV ◆ acetaminophen 325 mg

◆ propoxyphene napsylate 50 mg
Darvocet-N 100, IV ◆ acetaminophen 650 mg

Propacet 100 ◆ propoxyphene napsylate 100 mg
Empirin With Codeine III ◆ aspirin 325 mg

No. 3 ◆ codeine phosphate 30 mg
Empirin With Codeine III ◆ aspirin 325 mg

Fioricet With Codeine III ◆ acetaminophen 325 mg

◆ caffeine 40 mg
Selected opioid analgesic combination products (continued)

SUBSTANCE
SCHEDULE
Fiorinal With Codeine III ◆ aspirin 325 mg

◆ caffeine 40 mg
Lorcet 10/650 III ◆ acetaminophen 650 mg

◆ hydrocodone bitartrate 10 mg
Lortab 2.5/500 III ◆ acetaminophen 500 mg

◆ hydrocodone bitartrate 2.5 mg
Lortab 5/500 III ◆ acetaminophen 500 mg

Lortab 7.5/500 III ◆ acetaminophen 500 mg

Percocet 5/325 II ◆ acetaminophen 325 mg

◆ oxycodone hydrochloride 5 mg
Percodan-Demi II ◆ aspirin 325 mg

◆ oxycodone hydrochloride 2.25 mg
◆ oxycodone terephthalate 0.19 mg
Percodan, Roxiprin II ◆ aspirin 325 mg

◆ oxycodone hydrochloride 4.5 mg
◆ oxycodone terephthalate 0.38 mg
Roxicet II ◆ acetaminophen 325 mg

Roxicet 5/500, Roxilox II ◆ acetaminophen 500 mg

Roxicet Oral Solution II ◆ acetaminophen 325 mg

◆ oxycodone hydrochloride 5 mg/5 ml
Talacen IV ◆ acetaminophen 650 mg

◆ pentazocine hydrochloride 25 mg
Talwin Compound IV ◆ aspirin 325 mg

◆ pentazocine hydrochloride 12.5 mg
Tylenol With Codeine III ◆ acetaminophen 300 mg

(continued)
448 Pain management
Selected opioid analgesic combination products (continued)

SUBSTANCE
SCHEDULE


Tylox II ◆ acetaminophen 500 mg

Vicodin, Zydone III ◆ acetaminophen 500 mg

Vicodin ES III ◆ acetaminophen 750 mg

Pressure ulcers and
9 traumatic wound care

Preventing, staging, and
treating wounds
Pressure ulcer care 450

Pressure points: Common sites for ulcers 451
Staging pressure ulcers 452
Pressure reduction devices 454
Tailoring wound care to wound color 455
Wound care dressings 456
Choosing a wound dressing 457
Preventing skin tears 458
Traumatic wound care 459
Caring for a traumatic wound 460
449
450 Pressure ulcers and traumatic wound care
(See Pressure reduction devices, page

Pressure ulcer care 454.) Other therapeutic measures in-
clude reducing risk factors and using
As their name implies, pressure ulcers topical treatments, wound cleaning, de-
result when pressure — applied with bridement, and moist dressings to sup-
great force for a short period or with port wound healing.
less force over a longer period — im- The nurse usually performs or coor-
pairs circulation, depriving tissues of dinates treatments according to facility
oxygen and other life-sustaining nutri- policy. The procedures described here
ents. This process damages skin and address cleaning and dressing pressure
underlying structures. Untreated, the ulcers. Always follow the “Standard
ischemic lesions that result can lead to Precautions” guidelines of the Centers
serious infection. for Disease Control and Prevention.
Most pressure ulcers develop over
bony prominences, where friction and Equipment and preparation
shearing force combine with pressure
to break down skin and underlying Hypoallergenic tape or elastic netting
tissues. Common sites include the sa- ◆ piston-type irrigating system ◆ two
crum, coccyx, ischial tuberosities, and pairs of gloves ◆ normal saline solu-
greater trochanters. Other common tion, as ordered ◆ sterile 4 4 gauze
sites include the skin over the ears, pads ◆ selected topical dressing (moist
vertebrae, scapulae, elbows, knees, and saline gauze, hydrocolloid, transparent,
heels in bedridden and relatively im- alginate, foam, or hydrogel) ◆ linen-
mobile patients. (See Pressure points: saver pads ◆ impervious plastic trash
Common sites for ulcers.) bag ◆ disposable wound-measuring
Successful treatment of pressure ul- device ◆ sterile cotton swabs ◆ op-
cers involves relieving pressure, restor- tional: 21G needle and syringe, alcohol
ing circulation and, if possible, resolv- pad, pressure-reducing device, turning
ing or managing related disorders. Typ- sheet
ically, the effectiveness and duration of Assemble the equipment at the pa-
the treatment depend on the character- tient’s bedside. Cut the tape into strips
istics of the pressure ulcer. (See Staging for securing dressings. Loosen the lids
pressure ulcers, pages 452 and 453.) on cleaning solutions and medications
Ideally, prevention is the key to for easy removal. Make sure that the
avoiding extensive therapy. Preventive impervious plastic trash bag is within
measures include ensuring adequate reach.
nourishment and mobility to relieve
pressure and promote circulation. Implementation
When a pressure ulcer develops de-
spite preventive efforts, treatment in- ◆ Before performing any dressing
cludes methods to decrease pressure, change, wash your hands and review
such as frequent repositioning to short- the principles of standard precautions.
en the duration of the pressure and the
use of special equipment to reduce the Cleaning the pressure ulcer
intensity of the pressure. Treatment ◆ Provide privacy and explain the pro-
may also involve the use of special de- cedure to the patient to alleviate his
vices, such as beds, mattresses, mat- fears and promote cooperation.
tress overlays, and chair cushions.
Pressure points: Common sites for ulcers
Ulcers may develop at pressure

points, which are shown in these
illustrations. To help to prevent
ulcers, emphasize the importance Shoulder blade
of repositioning the patient fre-
quently and checking the skin
carefully for changes. Tailbone
Buttocks
Back of knee
Heels
Side Upper Upper Front Side

of head hip bone thigh bone of knee of ankle
Shoulder
◆ Position the patient in a way that ◆ Inspect the wound. Note the color,
maximizes his comfort while allowing amount, and odor of drainage and
easy access to the pressure ulcer site. necrotic debris. (See Tailoring wound
◆ Cover the bed linens with a linen- care to wound color, page 455.) Mea-
saver pad to prevent soiling. sure the perimeter of the wound with
◆ Open the normal saline solution the disposable wound-measuring de-
container and the piston syringe. Care- vice (a square, transparent card with
fully pour normal saline solution into concentric circles arranged in a bull’s-
an irrigation container to avoid eye fashion and bordered with a
splashing. (The container may be straightedge ruler).
clean or sterile, depending on facility ◆ Using the piston syringe, apply full
policy.) Put the piston syringe into the force to irrigate the pressure ulcer to
opening provided in the irrigation con- remove necrotic debris and help to de-
tainer. crease bacteria in the wound.
◆ Open the packages of supplies. ◆ Remove and discard the soiled
◆ Put on gloves to remove the old gloves and put on a fresh pair.
dressing and expose the pressure ulcer. ◆ Insert a gloved finger or a sterile
Discard the soiled dressing in the im- cotton swab into the wound to assess
pervious plastic trash bag to avoid con- wound tunneling or undermining. Tun-
taminating the sterile field and spread- neling usually signals extension of the
ing infection. wound along fascial planes. Gauge the
Staging pressure ulcers
The pressure ulcer staging system described here, used by the National Pressure Ulcer Advi-
sory Panel and the Agency for Health Care Policy and Research, reflects the anatomic depth
of exposed tissue. Keep in mind that if the wound contains necrotic tissue, you won’t be able
to determine the stage until you can see the wound base.
Suspected deep tissue injury

Deep tissue injury is characterized by a purple or maroon localized area of intact skin or a
blood-filled blister caused by damage of underlying soft tissue from pressure or shear. The
injury may be preceded by tissue that’s painful, firm, mushy, boggy, or warm or cool com-
pared to adjacent tissue. Further, it may be difficult to detect in individuals with dark skin
tones.
Stage I
A stage I pressure ulcer Reddened area
is characterized by in-
tact skin with non-
blanchable redness of a
localized area, usually Epidermis
over a bony promi-
Dermis
nence. Darkly pigment-
ed skin may not have
visible blanching, but Subcutaneous tissue
its color may differ Muscle
from the surrounding
area.
Bone
Stage II
A stage II pressure ul- Reddened area
cer is characterized by
partial-thickness loss of Blister
the dermis, presenting
as a shallow, open ul- Epidermis
cer with a red-pink
wound bed without Dermis
slough. It may also pre-
sent as an intact or Subcutaneous tissue
open serum-filled Muscle
blister
Bone
Stage III
A stage III pressure ul-
cer is characterized by
Epidermis
full-thickness tissue loss.
Subcutaneous fat may
be visible, but bone, Dermis
tendon, and muscle
aren’t exposed. Slough
may be present but Subcutaneous tissue
doesn’t obscure the
depth of tissue loss. Un- Muscle
dermining and tunnel-
ing may be present. The
depth of a stage III ul- Bone
cer varies by anatomical
location.
Stage IV
A stage IV pressure ul-
cer involves full-thick-
ness tissue loss with ex- Epidermis
posed bone, tendon, or
muscle. Slough or es-
char may be present on Dermis
some parts of the
wound bed. Undermin-
Subcutaneous tissue
ing and tunneling are
also common. The
Muscle
depth of a stage IV ul-
cer varies by anatomical
location. Bone
Unstageable
An unstageable ulcer is characterized by full-thickness tissue loss in which the base of the
ulcer in the wound bed is covered by slough, eschar, or both. Until enough slough or eschar
is removed to expose the base of the wound, the true depth, and therefore stage, can’t be
determined.
Pressure reduction devices
The use of special pads, mattresses, and beds can help to relieve pressure when a pa-
tient is confined to one position for long periods.
Gel pads Air-fluidized beds
Gel pads disperse pressure over a wide Air-fluidized beds contain beads that
surface area. move under an airflow to support the pa-
tient, thus reducing shearing force and
Water mattress or pads friction.
A wave effect provides even distribution
of body weight. Mechanical lifting devices
Lift sheets and other mechanical lifting
Alternating-pressure air mattress devices prevent shearing by lifting the pa-
Alternating deflation and inflation of the tient rather than dragging him across the
mattress tubes changes the areas of pres- bed.
sure.
Padding
Foam mattress or pads Pillows, towels, and soft blankets can re-
Foam areas, which must be at least 3” duce pressure in body hollows.
(7.5 cm) thick, cushion skin and minimize
pressure. Foot cradle
A foot cradle lifts the bed linens to relieve
Low-air-loss beds pressure over the feet.
The surface of low-air-loss beds consists
of inflated air cushions. Each section is
adjusted to provide optimal pressure re-
lief.
depth of the tunnel by determining Applying a moist saline

how far you can insert your finger or gauze dressing
the cotton swab. ◆ Irrigate the pressure ulcer with nor-
◆ Next, reassess the condition of the mal saline solution. Blot the surround-
skin and the ulcer. Note the character ing skin dry.
of the clean wound bed and the sur- ◆ Moisten the gauze dressing with
rounding skin. normal saline solution.
◆ If you observe adherent necrotic ◆ Gently place the dressing over the
material, notify a wound care specialist surface of the ulcer. To separate sur-
or a physician to ensure that appropri- faces within the wound, gently place a
ate debridement is performed. dressing between opposing wound sur-
◆ Prepare to apply the selected topical faces. To avoid damage to tissues,
dressing. Directions for application of don’t pack the gauze tightly.
topical moist saline gauze, hydrocol- ◆ Change the dressing often enough
loid, transparent, alginate, foam, and to keep the wound moist. (See Choos-
hydrogel dressings follow. For other ing a wound dressing, page 457.)
dressings or topical agents, follow facil-
ity protocol or the manufacturer’s in- Applying a hydrocolloid dressing
structions. (See Wound care dressings, ◆ Irrigate the pressure ulcer with nor-
page 456.) mal saline solution. Blot the surround-
ing skin dry.
Tailoring wound care to wound color
You can promote healing by keeping the wound moist, clean, and free from debris. For
open wounds, you can use wound color to guide the specific management approach that
will aid healing.
WOUND COLOR MANAGEMENT TECHNIQUE
Red ◆ Cover the wound, keep it moist and clean, and protect it from
trauma.
◆ Use a transparent dressing (such as Tegaderm or OpSite) over
a gauze dressing moistened with normal saline solution, or use a
hydrogel, foam, or hydrocolloid dressing to insulate and protect
the wound.
Yellow ◆ Clean the wound and remove the yellow layer.

◆ Cover the wound with a moisture-retentive dressing, such as a
hydrogel or foam dressing, or a moist gauze dressing with or
without a debriding enzyme.
◆ Consider hydrotherapy with whirlpool or pulsatile lavage.
Black ◆ Debride the wound as ordered. Use an enzyme product (such

as Accuzyme or Panafil), conservative sharp debridement, or
hydrotherapy with whirlpool or pulsatile lavage.
◆ Don’t debride noninfected heel ulcers or wounds with an inad-
equate blood supply. Keep them clean and dry.
◆ Choose a clean, dry, presized dress- ◆ Change a hydrocolloid dressing

ing, or cut one to overlap the pressure every 2 to 7 days as necessary — for ex-
ulcer by about 1 (2.5 cm). Remove the ample, if the patient complains of pain,
dressing from its package, pull the re- if the dressing no longer adheres, or if
lease paper from the adherent side of leakage occurs.
the dressing, and apply the dressing to
the wound. To minimize irritation, Applying a transparent dressing
carefully smooth out wrinkles as you ◆ Irrigate the pressure ulcer with nor-
apply the dressing. mal saline solution. Blot the surround-
◆ If the edges of the dressing must be ing skin dry.
secured with hypoallergenic tape, apply ◆ Clean and dry the wound as de-
a skin sealant to the intact skin around scribed above.
the ulcer. After the area dries, tape the ◆ Select a dressing to overlap the ul-
dressing to the skin. The sealant pro- cer by 2 (5 cm).
tects the skin and promotes adherence ◆ Gently lay the dressing over the ul-
of the tape. Avoid using tension or cer. To prevent shearing force, don’t
pressure when applying the tape. stretch the dressing. Press firmly on
◆ Remove the gloves and discard the edges of the dressing to promote
them in the impervious plastic trash adherence. Although this type of dress-
bag. Dispose of refuse according to fa- ing is self-adhesive, you may need to
cility policy and wash your hands.
Wound care dressings
Some dressings absorb moisture from a wound bed, whereas others add moisture. Use
the chart below to quickly determine the category of dressing that’s appropriate for the
patient.
Moisture scale
– – Absorb Neutral + + Add

moisture (maintain existing moisture level) moisture
◆ Alginates ◆ Foams ◆ Composites ◆ Transparent ◆ Sheet ◆ Amorphous

◆ Specialty ◆ Hydro- ◆ Mini-VAC films hydrogels hydrogel
absorptives colloids device ◆ Biological ◆ Debriding
◆ Vacuum- ◆ Compres- dressings agents
assisted clo- sion dressings ◆ Collagen
sure (VAC) dressings
device ◆ Contact
◆ Gauze layers
◆ Warm-up
therapy
system
tape the edges to prevent them from ◆ If the wound is draining heavily,
curling. change the dressing once or twice daily
◆ If necessary, aspirate accumulated for the first 3 to 5 days. As the drain-
fluid with a 21G needle and syringe. age decreases, change the dressing less
After aspirating the pocket of fluid, frequently — every 2 to 4 days, or as
clean the aspiration site with an alco- ordered. When the drainage stops or
hol pad and cover it with another strip the wound bed looks dry, stop using
of transparent dressing. an alginate dressing.
◆ Change the dressing every 3 to 7
days, depending on the amount of Applying a foam dressing
drainage. ◆ Irrigate the pressure ulcer with nor-
mal saline solution. Blot the surround-
Applying an alginate dressing ing skin dry.
◆ Irrigate the pressure ulcer with nor- ◆ Gently lay the foam dressing over
mal saline solution. Blot the surround- the ulcer.
ing skin dry with a sterile 4 4 ◆ Use hypoallergenic tape, elastic net-
gauze pad. ting, or gauze to hold the dressing in
◆ Apply the alginate dressing to the place.
surface of the ulcer. Cover the area ◆ Change the dressing when the foam
with a secondary dressing (such as no longer absorbs the exudate.
gauze pads) as ordered. Secure the
dressing with hypoallergenic tape or
elastic netting.
Choosing a wound dressing
Use the information below to determine the type of dressing that’s appropriate for the
patient.
Gauze dressings Alginate dressings

Made of absorptive cotton or synthetic Made from seaweed, alginate dressings
fabric, gauze dressings are permeable to are nonwoven, absorptive dressings that
water, water vapor, and oxygen and may are available as soft, white sterile pads or
be impregnated with hydrogel or another ropes. They absorb excessive exudate and
agent. When you’re uncertain about which may be used on infected wounds. As these
type of dressing to use, you may apply a dressings absorb exudate, they turn into a
gauze dressing moistened with saline so- gel that keeps the wound bed moist and
lution until a wound specialist recom- promotes healing. When exudate is no
mends definitive treatment. longer excessive, switch to another type of
dressing.
Hydrocolloid dressings
Hydrocolloid dressings are adhesive, mold- Foam dressings
able wafers made of a carbohydrate-based Foam dressings are spongelike polymer
material. They usually have waterproof dressings that may be impregnated or
backings. These dressings are imperme- coated with other materials. They’re some-
able to oxygen, water, and water vapor, what absorptive and may be adherent.
and most have some absorptive proper- These dressings promote moist wound
ties. healing and are useful when a nonadher-
ent surface is desired.
Transparent film dressings
Transparent film dressings are clear, Hydrogel dressings
adherent, and nonabsorptive. These Water-based and nonadherent, hydrogel
polymer-based dressings are permeable to dressings are polymer-based dressings
oxygen and water vapor but not to water. that have some absorptive properties.
Their transparency allows inspection of They’re available as a gel in a tube, as
the wound. Because they can’t absorb flexible sheets, and as saturated gauze
drainage, they’re used on partial-thickness packing strips. They may have a cooling
wounds with minimal exudate. effect that eases pain, and they’re used
when the wound needs moisture.
Applying a hydrogel dressing surrounding intact skin can become

◆ Irrigate the pressure ulcer with nor- macerated.
mal saline solution. Blot the surround- ◆ Hydrogel dressings also come in a
ing skin dry. prepackaged, saturated gauze for
◆ Apply gel to the wound bed. wounds that require “dead space” to
◆ Cover the area with a secondary be filled. Follow the manufacturer’s di-
dressing. rections for usage.
◆ Change the dressing daily or as
needed to keep the wound bed moist. Preventing pressure ulcers
◆ If the dressing that you select comes ◆ Turn and reposition the patient
in sheet form, cut the dressing to every 1 to 2 hours, unless contraindi-
match the wound base. Otherwise, the cated. For a patient who can’t turn
Preventing skin tears
As aging occurs, the skin becomes more ◆ using nonadhering dressings or those
prone to tearing. By taking these precau- with minimal adherent, such as paper
tions, you can substantially reduce a pa- tape, and using a skin barrier wipe before
tient’s risk. applying dressings
Prevent skin tears by: ◆ removing tape carefully
◆ using proper techniques for lifting, posi- ◆ using wraps, such as a stockinette or
tioning, transferring, and turning the pa- soft gauze, to protect areas of skin where
tient to reduce or eliminate friction or the risk of tearing is high
shear ◆ telling the patient to avoid sudden or
◆ padding support surfaces where risk is sharp movements that can pull the skin
greatest such as bed rails and limb sup- and possibly cause a skin tear
ports on a wheelchair ◆ applying moisturizing lotion twice daily
◆ using pillows or cushions to support the to areas at risk.
patient’s arms and legs
◆ telling the patient to add protection by
wearing long-sleeved shirts and long
pants, as weather permits
himself or who’s turned on a schedule, patient and his family. Encourage their
use a pressure-reducing device, such as participation in the treatment and pre-
air, gel, or a 4 (10 cm) foam-mattress vention of pressure ulcers by having
overlay. Low- or high-air-loss therapy them perform a position change cor-
may be indicated to reduce excessive rectly after you’ve demonstrated how.
pressure and promote evaporation of ◆ Avoid placing the patient directly on
excess moisture. As appropriate, imple- the trochanter. Instead, place him on
ment active or passive range-of-motion his side at about a 30-degree angle.
exercises to relieve pressure and pro- ◆ Except for brief periods, avoid rais-
mote circulation. To save time, coming the head of the bed more than 30
bine these exercises with bathing, if degrees to prevent shearing pressure.
applicable. ◆ Direct the patient who’s confined to
◆ When turning the patient, lift him a chair or wheelchair to shift his
rather than slide him because sliding weight every 15 minutes to promote
increases friction and shear. Use a blood flow to compressed tissues.
turning sheet and get help from Show a paraplegic patient how to shift
coworkers, if necessary. (See Prevent- his weight by doing push-ups in the
ing skin tears.) wheelchair. If he needs your help, sit
◆ Use pillows to position the patient next to him and help him to shift his
and increase his comfort. Eliminate weight to one buttock for 60 seconds.
wrinkles in the sheets because they Repeat the procedure on the other side.
can increase pressure and cause dis- Provide him with pressure-relieving
comfort. cushions, as appropriate. However,
◆ Post a turning schedule at the pa- avoid seating the patient on a rubber
tient’s bedside. Adapt position changes or plastic doughnut, which can in-
to his needs. Emphasize the impor- crease localized pressure at vulnerable
tance of regular position changes to the points.
◆ Adjust or pad appliances, casts, or fection or cellulitis can lead to sep-

splints, as needed, to ensure proper fit ticemia. Severe erythema may signal
and avoid increased pressure and im- worsening cellulitis, which indicates
paired circulation. that the offending organisms have in-
◆ Tell the patient to avoid heat lamps vaded the tissue and are no longer lo-
and harsh soaps because they dry the calized.
skin. Applying lotion after bathing will
help to keep his skin moist. Also tell Documentation
him to avoid vigorous massage because Record the date and time of initial and
it can damage capillaries. subsequent treatments and note the
◆ If the patient’s condition permits, specific treatment given. Detail the pre-
recommend a diet that includes ade- ventive strategies performed. Docu-
quate calories, protein, and vitamins. ment the location and size (length,
Dietary therapy may involve nutritional width, and depth) of the pressure ul-
consultation and the use of food sup- cer; the color and appearance of the
plements, enteral feeding, or total par- wound bed; the amount, odor, color,
enteral nutrition. and consistency of drainage; and the
◆ If diarrhea develops or if the patient condition of the surrounding skin. Re-
is incontinent, clean and dry the soiled assess pressure ulcers at least weekly.
skin. Then apply a protective moisture Update the care plan as needed.
barrier to prevent skin maceration. Note any change in the condition or
◆ Make sure that the patient and his size of the pressure ulcer and any ele-
family and caregivers learn strategies vation of skin temperature on the clini-
for preventing and treating pressure ul- cal record. Document when the physi-
cers so that they understand the impor- cian was notified of pertinent abnormal
tance of care, the choices that are observations. Record the patient’s tem-
available, the rationales for treatment, perature daily on the graphic sheet to
and their own role in selecting pressure allow easy assessment of body temper-
ulcer prevention goals and shaping the ature patterns.
patient’s care plan.
Special considerations Traumatic wound care

◆ Avoid using elbow or heel protec-
tors that fasten with a single narrow Traumatic wounds include abrasions,
strap. The strap may impair neurovas- lacerations, bites, and penetrating
cular function in the involved hand, wounds. In an abrasion, the skin is
arm, or foot. scraped and partial loss of the skin sur-
◆ Avoid using artificial sheepskin. It face occurs. In a laceration, tearing of
doesn’t reduce pressure, and it may the skin causes jagged, irregular edges.
create a false sense of security. The severity of a laceration depends
◆ Repair of stage III and stage IV ul- on its size, depth, and location. Bite
cers may require surgical intervention wounds may be caused by many types
(such as direct closure, skin grafting, of animals. A penetrating wound can
and flaps), depending on the patient’s occur when a pointed object, such as a
needs. knife or glass fragment, penetrates the
◆ Infection may cause foul-smelling skin.
drainage, persistent pain, severe ery-
thema, induration, and elevated skin
and body temperatures. Advancing in-
Caring for a traumatic wound
When treating a patient with a traumatic wound, begin by assessing the ABCs: airway,
breathing, and circulation. Move on to the wound itself only after the ABCs are stable.
Here are the basic steps to follow in caring for each type of traumatic wound.
Abrasion ◆ Apply antibacterial ointment, as or-

◆ Flush the area of the abrasion with nor- dered, to prevent infection.
mal saline solution or a wound cleaning ◆ Apply a dry sterile dressing over the
solution. wound to absorb drainage and help pre-
◆ Use a sterile 4” 4” gauze pad moist- vent bacterial contamination.
ened with normal saline solution to re-
move dirt or gravel. Gently rub toward the Bite
entry point to work contaminants back out ◆ Immediately irrigate the wound with
the way they entered. copious amounts of normal saline solu-
◆ If the wound is extremely dirty, you tion. Don’t immerse and soak the wound
may need to scrub it with a surgical brush. because this may allow bacteria to float
Be as gentle as possible because this back into the tissue.
process is painful for the patient. ◆ Clean the wound with sterile 4” 4”
◆ Allow a small wound to dry and form a gauze pads and an antiseptic solution such
scab. Cover a larger wound with a nonad- as povidone-iodine.
herent pad or petroleum gauze and a light ◆ Assist with debridement, if ordered.
dressing. Apply antibacterial ointment, if ◆ Apply a loose dressing. If the bite is lo-
ordered. cated on an extremity, elevate the area to
reduce swelling.
Laceration ◆ Ask the patient about the animal that
◆ Moisten a sterile 4” 4” gauze pad bit him to determine whether there’s a
with normal saline solution or a wound risk of rabies. Administer rabies and
cleaning solution. Gently clean the wound, tetanus shots, as needed.
beginning at the center and working out
to approximately 2” (5 cm) beyond the Penetrating wound
edge of the wound. When the pad be- ◆ If the wound is minor, allow it to bleed
comes soiled, discard it and use a new for a few minutes before cleaning it. A
one. Continue until the wound appears larger puncture wound may require irriga-
clean. tion.
◆ If necessary, irrigate the wound with a ◆ Cover the wound with a dry dressing.
50-ml catheter-tip syringe and normal ◆ If the wound contains an embedded
saline solution. foreign object, such as a shard of glass or
◆ Assist the physician in suturing the metal, stabilize the object until the physi-
wound, if necessary; apply sterile strips of cian can remove it. When the object is re-
porous tape if suturing isn’t needed. moved and bleeding is under control,
clean the wound as you would a lacera-
tion.
Equipment and preparation ◆ nonadherent pads ◆ petroleum

gauze ◆ antibacterial ointment ◆
Sterile basin ◆ normal saline solution 50-ml catheter-tip syringe ◆ porous
◆ sterile 4 4 gauze pads ◆ sterile tape ◆ linen-saver pad
gloves ◆ clean gloves ◆ surgical brush
Place a linen-saver pad under the

area to be cleaned. Remove any cloth-
ing covering the wound.
Assemble the needed equipment at
the patient’s bedside. Fill a sterile basin
with normal saline solution. Depending
on the nature and location of the
wound, wear sterile or clean gloves to
avoid spreading infection.
Implementation
◆ Administer pain medication, if or-

dered.
◆ Wash your hands and apply appro-
priate protective equipment.
◆ For a description of the specific care
of a traumatic wound, see Caring for a
traumatic wound.
◆ When irrigating a traumatic wound,
avoid using more than 8 psi of pres-
sure. High-pressure irrigation can seri-
ously interfere with healing and allow
bacteria to infiltrate the tissue.
◆ Avoid cleaning a traumatic wound
with alcohol, which causes pain and
tissue dehydration. Avoid using anti-
septics for wound cleaning because
they can impede healing.
◆ Observe the patient for signs and
symptoms of infection, such as warm,
red skin at the site or purulent dis-
charge.
◆ Observe all dressings. If edema is
present, adjust the dressing to avoid
impairing circulation to the area.
Documentation
Document the date and time of the
procedure, the size and condition of
the wound, medication administration,
specific wound care measures taken,
and patient teaching provided.
10 Precautions
Preventing the spread of infection
Standard precautions 463

Transmission-based precautions 464
Airborne precautions 464
Droplet precautions 464
Contact precautions 465
List of reportable diseases and infections 465
Basic procedures 467
Hand hygiene and hand rubs 467
Putting on and removing a gown 467
Putting on and removing a mask 468
Removing contaminated gloves 468
Discarding contaminated equipment 469
Removing soiled linens 469
Disposing of soiled dressings 469
Discarding disposable equipment 470
Disposing of body fluids 470
462
Standard precautions 463
The Hospital Infection Control Prac- or body fluids, secretions, or excre-

tices Advisory Committee (HICPAC) of tions; also wash your hands before and
the Centers for Disease Control and after providing patient care and after
Prevention (CDC) has developed guide- removing gloves.
lines for isolation precautions in hospi- ◆ Use nonantimicrobial soap for rou-
tals. These guidelines have two levels tine hand washing.
of precautions: ◆ Wear gloves if you will or could
◆ Standard precautions come in contact with blood, speci-
◆ Transmission-based precautions, mens, tissue, body fluids, secretions,
which are further divided into airborne excretions, or contaminated surfaces or
precautions, droplet precautions, and objects.
contact precautions. ◆ Change your gloves between tasks
and procedures performed on the same
patient if you touch anything that
Standard precautions might have a high concentration of mi-
croorganisms. Also change gloves be-
Standard precautions are designed to tween patient contacts to avoid cross-
decrease the risk of transmission of mi- contamination. Remove your gloves
croorganisms from recognized and un- immediately after use and before
recognized sources of infection. They touching noncontaminated areas, and
should be followed at all times and wash your hands. Vinyl and nitrile
with every patient. gloves are available for anyone who’s
HICPAC and the CDC define these allergic to latex.
materials as infectious, and standard ◆ Wear a gown, eye protection (gog-
precautions must be observed: gles or glasses), and a mask during
◆ blood procedures (such as extubation,
◆ body fluids, secretions, and excre- surgery, endoscopic procedures, and
tions (except sweat) dialysis) that are likely to generate
◆ nonintact skin droplets of blood or body fluids, secre-
◆ mucous membranes. tions, or excretions.
Standard precautions combine the ◆ Carefully handle used patient care
major features of universal precautions, equipment that’s soiled with blood,
which were developed specifically to re- body fluids, secretions, or excretions to
duce the transmission of blood-borne prevent exposure to skin and mucous
pathogens, such as human immunodefi- membranes, contamination of clothing,
ciency virus and hepatitis B virus (HBV), and transfer of microorganisms to oth-
and body substance isolation, which er patients and environments. Patient
was developed to decrease the risk of care equipment must be cleaned with a
transmission of pathogens from moist facility-approved disinfectant between
body surfaces. Because standard precau- patients. Discard disposable equipment
tions reduce the risk of transmission of appropriately.
blood-borne and other pathogens, many ◆ Make sure that procedures for rou-
patients with diseases or conditions that tine care, cleaning, and disinfection of
previously required category- or disease- environmental surfaces and equipment
specific isolation precautions now re- are followed.
quire only standard precautions. ◆ Keep contaminated linens away
from your body to prevent contamina-
Implementation tion and transfer of microorganisms.
◆ Wash your hands immediately if Place linens in properly labeled con-
they become contaminated with blood tainers and make sure that the linens
464 Precautions
are transported and processed accord- wound infections (contact). In fact,

ing to facility policy. transmission-based precautions replace
◆ Handle used needles and other all older categories of isolation. One or
sharps carefully. Don’t bend them, more types of transmission-based pre-
break them, reinsert them into their cautions may be combined and fol-
original sheaths, or handle them un- lowed when a patient has a disease
necessarily. Immediately after use, dis- with multiple routes of transmission.
card them intact in an impervious dis-
posal box. These measures reduce the Airborne precautions
risk of accidental injury and infection.
◆ Use sharps with safety features Along with standard precautions, fol-
whenever available. low these precautions:
◆ Use mouthpieces, resuscitation ◆ Place the patient in a private room
bags, or other ventilation devices in that has monitored negative air pres-
place of mouth-to-mouth resuscitation sure in relation to surrounding areas, 6
whenever possible. to 12 air exchanges per hour, and ap-
◆ Place the patient who can’t maintain propriate outdoor air discharge or high-
appropriate hygiene or who contami- efficiency filtration of room air. The
nates the environment in a private room door should remain closed. If a
room. Notify infection control personnel. private room isn’t available, consult
◆ If you have an exudative lesion, with infection control personnel. As an
avoid direct patient contact until the alternative, he may be placed in a
condition has resolved and the employ- room with a patient who has an active
ee health provider clears you. infection with the same microorgan-
◆ Because precautions can’t be speci- ism.
fied for every clinical situation, use ◆ Wear respiratory protection, such as
your judgment in individual cases. Re- a surgical mask or N-95 respirator (for
fer to your facility’s infection control tuberculosis [TB]), when entering the
manual or check with infection control room of a patient with a known or sus-
personnel when you need more infor- pected respiratory tract infection. Per-
mation. sons immune to measles and varicella
◆ If occupational exposure to blood is don’t need to wear respiratory protec-
likely, get vaccinated with the HBV tion when entering the room of a pa-
vaccine series. tient with these illnesses.
◆ Limit patient transport and move-
ment out of the room. If the patient
Transmission-based precautions must leave the room, have him wear a
surgical mask.
Whenever a patient is known or sus-
pected to be infected with highly conta- Droplet precautions
gious or epidemiologically important
pathogens that are transmitted by air, In addition to standard precautions,
droplet, or contact with dry skin or oth- follow these precautions:
er contaminated surfaces, follow trans- ◆ Place the patient in a private room.
mission-based precautions along with If a private room isn’t available, con-
standard precautions. Examples of such sult with infection control personnel.
pathogens include those that cause As an alternative, he may be placed in
measles (air); influenza (droplet); and a room with a patient who has an
GI tract, respiratory tract, skin, and active infection with the same
Transmission-based precautions 465
microorganism. Special ventilation isn’t Contact precautions

necessary.
◆ Wear a mask when working within In addition to standard precautions,
3⬘ (0.9 m) of the infected patient. For a follow these precautions:
patient with known TB, it’s necessary ◆ Place the patient in a private room.
to wear an N-95 respirator. If a private room isn’t available, con-
◆ Instruct visitors to stay at least 3⬘ sult with infection control personnel.
away from the infected patient. As an alternative, he may be placed in
◆ Limit movement of the patient from a room with a patient who has an ac-
the room. If the patient must leave the tive infection with the same micro-
room, have him wear a surgical mask. organism.
◆ Wear gloves whenever you enter
N-95 respirator the patient’s room. Always change
You’re required to wear a mask, called them after contact with infected mater-
a respirator, when caring for a patient ial. Remove them before leaving the
with known or suspected infectious room. Wash your hands immediately
pulmonary TB. The specific type that with an antimicrobial soap, or rub
the National Institute for Occupational them with a waterless antiseptic.
Safety and Health and the Occupation- Then, avoid touching contaminated
al Safety and Health Administration surfaces.
has approved for this purpose is the ◆ Wear a gown when entering the pa-
N-95 respirator. This type of respirator tient’s room if you think your clothing
effectively protects and screens the will have extensive contact with him or
wearer from at least 95% of particles anything in his room or if he has diar-
the size of the TB droplet nuclei, if the rhea or is incontinent. Remove the
respirator fits correctly and there’s gown before leaving the room and
minimal face-seal leakage. Fit testing, wash your hands.
which detects such leakage, is manda- ◆ Limit the patient’s movement from
tory when a respirator is first given to the room, and check with infection
an employee. Make sure you wash control personnel whenever he must
your hands before and after handling leave it.
the mask.
List of reportable diseases and infections
The Centers for Disease Control and Pre- authorities. These authorities notify the
vention (CDC), the Occupational Safety state health department, which reports
and Health Administration, the Joint Com- the diseases to the appropriate federal
mission on Accreditation of Healthcare Or- agency or national organization.
ganizations, and the American Hospital Here is the CDC’s list of nationally no-
Association all require health care facili- tifiable infectious diseases for 2009. Each
ties to document and report certain dis- state also keeps a list of reportable dis-
eases acquired in the community or in eases appropriate to its region.
hospitals and other health care facilities.
Generally, the health care facility re-
ports diseases to the appropriate local
(continued)
466 Precautions
List of reportable diseases and infections (continued)
◆ Acquired immunodeficiency syndrome ◆ Plague

◆ Anthrax ◆ Poliomyelitis (paralytic)
◆ Arboviral neuroinvasive and nonneu- ◆ Psittacosis (ornithosis)
roinvasive diseases ◆ Q fever
◆ Botulism (food-borne, infant, other ◆ Rabies (animal, human)
[wound and unspecified]) ◆ Rocky Mountain spotted fever
◆ Brucellosis ◆ Rubella (German measles) and congen-
◆ Chancroid ital syndrome
◆ Chlamydia trachomatis, genital infections ◆ Salmonellosis
◆ Cholera ◆ Severe acute respiratory syndrome-
◆ Coccidioidomycosis associated coronavirus
◆ Cryptosporidiosis ◆ Shigatoxin-producing Escherichia coli
◆ Cyclosporiasis ◆ Shigellosis
◆ Diphtheria ◆ Smallpox
◆ Ehrlichiosis/anaplasmosis (human ◆ Streptococcal disease, invasive,
granulocytic, human monocytic, human group A
[other or unspecified agent]) ◆ Streptococcal toxic shock syndrome
◆ Giardiasis ◆ Streptococcus pneumoniae, drug-
◆ Gonorrhea resistant, invasive disease
◆ Haemophilus influenzae, invasive disease ◆ Streptococcus pneumoniae, invasive, in
◆ Hansen’s disease (leprosy) children ages younger than age 5
◆ Hantavirus pulmonary syndrome ◆ Syphilis (primary, secondary, latent,
◆ Hemolytic uremic syndrome, postdiar- early latent, late latent, latent unknown
rheal duration, neurosyphilis, late nonneuro-
◆ Hepatitis, viral, acute (hepatitis A acute, logic, syphilitic stillbirth)
hepatitis B acute, hepatitis B virus perina- ◆ Syphilis, congenital
tal infection, hepatitis C acute) ◆ Tetanus
◆ Hepatitis, viral, chronic (chronic hepati- ◆ Toxic shock syndrome (other than
tis B, hepatitis C virus infection [past or Streptococcus bacteria)
current]) ◆ Trichinosis
◆ Human immunodeficiency virus ◆ Tuberculosis
◆ Influenza-associated pediatric ◆ Tularemia
mortality ◆ Typhoid fever
◆ Legionella infections (legionnaires’ ◆ Vancomycin-intermediate Staphylo-
disease) coccus aureus
◆ Listeriosis ◆ Vancomycin-resistant Staphylococcus
◆ Lyme disease aureus
◆ Malaria ◆ Varicella (morbidity)
◆ Measles ◆ Varicella (deaths only)
◆ Meningococcal disease ◆ Vibriosis
◆ Mumps ◆ Yellow fever
◆ Novel influenza A virus infections
◆ Pertussis
Basic procedures
Hand hygiene and hand rubs
In 2002, the Centers for Disease Control agent or an antiseptic agent, hand wash-
and Prevention (CDC) published its Guide- ing is still the single most effective
line for Hand Hygiene in Health Care Set- method for preventing the spread of in-
tings. Hand hygiene is a general term that fection.
refers to hand washing, antiseptic hand
washing, antiseptic hand rubs, and surgi- Hand rubs
cal hand antisepsis. Hand hygiene also includes the use of
rubs or hand sanitizers. An antiseptic
Hand washing hand rub involves applying an antiseptic,
Redefined by the CDC guideline, hand alcohol-containing product that’s designed
washing refers to washing the hands with to reduce the number of viable microor-
plain (such as nonantimicrobial) soap and ganisms on the skin, to all surfaces of the
water. The use of an antiseptic agent hands and rubbing until the product has
(such as chlorhexidine, triclosan, or dried (usually within 30 seconds). These
iodophor) to wash the hands is an anti- products are also referred to as waterless
septic hand wash. Hand washing is ap- antiseptic agents because no water is re-
propriate whenever the hands are soiled quired. Alcohol hand rubs usually contain
or contaminated with infectious material. emollients to prevent skin drying and
Surgical personnel perform surgical hand chapping. Hand rubs and sanitizers are
antisepsis preoperatively to eliminate appropriate for decontaminating the
transient bacteria and reduce resident hands after minimal contamination has
hand flora. Whether it involves a plain occurred.
Putting on and removing a gown ◆ Because the outside surfaces of the

barrier clothing are contaminated, keep
Handling isolation clothing properly is your gloves on when taking the cloth-
an important part of protecting yourself ing off.
and avoiding contamination. Follow ◆ First, untie the waist strings of the
these steps when using a gown. gown and then untie the neck straps.
Grasp the outside of the gown at the
Implementation back of the shoulders and pull it down
◆ Put on the gown and wrap it over your arms, turning it inside out to
around the back of your clothing. contain pathogens as you remove it.
◆ Tie the strings or fasten the snaps ◆ Holding the gown well away from
or pressure-sensitive tabs at the neck. you, fold it inside out. Discard the
◆ Make sure that your clothing is gown in the laundry if it’s cloth and in
completely covered and secure the a trash container if it’s paper. Wash
gown at the waist. Put on your your hands.
gloves.
468 Precautions
Putting on and removing a mask ◆ Pull downward so that the glove

turns inside out as it comes off, as
Wear a face mask to avoid inhaling air- shown below. Keep the glove from
borne particles. Follow these steps your dominant hand in your nondomi-
when using a mask. nant hand after removing it.
Implementation
◆ Wash your hands. Place the mask
snugly over your nose and mouth. Se-
cure the ear loops or tie the strings be-
hind your head high enough so that
the mask won’t slip off.
◆ If the mask has a metal strip,
squeeze it to fit your nose firmly but
comfortably. If you wear eyeglasses,
tuck the mask under their lower edge.
◆ To remove your mask, untie it,
holding it by the strings, or slip the ear
loops off the ears. Discard it in the
trash container. (If the patient’s disease ◆ Insert the first two fingers of your
is spread by airborne pathogens, con- ungloved dominant hand under the
sider removing the mask last.) edge of the nondominant glove, as
shown below. Avoid touching the outer
Removing contaminated gloves surface of the glove or folding it
against the wrist of your nondominant
To prevent the spread of pathogens hand.
from contaminated gloves to your skin,
carefully follow these steps.
Implementation
◆ Using your nondominant hand,
pinch the glove of the dominant hand
near the top, as shown below. Don’t
allow the outer surface of the glove to
buckle inward against your skin.
◆ Pull downward so that the glove

turns inside out as it comes off, as
shown at the top of the next column.
Continue pulling until the glove com-
pletely encloses the glove from your
dominant hand and has its uncontami-
nated inner surface facing out.
the fabric so that the soiled areas are

on the inside of the folds. Then roll or
fold the linens together in one bundle.
◆ When carrying linens, hold them
away from your body to avoid contam-
inating your clothes.
◆ Bag the linens in the patient’s room
as soon as possible. Avoid placing
them on chairs, tables, or the floor.
Don’t sort or rinse linens in patient
care areas. Place soiled linens in
leakproof bags.
◆ After you put the linens in the bag,
close the bag securely. Then remove
your gloves and wash your hands be-
◆ Discard the gloves in the appropri- fore carrying the bag to its appropriate
ate trash container and wash your destination.
hands.
Disposing of soiled dressings
Discarding contaminated
equipment ◆ Dispose of all wound dressings in a
way that confines and contains blood
To protect yourself and the patient or body fluids. Avoid touching soiled
from infection, observe precautions areas on the dressing.
when disposing of soiled linens or ◆ Usually, you must wear nonsterile
dressings, used disposable equipment, gloves to handle and remove soiled
and contaminated reusable equipment. dressings. If the wound is large and
Have a biohazard container available, draining, you’ll also need to wear a
as needed, to dispose of contaminated gown.
waste.
Regulations for the disposal of con- Large dressings
taminated waste vary from state to ◆ Immediately after removing a large
state and may change periodically. Fol- dressing, fold the dressing inward to
low facility policy for discarding conta- enclose the soiled areas.
minated waste. ◆ Wrap the large dressing in the dis-
posable linen-saver pad used during
Removing soiled linens the dressing change.
◆ Dispose of the dressing in a red-
◆ All linens used in patient care set- bagged biohazard container if the
tings are considered soiled. If you’re dressing is saturated with blood. Other-
handling visibly soiled linens, wearing wise, it can be disposed of in the regu-
gloves is recommended. If the bed lar trash container.
linens are saturated with blood, feces, ◆ Remove the gloves and wash your
urine, or other body fluids, it’s also hands.
recommended that you wear a gown.
◆ Handle linens as little as possible Small dressings
and with minimum agitation to prevent ◆ When removing a small dressing,
contaminating yourself. If certain areas enclose it in the disposable glove that
of the linens are heavily soiled, fold you used to remove it. Holding the
470 Precautions
dressing in your gloved hand, pull the

glove off with the inside surface facing
out to contain the dressing. Don’t
touch the dressing with your bare
hands.
◆ After you’ve sealed the dressing in-
side the disposable glove, discard both
gloves and the dressing in the trash
container in the patient’s room. Wash
your hands.
Discarding disposable equipment
◆ When disposing of a sharp object

that’s contaminated with potentially in-
fectious materials, place it in an ap-
proved sharps container. Other contam-
inated disposable items should be
placed in a red-bagged biohazard con-
tainer if they contain large amounts of
blood. Items with small amounts of
dried blood can be disposed of in the
regular trash container.
◆ When transporting a waste bag,
hold it away from your body to prevent
inadvertent injury from sharp objects
that may protrude through the bag.
Wash your hands after handling
equipment.
Disposing of body fluids
◆ Check facility policy before han-

dling infectious waste. Large amounts
of secretions, excretions, or bulk blood
may be carefully poured into a sanitary
sewer. If you pour fluids into a hopper,
you’re required to wear a splash
guard as well as personal protective
equipment.
11 Troubleshooting
Spotting and correcting
equipment problems
I.V. equipment 472

Peripheral I.V. lines 472
Central venous lines 477
Infusion control devices 480
I.V. flow rates 481
Infusion interruptions 483
Implanted ports 484
Cardiovascular monitors and devices 485
Blood pressure readings 485
Cardiac monitors 486
Intra-aortic balloon pumps 488
Pacemakers 490
Arterial lines 492
Arterial line, accidental removal of 495
Respiratory monitors and devices 495
Pulse oximeters 495
Sv–O2 monitors 496
Ventilators 498
Endotracheal or tracheostomy tube,
accidental removal of 500
Chest drains 501
GI tubes 502
Nasoenteric-decompression tubes 502
T tubes 502
Total parenteral nutrition setups 503
Tube feedings 504
Neurologic monitors 505
Damped ICP waveforms 505
Bispectral index monitoring 506
Troubleshooting sensor problems 506
471
472 Troubleshooting
I.V. equipment
Peripheral I.V. lines

SIGNS AND POSSIBLE INTERVENTIONS
SYMPTOMS CAUSES
Local complications
Phlebitis ◆ Poor blood flow ◆ Remove the venipuncture de-
◆ Tenderness at the around the venipuncture vice.
tip of and above the device ◆ Apply warm soaks. Elevate the
venipuncture device ◆ Tip of the catheter extremity if edema is present.
◆ Redness at the tip located next to the vessel ◆ Notify the physician. Document
of the catheter and wall the patient’s condition and your
along the vein ◆ Friction from move- interventions.
◆ Puffy area over the ment of the catheter in PREVENTION
vein the vein ◆ Restart the infusion according
◆ Vein hard on ◆ Venipuncture device to facility policy, preferably in the
palpation left in the vein too long other arm, using a larger vein for
◆ Possible fever ◆ Clotting at the catheter an irritating solution, or restart
tip (thrombophlebitis) with a smaller-gauge device to en-
◆ Drug or solution with sure adequate blood flow.
a high or low pH or high ◆ Tape the device securely to pre-
osmolarity vent motion.
Extravasation ◆ Venipuncture device ◆ Remove the venipuncture

◆ Swelling at and dislodged from the vein device. Notify the physician and
above the I.V. site or perforated vein follow facility policy.
(may extend along the ◆ Vesicant in the tissue ◆ Monitor the patient’s pulse and
entire limb) capillary refill time.
◆ Discomfort, burn- ◆ Restart the infusion in another
ing, or pain at the site limb.
(but may be painless) ◆ Notify the physician. Document
◆ Tight feeling at the the patient’s condition and your
site interventions.
◆ Decreased skin PREVENTION
temperature around ◆ Check the site often.
the site ◆ Don’t obscure the area above
◆ Blanching at the the site with tape.
site ◆ Teach the patient to observe
◆ Continuing fluid the I.V. site and advise him to re-
infusion even when port pain or swelling.
the vein is occluded
(although the rate
may decrease)
Catheter ◆ Loosened tape or tub- ◆ Remove the I.V. catheter.

dislodgment ing snagged in the bed PREVENTION
◆ Catheter partially linens, resulting in partial ◆ Tape the venipuncture device
backed out of the vein retraction of the catheter securely on insertion.
◆ Solution infiltrating ◆ Catheter pulled out by
the tissue a confused patient
I.V. equipment 473
Peripheral I.V. lines (continued)

SYMPTOMS CAUSES
Local complications (continued)

Occlusion ◆ I.V. flow interrupted ◆ Use a mild flush injection. Don’t
◆ I.V. fluid that ◆ Saline lock not flushed force it. If you’re unsuccessful,
doesn’t flow ◆ Backflow of blood in reinsert the I.V. line.
the line when the patient PREVENTION
walks ◆ Maintain the I.V. flow rate.
◆ Line clamped too long ◆ Flush the line before and after
intermittent piggyback administra-
tion, according to facility policy.
◆ Have the patient walk with his
arm folded to his chest to reduce
the risk of blood backflow.
Vein irritation or ◆ Solution with a high ◆ Decrease the flow rate.

pain at the I.V. site or low pH or high osmo- ◆ Try using an electronic flow
◆ Pain during infu- larity, such as 40 mEq/L device to achieve a steady flow.
sion of potassium chloride, ◆ Change the I.V. site.
◆ Possible blanching phenytoin, and some an- PREVENTION
if vasospasm occurs tibiotics (erythromycin, ◆ Dilute the solutions before
◆ Red skin over the nafcillin, and vancomycin) administration. For example, give
vein during infusion antibiotics in a 250-ml solution
◆ Rapidly developing rather than a 100-ml solution.
signs of phlebitis ◆ If long-term therapy with an ir-
ritating drug is planned, ask the
physician to use a central I.V. line.
Severed catheter ◆ Catheter inadvertently ◆ If a broken part is visible, at-

◆ Leakage from the cut by scissors tempt to retrieve it. If you’re un-
catheter shaft ◆ Reinsertion of the nee- successful, notify the physician.
dle into the catheter ◆ If a portion of the catheter en-
ters the bloodstream, place a
tourniquet above the I.V. site to
prevent progression of the broken
part. Immediately notify the physi-
cian and radiology department.
◆ Document the patient’s condi-
tion and your interventions.
PREVENTION
◆ Don’t use scissors around the
I.V. site.
◆ Never reinsert a needle into the
catheter.
◆ Remove an unsuccessfully
inserted catheter and needle
together.
(continued)
474 Troubleshooting

SYMPTOMS CAUSES

Hematoma ◆ Vein punctured ◆ Remove the venipuncture de-
◆ Tenderness at the through the opposite wall vice and restart the infusion in the
venipuncture site at the time of insertion opposite limb.
◆ Bruised area ◆ Leakage of blood into ◆ Apply pressure and cold com-
around the site the tissue presses to the affected area.
◆ Recheck the site for bleeding.
◆ Document the patient’s condi-
tion and your interventions.
PREVENTION
◆ Choose a vein that can accom-
modate the size of the venipunc-
ture device.
◆ Release the tourniquet as soon
as a successful insertion is
achieved.
Venous spasm ◆ Severe vein irritation ◆ Apply warm soaks over the
◆ Pain along the vein as a result of irritating vein and surrounding area.
◆ Sluggish flow rate drugs or fluids ◆ Decrease the flow rate.
when the clamp is ◆ Administration of cold PREVENTION
completely open fluids or blood products ◆ Use a blood warmer for blood
◆ Blanched skin over ◆ Very rapid flow rate or packed red blood cells.
the vein (with fluids at room tem-
perature)
Vasovagal reaction ◆ Vasospasm as a result ◆ Lower the head of the bed.

◆ Sudden collapse of of anxiety or pain ◆ Have the patient take deep
the vein during breaths.
venipuncture ◆ Check the patient’s vital signs.
◆ Sudden pallor, PREVENTION
sweating, faintness, ◆ To relieve the patient’s anxiety,
dizziness, and nausea prepare him for the procedure.
◆ Decreased blood ◆ Use a local anesthetic to pre-
pressure vent pain.
Thrombosis ◆ Injury to the endothe- ◆ Remove the venipuncture de-

◆ Painful, reddened, lial cells of the vein wall, vice. Restart the infusion in the
and swollen vein allowing platelets to ad- opposite limb, if possible. Notify
◆ Sluggish or here and thrombi to form the physician.
stopped I.V. flow ◆ Apply warm soaks.
◆ Watch for an I.V. therapy-
related infection.
PREVENTION
◆ Use proper venipuncture tech-
niques to reduce injury to the vein.
I.V. equipment 475

SYMPTOMS CAUSES

Thrombophlebitis ◆ Thrombosis and in- ◆ Follow the interventions for
◆ Severe discomfort flammation thrombosis. Notify the physician.
at the site PREVENTION
◆ Reddened, swollen, ◆ Check the site frequently. Re-
and hardened vein move the venipuncture device at
the first sign of redness and ten-
derness.
Nerve, tendon, or ◆ Improper venipuncture ◆ Stop the procedure.

ligament damage technique, resulting in in- PREVENTION
◆ Extreme pain (simi- jury to the surrounding ◆ Don’t repeatedly penetrate tis-
lar to electrical shock nerves, tendons, or liga- sues with the venipuncture device.
when the nerve is ments ◆ Don’t apply excessive pressure
punctured), numbness, ◆ Tight taping or im- when taping; don’t encircle the
and muscle contraction proper splinting with an limb with tape.
◆ Delayed effects, in- arm board ◆ Pad the arm boards and the
cluding paralysis, tape securing the arm boards, if
numbness, and defor- possible.
mity
Systemic complications
Circulatory ◆ Roller clamp loosened ◆ Raise the head of the bed.
overload to allow run-on infusion ◆ Administer oxygen, if needed.
◆ Discomfort ◆ Flow rate too rapid ◆ Reduce the infusion rate to a
◆ Jugular vein disten- ◆ Miscalculation of fluid keep-vein-open rate and notify
tion requirements the physician.
◆ Respiratory distress ◆ Give drugs as ordered.
◆ Increased blood PREVENTION
pressure ◆ Use a pump, controller, or rate
◆ Crackles minder for an elderly or compro-
◆ Increased difference mised patient.
between fluid intake ◆ Recheck calculations of the
and output patient’s fluid requirements.
◆ Monitor the infusion frequently.
Systemic infection ◆ Failure to maintain ◆ Notify the physician.

(septicemia or aseptic technique during ◆ Administer medications, as
bacteremia) insertion or site care prescribed.
◆ Fever, chills, and ◆ Severe phlebitis, caus- ◆ Culture the site and the device.
malaise for no appar- ing organism growth ◆ Monitor the patient’s vital
ent reason ◆ Poor taping that per- signs.
◆ Contaminated I.V. mits the venipuncture de- PREVENTION
site, usually with no vice to move, introducing ◆ Use scrupulous aseptic tech-
visible signs of infec- organisms into the blood- nique when handling solutions
tion at the site stream and tubing, inserting a venipunc-
ture device, and discontinuing the
infusion.
(continued)
476 Troubleshooting

SYMPTOMS CAUSES
Systemic complications (continued)

Systemic infection ◆ Prolonged indwelling ◆ Secure all connections.
(continued) time ◆ Change the I.V. solutions, tub-
◆ Compromised immune ing, and venipuncture device at the
system recommended times.
Speed shock ◆ Too rapid injection of ◆ Discontinue the infusion.

◆ Flushed face, drug, causing plasma lev- ◆ Begin an infusion of dextrose
headache els to become toxic 5% in water at a keep-vein-open
◆ Tightness in the ◆ Improper administra- rate.
chest tion of a bolus infusion ◆ Notify the physician.
◆ Irregular pulse (especially additives) PREVENTION
◆ Syncope ◆ Check the infusion guidelines
◆ Rapid hypertension before giving a drug.
◆ Shock ◆ Dilute the drug with a compati-
◆ Cardiac arrest ble solution.
Air embolism ◆ Solution container ◆ Discontinue the infusion.

◆ Respiratory distress empty ◆ Place the patient in left lateral
◆ Unequal breath ◆ Tubing disconnected Trendelenburg’s position to allow
sounds air to enter the right atrium and
◆ Chest pain, dyspnea disperse through the pulmonary
◆ Anxiety artery.
◆ Weak, rapid pulse ◆ Administer oxygen.
◆ Increased central ◆ Notify the physician.
venous pressure ◆ Document the patient’s condi-
◆ Decreased blood tion and your interventions.
pressure PREVENTION
◆ Altered conscious- ◆ Purge the tubing of air com-
ness pletely before starting an infusion.
◆ Use the air-detection device on
the pump or an air-eliminating fil-
ter proximal to the I.V. site.
◆ Secure all connections.
Allergic reaction ◆ Allergens such as ◆ If a reaction occurs, stop the in-

◆ Itching medications fusion immediately.
◆ Watery eyes and ◆ Maintain a patent airway.
nose ◆ Notify the physician.
◆ Bronchospasm ◆ Administer an antihistaminic
◆ Wheezing corticosteroid and antipyretic, as
◆ Urticarial rash ordered.
◆ Give 0.2 to 0.5 ml of 1:1,000
aqueous epinephrine subcuta-
neously, as ordered. Repeat every
10 to 15 minutes as needed.
I.V. equipment 477

SYMPTOMS CAUSES
Systemic complications (continued)

Allergic reaction PREVENTION
(continued) ◆ Obtain the patient’s allergy his-
◆ Anaphylactic reac- tory. Look for cross-allergies.
tion, which may occur ◆ Assist with test dosing.
within minutes (flush- ◆ Monitor the patient carefully
ing, chills, anxiety, agi- during the first 15 minutes of ad-
tation, itching, palpita- ministering of a new drug.
tions, paresthesia,
throbbing in the ears,
wheezing, coughing,
seizures, cardiac ar-
rest)
Central venous lines

SYMPTOMS CAUSES
Pneumothorax, ◆ Lung puncture by the ◆ Notify the physician and stop

hemothorax, catheter during insertion the infusion.
chylothorax, or exchange over a guide ◆ Remove the catheter or assist
hydrothorax wire with removal, as ordered.
◆ Chest pain ◆ Large blood vessel ◆ Administer oxygen, as ordered.
◆ Dyspnea puncture with bleeding ◆ Set up and assist with chest
◆ Cyanosis inside or outside the lung tube insertion.
◆ Decreased breath ◆ Lymph node puncture ◆ Document all interventions.
sounds on the affected with leakage of lymph PREVENTION
side fluid ◆ Position the patient head-down
◆ With hemothorax, ◆ Infusion of solution with a rolled towel between his
decreased hemoglobin into the chest area scapulae to dilate and expose the
levels because of through an infiltrated internal jugular or subclavian vein
blood pooling catheter as much as possible during
◆ Abnormal findings catheter insertion.
on chest X-ray ◆ Assess the patient for early
◆ Apprehension signs of fluid infiltration (swelling
in the shoulder, neck, chest, and
arm).
◆ Ensure that the patient is im-
mobilized and prepared for inser-
tion.
◆ Minimize the patient’s activity
after insertion, especially with a
peripheral catheter.
(continued)
478 Troubleshooting
Central venous lines (continued)

SYMPTOMS CAUSES
Air embolism ◆ Intake of air into the ◆ Clamp the catheter immediately.
◆ Respiratory dis- central venous system dur- ◆ Place the patient in left lateral
tress ing catheter insertion or Trendelenburg’s position so that air
◆ Chest pain tubing changes, or inad- can enter the right atrium and pul-
◆ Unequal breath vertent opening, cutting, monary artery. Make sure that he
sounds or breaking of the catheter remains in this position for 20 to
◆ Weak, rapid pulse 30 minutes.
◆ Increased central ◆ Don’t recommend Valsalva’s
venous pressure maneuver because a large air in-
◆ Decreased blood take worsens the condition.
pressure ◆ Administer oxygen.
◆ Churning murmur ◆ Notify the physician.
over the precordium ◆ Document all interventions.
◆ Alteration in con- PREVENTION
sciousness or loss of ◆ Purge all air from the tubing
consciousness before hookup.
◆ Anxiety ◆ Teach the patient to perform
Valsalva’s maneuver during
catheter insertion and tubing
changes.
◆ Use air-eliminating filters or an
infusion device with air-detection
capability.
◆ Use luer-lock tubing, tape the
connections, or use locking devices
for all connections.
Thrombosis ◆ Sluggish flow rate ◆ Notify the physician.

◆ Edema at the ◆ Composition of the ◆ Stop the infusion.
puncture site catheter material (poly- ◆ Infuse a dose of heparin or a
◆ Erythema vinyl chloride catheters are thrombolytic, if ordered.
◆ Ipsilateral swelling more thrombogenic) ◆ Don’t use the limb on the affect-
of the arm, neck, and ◆ Hematopoietic status of ed side for subsequent venipunc-
face the patient ture.
◆ Pain along the ◆ Infusion of irritating so- ◆ Verify thrombosis with diagnos-
vein lutions tic studies.
◆ Fever, malaise ◆ Repeated or long-term PREVENTION
◆ Jugular vein dis- use of the same vein ◆ Verify placement of the catheter
tention ◆ Preexisting cardiovascu- tip in the superior vena cava (SVC)
lar disease before using the catheter. If the tip
◆ Simultaneous adminis- isn’t in the SVC, the catheter
tration of incompatible shouldn’t be used.
medications or inadequate
flushing between adminis-
tration of incompatible
medications
I.V. equipment 479

SYMPTOMS CAUSES
Thrombosis ◆ Irritation of the vein

(continued) during insertion of a cen-
tral venous catheter
◆ Improper location of
catheter in the subclavian
or brachiocephalic vein
Infection ◆ Failure to maintain ◆ Monitor the patient’s tempera-

◆ Redness, warmth, aseptic technique during ture and vital signs frequently.
tenderness, and catheter insertion or care ◆ Culture the site if drainage is
swelling at the inser- ◆ Failure to comply with present.
tion or exit site the dressing-change pro- ◆ Re-dress the site using aseptic
◆ Possible exudate tocol technique.
of purulent material ◆ Wet or soiled dressing ◆ Use an antibiotic ointment local-
◆ Local rash or pus- remaining on the site ly, as needed.
tules ◆ Immunosuppression ◆ Treat the patient systemically
◆ Fever, chills, ◆ Irritated suture line with an antibiotic or an antifungal,
malaise ◆ Contaminated catheter depending on the culture results
◆ Leukocytosis or solution and the physician’s order.
◆ Nausea and vom- ◆ Frequent opening of ◆ Draw central and peripheral
iting the catheter blood cultures; if the same organ-
◆ Elevated urine ism appears in both, then the
glucose level catheter is the primary source of
infection and should be removed.
Staphylococcus epidermidis is the
most common organism.
◆ If the cultures don’t match but
are positive, the catheter may be
removed or the infection may be
treated through the catheter.
◆ Treat the patient with an antibi-
otic, as ordered.
◆ If the catheter is removed, cul-
ture its tip.
◆ Document all interventions.
PREVENTION
◆ Maintain sterile technique using
sterile gloves, masks, and gowns,
when appropriate.
◆ Observe dressing-change
protocols.
(continued)
480 Troubleshooting

SYMPTOMS CAUSES
Infection ◆ Teach the patient about restric-

(continued) tions on swimming, bathing, and
other physical activities.
◆ Change a wet or soiled dress-
ing immediately.
◆ Change the dressing more fre-
quently if the catheter is located in
the femoral area or near a tra-
cheostomy. Perform tracheostomy
care after catheter care.
◆ Examine the solution for
cloudiness and turbidity before in-
fusing; check the fluid container
for leaks.
◆ Monitor the urine glucose level
in the patient who’s receiving total
parenteral nutrition (TPN); if the
level is greater than 2+, he may
have early sepsis.
◆ Use a 1.2-micron filter for
three-in-one TPN solutions.
◆ Change the catheter according
to facility protocol.
◆ Keep the system closed as
much as possible.
Infusion control devices

When the alarm goes off, check for these problems.
PROBLEMS INTERVENTIONS
Air in the line While setting up, make sure that all air is out of the line, including air
trapped in Y-injection sites. Also, check that the connections are se-
cure and that the container is filled properly. Withdraw any air from a
piggyback port with a syringe or an air-eliminating filter. A wet-air
detector may give a false reading.
Infusion Reset the pump, as ordered, or discontinue the infusion. A slow keep-
completed vein-open rate usually keeps the I.V. line patent as long as enough
fluid remains.
I.V. equipment 481
Infusion control devices (continued)
Empty container Check for adequate fluid levels in the I.V. container and have another
container available before the last one runs out.
Low battery Battery life varies; keep the machine plugged in on AC power as much
as possible, especially while the patient is in bed. If the alarm goes
off, plug in the machine immediately, or power may be lost for a while
(usually a half-hour to several hours).
Occlusion Check that all clamps are open, look for kinked tubing, and check the
patency of the venipuncture device.
Rate change Check that the infusion control device displays the ordered rate. The
patient or a family member may have tampered with the controls.
Open door The door should be closed. It may not shut if the device isn’t set up
properly (for example, if the cassette isn’t inserted all the way).
Malfunction A mechanical failure usually must be handled by the biomedical engi-

neering department or the manufacturer. Disconnect the infusion con-
trol device. Label it clearly with a sign that says DO NOT USE, and indi-
cate the specific problem.
I.V. flow rates

PROBLEMS AND INTERVENTIONS
POSSIBLE CAUSES
Flow rate too fast

Clamp manipulated by the Instruct the patient not to touch the clamp and place tape
patient or a visitor over it. Administer the I.V. solution with an infusion pump
or a controller, if necessary. Set the safety on the back of
the pump.
Tubing disconnected from Using alcohol, wipe the distal end of the tubing with luer-
the catheter lock connections. Reinsert the end of the tubing firmly into
the catheter hub and apply tape at the connection site.
Change in the patient’s Use an infusion pump or a controller to ensure the correct
position flow rate.
Flow clamp drifting as a Place tape below the clamp.

result of patient movement
(continued)
482 Troubleshooting
I.V. flow rates (continued)

POSSIBLE CAUSES
Flow rate too slow

Venous spasm after Apply warm soaks over the site.
insertion
Venous obstruction as a Secure the I.V. line with a padded arm board, if necessary.
result of bending the pa- Frequently check the patient’s neurovascular status, and
tient’s arm monitor him according to facility policy.
Pressure change (as a re- Readjust the flow rate.

sult of decreased fluid in
the bottle)
Elevated blood pressure Readjust the flow rate. Use an infusion pump or a con-
troller to ensure the correct rate.
Cold solution Allow the solution to warm to room temperature before

hanging the bag.
Change in the viscosity of Readjust the flow rate.

the solution from an added
drug
I.V. container that’s too Hang the container higher or remind the patient to keep
low or a patient’s arm or his arm below the level of his heart.
leg that’s too high
Excess tubing dangling be- Replace the tubing with a shorter piece or tape the excess
low the insertion site tubing to the I.V. pole below the flow clamp (making sure
that the tubing isn’t kinked).
Venipuncture device that’s Remove the venipuncture device in use and insert a larger-
too small bore venipuncture device, or use an infusion pump.
Infiltration or clotted Remove the venipuncture device in use and insert a new
venipuncture device one.
Kinked tubing Check the tubing over its entire length and unkink it.
Tubing compressed at the Massage or milk the tubing by pinching and wrapping it
clamped area around a pencil four or five times. Then quickly pull the
pencil out of the coiled tubing.
I.V. equipment 483
Infusion interruptions 0.45-micron filter to eliminate air and

microorganisms from the system.
When an infusion stops, assess the I.V. If you use the wrong size or type
system systematically — from the pa- of filter, the solution may not pass
tient to the fluid container — for poten- through it. For example, such drugs as
tial trouble areas. amphotericin B and lymphocyte im-
mune globulin (Atgam) consist of
Check the I.V. site molecules that are too large to pass
Check for infiltration or phlebitis, through a 0.22-micron filter; they
which may slow or stop the flow rate. rapidly block the filter and stop the
I.V. flow. If necessary, replace the
Check for patency filter.
Evaluate the I.V. device for patency The interval between filter changes
and catheter-related complications, is usually every 72 hours, depending
keeping in mind that several factors on the manufacturer’s instructions.
can affect it. Change the filter, if necessary.
◆ Increased blood pressure may stop
the I.V. flow if the patient’s limb is Check the clamps
flexed or is lying directly on the I.V. Make sure that the flow clamps are
site. Reposition the limb as necessary. open. Check all clamps, including the
◆ If the patient’s arm is wrapped with roller clamp and any clamps on sec-
tape, a tourniquet effect may reduce ondary sets such as a slide clamp on a
the I.V. flow rate. Taping the I.V. site filter. A roller clamp may become
too tightly can cause the same prob- jammed if the roller is pushed up too
lem. Release or remove the tape and far.
reapply it.
◆ Local edema or poor tissue perfu- Check the tubing
sion as a result of disease can block Determine if the tubing is kinked or if
the venous flow. Move the I.V. line to the patient is lying on it. Also check
an unaffected site. whether the tubing remains crimped
◆ Infusion of incompatible fluid or where a clamp was tightened around
medication may cause a precipitate to it. If so, gently squeeze the area be-
form. This can block the I.V. tubing tween your fingers to round out the
and venipuncture device and may even tubing to its original shape or change
expose the patient to a life-threatening the tubing altogether.
embolism. Always check the compati-
bility of all medications and the I.V. so- Check the air vents
lution before administering them. Re- If you’re using an evacuated glass con-
place the venipuncture device if it’s oc- tainer, you’ll need an air vent to make
cluded. the I.V. solution flow. Insert one, as
needed. On a volume-control set, the
Check the filter air vent is usually located at the top of
Use filters with total parenteral nutri- the calibrated chamber. If the solution
tion (TPN) and medications that re- flow stops, check the patency of the
quire filtering. Make sure that the in- vent and the position of the vent
line filter is the right size and type. clamp. Follow the manufacturer’s in-
TPN fluids are run through a 0.22- or structions to check the vent’s patency.
484 Troubleshooting
Check the fluid level tration set has been pushed far enough
Observe the fluid level in the I.V. con- into the container to allow the solution
tainer. If the container is empty, re- to flow.
place it, as ordered. If the solution is If you can’t identify the problem
cold, it may be causing venous spasm, with this series of checks, remove the
thus decreasing the flow rate. Applying I.V. line and restart it at a different site.
warm compresses can relieve venous Document the episode in the patient’s
spasm and increase the flow rate. Make chart.
sure that other solutions are given at
room temperature. Finally, check to see
if the spike at the end of the adminis-
Implanted ports
POSSIBLE CAUSES
Inability to flush the

implanted port or with-
draw blood
◆ Kinked tubing or closed ◆ Check the tubing or clamp.
clamp
◆ Incorrect needle place- ◆ Regain access to the device.

ment
◆ Needle not advanced
through the septum
◆ Clot formation ◆ Assess the patency of the device by trying to flush the
implanted port.
◆ Notify the physician and obtain an order for a throm-
bolytic.
◆ Teach the patient to recognize clot formation, to notify
the physician if it occurs, and to avoid forcibly flushing the
implanted port.
◆ Kinked catheter, ◆ Notify the physician immediately.

catheter migration, port ◆ Tell the patient to notify the physician or home care
rotation nurse if he has difficulty using the implanted port.
Inability to palpate the

implanted port
◆ Deeply implanted port ◆ Note the portal chamber scar to locate the correct spot
for palpation.
◆ Use deep palpation to locate the implanted port.
◆ Ask another nurse to locate the implanted port. If you
can’t feel the port, don’t attempt to access it.
◆ Use a 11⁄2⬙ or 2⬙ noncoring needle to gain access to the
implanted port.
Cardiovascular monitors and

devices
Blood pressure readings

POSSIBLE CAUSES
False high reading

Cuff that’s too small Make sure that the bladder of the cuff is 20% wider than
the circumference of the arm or leg that’s being used for
measurement.
Cuff that’s wrapped too Tighten the cuff.

loosely, reducing its effec-
tive width
Slow deflation of the cuff, Never deflate the cuff more slowly than 2 mm Hg per
causing venous congestion heartbeat.
in the arm or leg
Tilted mercury column Read pressures with the mercury column vertical.
Poorly timed measurement Postpone blood pressure measurement or help the patient
(after the patient has eat- to relax before taking pressure measurements.
en, ambulated, appeared
anxious, or flexed his arm
muscles)
False low reading

Incorrect position of the Make sure that the arm or leg is level with the patient’s
arm or leg heart.
Mercury column below eye Read the mercury column at eye level.
level
Failure to notice an auscul- Estimate systolic pressure by palpation before actually

tatory gap (sound fades measuring it. Then check this pressure against the mea-
out for 10 to 15 mm Hg, sured pressure.
then returns)
Inaudible low-volume Before reinflating the cuff, instruct the patient to raise his
sounds arm or leg to decrease venous pressure and amplify low-
volume sounds. After you inflate the cuff, tell the patient to
lower his arm or leg. Then deflate the cuff and listen. If
you still don’t detect low-volume sounds, use Doppler
ultrasonography or chart the palpated systolic pressure
according to facility policy.
486 Troubleshooting
Cardiac monitors
POSSIBLE CAUSES
False high-rate alarm

Monitor is interpreting Reposition the electrodes to the lead where the QRS com-
large T waves as QRS complexes are taller than the T waves.
plexes, which doubles the
rate
Skeletal muscle activity Place the electrodes away from major muscle masses.
False low-rate alarm

Shift in the electrical axis Reapply the electrodes. Set the gain so that the height of
caused by patient move- the complex exceeds 1 mV.
ment, making QRS com-
plexes too small to register
Low amplitude of the QRS Increase the gain.

complex
Poor contact between the Reapply the electrodes.

skin and electrodes
Low amplitude
Gain dial set too low Increase the gain.
Poor contact between skin Check the connections on all lead wires and the monitoring
and electrodes, dried gel, cable. Replace or reapply the electrodes as necessary.
broken or loose lead wires,
poor connection between
the patient and monitor,
malfunctioning monitor,
physiologic loss of ampli-
tude of the QRS complex
Wandering baseline
Poor electrode placement Reposition or replace the electrodes.
or poor skin contact
Movement of the thorax Reposition the electrodes.

with respirations
Artifact
(waveform interference)
Patient having seizures, Notify the physician and treat the patient, as ordered.
chills, or anxiety Keep the patient warm and reassure him.
Cardiac monitors (continued)

POSSIBLE CAUSES
Artifact (continued)
Patient movement Help the patient to relax.
Electrodes applied improp- Check the electrodes and reapply them, if necessary. Make
erly sure the patient’s skin has been prepared properly.
Static electricity Make sure that the cables don’t have exposed connectors.
Change static-causing clothing.
Electrical short circuit in Replace the broken equipment. Use stress loops to apply
the lead wires or cable the lead wires.
Interference from de- Regulate the humidity to 40%.

creased room humidity
Broken lead wires

or cable
Tension on the lead wires Replace and retape the lead wires, taping part of the wire
as a result of repeated into a loop. This absorbs tension that would otherwise tug
pulling at the ends of the wire.
Cables and lead wires Clean the cable and the lead wires with soapy water. Don’t
cleaned with alcohol or let the ends of the cable get wet because an electric shock
acetone, causing brittle- to the patient could occur. Replace the cable as necessary.
ness
60-cycle interference
(fuzzy baseline)
Electrical interference from Attach the electrical equipment to a common ground,
other equipment in the checking the plugs for loose prongs.
room
Patient’s bed improperly Attach the bed ground to the room’s common ground.
grounded
Skin excoriation under

electrode
Patient allergic to the elec- Remove the electrodes and apply hypoallergenic elec-
trode adhesive trodes.
Electrode remaining on the Remove the electrode, clean the site, and reapply the elec-
skin for too long trode at a new site.
488 Troubleshooting
Intra-aortic balloon pumps

When the patient undergoes intra-aortic balloon counterpulsation, you must respond to
equipment problems immediately.

POSSIBLE CAUSES
High gas leakage

Balloon leakage or abrasion Check for blood in the tubing. Stop pumping. Contact the
physician to remove the balloon. The catheter should be
removed within 30 minutes.
Condensation in the exten- Remove the condensate from the tubing and the volume-
sion tubing, volume-limiter limiter disk. Refill, autopurge, and resume pumping.
disk, or both
Kink in the balloon catheter Check the catheter and tubing for kinks and loose con-
or tubing nections. Refill and resume pumping.
Tachycardia (rapid flow of he- Change the wean control to 1:2, or operate in ON, or
lium, causing insufficient fill manual, mode. Note: Gas alarms are off in manual mode.
pressure) Autopurge the balloon every 1 to 2 hours and monitor
the balloon pressure waveform closely.
Malfunctioning or loose vol- Replace or tighten the volume-limiter disk. Refill, auto-
ume-limiter disk purge, and resume pumping.
System leak Perform a leak test.
Balloon line block

(automatic mode only)
Kink in the balloon catheter Check the catheter and tubing for kinks. Refill and re-
or tubing sume pumping.
Balloon catheter not unfurled; Contact the physician to verify placement; the balloon
sheath or balloon positioned may need to be repositioned or inflated manually.
too high
Condensation in the tubing, Remove the condensate from the tubing and volume-
volume-limiter disk, or both limiter disk. Refill, autopurge, and resume pumping.
Balloon too large for the Decrease the volume-control percentage by one notch.
aorta
Malfunctioning volume- Replace the volume-limiter disk. Refill, autopurge, and

limiter disk or incorrect resume pumping.
volume-limiter disk size
Intra-aortic balloon pumps (continued)

POSSIBLE CAUSES
No electrocardiogram (ECG)
trigger
Inadequate signal Adjust the ECG gain and change the lead or the trigger
mode. Replace the lead.
Lead disconnected Replace the lead.
Improper ECG input mode Adjust the ECG input to the appropriate mode (skin or
(skin or monitor) selected monitor). Apply new electrodes, as needed.
No arterial pressure
trigger
Arterial line damped Flush the line.
Arterial line open to the at- Check the connections on the arterial pressure line.
mosphere
Trigger mode change

Trigger mode changed while Resume pumping.
pumping
Irregular heart rhythm

Patient’s rhythm is irregular Change to R or QRS sense, if necessary, to accommodate
(such as atrial fibrillation or the irregular rhythm.
ectopic beats)
Erratic atrioventricular
pacing
Demand for paced rhythm Change to the pacer reject trigger or QRS sense.
occurs during atrioventricular
sequential trigger mode
Noisy ECG signal

Malfunctioning leads Replace the leads; check the ECG cable and electrodes.
Electrocautery in use Switch to the arterial pressure trigger.
Internal trigger Select an alternative trigger if the patient has a heartbeat

Trigger mode set on internal or rhythm. Caution: Use an internal trigger only during
80 beats/minute cardiopulmonary bypass surgery or cardiac arrest.
Purge incomplete Initiate autopurge again or initiate pumping.

OFF button pressed during
autopurge, interrupting the
purge cycle
(continued)
490 Troubleshooting
Intra-aortic balloon pumps (continued)

POSSIBLE CAUSES
High fill pressure

Malfunctioning volume- Replace the volume-limiter disk. Refill, autopurge, and
limiter disk resume pumping.
Occluded vent line or valve Attempt to resume pumping. If this doesn’t correct the
problem, contact the manufacturer.
No balloon drive
No volume-limiter disk Insert the volume-limiter disk and lock it securely in
place.
Tubing disconnected Reconnect the tubing. Refill, autopurge, and pump.
Incorrect timing
INFLATE and DEFLATE controls Place the INFLATE and DEFLATE controls at set midpoints.
set improperly Reassess the timing and readjust.
Low volume percentage

Volume-control percentage Assess the cause of the decreased volume and reset, if
not set on 100% necessary.
Pacemakers
Life-threatening arrhythmias can result when the patient’s pacemaker sends an impulse
that’s too weak to stimulate the heart (failure to capture). Furthermore, the pacemaker
may not detect ventricular depolarization (failure to sense) or may not send an impulse
at all (failure to fire). Below are rhythm strips that compare these problems with a nor-
mal wave strip as well as lists of possible causes and interventions.
Normal
The location of the spike is your first clue that the pacemaker is functioning normally.
Pacemakers (continued)
Failure to capture
Causes Interventions
◆ Pacemaker output too low ◆ Increase the pacemaker output.
◆ Catheter dislodged ◆ Reposition the catheter.
◆ Loose connections ◆ Secure all connections.
Failure to sense
◆ Incorrect sensitivity setting ◆ Adjust the sensitivity setting.
Failure to fire
◆ Loose lead hookups ◆ Secure the lead hookups.
◆ Dead battery ◆ Replace the battery.
◆ Malfunctioning pulse generator ◆ Replace the pulse generator.
492 Troubleshooting
Arterial lines
PROBLEMS POSSIBLE CAUSES INTERVENTIONS
Damped waveform Air in the system Check the system for air, paying particu-
Appearing as a small lar attention to the tubing and the di-
waveform with a aphragm of the transducer. If you find
slow rise in the air, aspirate it or force it from the sys-
anacrotic limb and a tem through a stopcock port. Never
reduced or nonexis- flush a fluid that contains air bubbles
tent dicrotic notch, a into a patient.
damped waveform
may result from in- Loose connection Check and tighten all connections.
terference with the
transmission of the Clotted catheter tip Attempt to aspirate the clot. If you’re
physiologic signal to successful, flush the line. If you’re unsuc-
the transducer. cessful, avoid flushing the line because
you could dislodge the clot.
Catheter tip resting Reposition the catheter by carefully ro-

against the arterial tating it or pulling it back slightly. Antici-
wall pate a possible change in the catheter
placement site and assist, as appropri-
ate.
Kinked tubing Unkink the tubing.
Inadequately inflated Inflate the pressure infuser bag to

pressure infuser bag 300 mm Hg.
Drifting waveform Temperature change Allow the temperature of the flush solu-
Waveform floats in the flush solution tion to stabilize before the infusion.
above and below the
baseline. Kinked or com- Check the cable and relieve the kink or
pressed monitor compression.
cable
Inability to flush Incorrectly positioned Reposition the stopcocks properly.

the arterial line or stopcocks
to withdraw blood
Activating the contin- Kinked tubing Unkink the tubing.
uous flush device
doesn’t move the Inadequately inflated Inflate the pressure infuser bag to
flush solution, and pressure infuser bag 300 mm Hg.
blood can’t be with-
drawn from the Clotted catheter tip Attempt to aspirate the clot. If you’re
stopcock. successful, flush the line. If you’re unsuc-
cessful, avoid flushing the line because
Arterial lines (continued)
Inability to flush Catheter tip resting Reposition the catheter insertion area
the arterial line or against the arterial and flush the catheter. Alternatively,
to withdraw blood wall reposition the catheter by carefully rotat-
(continued) ing it or pulling it back slightly.
Position of the inser- Check the position of the insertion area

tion area and change it, as indicated. For radial
and brachial arterial lines, use a padded
arm board to immobilize the area ac-
cording to facility policy. With a femoral
arterial line, keep the head of the bed at
a 45-degree angle or less to prevent the
catheter from kinking.
Artifact Electrical interference Check the electrical equipment in the

Waveform tracings room.
follow an erratic
pattern or don’t ap- Patient movement Ask the patient to lie quietly while you
pear as a recogniz- try to read the monitor.
able diagnostic pat-
tern. Catheter whip or fling Shorten the tubing, if possible.
(excessive movement
of the catheter tip)
False high- Improper calibration Recalibrate the system.

pressure reading
Arterial pressure ex- Transducer positioned Relevel the transducer with the phlebo-
ceeds the patient’s below the phlebostat- static axis.
normal pressure ic axis
without a significant
change in the base- Catheter kinked Unkink the catheter.
line clinical findings.
Before responding Clotted catheter tip Attempt to aspirate the clot. If you’re suc-
to this high-pressure cessful, flush the line. If you’re unsuc-
reading, recheck the cessful, avoid flushing the line because
system to make sure you could dislodge the clot.
that the reading is
accurate. Catheter tip resting Flush the catheter or reposition it by
against the arterial carefully rotating it or pulling it back
line slightly.
I.V. tubing too long Shorten the tubing by removing the ex-
tension tubing (if used), or replace the
administration set with a set that has
shorter tubing.
Small air bubbles in Remove the air bubbles.

the tubing close to
the patient (continued)
494 Troubleshooting
Arterial lines (continued)
False low-pressure Improper calibration Recalibrate the system.

reading
Arterial pressure Transducer positioned Relevel the transducer with the phlebo-
drops below the above the level of the static axis.
patient’s normal phlebostatic axis
pressure without a
significant change in Loose connections Check and tighten all connections.
the baseline clinical
findings. Before Catheter kinked Unkink the catheter.
responding to this
low-pressure read- Clotted catheter tip Attempt to aspirate the clot. If you’re
ing, recheck the sys- successful, flush the line. If you’re unsuc-
tem to ensure that cessful, avoid flushing the line because
the reading is accu- you could dislodge the clot.
rate.
Catheter tip resting Reposition the catheter insertion area
against the arterial and flush the catheter. Alternatively,
line reposition the catheter by carefully rotat-
ing it or pulling it back slightly.
I.V. tubing too long Shorten the tubing by removing the ex-
tension tubing (if used), or replace the
administration set with a set that has
shorter tubing.
Large air bubble close Reprime the transducer.

to the transducer
No waveform No power supply Turn on the power.

No waveform
appears on the Loose connections Check and tighten all connections.
monitor.
Stopcocks turned off Position the stopcocks properly. Make
to the patient sure that the transducer is open to the
catheter.
Transducer discon- Reconnect the transducer to the monitor

nected from the moni- module.
tor module
Occluded catheter tip Attempt to aspirate the clot. If you’re

successful, flush the line. If you’re unsuc-
cessful, avoid flushing the line because
Catheter tip resting Flush the catheter or reposition it by

against the arterial carefully rotating it or pulling it back
wall slightly.
Arterial line,
accidental removal of
Respiratory monitors
and devices
If the patient removes his arterial line,
he’s in danger of hypovolemic shock Pulse oximeters
from blood loss. Here’s what to do.
To maintain a continuous display of ar-
Stanching the blood flow terial oxygen saturation levels, keep the
◆ Apply direct pressure to the inser- monitoring site clean and dry. Make
tion site immediately and send some- sure that the skin doesn’t become irri-
one to call the physician. Maintain tated from the adhesives used to keep
firm, direct pressure on the insertion the disposable probes in place. You
site for 5 to 10 minutes to encourage may need to change the site if this
clot formation because arterial blood happens. Nondisposable probes that
flows under extremely high intravascu- don’t need tape can be used to replace
lar pressure. disposable probes that irritate the skin.
◆ Check the patient’s I.V. line and, if Another common problem with
ordered, increase the flow rate tem- pulse oximeters is failure to obtain a
porarily to compensate for blood loss. signal. If this happens, your first reac-
tion should be to check the patient’s
When the bleeding stops vital signs. If they’re sufficient to pro-
◆ Apply a sterile pressure dressing. duce a signal, check for problems, in-
◆ Reassess the patient’s level of concluding a poor connection, inadequate
sciousness (LOC) and comfort and re- or intermittent blood flow to the site,
assure him. Losing large quantities of and equipment malfunction.
blood may have significant psychologi-
cal and physiologic effects. Poor connection
◆ Estimate the amount of blood loss Check to see if the sensors are aligned
from what you see and from changes properly. Make sure that the wires are
in the patient’s blood pressure and intact and fastened securely and that
heart rate. the pulse oximeter is connected to a
◆ When the physician arrives, help power source.
him to reinsert the catheter, ensuring
that the patient’s arm is immobilized Inadequate or intermittent blood
and that the tubing and catheter are se- flow to the site
cured. Check the patient’s pulse rate and cap-
◆ Withdraw blood for a complete illary refill time and take corrective ac-
blood count and arterial blood gas tion if blood flow to the site is de-
analysis, as ordered. creased. This may mean loosening re-
straints, removing tight-fitting clothing,
Ongoing care taking off a blood pressure cuff, or
◆ Closely monitor the patient’s vital checking arterial and I.V. lines. If none
signs, LOC, skin color, temperature, of these interventions works, you may
and circulation to the extremity. need to find an alternate site. Finding a
◆ Watch for further bleeding or site with proper circulation may prove
hematoma. challenging in a patient who’s receiv-
◆ Decrease the I.V. flow rate to the ing a vasoconstrictor.
previous level after the patient’s condi-
tion has stabilized.
496 Troubleshooting
Equipment malfunction yourself or another healthy person.

Remove the pulse oximeter from the This will tell you if the equipment is
patient, set the alarm limits at 90% working correctly.
and 100%, and try the instrument on
Sv̄O2 monitors
–
During continuous mixed venous oxygen saturation (Sv O2) monitoring, watch for signs
of equipment malfunction so that you can distinguish them from changes in the pa-
tient’s condition and respond appropriately. This chart identifies common problems,
their causes, and nursing interventions.
POSSIBLE CAUSES
Low-intensity alarm
sounds
Inadequate blood flow past ◆ Look for and straighten obvious kinks in the
the catheter tip catheter.
◆ Follow facility procedure to ensure distal lumen
patency.
◆ Check for a proper connection between the optical
module and the computer.
Damaged fiber-optic filaments ◆ Replace the catheter.
Damped intensity
Blood clot over the catheter ◆ Follow facility procedure to ensure distal lumen
tip patency.
Wedging of the catheter tip ◆ Reposition the catheter.
Erratic intensity
Blood clot over the catheter ◆ Follow facility procedure to ensure distal lumen
tip patency.
Wedging of the catheter tip ◆ Reposition the catheter.
High-intensity alarm
sounds
Catheter tip pressing against ◆ Reposition the catheter and examine the pressure
the vessel wall waveform to confirm the proper position.
Catheter floating distally into ◆ Check the status of the balloon and confirm the
the wedge position proper position by examining the pressure wave-
form.
◆ Reposition the catheter, as needed.
Sv̄O2 monitors (continued)

POSSIBLE CAUSES
LOW-LIGHT message
Poor connection between the ◆ Disconnect the catheter from the optical module,
catheter and the optical mod- close the lid, and place the optical module out of di-
ule rect light. If the LOW-LIGHT message disappears, the
problem is the catheter. Check the connection and
reattach as needed.
Defective optical module ◆ Replace the optical module.
Poor connection between the ◆ Check the connections and reconnect as needed.
optical module and the com- Turn off the computer for a few seconds and turn it
puter back on. You’ll hear two beeps if the computer is
functional and the connections are secure.
Damaged fiber-optic filaments ◆ Gently manipulate the catheter, particularly

around the insertion site. If this doesn’t solve the
problem, replace the catheter.
CAL FAIL message

Unsuccessful preinsertion cali- ◆ Verify correct attachment between the catheter
bration and the optical module. Repeat calibration.
◆ If the CAL FAIL message still appears, replace the
optical module.
Dashes in oxygen
saturation display
Improper preinsertion calibra- ◆ Verify correct attachment between the catheter
tion and the optical module. Repeat calibration.
Malfunction of the optical ◆ If dashes continue to appear, replace the optical

module module. Repeat calibration.
Catheter damage ◆ Gently manipulate the catheter. If the monitor

doesn’t compute a range, replace the catheter. Re-
peat calibration.
Improper positioning of the ◆ Reposition the catheter.

catheter tip
Loss of electronic memory ◆ Determine the cause of the power loss and then
repeat calibration.
498 Troubleshooting
Ventilators
Most ventilators have alarms to warn you of hazardous situations — for instance, when
inspiratory pressure rises too high or drops too low. Use this chart to help you respond
to a ventilator alarm quickly and effectively.
POSSIBLE CAUSES
Low pressure
Tube disconnected from the Reconnect the tube to the ventilator.
ventilator
Endotracheal (ET) tube displaced If extubation or displacement has occurred, open the
above the vocal cords or trache- patient’s airway, ventilate the patient manually, and
ostomy tube extubated call the physician.
Leaking tidal volume from low Listen for a whooshing sound (an air leak) around the
cuff pressure (as a result of an tube and check the cuff pressure. If you can’t maintain
underinflated or ruptured ET pressure, the physician may insert a new tube.
cuff or a leak in the cuff or
one-way valve)
Ventilator malfunction Disconnect the patient from the ventilator and venti-
late him manually, if necessary. Get another ventilator.
Leak in the ventilator circuitry Make sure that all connections are intact. Check the
(from a loose connection or a humidification container and tubing for holes or leaks.
hole in the tubing, loss of a Replace them, if necessary.
temperature-sensing device, or a
cracked humidification container)
High pressure
Increased airway pressure or Auscultate the lungs for evidence of increasing lung
decreased lung compliance as consolidation, barotrauma, or wheezing. Call the
a result of worsening disease physician, if necessary.
Patient biting on the ET tube If needed, insert a bite block.
Secretions in the airway Suction the patient or have him cough.
Condensation in the large-bore Remove any condensation.

tubing
Intubation of the right main- Check the position of the tube. If the position is incor-
stem bronchus rect, notify the physician. It will need to be reposi-
tioned.
Patient coughing, gagging, or If the patient is fighting the ventilator in any way, he
trying to talk may need a sedative or neuromuscular blocker. Ad-
minister the drug, as ordered.
Ventilators (continued)
POSSIBLE CAUSES
High pressure (continued)

Chest-wall resistance Reposition the patient if his position limits chest ex-
pansion. If repositioning is ineffective, give him the
prescribed analgesic.
Malfunctioning high-pressure Have the faulty equipment replaced.

relief valve
Bronchospasm, pneumothorax, Assess the patient to determine the cause. Report the
or barotrauma disorder to the physician and treat, as ordered.
Spirometer or low exhaled

tidal volume, or low exhaled
minute volume
Power interruption Check all electrical connections.
Loose connection or leak in the Make sure that all connections in the delivery system
delivery system are secure. Check for leaks.
Leaking cuff or inadequate cuff Listen for a leak with a stethoscope. Reinflate the cuff
seal according to facility policy. Replace the cuff, if neces-
sary.
Leaking chest tube Check all chest tube connections. Make sure that the
water seal is intact and then notify the physician.
Increased airway resistance in Auscultate the lungs for signs of airway obstruction,
a patient who’s on a pressure- barotrauma, or lung consolidation.
cycled ventilator
Disconnected spirometer Make sure that the spirometer is connected.
Any change that sets off high- See the interventions for high- and low-pressure
or low-pressure alarms and alarms.
prevents delivery of the full air
volume
Malfunctioning volume- Alert the respiratory therapist to replace the device.

measuring device
High respiratory rate

Anxiety Assess the patient to determine the cause. Dispel the
patient’s fears, if possible, and sedate him, if neces-
sary. Establish an effective means of communication.
Pain Position the patient comfortably. Administer a medica-

tion for pain, as ordered.
(continued)
500 Troubleshooting
Ventilators (continued)
POSSIBLE CAUSES
High respiratory rate

(continued)
Secretions in the airway Suction the patient.
Low positive end-expiratory

pressure (PEEP)/continuous
positive airway pressure
Leak in the system Make sure that all connections are secure. Check for
holes in the tubing and replace it, if necessary.
Mechanical failure of the PEEP Discontinue PEEP and call a respiratory therapist.
mechanism
Endotracheal or tracheostomy ◆ Keep the stoma open with a Kelly

tube, accidental removal of clamp and try to insert a new tube. If
you can’t get the tube in, insert a suc-
If an endotracheal (ET) or tracheosto- tion catheter instead and thread the
my tube is accidentally removed or if tube over the catheter.
the patient deliberately removes it, im- ◆ Call a code if you can’t establish an
mediately take these steps. effective airway and you no longer de-
tect a pulse. Then either ventilate with
ET tube a face mask and resuscitation bag or
◆ Remove any remaining part of the remove the Kelly clamp to close the
tube. stoma and perform mouth-to-mouth re-
◆ Ventilate the patient using common suscitation until the physician arrives.
resuscitation techniques or a handheld If air leaks from the stoma, cover it
resuscitation bag. with an occlusive dressing.
◆ Send someone to notify the physi- Alert Don’t leave the patient
cian. alone until you’ve established
◆ Restrain the patient according to fa- that he has an effective airway and
cility policy if he extubated himself. can breathe comfortably.
◆ After the tube is reinserted, periodi- ◆ When a new tracheostomy tube is
cally check the position of the tube in place and the patient can breathe
and the condition of the tape or the ET more easily, give him supplemental hu-
tube holder that’s holding it. For a se- midified oxygen until he receives a full
cure fit, anchor the tape from the nape evaluation.
of the patient’s neck to and around the ◆ Monitor the patient’s vital signs,
tube. skin color, and level of consciousness
and, unless contraindicated, elevate the
Tracheostomy tube head of his bed.
◆ Remove any remaining part of the
tube.
Chest drains
Patient rolls over on the ◆ Reposition the patient and remove any kinks in the tubing.
drainage tubing, causing ◆ Auscultate for decreased breath sounds and percuss for
obstruction dullness, which indicates fluid accumulation, or for hyper-
resonance, which indicates air accumulation.
Dependent loops in the ◆ Make sure that the chest drainage unit sits below the
tubing trap fluids and pre- patient’s chest level. If necessary, raise the bed slightly to
vent effective drainage increase gravity flow. Remove any kinks in the tubing.
◆ Monitor the patient for decreased breath sounds and
percuss for dullness.
No drainage appears in the ◆ If blood or other fluid is draining, suspect a clot or ob-
collection chamber struction in the tubing. Gently milk the tubing to expel the
obstruction, if facility policy permits.
◆ Monitor the patient for lung tissue compression caused
by accumulated pleural fluid.
Substantial increase in ◆ Monitor the patient’s vital signs. Look for an increased
bloody drainage, indicating pulse rate, decreased blood pressure, and orthostatic
possible active bleeding or changes that may indicate acute blood loss.
drainage of old blood ◆ Measure the drainage every 15 to 30 minutes to deter-
mine if it’s occurring continuously or in one gush as a result
of position changes.
No bubbling in the suction- ◆ Check for obstructions in the tubing. Make sure that all
control chamber of the connections are tight.
◆ Check that the suction apparatus is turned on. Increase
the suction slowly until you see gentle bubbling.
Loud, vigorous bubbling in ◆ Turn down the suction source until bubbling is just visi-
the suction-control chamber ble.
Constant bubbling in the ◆ Assess the chest drainage unit and the tubing for an air leak.
water-seal chamber ◆ If an air leak isn’t noted in the external system, notify
the physician immediately. Leaking and trapping of air in
the pleural space can result in a tension pneumothorax.
Evaporation causes the water ◆ Using a syringe and needle, add water or normal saline
level in the suction-control solution through a resealable diaphragm on the back of the
chamber to drop below the suction-control chamber.
desired level of –20 cm H2O
Patient has trouble breath- ◆ Raise the head of the bed and reposition the unit so that
ing immediately after a gravity promotes drainage.
special procedure; the chest ◆ Perform a quick respiratory assessment and take the pa-
drainage unit is improperly tient’s vital signs. Make sure that the water-seal and suc-
placed on the patient’s bed, tion-control chambers contain enough water.
interfering with drainage (continued)
502 Troubleshooting
Chest drains (continued)
As the bed lowers, the chest ◆ Don’t clamp the chest tube because doing so could
drainage unit is caught under cause a tension pneumothorax.
the bed; the tubing comes ◆ Irrigate the tubing, using the sealed jar of sterile
apart and becomes contami- water or normal saline solution kept at the patient’s
nated bedside.
◆ Insert the distal end of the chest tube into the jar of
sterile fluid until the end of the tube is 2 to 4 cm be-
low the top of the water.
◆ Ask another nurse to obtain and set up a new
closed chest drainage system.
◆ Attach the chest tube to the new unit.
◆ Avoid manipulating a tube in a pa-

GI tubes tient who had the tube inserted during
surgery because you may disturb new
Nasoenteric-decompression tubes sutures.
◆ Don’t try to reposition the tube in a
If the patient’s nasoenteric-decompres- patient who was difficult to intubate
sion tube appears to be obstructed, no- (because of an esophageal stricture, for
tify the physician immediately. He may example).
order these measures to restore paten-
cy quickly and efficiently: T tubes
◆ First, disconnect the tube from the
suction source and irrigate it with nor- T tubes, which are typically inserted in
mal saline solution. Use gravity flow to the common bile duct after cholecys-
help clear the obstruction, unless or- tectomy, may become blocked by vis-
dered otherwise. cous bile or clots. Notify the physician
◆ If irrigation doesn’t establish paten- and take these steps while you wait for
cy, the position of the tube against the him to arrive.
gastric mucosa may be causing the ob- ◆ Unclamp the T tube (if it was
struction. Gentle tugging may help. For clamped before and after a meal) and
a double-lumen tube, such as a Salem connect the tube to a closed gravity-
pump, irrigate the pigtail port (blue) drainage system.
with 10 to 30 cc of air to help move the ◆ Inspect the tube carefully to detect
tube away from the mucosa. kinks or obstructions.
If these measures don’t work, the ◆ Irrigate the tube with normal saline
tube may be kinked and may need ad- solution, if ordered, and prepare the
ditional manipulation. Before proceed- patient for direct X-ray of the common
ing, follow these precautions: bile duct (cholangiography). Briefly de-
◆ Never reposition or irrigate a scribe these measures to the patient to
nasoenteric-decompression tube (with- reduce his apprehension and promote
out a physician’s order) in a patient his cooperation.
who has had GI surgery.
GI tubes 503
Total parenteral nutrition setups

POSSIBLE CAUSES
Clotted catheter
Interrupted flow rate, hypo- ◆ Reposition the patient on his side. Attempt to aspi-
glycemia, no blood return rate the clot. If the clot remains, use a thrombolytic,
Dislodged catheter
Catheter out of the vein, anterior ◆ Place a sterile gauze pad on the site and apply
chest pain, neck pain pressure if the catheter is completely out. For partial
displacement, call the physician.
◆ Prepare the patient for an X-ray and repositioning
with a guide wire or for removal and replacement.
Air embolism
Chest pain, tachycardia, hypoten- ◆ Clamp the catheter.
sion, fear, seizures, loss of con- ◆ Place the patient in Trendelenburg’s position on his
sciousness, cardiac arrest left side. Give oxygen, as ordered.
◆ If cardiac arrest occurs, begin cardiopulmonary re-
suscitation.
Thrombosis
Erythema, edema, or pain at the ◆ Anticipate prompt removal of the catheter.
insertion site or along the vein; ◆ Administer heparin, as ordered.
ipsilateral swelling of the arm, ◆ Prepare for a venous flow study, as ordered.
neck, and face; tachycardia
Too-rapid infusion
Nausea, headache, lethargy, hy- ◆ Check the infusion rate.
perglycemia ◆ Check the infusion pump.
Extravasation
Swelling or pain around the in- ◆ Stop the infusion and assess the patient for car-
sertion site diopulmonary abnormalities.
◆ Obtain a chest X-ray, if needed.
Hyperglycemia
Fatigue, restlessness, weakness, ◆ Start insulin therapy, as ordered.
confusion ◆ Slow the total parenteral nutrition (TPN) infusion
rate, as ordered.
Hypoglycemia
Headache, sweating, dizziness, ◆ Give dextrose I.V. (10% as an infusion, 50% as an
palpitations I.V. bolus), as ordered.
◆ Avoid abrupt increases or decreases in the TPN
flow rate; wean the patient from TPN slowly.
(continued)
504 Troubleshooting
Total parenteral nutrition setups (continued)

POSSIBLE CAUSES
Cracked or broken tubing ◆ Apply a padded hemostat above the break to pre-
Fluid leakage vent air from entering the line.
Sepsis ◆ Remove the catheter and culture the tip.

Fever, chills, leukocytosis, posi- ◆ Give the appropriate antibiotic.
tive blood cultures, glucose intol-
erance
Tube feedings
Obstruction or clogging of ◆ Flush the tube with warm water or cranberry juice. If
the tube necessary, replace the tube.
◆ Flush the tube with 50 ml of water after each feeding
or 30 ml of water every 2 hours if the patient is receiving
continuous feeding, to remove excess sticky formula,
which could occlude the tube.
Aspiration of gastric secre- ◆ Discontinue the feeding immediately.

tions ◆ Perform tracheal suction of the aspirated contents, if
possible.
◆ Notify the physician. He may order a prophylactic an-
tibiotic or chest physiotherapy.
◆ Check the tube placement before the feeding and ele-
vate the head of the bed to prevent complications.
Nasal or pharyngeal irrita- ◆ Change the tube position. If necessary, replace the
tion or necrosis tube.
◆ Provide frequent oral hygiene with mouthwash or
lemon-glycerin swabs. Use petroleum jelly on cracked
lips.
Vomiting, bloating, diarrhea, ◆ Reduce the flow rate.

or cramps ◆ As ordered, administer metoclopramide to increase
GI motility.
◆ Warm the formula.
◆ Position the patient on his right side, with his head
elevated, for 30 minutes after the feeding to facilitate
gastric emptying.
◆ Notify the physician. He may reduce the amount of
formula given during each feeding.
◆ Check for residual feeding at least once a shift or
Neurologic monitors 505
Neurologic monitors
Damped ICP waveforms

An intracranial pressure (ICP) waveform that looks like the one shown below signals a
problem with the transducer or monitor. Check for obstruction of the line, and determine
if the transducer needs rebalancing.
mm Hg
30
20
10
minutes 1
2
Transducer or ◆ Turn the stopcock of the transducer off to the patient.

monitor needs ◆ Open the stopcock to air and balance the transducer.
recalibration ◆ Recalibrate the transducer and monitor.
Air in the line ◆ Turn the stopcock off to the patient.

◆ Using a syringe, flush the air out through an open stopcock
port with sterile normal saline solution. Note: Never use heparin to
flush the ICP line. You could accidentally inject some of the drug
into the patient and cause bleeding.
◆ Rebalance and recalibrate the transducer and monitor.
Loose connection in ◆ Check the tubing and stopcocks for moisture, which may indi-
the line cate a loose connection.
◆ Turn the stopcock off to the patient and then tighten all of the
connections.
◆ To prevent problems, make sure that the patient can turn his
head without straining the tubing.
Disconnection in the ◆ Turn the stopcock off to the patient immediately. (Rapid loss of
line CSF through a ventricular catheter may allow the ICP to drop pre-
cipitously, causing a brain herniation.)
◆ Replace the equipment using sterile technique to reduce risk of
infection. Notify the physician of system integrity.
Change in the pa- ◆ Reposition the balancing port of the transducer level with Mon-
tient’s position ro’s foramen.
◆ Rebalance and recalibrate the transducer and monitor. Always
balance and recalibrate the transducer and monitor at least once
every 4 hours and whenever the patient is repositioned.
Tubing, catheter, or ◆ Notify the physician. He may want to irrigate the screw or the
screw occluded with catheter with a small amount (0.1 ml) of sterile normal saline solu-
blood or brain tissue tion. Never irrigate the screw or catheter yourself.
506 Troubleshooting
Bispectral index monitoring
Bispectral index monitoring requires the use of a monitor and cable connected to a sen-
sor applied to the patient’s forehead (as shown below). The sensor obtains information
about the patient’s electrical brain activity.
Bispectral index monitor Bispectral index sensor
Real-time EEG
Current
bispectral
index value
Interface cable
Power button
Troubleshooting sensor problems
When initiating bispectral index monitoring, be aware that the monitor may display
messages that indicate a problem. This chart highlights these messages and offers pos-
sible solutions.
MESSAGE POSSIBLE SOLUTIONS
High impedance Check sensor adhesion; reapply firm pressure to each of the num-
message bered circles on the sensor for 5 seconds; if message continues,
check the connection between the sensor and the monitor; if neces-
sary, apply a new sensor.
Noise message Remove possible pressure on the sensor; investigate possible large
stimulus such as electrocautery.
Lead-off message Check sensor for electrode displacement or lifting; reapply with firm
pressure or, if necessary, apply a new sensor.
Reviewing the methods
Administration guidelines 508

Precautions for drug administration 508
Topical administration 510
Topical drugs 510
Transdermal medications 511
Nitroglycerin ointment 513
Eye medications 514
Eye medication disks 515
Eardrops 516
Nasal medications 517
Vaginal medications 519
Respiratory administration 520
Handheld oropharyngeal inhalers 520
Enteral administration 522
Oral drugs 522
Drug delivery through a nasogastric tube or
gastrostomy button 523
Buccal, sublingual, and translingual medications 524
Rectal suppositories or ointment 525
Parenteral administration 527
Subcutaneous injection 527
Intradermal injection 529
I.M. injection 530
Z-track injection 532
Drug infusion through a secondary I.V. line 533
I.V. bolus injection 535
Special administration 536
Epidural analgesics 536
507
that the physician signs for it within

Administration the time specified by facility policy.
guidelines
Give labeled medication
Precautions for drug Don’t give medication from a poorly la-
administration beled or unlabeled container. Further-
more, don’t attempt to label drugs or
Whenever you administer medication, reinforce drug labels yourself; a phar-
observe these precautions to ensure macist must do that.
that you’re giving the right drug in the
right dose to the right patient. Monitor medication
Never give a medication that someone
Check the order else has poured or prepared. Never al-
Check the order on the patient’s med- low your medication cart or tray out of
ication record against the physician’s your sight. Never return unwrapped or
order. prepared medications to stock contain-
ers. Instead, dispose of them and notify
Check the label the pharmacy.
Check the label on the medication
three times before administering it to a Respond to the patient’s
patient to ensure that you’re adminis- questions
tering the prescribed medication in the If the patient questions you about his
prescribed dose. Check it when you medication or the dosage, check his
take the container from the shelf or medication record again. If the medica-
drawer, right before pouring the med- tion is correct, reassure him that it’s
ication into the medication cup or correct. Make sure to tell him about
drawing it into the syringe, and before changes in his medication or dosage.
returning the container to the shelf or Instruct him, as appropriate, about
drawer. If you’re administering a unit- possible adverse reactions and encour-
dose medication, check the label for age him to report any that he experi-
the third time immediately after pour- ences.
ing the medication and again before
discarding the wrapper. Don’t open a Monitor the patient’s response to
unit-dose medication until you’re at the medication
patient’s bedside. To assess the patient’s response to
medication, be aware of his condition
Confirm the patient’s identity and what the drug’s desired or expect-
Before giving the medication, confirm ed effect should be. For example, if the
the patient’s identity by checking two patient is receiving an antiarrhythmic
patient identifiers. Then make sure that but continues to have premature ven-
you have the correct medication. tricular contractions, tell the physician
Explain the procedure to the patient that the drug isn’t having the desired
and provide privacy. effect. Monitor the patient’s condition
carefully; changes such as weight loss
Have a written order or gain can affect the action of some
Make sure that you have a written or- drugs. Other factors, such as the pa-
der for every medication that’s to be tient’s age, body build, gender, and
given. If the order is verbal, make sure emotional state, may also affect his
Administration guidelines 509
response to drug therapy. Also, check administering medications. In some in-

the results of laboratory tests, which stances, sensitivity tests may be per-
can indicate a therapeutic effect, an ad- formed before the first dose is given.
verse effect, or a toxic level. For some patients, genetic testing for
the detection of certain alleles can re-
Monitor drug interactions veal increased risks for hypersensitivity
Because many patients receive more reactions. Be aware that a negative his-
than one drug, it’s important to under- tory doesn’t rule out future allergic re-
stand drug interactions. A drug interac- actions. Other undesirable effects to
tion is a change in drug absorption, watch for when administering drugs
distribution, metabolism, and excretion include idiosyncratic reactions and
that may occur with or shortly after dependence.
administration of another drug. A de-
sirable interaction is used to help to Document carefully
maintain an effective blood level, or Documenting all medications given to
minimize or prevent adverse effects. a patient provides a legal record of
Some interactions, however, can drugs the patient received during his
have undesirable results, such as stay in the facility. Medication adminis-
weakening a drug’s desired effects or tration involves documenting on a
exaggerating its toxic ones. For exam- medication administration record
ple, a patient who smokes require larg- (MAR) as well as in the nurse’s notes.
er doses of theophylline than a non- After administering a drug, document
smoking patient because cigarette on the patient’s Kardex or computer
smoke activates oxidative enzymes in files the drug name, dosage, route and
the liver, increasing drug metabolism. time of administration, and your signa-
ture and title. In the nurse’s notes, in-
Watch for adverse effects clude any assessment data that refer to
When you administer a drug, you must the patient’s response to the medica-
be able to recognize and identify ad- tion and any adverse effects of the
verse effects and toxic and allergic re- medication.
actions. Some adverse effects are tran- If your facility documents medica-
sient and subside as the patient devel- tions digitally, make sure you enter
ops a tolerance for the drug; others each drug immediately after you give
may require a change in therapy. it. This gives all health care team
A toxic reaction to a drug can be members access to current medication
acute, resulting from an excessive dose information and is especially important
(an acetaminophen overdose, for in- if the system has no hard-copy backup.
stance), or chronic, resulting from pro- Always write legibly. Use only ac-
gressive accumulation of the drug in ceptable abbreviations, and use them
the body. It can also result from im- correctly. When in doubt as to how to
paired metabolism or excretion that re- abbreviate a term, spell it out. When
sults in elevated blood levels of a drug. documenting parenteral medications,
A drug allergy (hypersensitivity) re- be sure to include the injection site
sults from an antigen-antibody reaction and the route used. After administer-
in a susceptible patient. Such a reac- ing the first dose, sign your full name,
tion can range from mild urticaria to licensure status, and identifying ini-
potentially fatal anaphylaxis. Always tials in the appropriate place on the
check for known drug allergies before MAR.
To apply a paste, a cream, or an ointment

Topical administration ◆ Open the container. Place the cap
upside down to avoid contaminating its
Topical drugs inner surface.
◆ Remove a tongue blade from its
Topical drugs, such as lotions and oint- sterile wrapper and cover one end of it
ments, are applied directly to the pa- with medication from the tube or jar.
tient’s skin. They’re commonly used Transfer the medication from the
for local, rather than systemic, effects. tongue blade to your gloved hand.
Typically, they must be applied two or ◆ Apply the medication to the affected
three times per day to achieve a full area with long, smooth strokes that fol-
therapeutic effect. low the direction of hair growth, as
shown below.
Equipment
Patient’s medication record and chart
◆ prescribed medication ◆ sterile
tongue blades ◆ gloves ◆ sterile
4⬙ ⫻ 4⬙ gauze pads ◆ transparent
semipermeable dressing ◆ adhesive
tape ◆ solvent (such as cottonseed oil)
◆ optional: cotton-tipped applicators,
cotton gloves, or terry cloth scuffs
Implementation
◆ Verify the order on the patient’s
medication record by checking it
against the physician’s order. Check
the patient’s medication record for
allergies.
two patient identifiers. This technique avoids forcing med-
◆ Explain the procedure to the patient ication into the hair follicles, which can
because, after discharge, he may have cause irritation and lead to folliculitis.
to apply the medication by himself. ◆ When applying medication to the pa-
◆ Wash your hands to prevent cross- tient’s face, use a cotton-tipped applicator
contamination and glove your domi- for small areas such as under the eyes.
nant hand. For larger areas, use a sterile gauze pad
◆ Help the patient into a comfortable and follow the directions shown below.
position and expose the area to be
treated. Make sure that the skin or mu-
cous membrane is intact (unless the
medication has been ordered to treat a
skin lesion). Application of medication
to broken or abraded skin may cause
unwanted systemic absorption and re-
sult in further irritation.
◆ If necessary, clean the skin of de-
bris. You may need to change the glove
if it becomes soiled.
◆ To prevent contamination of the medication. Hold the container 6⬙ to

medication, use a new sterile tongue 12⬙ (15 to 30.5 cm) from the skin or
blade each time you remove medica- follow the manufacturer’s recommen-
tion from the container. dation. Spray the medication evenly
over the treatment area to apply a thin
To remove an ointment film.
◆ Wash your hands and put on ◆ To apply a powder, dry the skin sur-
gloves. Then gently swab ointment face and apply a thin layer of powder
from the patient’s skin with a sterile over the treatment area.
4⬙ ⫻ 4⬙ gauze pad saturated with a sol- ◆ To protect applied medications and
vent such as cottonseed oil. Remove prevent them from soiling the pa-
remaining oil by wiping the area with a tient’s clothes, tape a sterile gauze
clean sterile gauze pad. Don’t wipe too pad or a transparent semipermeable
hard because you could irritate the dressing over the treated area. If
skin. you’re applying topical medication to
his hands, cover them with cotton
To apply other topical medications gloves; if you’re applying medication
◆ To apply a shampoo, follow package to his feet, cover them with terry cloth
directions. Apply medication with your scuffs.
fingertips, or instruct the patient to do ◆ Assess the patient’s skin for signs of
so, as shown below. Massage it into irritation, allergic reaction, or break-
the scalp, if appropriate. down.
◆ To prevent skin irritation from an
accumulation of medication, remove
residue from previous applications be-
fore each new application.
◆ Always wear gloves to prevent your
skin from absorbing the medication.
◆ Never apply ointment to the eyelids
or ear canal unless ordered. The oint-
ment may congeal and occlude the tear
duct or ear canal.
◆ Inspect the treated area frequently
◆ To apply topical antifungal creams for adverse or allergic reactions.
and nail lacquers, wash the affected
area with soap and water. Apply cream Transdermal medications
and rub it gently into the nail beds. If
the patient has athlete’s foot, you can Given through an adhesive patch or a
enhance absorption by applying the measured dose of ointment applied to
medication at night and covering the the skin, transdermal drugs deliver
affected area with clean socks. Apply constant, controlled medication directly
nail lacquers to the entire nail, starting into the bloodstream for a prolonged
at the nail bed. Allow the lacquer to systemic effect.
dry thoroughly, which takes 5 to 10 Medications that are available in
minutes. transdermal form include nitroglycerin,
◆ To apply an aerosol spray, shake which is used to control angina; sco-
the container, if indicated, to mix the polamine, which is used to treat
motion sickness; estradiol, which is ◆ Apply the strip to any dry, hairless
used for postmenopausal hormone re- area of the body. Don’t rub the oint-
placement; clonidine, which is used to ment into the skin.
treat hypertension; nicotine, which is ◆ Tape the application strip and oint-
used for smoking cessation; fentanyl, ment to the skin. If desired, cover the
which is used to control chronic pain; application strip with plastic wrap and
and estrogen and progesterone, which tape the wrap in place.
are used for hormonal birth control.
Nitroglycerin ointment dilates the To apply a transdermal patch
coronary vessels for 4 hours; a patch ◆ Open the package and remove the
can produce the same effect for as long patch.
as 24 hours. ◆ Without touching the adhesive sur-
The scopolamine patch can relieve face, remove the clear plastic backing.
motion sickness for as long as 72 ◆ Apply the patch to a dry, hairless
hours. Transdermal estradiol and hor- area — behind the ear, for example, as
monal birth control last for up to 1 with scopolamine. Avoid areas that
week; clonidine and nicotine, 24 hours; may cause uneven absorption, such as
and fentanyl, up to 72 hours. skin folds or scars, or irritated or dam-
aged skin. Don’t apply the patch below
Equipment the elbow or knee.
◆ gloves ◆ prescribed medication After applying transdermal medications
(patch or ointment) ◆ application strip ◆ Instruct the patient to keep the area
or measuring paper (for nitroglycerin around the patch or ointment as dry as
ointment) ◆ adhesive tape ◆ optional: possible.
plastic wrap or semipermeable dressing ◆ Wash your hands immediately after
(for nitroglycerin ointment) applying the patch or ointment.
Implementation Special considerations

◆ Verify the order on the patient’s ◆ Apply daily transdermal medica-
medication record by checking it tions at the same time every day to en-
against the physician’s order. Check sure a continuous effect, but alternate
the patient’s medication record for the application sites to avoid skin irri-
allergies. tation.
◆ Confirm the patient’s identity using ◆ Before applying nitroglycerin oint-
two patient identifiers. ment, obtain the patient’s baseline
◆ Wash your hands and put on blood pressure. Obtain another blood
gloves. pressure reading 5 minutes after apply-
◆ Make sure that previously applied ing the ointment. If the blood pressure
medication has been removed. has dropped significantly and the pa-
◆ Locate a new site for application, tient has a headache, notify the physi-
different from the previous site. cian immediately. If the blood pressure
has dropped but the patient has no
To apply transdermal ointment symptoms, instruct him to lie still until
◆ Place the prescribed amount of oint- the blood pressure returns to normal.
ment on the application strip or mea- ◆ Before reapplying nitroglycerin oint-
suring paper, taking care not to get any ment, remove the plastic wrap, the
on your skin. application strip, and any ointment
remaining on the skin at the previous ◆ Squeeze the prescribed amount of

site. ointment onto the ruled paper, as
◆ When applying a scopolamine shown below.
patch, instruct the patient not to drive
or operate machinery until his re-
sponse to the drug has been deter-
mined.
◆ If the patient is using a clonidine
patch, encourage him to check with his
physician before using over-the-counter
cough preparations. They may counter-
act the effects of clonidine.
Nitroglycerin ointment
Unlike most topical medications, nitro-

glycerin ointment is used for its trans- ◆ After measuring the correct amount
dermal systemic effect. It’s used to di- of ointment, tape the paper, with the
late the arteries and veins, thus im- drug side down, directly to the skin.
proving cardiac perfusion in a patient Some health care facilities require you
with cardiac ischemia or angina pec- to use the paper to apply the medica-
toris. tion to the patient’s skin, usually on
Nitroglycerin ointment is prescribed the chest or arm. Spread a thin layer of
by the inch and comes with a rectan- ointment over a 3⬙ (7.5-cm) area.
gular piece of ruled paper to be used in
applying the medication. Special considerations
◆ For increased absorption, the physi-
Equipment cian may request that you cover the
Patient’s medication record and chart site with plastic wrap or transparent
◆ ointment ◆ ruled paper ◆ plastic semipermeable dressing, as shown
wrap or transparent semipermeable below.
dressing ◆ adhesive tape ◆ sphygmo-
manometer ◆ optional: gloves
Implementation
allergies.
◆ Take a patient’s baseline blood pres-
sure for comparison with later read-
ings.
◆ Wash your hands. Then put on ◆ After 5 minutes, record the patient’s
gloves if you wish to avoid contact blood pressure. If it has dropped signif-
with the medication. icantly and he has a headache (as a
result of vasodilation of blood vessels means left eye, and “OU” means both
in his head), notify the physician. eyes.
◆ If the patient’s blood pressure has ◆ Wash your hands and put on
dropped but he has no adverse reac- gloves.
tions, instruct him to lie still until it re- ◆ If the patient has an ocular dress-
turns to normal. ing, remove it by pulling it down and
away from his forehead. Avoid contam-
Eye medications inating your hands.
◆ To remove exudate or meibomian
Eye medications — drops or oint- gland secretions, clean around the eye
ment — serve diagnostic and therapeu- with sterile cotton balls or sterile gauze
tic purposes. During an eye examina- pads moistened with warm water or
tion, these medications can be used to normal saline solution. Have the pa-
anesthetize the eye, dilate the pupil, tient close his eye and then gently
and stain the cornea to identify anom- wipe the eyelids from the inner to the
alies. Therapeutic uses include lubri- outer canthus. Use a fresh cotton ball
cation of the eye and treatment of or gauze pad for each stroke.
such conditions as glaucoma and in- ◆ Have the patient sit or lie in the
fections. supine position. Instruct him to tilt his
head back and toward his affected eye
Equipment and preparation so that excess medication can flow
Patient’s medication record and chart away from the tear duct, minimizing
◆ prescribed eye medication ◆ sterile systemic absorption through the nasal
cotton balls ◆ gloves ◆ warm water or mucosa.
normal saline solution ◆ sterile gauze ◆ Remove the dropper cap from the
pads ◆ facial tissue ◆ optional: ocular medication container and draw the
dressing medication into it.
Make sure that the medication is la- ◆ Before instilling eyedrops, instruct
beled for ophthalmic use. Then check the patient to look up and away. This
the expiration date. Remember to date moves the cornea away from the lower
the container after the first use. lid and minimizes the risk of touching
Inspect ocular solutions for cloudi- it with the dropper.
ness, discoloration, and precipitation,
but remember that some eye medica- To instill eyedrops
tions are suspensions and normally ap- ◆ Steady the hand that’s holding the
pear cloudy. Don’t use a solution that dropper by resting it against the pa-
appears abnormal. tient’s forehead. With your other hand,
pull down the lower lid of the affected
Implementation eye and instill the drops in the con-
◆ Verify the order on the patient’s junctival sac. Never instill eyedrops di-
medication record by checking it rectly onto the eyeball.
against the physician’s order. Check Patient teaching tips When
the patient’s medication record for al- teaching an elderly patient how
lergies. to instill eyedrops, keep in mind that
◆ Make sure that you know which eye he may have difficulty sensing drops
to treat because different medications in the eye. Suggest chilling the med-
or doses may be ordered for each eye. ication slightly to enhance the sensa-
Know that “OD” means right eye, “OS” tion.
To apply eye ointment dropper before returning it to the bot-

◆ Squeeze a small ribbon of medica- tle. If the dropper or bottle tip becomes
tion on the edge of the conjunctival contaminated, discard it and use an-
sac, from the inner to the outer can- other sterile dropper.
thus, as shown below. Cut off the rib-
bon by turning the tube. Eye medication disks
Small and flexible, an eye medication

disk is an oval disk that can release
medication (such as pilocarpine) in
the eye for up to 1 week. Floating be-
tween the eyelids and the sclera, the
disk stays in the eye while the patient
sleeps and even during swimming and
other athletic activities. The disk frees
the patient from the need to remem-
ber to instill his eye medication. Mois-
ture in the eye or the use of contact
lenses doesn’t adversely affect the
After instilling eyedrops or applying disk.
ointment
◆ Instruct the patient to close his eyes Equipment
gently, without squeezing the lids shut. Patient’s medication record and chart
If you instilled drops, tell him to blink. ◆ prescribed eye medication ◆ sterile
If you applied ointment, tell him to roll gloves
his eyes behind closed lids to help to
distribute the medication over the eye- Implementation
ball. ◆ Verify the order on the patient’s
◆ Use a clean facial tissue to remove medication record by checking it
excess medication leaking from the against the physician’s order. Check
eye. Use a fresh tissue for each eye to the patient’s medication record for
prevent cross-contamination. allergies.
◆ Apply a new ocular dressing, if nec- ◆ Confirm the patient’s identity using
essary. two patient identifiers.
◆ Remove and discard gloves. Then ◆ Make sure that you know which eye
wash your hands. to treat because different medications
or doses may be ordered for each eye.
◆ When administering an eye med- To insert an eye medication disk
ication that may be absorbed systemi- ◆ Wash your hands and put on sterile
cally, press your thumb on the inner gloves.
canthus for 1 to 2 minutes after instil- ◆ Press your fingertip against the disk
lation, while the patient closes his so that it sticks lengthwise across your
eyes. fingertip.
◆ To maintain the sterility of the drug ◆ Gently pull the patient’s lower eye-
container, never touch the tip of the lid away from the eye and place the
dropper or bottle to the eye area. Dis- disk in the conjunctival sac. The disk
card any solution that remains in the
should lie horizontally, as shown be- lid with one hand to expose the disk.
low, not vertically. The disk will adhere Then pinch it with the thumb and fore-
to the eye naturally. finger of your other hand and remove it.
◆ If the disk is located in the upper
eyelid, apply long, circular strokes to
the closed eyelid with your finger until
you can see the disk in the corner of
the eye. Then place your finger directly
on the disk, move it to the lower scle-
ra, and remove it as you would a disk
located in the lower lid.
◆ If the patient will continue therapy
with an eye medication disk after dis-
charge, teach him to insert and remove
◆ Pull the lower eyelid out, up, and it himself. Ask him to demonstrate the
over the disk. Tell the patient to blink techniques for you.
several times. If the disk is still visible, ◆ Explain that mild reactions are com-
pull the lower lid out and over the disk mon, but should subside within the
again. Tell him that after the disk is in first 6 weeks of use. Foreign-body sen-
place, he can adjust its position by sation in the eye, mild tearing, redness
pressing his finger against his closed of the eye or eyelid, increased mucus
lid. Warn him not to rub his eye or discharge, and itchiness can occur.
move the disk across the cornea. Blurred vision, stinging, swelling, and
◆ If the disk falls out, rinse it in cool headaches can occur with pilocarpine,
water and reinsert it. If the disk ap- specifically. Tell the patient to report
pears bent, replace it. persistent or severe signs or symptoms.
◆ If both eyes are being treated with
medication disks, replace both disks at Eardrops
the same time.
◆ If the disk slips out of position re- Eardrops may be instilled to treat infec-
peatedly, reinsert it under the upper tion or inflammation, to soften ceru-
eyelid. To do this, gently lift and evert men for later removal, to produce local
the upper eyelid and insert the disk in anesthesia, or to facilitate the removal
the conjunctival sac. Gently pull the lid of an insect trapped in the ear.
back into position and tell the patient
to blink several times. The more he Equipment and preparation
uses the disk, the easier it should be Patient’s medication record and chart
for him to retain it. If not, notify the ◆ prescribed eardrops ◆ light source ◆
physician. facial tissue or cotton-tipped applicator
◆ optional: cotton ball, bowl of warm
To remove an eye medication disk water
◆ To remove the disk with one finger, Warm the medication to body tem-
put on sterile gloves and evert the lower perature in the bowl of warm water or
eyelid to expose the disk. Use the fore- carry it in your pocket for 30 minutes
finger of your other hand to slide the before administration. If necessary, test
disk into the lid and out of the patient’s the temperature by placing a drop on
eye. To use two fingers, evert the lower your wrist. (If the medication is too
hot, it may burn the patient’s eardrum.) ◆ Instruct the patient to remain on his
To avoid injuring the ear canal, check side for 5 to 10 minutes to allow the
the dropper before use to make sure medication to run down into the ear
that it isn’t chipped or cracked. canal.
◆ Tuck the cotton ball (if ordered)
Implementation loosely into the opening of the ear
◆ Verify the order on the patient’s canal to prevent the medication from
medication record by checking it leaking out. Be careful not to insert it
against the physician’s order. Check too deeply into the canal because doing
the patient’s medication record for also would prevent drainage of secretions
lergies. and increase pressure on the eardrum.
◆ Wash your hands. ◆ Clean and dry the outer ear.
◆ Confirm the patient’s identity using ◆ If ordered, repeat the procedure in
two patient identifiers. the other ear after 5 to 10 minutes.
◆ Have the patient lie on the side op- ◆ Help the patient into a comfortable
posite the affected ear. position.
◆ Straighten the patient’s ear canal. ◆ Wash your hands.
For an adult, pull the auricle up and
back. Special considerations
Age alert For an infant or a ◆ Some conditions make the normally
child younger than age 3, gen- tender ear canal even more sensitive,
tly pull the auricle down and back — so be especially gentle when perform-
the ear canal is straighter at this age. ing this procedure.
◆ Using a light source, examine the ear ◆ To prevent injury to the eardrum
canal for drainage. If you find any, clean when inserting a cotton-tipped applica-
the canal with a facial tissue or cotton- tor, make sure that the cotton tip al-
tipped applicator. Drainage can reduce ways remains in view. After applying
the effectiveness of the medication. eardrops to soften cerumen, irrigate the
◆ Compare the label on the eardrops ear, as ordered, to facilitate its removal.
with the order on the patient’s medica- ◆ If the patient has vertigo, keep the
tion record. Check the label again side rails of his bed up, and assist him
while drawing the medication into the as necessary during the procedure.
dropper. Check the label for the final Move slowly and unhurriedly to avoid
time before returning the eardrops to exacerbating his vertigo.
the shelf or drawer. ◆ If necessary, teach the patient to in-
◆ To avoid damaging the ear canal still the eardrops correctly so that he
with the dropper, gently rest the hand can continue treatment at home. Re-
that’s holding the dropper against the view the procedure, and let the patient
patient’s head. Straighten the patient’s try it himself while you observe.
ear canal and instill the ordered num-
ber of drops. To avoid patient discom- Nasal medications
fort, aim the dropper so that the drops
fall against the sides of the ear canal, Nasal medications may be instilled
not on the eardrum. Hold the ear canal through drops, a spray (using an atom-
in position until you see the medica- izer), or an aerosol (using a nebulizer).
tion disappear down the canal. After Most produce local rather than systemic
instilling the drops, lightly massage the effects. Nasal medications include vaso-
tragus of the ear or apply gentle pres- constrictors, antiseptics, anesthetics,
sure. hormones, vaccines, and corticosteroids.
Equipment Age alert For a child or an

Patient’s medication record and chart uncooperative patient, place a
◆ prescribed medication ◆ emesis short piece of soft tubing on the end
basin (for nose drops) ◆ facial tissues of the dropper to avoid damaging the
◆ optional: pillow, piece of soft rubber mucous membranes.
or plastic tubing, gloves ◆ Instill the prescribed number of
drops, observing the patient for signs
Implementation of discomfort.
◆ Verify the order on the patient’s ◆ Keep the patient’s head tilted back
medication record by checking it for at least 5 minutes. Have him
against the physician’s order. Check the breathe through his mouth to prevent
patient’s medication record for allergies. the drops from leaking out and to al-
◆ Confirm the patient’s identity using low time for the medication to work.
two patient identifiers. ◆ Keep an emesis basin handy so that
◆ Wash your hands. Put on gloves, if the patient can expectorate medication
necessary. that flows into the oropharynx and
◆ Have the patient blow his nose to mouth. Use facial tissues to wipe ex-
clear secretions and enhance drug ab- cess medication from the patient’s face.
sorption. ◆ Instruct the patient not to blow his
nose for several minutes after instilla-
To instill nose drops tion.
◆ Draw some medication into the ◆ Clean the dropper. Return the drop-
dropper. per to the bottle and close it tightly.
◆ To reach the ethmoidal and sphe-
noidal sinuses, have the patient lie on To use a nasal spray
his back, with his neck hyperextended ◆ Have the patient sit upright, with
and his head tilted back over the edge his head erect.
of the bed. Support his head with one ◆ Remove the protective cap from the
hand to prevent neck strain. atomizer.
◆ To reach the maxillary and frontal ◆ Occlude one of the patient’s nos-
sinuses, have the patient lie on his trils, and insert the atomizer tip about
back, with his head toward the affected 1
⁄2⬙ (1.3 cm) into the open nostril. Po-
side and hanging slightly over the edge sition the tip straight up, toward the in-
of the bed. Ask him to rotate his head ner canthus of the eye.
laterally after hyperextension. Support ◆ Depending on the drug, have the
his head with one hand to prevent patient hold his breath or inhale.
neck strain. Squeeze the atomizer once quickly and
◆ To relieve ordinary nasal conges- firmly — just enough to coat the inside
tion, help the patient into a reclining or of the nose. Excessive force may propel
supine position, with his head tilted the medication into the patient’s sinus-
slightly toward the affected side. Aim es and cause a headache. Repeat the
the dropper upward, toward the pa- procedure in the other nostril, as or-
tient’s eye, rather than downward, dered.
toward his ear. ◆ Tell the patient to keep his head tilt-
◆ Insert the dropper about 1⁄3⬙ (8 mm) ed back for several minutes, to breathe
into the nostril. Make sure that it slowly through his nose, and not to
doesn’t touch the sides of the nostril to blow his nose to ensure that the med-
avoid contaminating the dropper or ication has time to work.
making the patient sneeze.
To use a nasal aerosol administration is most effective when

◆ Insert the medication cartridge ac- the patient can remain lying down af-
cording to the manufacturer’s direc- terward, to retain the medication.
tions. Shake it well before each use
and remove the protective cap. Equipment
◆ Hold the aerosol between your Patient’s medication record and chart
thumb and index finger, with the index ◆ prescribed medication and applica-
finger on top of the cartridge. tor, if needed ◆ gloves ◆ water-soluble
◆ Tilt the patient’s head back slightly, lubricant ◆ cotton balls ◆ soap and
and carefully insert the adapter tip into warm water ◆ small sanitary pad
one nostril. Depending on the medica-
tion, tell the patient to hold his breath Implementation
or to inhale. ◆ Verify the order on the patient’s
◆ Press your fingers together firmly to medication record by checking it
release one measured dose of medica- against the physician’s order. Check
tion. the patient’s medication record for
◆ Shake the aerosol and repeat the allergies.
procedure to instill medication into the ◆ Confirm the patient’s identity using
other nostril. two patient identifiers.
◆ Remove the cartridge and wash the ◆ Ask the patient to void.
nasal adapter daily in lukewarm water. ◆ Wash your hands, explain the proce-
Allow the adapter to dry before rein- dure to the patient, and provide privacy.
serting the cartridge. ◆ Ask the patient if she would rather
◆ Tell patient not to blow his nose for insert the medication herself. If so, pro-
at least 2 minutes afterward. vide appropriate instructions. If not,
proceed with the following steps.
Special consideration ◆ Help her into the lithotomy position
◆ Calcitonin (Miacalcin), a hormone and expose only the perineum.
used for osteoporosis, should be given
in only one nostril daily, with the nos- To insert a suppository
trils alternated each day. Be sure to ◆ Remove the suppository from the
document which nostril is used. wrapper and lubricate it with a water-
soluble lubricant.
Vaginal medications ◆ Put on gloves and expose the vagi-
na by spreading the labia.
Vaginal medications include supposito- ◆ If you see discharge, wash the area
ries, creams, gels, and ointments. with several cotton balls soaked in
These medications can be inserted as warm, soapy water. Clean each side of
topical treatment for infection (particu- the perineum and then the center, us-
larly Trichomonas vaginalis and candi- ing a fresh cotton ball for each stroke.
dal vaginitis) or inflammation or as a While the labia are still separated, in-
contraceptive. Suppositories melt when sert the suppository 3⬙ to 4⬙ (7.5 to
they come in contact with the warm 10 cm) into the vagina.
vaginal mucosa, and their medication
diffuses topically — as effectively as To insert an ointment, a cream, or a gel
creams, gels, and ointments. ◆ Fit the applicator to the tube of
Vaginal medications usually come medication and gently squeeze the
with a disposable applicator that al- tube to fill the applicator with the pre-
lows placement of medication in the scribed amount of medication. Lubri-
anterior and posterior fornices. Vaginal cate the applicator tip.
◆ Put on gloves and expose the vagina. lining of the respiratory tract absorbs
◆ Insert the applicator about 2⬙ the inhalant almost immediately. Ex-
(5 cm) into the patient’s vagina and amples of inhalants are bronchodila-
administer the medication by depress- tors, which are used to improve airway
ing the plunger on the applicator. patency and facilitate drainage of mu-
◆ Instruct the patient to remain in a cus, and mucolytics, which liquefy
supine position, with her knees flexed, tenacious bronchial secretions.
for 5 to 10 minutes, to allow the med-
ication to flow into the posterior fornix. Equipment
After vaginal insertion ◆ metered-dose inhaler or turbo-
◆ Wash the applicator with soap and inhaler ◆ prescribed medications ◆
warm water and store or discard it, as normal saline solution ◆ optional:
appropriate. Label it so that it will be spacer or extender
used only for the same patient.
◆ Remove and discard your gloves. Implementation
◆ To prevent the medication from soil- ◆ Verify the order on the patient’s
ing the patient’s clothing and bedding, medication record by checking it
provide a sanitary pad. against the physician’s order. Check the
◆ Help the patient to return to a com- patient’s medication record for allergies.
fortable position and advise her to re- ◆ Confirm the patient’s identity using
main in bed as much as possible for two patient identifiers.
the next several hours. To use a metered-dose inhaler
◆ Wash your hands thoroughly. ◆ Shake the inhaler bottle. Remove
the cap and insert the stem into the
Special considerations small hole on the flattened portion of
◆ Refrigerate vaginal suppositories the mouthpiece, as shown below.
that melt at room temperature.
◆ If possible, teach the patient how to
insert vaginal medication. She may
need to administer it herself after dis-
charge. Give her a patient-teaching
sheet if one is available.
◆ Instruct the patient not to wear a
tampon after inserting vaginal medica-
tion because it will absorb the medica-
tion and decrease its effectiveness.
Respiratory administration
Handheld oropharyngeal inhalers ◆ If the metered-dose inhaler has a

spacer built into the inhaler, pull the
Handheld inhalers include the metered- spacer away from the section holding
dose inhaler, with or without a spacer, the medication canister until it clicks
the turbo-inhaler, and the nasal inhaler. into place.
These devices deliver topical medica- ◆ Have the patient exhale. Place the
tions to the respiratory tract, producing inhaler about 1⬙ (2.5 cm) in front of
local and systemic effects. The mucosal his open mouth.
Respiratory administration 521
◆ As you push the bottle down stem of the mouthpiece. Screw the in-
against the mouthpiece, instruct the haler together again.
patient to inhale slowly through his ◆ Holding the inhaler with the mouth-
mouth and to continue inhaling until piece at the bottom, slide the sleeve all
his lungs feel full. Compress the bottle the way down and then up again to
against the mouthpiece only once. puncture the capsule and release the
◆ Remove the inhaler and tell the pa- medication. Do this only once.
tient to hold his breath for several sec- ◆ Have the patient exhale completely
onds. Then instruct him to exhale slow- and tilt his head back. Instruct him to
ly through pursed lips to keep the distal place the mouthpiece in his mouth,
bronchioles open, allowing increased close his lips around it, and inhale
absorption and diffusion of the drug. once. Tell him to hold his breath for
◆ Have the patient gargle with tap several seconds.
water, if desired, to remove the med- ◆ Remove the inhaler from the pa-
ication from his mouth and the back of tient’s mouth and tell him to exhale as
his throat. much air as possible.
◆ Have the patient wait 1 to 3 min- ◆ Repeat the procedure until all of the
utes before another inhalation is ad- medication in the device has been in-
ministered. haled.
◆ Rinse the mouthpiece thoroughly ◆ Have the patient gargle with normal
with warm water to prevent the accu- saline solution, if desired.
mulation of residue. ◆ Discard the empty medication cap-
sule. Rinse the inhaler with warm wa-
To use a turbo-inhaler ter at least once per week.
◆ Hold the mouthpiece in one hand.
With the other hand, slide the sleeve To use a nasal inhaler
away from the mouthpiece as far as ◆ Have the patient clear his nostrils
possible, as shown below. by blowing his nose
◆ Shake the medication cartridge and
then insert it into the adaptor. (Before
inserting a refill cartridge, remove the
protective cap from the stem.)
◆ Remove the protective cap from the
adapter tip.
◆ The patient should hold the inhaler
with his index finger on top of the car-
tridge and his thumb under the nasal
adapter. The adapter tip should point
toward the patient.
◆ Have the patient tilt his head back
and place the adapter tip into one nos-
tril. He should occlude the other nostril
with his finger.
◆ Instruct the patient to inhale gently
as he presses the adapter and the car-
tridge together to release a measured
◆ Unscrew the tip of the mouthpiece dose of medication. Follow the manu-
by turning it counterclockwise. facturer’s instructions; with some med-
◆ Press the colored portion of the ications such as dexamethasone sodi-
medication capsule into the propeller um phosphate, inhaling isn’t desirable.
◆ Tell the patient to remove the in- such as mixing with juice to make
haler from his nostril and hold his them more palatable.
breath for a few seconds. Oral drugs are sometimes prescribed
◆ Have the patient exhale through his in higher dosages than their parenteral
mouth. equivalents because, after absorption
◆ Have the patient shake the inhaler through the GI system, the liver breaks
and repeat the procedure in the other them down before they reach the sys-
nostril. temic circulation.
Special considerations Equipment

◆ Teach the patient how to use the in- Patient’s medication record and chart
haler so that he can continue treat- ◆ prescribed medication ◆ optional:
ments after discharge, if necessary. Ex- medication cup; appropriate vehicle
plain that an overdose can cause the (such as jelly or applesauce) for
medication to lose its effectiveness. Tell crushed pills commonly used with chil-
him to record the date and time of dren or elderly patients, or juice, water,
each inhalation as well as his response. or milk for liquid medications; and
◆ Some oral respiratory drugs can crushing or cutting device
cause restlessness, palpitations, ner-
vousness, other systemic effects, and Implementation
hypersensitivity reactions, such as a ◆ Verify the order on the patient’s
rash, urticaria, and bronchospasm. medication record by checking it
◆ If the patient has heart disease, use against the physician’s order. Check
caution when administering an oral the patient’s medication record for
respiratory drug because it can potenti- allergies.
ate coronary insufficiency, cardiac ar- ◆ Confirm the patient’s identity using
rhythmias, or hypertension. If paradox- two patient identifiers.
ical bronchospasm occurs, discontinue ◆ Wash your hands.
the drug and call the physician. ◆ Assess the patient’s condition, in-
◆ If the patient is using a bronchodila- cluding his level of consciousness, abil-
tor and a steroid, have him use the ity to swallow, and vital signs, as need-
bronchodilator first, wait 5 minutes, ed. Changes in his condition may war-
and then use the corticosteroid. rant withholding medication.
◆ Give the patient his medication and,
as needed, liquid to aid swallowing,
minimize adverse effects, or promote
Enteral administration absorption. If appropriate, crush the
medication to facilitate swallowing.
Oral drugs ◆ Stay with the patient until he has
swallowed the drug. If he seems con-
Most drugs are administered orally be- fused or disoriented, check his mouth
cause this route is usually the safest, to make sure that he has swallowed it.
most convenient, and least expensive. Return and reassess the patient’s re-
Drugs for oral administration are avail- sponse within 1 hour after giving the
able in many forms, including tablets, medication.
enteric-coated tablets, capsules, syrups,
elixirs, oils, liquids, suspensions, pow- Special considerations
ders, and granules. Some require spe- ◆ To avoid damaging or staining
cial preparation before administration, the patient’s teeth, give acid or iron
preparations through a straw. An
unpleasant-tasting liquid can usually be To give a drug through an NG tube

made more palatable if taken through a ◆ Wash your hands and put on
straw because the liquid comes in con- gloves.
tact with fewer taste buds. ◆ Unpin the tube from the patient’s
◆ If the patient can’t swallow a whole gown. To avoid soiling the sheets dur-
tablet or capsule, ask the pharmacist if ing the procedure, drape the patient’s
the drug is available in liquid form or if it chest with a towel or linen-saver pad.
can be administered by another route. If ◆ Help the patient into Fowler’s posi-
not, ask him if you can crush the tablet tion, if his condition allows.
or open the capsule and mix it with food. ◆ After unclamping the tube, attach
the catheter tip syringe and gently draw
Drug delivery through a back on the piston of the syringe. Place
nasogastric tube or a small amount of gastric contents on
gastrostomy button the pH test strip. The appearance of
gastric contents and pH ⱕ 5 implies that
In addition to providing an alternate the tube is patent and in the stomach.
means of nourishment, a nasogastric ◆ If no gastric contents appear or if
(NG) tube allows direct instillation of you meet resistance, the tube may be
medication into the GI system for the lying against the gastric mucosa. With-
patient who can’t ingest it orally. A draw the tube slightly or turn the pa-
gastrostomy button, inserted into an tient to free it.
established stoma, lies flush with the ◆ Clamp the tube, detach the syringe,
skin and receives a feeding tube. and lay the end of the tube on a
4⬙ ⫻ 4⬙ gauze pad.
Equipment and preparation ◆ If the medication is in tablet form,
Patient’s medication record and chart crush it before mixing it with the dilu-
◆ prescribed medication ◆ towel or ent. (Make sure that the particles are
linen-saver pad ◆ 50- or 60-ml piston- small enough to pass through the eyes
type catheter-tip syringe ◆ feeding tub- at the distal end of the tube.) Open the
ing ◆ two 4⬙ ⫻ 4⬙ gauze pads ◆ pH capsules and pour them into the dilu-
test strip ◆ gloves ◆ diluent (juice, wa- ent. Pour liquid medications into the
ter, or a nutritional supplement) ◆ cup diluent and stir well.
for mixing medication and fluid ◆ ◆ Reattach the syringe, without the
spoon ◆ 50-ml cup of water ◆ gastros- piston, to the end of the tube. Holding
tomy tube and funnel, if needed ◆ op- the tube upright at a level slightly
tional: pill-crushing equipment, clamp above the patient’s nose, open the
(if not already attached to the tube) clamp and pour in the medication
Gather the equipment for use at the slowly and steadily, as shown below.
patient’s bedside. Liquids should be at
room temperature to avoid abdominal
cramping. Make sure that the cup, sy-
ringe, spoon, and gauze are clean.
Implementation
against the physician’s order. Check the
patient’s medication record for allergies.
◆ To prevent air from entering the pa- ◆ After instilling all of the medication,
tient’s stomach, hold the tube at a pour 30 to 50 ml of water into the sy-
slight angle and add more medication ringe and allow it to flow through the
before the syringe empties. tube.
◆ If the medication flows smoothly, ◆ When all of the water has been de-
slowly give the entire dose. If it doesn’t livered, remove the feeding tube and
flow, it may be too thick. In this case, replace the safety plug. Keep the pa-
dilute it with water. If you suspect that tient in semi-Fowler’s position for 30
the placement of the tube is inhibiting minutes after giving the medication.
the flow, stop the procedure and re-
evaluate the placement. Special considerations
◆ Watch the patient’s reaction and ◆ If you must give a tube feeding as
stop administration immediately if she well as instill medication, give the
shows signs of discomfort. medication first to ensure that the pa-
◆ As the last of the medication flows tient receives it all. Don’t give foods
out of the syringe, start to irrigate the that interact adversely with the drug.
tube by adding 30 to 50 ml of water Tube feedings must be withheld 2
(15 to 30 ml for a child). Irrigation hours before and 2 hours after pheny-
clears medication from the tube and toin or warfarin administration.
reduces the risk of clogging. ◆ If residual stomach contents exceed
◆ When the water stops flowing, 100 ml, withhold the medication and
clamp the tube. Detach the syringe and feeding and notify the physician. Ex-
discard it properly. cessive stomach contents may indicate
◆ Fasten the tube to the patient’s intestinal obstruction or paralytic ileus.
gown and make sure that the patient is ◆ If the NG tube is on suction, turn it
comfortable. off for 20 to 30 minutes after giving the
◆ Leave the patient in Fowler’s posi- medication.
tion or on her right side, with her head ◆ Document the amount of water and
partially elevated, for at least 30 min- medication given.
utes to facilitate flow and prevent
esophageal reflux. Buccal, sublingual, and
translingual medications
To give a drug through a gastrostomy
button Certain drugs are given buccally (be-
◆ Help the patient into an upright po- tween the patient’s cheek and teeth) or
sition. sublingually (under the patient’s
◆ Wash your hands. Put on gloves tongue) to bypass the digestive tract
and open the safety plug on top of the and facilitate their absorption into the
device. bloodstream.
◆ Attach the feeding tube set to the Drugs that are given buccally in-
button. clude nitroglycerin and methyltesto-
◆ Remove the piston from the catheter- sterone. Drugs that are given sublin-
tipped syringe and insert the tip into the gually include ergotamine tartrate,
distal end of the feeding tube. isosorbide, and nitroglycerin. Translin-
◆ Pour the prescribed medication into gual drugs, which are sprayed onto the
the syringe, and allow it to flow into tongue, include nitrate preparations for
the stomach. patients with chronic angina. When us-
ing either administration method,
observe the patient carefully to ensure Rectal suppositories or ointment

that he doesn’t swallow the drug or ex-
perience mucosal irritation. A rectal suppository is a small, solid,
medicated mass, usually cone-shaped,
Equipment with a cocoa butter or glycerin base. It
Patient’s medication record and chart may be inserted to stimulate peristalsis
◆ prescribed medication ◆ medication and defecation or to relieve pain, vom-
cup iting, and local irritation. An ointment
is a semisolid medication that’s used to
Implementation produce local effects. It may be applied
◆ Verify the order on the patient’s externally to the anus or internally to
medication record by checking it the rectum.
the patient’s medication record for al- Equipment and preparation
lergies. Patient’s medication record and chart
◆ Confirm the patient’s identity using ◆ rectal suppository or tube of oint-
two patient identifiers. ment and ointment applicator ◆
◆ Wash your hands. 4⬙ ⫻ 4⬙ gauze pads ◆ gloves ◆ water-
◆ For buccal administration, place the soluble lubricant ◆ optional: bedpan
tablet in the patient’s buccal pouch, Store rectal suppositories in the re-
between his cheek and his teeth. frigerator until they are needed, to pre-
◆ For sublingual administration, place vent softening and possible decreased
the tablet under the patient’s tongue. effectiveness of the medication. A soft-
◆ Instruct the patient to keep the ened suppository is difficult to handle
medication in place until it dissolves and insert. To harden it again, hold the
completely to ensure absorption. suppository (in its wrapper) under cold
◆ Caution the patient against chewing running water.
the tablet or touching it with his
tongue, to prevent accidental swallow- Implementation
ing. ◆ Verify the order on the patient’s
◆ For translingual administration, medication record by checking it
hold the medication canister vertically, against the physician’s order. Check
with the valve head at the top, and the patient’s medication record for
then spray the orifice as close to the allergies.
patient’s mouth as possible. ◆ Confirm the patient’s identity using
◆ Spray the dose onto the patient’s two patient identifiers.
tongue by pressing firmly on the but- ◆ Wash your hands.
ton. Have the patient wait 10 seconds
before swallowing. To insert a rectal suppository
◆ Place the patient on his left side in
Special considerations Sims’ position. Drape him with the
◆ Don’t give liquids because some bedcovers, exposing only the buttocks.
buccal tablets may take up to 1 hour to Put on gloves. Unwrap the suppository
be absorbed. and lubricate it with water-soluble lu-
◆ If the patient has angina, tell him to bricant.
wet the nitroglycerin tablet with saliva ◆ Lift the patient’s upper buttock with
and to keep it under his tongue until your nondominant hand to expose the
it’s fully absorbed. anus.
◆ Instruct the patient to take several ing a small amount from the tube be-
deep breaths through his mouth to re- fore you attach the applicator.
lax the anal sphincter and reduce anxi- ◆ Lift the patient’s upper buttock with
ety during drug insertion. your nondominant hand to expose the
◆ Using the index finger of your domi- anus.
nant hand, insert the suppository — ◆ Tell the patient to take several deep
tapered end first — about 3⬙ (7.5 cm) breaths through his mouth to relax the
until you feel it pass the internal anal anal sphincter and reduce discomfort
sphincter, as shown below. during insertion. Then gently insert the
applicator, directing it toward the um-
bilicus, as shown below.
◆ Direct the tapered end of the sup-

pository toward the side of the rectum
so that it touches the membranes. ◆ Squeeze the tube to eject medica-
◆ Encourage the patient to lie quietly tion.
and, if applicable, to retain the suppos- ◆ Remove the applicator, and place a
itory for the correct length of time. folded 4⬙ ⫻ 4⬙ gauze pad between the
Press on the anus with a gauze pad, if patient’s buttocks to absorb excess
necessary, until the urge to defecate ointment. Disassemble the tube and
passes. applicator. Recap the tube. Clean the
◆ Discard the used equipment. applicator with soap and warm water.
Remove and discard the gloves and
To apply an ointment wash your hands thoroughly.
◆ Put on gloves.
◆ For external application, use gloves Special considerations
or a gauze pad to spread the medica- ◆ Because the intake of food and fluid
tion over the anal area. stimulates peristalsis, a suppository for
◆ For internal application, attach the relieving constipation should be insert-
applicator to the tube of ointment and ed about 30 minutes before mealtime
coat the applicator with water-soluble to help soften the stool and facilitate
lubricant. defecation. A medicated retention sup-
◆ Expect to use about 1⬙ (2.5 cm) of pository should be inserted between
ointment. To gauge how much pressure meals.
to use during application, try squeez- ◆ Tell the patient not to expel the sup-
pository. If he has difficulty retaining
it, put him on a bedpan.
◆ Make sure that the patient’s call needle and the ampule. Attach the ap-
button is handy and watch for his sig- propriate size and gauge needle to the
nal because he may be unable to sup- syringe.
press the urge to defecate.
◆ Inform the patient that the supposi- For single-dose or multidose vials
tory may discolor his next bowel move- Reconstitute powdered drugs according
ment. to the instructions on the label. Clean
the rubber stopper of the vial with an
alcohol pad. Pull the plunger of the sy-
Parenteral administration ringe back until the volume of air in
the syringe equals the volume of drug
Subcutaneous injection to be withdrawn from the vial. Insert
the needle into the vial. Inject the air,
A subcutaneous injection allows slow- invert the vial, and keep the bevel tip
er, more sustained drug administration of the needle below the level of the so-
than I.M. injection. Drugs and solu- lution as you withdraw the prescribed
tions for subcutaneous injections are amount of medication. Cover the nee-
injected through a relatively short dle with the needle sheath. Tap the sy-
needle, using meticulous sterile ringe to clear air from it. Check the
technique. drug label against the patient’s medica-
tion record.
Patient’s medication record and chart Implementation
◆ prescribed medication ◆ needle of ◆ Verify the order on the patient’s
appropriate gauge and length ◆ gloves medication record by checking it
◆ 1- to 3-ml syringe ◆ alcohol pads ◆ against the physician’s order. Check
optional: antiseptic cleaner, filter nee- the patient’s medication record for
dle, insulin syringe, insulin pump allergies.
Inspect the medication to make sure ◆ Confirm the patient’s identity using
that it isn’t cloudy and doesn’t contain two patient identifiers.
precipitates. ◆ Select the injection site from those
Wash your hands. Select a needle of shown below, and tell the patient
the proper gauge and length. where you’ll be giving the injection.
Age alert An average adult
patient requires a 25G 5⁄8⬙ nee-
dle; an infant, a child, or an elderly
or thin patient usually requires a 25G
to 27G 1⁄2⬙ needle.
For single-dose ampules

Wrap the neck of the ampule in an al-
cohol pad and snap off the top, away
from you. If desired, attach a filter
needle and withdraw the medication.
Tap the syringe to clear air from it.
Cover the needle with the needle
sheath. Before discarding the ampule,
check the label against the patient’s
medication record. Discard the filter
◆ Put on gloves. Position and drape

the patient, if necessary.
◆ Clean the injection site with an al-
cohol pad. Loosen the protective nee-
dle cover. 45-degree angle
◆ With your nondominant hand, 90-degree angle
pinch the skin around the injection site
firmly to elevate the subcutaneous tis-
sue, forming a 1⬙ (2.5-cm) fat fold, as
shown below.
Muscle Skin
Subcutaneous tissue
◆ Release the skin to avoid injecting

the drug into compressed tissue and ir-
ritating the nerves.
◆ Pull the plunger back slightly to
check for blood return. If none ap-
◆ Holding the syringe in your domi- pears, slowly inject the drug. If blood
nant hand (while pinching the skin appears on aspiration, withdraw the
around the injection site with the needle, prepare another syringe, and
thumb and index finger of your non- repeat the procedure.
dominant hand), grip the needle ◆ After injection, remove the needle
sheath between the fourth and fifth fin- at the same angle used for insertion.
gers of your nondominant hand, and Cover the site with an alcohol pad and,
pull back to uncover the needle. Don’t if appropriate, massage the site gently.
touch the needle. ◆ Remove the alcohol pad and check
◆ Position the needle with its bevel the injection site for bleeding or bruis-
up. ing.
◆ Tell the patient that he’ll feel a prick ◆ Dispose of injection equipment ac-
as the needle is inserted. Insert the cording to facility policy. Don’t recap
needle quickly in one motion at a 45- the needle.
or 90-degree angle, as shown at the top
of the next column, depending on the Special considerations
length of the needle, the medication, ◆ Don’t aspirate for blood return
and the amount of subcutaneous tissue when giving insulin or heparin. It isn’t
at the site. Some drugs, such as hepa- necessary with insulin and may cause
rin, should always be injected at a a hematoma with heparin.
90-degree angle. ◆ Repeated injections in the same site
can cause lipodystrophy. A natural im-
mune response, this complication can
be minimized by rotating injection
sites.
Intradermal injection surface, with the ventral forearm ex-

posed.
Used primarily for diagnostic purposes, ◆ Wash your hands and put on
as in allergy or tuberculin testing, an gloves.
intradermal injection is administered in ◆ With an alcohol pad, clean the sur-
small amounts, usually 0.5 ml or less, face of the ventral forearm about two
into the outer layers of the skin. Be- or three fingerbreadths distal to the an-
cause little systemic absorption takes tecubital space. Make sure that the test
place, this type of injection is used pri- site is free from hair and blemishes. Al-
marily to produce a local effect. low the skin to dry completely before
The ventral forearm is the most administering the injection.
commonly used site because of its easy ◆ While holding the patient’s forearm
access and lack of hair. in your hand, stretch the skin taut with
your thumb.
Equipment ◆ With your free hand, hold the nee-
Patient’s medication record and chart dle at a 15-degree angle to the patient’s
◆ prescribed medication ◆ tuberculin arm, with its bevel up.
syringe with a 26G or 27G 1⁄2⬙ to 5⁄8⬙ ◆ Insert the needle about 1⁄8⬙ (3 mm)
needle ◆ gloves ◆ alcohol pads ◆ below the epidermis. Stop when the
marking pen bevel tip of the needle is under the
skin and inject the antigen slowly. You
Implementation should feel some resistance as you do
◆ Verify the order on the patient’s this, and a wheal should form as you
medication record by checking it inject the antigen, as shown below.
allergies.
◆ Locate an injection site from those
shown below, and tell the patient
where you’ll be giving the injection.
If no wheal forms, you have inject-

ed the antigen too deeply. Withdraw
the needle, and administer another test
dose at least 2⬙ (5 cm) from the first
site.
◆ Withdraw the needle at the same
angle at which it was inserted. Don’t
rub the site. This could irritate the un-
derlying tissue, which may affect the
test results.
◆ Circle each test site with a marking
pen, and label each site according to
◆ Instruct the patient to sit up and to the recall antigen given. Tell the patient
extend and support her arm on a flat to avoid washing off the circles until
the test is completed.
◆ Dispose of needles and syringes ac- ◆ Confirm the patient’s identity using
cording to facility policy. two patient identifiers.
◆ Remove and discard your gloves. ◆ Provide privacy and explain the pro-
◆ Assess the patient’s response to the cedure to the patient.
skin testing in 24 to 48 hours. ◆ Wash your hands and select an ap-
propriate injection site. Avoid any site
Special considerations that’s inflamed, edematous, or irritated
◆ If the patient is hypersensitive to or that contains moles, birthmarks,
the test antigens, he can have a severe scar tissue, or other lesions. The dor-
anaphylactic response. Be prepared to sogluteal and ventrogluteal muscles are
give an immediate epinephrine injec- the most common sites, as shown
tion and other emergency resuscitation below.
procedures. Be especially alert after
giving a test dose of penicillin or
tetanus antitoxin. Posterior superior
iliac spine
I.M. injection
An I.M. injection deposits medication

deep into well-vascularized muscle for
rapid systemic action and absorption of
up to 5 ml.
Equipment and preparation Sciatic nerve

Greater trochanter
◆ prescribed medication ◆ diluent or of femur
filter needle, if needed ◆ 3- to 5-ml sy-
ringe ◆ 20G to 25G 1⬙ to 3⬙ needle ◆
gloves ◆ alcohol pads ◆ marking pen
Iliac crest
The prescribed medication must be
sterile. The needle may be packaged
separately or already attached to the
syringe. Needles used for I.M. injec-
tions are longer than subcutaneous
needles because they reach deep into
the muscle. Needle length also depends
on the injection site, the patient’s size,
and the amount of subcutaneous fat
covering the muscle.
Wipe the stopper of the vial with al-
cohol, and draw the prescribed amount
Greater trochanter
of medication into the syringe. of femur
Anterior superior
Implementation
iliac spine
allergies.
◆ Loosen, but don’t remove, the nee-

◆ The deltoid muscle may be used for dle sheath.
injections of 2 ml or less, as shown ◆ Clean the site by moving an alcohol
below. pad in circles, increasing in diameter to
about 2⬙ (5 cm). Allow the skin to dry;
Acromial process alcohol causes an unpleasant stinging
sensation during injection.
◆ Put on gloves. With the thumb and
Humerus index finger of your nondominant
hand, gently stretch the skin, pulling it
Deep brachial taut.
artery ◆ With the syringe in your dominant
hand, remove the needle sheath with
Radial the free fingers of your other hand.
nerve ◆ Position the syringe perpendicular
to the skin surface and a couple of
inches from the skin. Tell the patient
that he’ll feel a prick. Then quickly
and firmly thrust the needle into the
muscle.
◆ Pull back slightly on the plunger to
aspirate for blood. If none appears, in-
ject the medication slowly and steadily
◆ The vastus lateralis muscle is usual- to allow the muscle to distend gradual-
ly used in children; the rectus femoris ly. You should feel little or no resis-
muscle may be used in infants, as tance. Gently, but quickly, remove the
shown below. needle at a 90-degree angle.
◆ If blood appears, the needle is in a
blood vessel. Withdraw it, prepare a
Greater trochanter fresh syringe, and inject the medication
of femur at another site.
◆ Using a gloved hand, apply gentle
pressure to the site with the used alco-
hol pad. Massage the relaxed muscle,
unless contraindicated, to distribute the
Rectus drug and promote absorption.
femoris ◆ Inspect the site for bleeding or
bruising. Apply pressure or ice, as nec-
essary.
Vastus lateralis ◆ Discard all equipment properly.
Don’t recap needles; put them in an
appropriate biohazard container to
avoid needle-stick injuries.
◆ Remember to rotate injection sites ◆ Some drugs are dissolved in oil to
for the patient who requires repeated slow absorption. Mix them well before
injections. use.
◆ Position and drape the patient ap-
propriately.
◆ Never inject into the gluteal mus- Implementation

cles of a child who has been walking ◆ Verify the order on the patient’s
for less than 1 year. medication record by checking it
◆ If the patient must have repeated against the physician’s order. Check
injections, consider numbing the area the patient’s medication record for al-
with ice before cleaning it. If you must lergies.
inject more than 5 ml, divide the solu- ◆ Confirm the patient’s identity using
tion and inject it at two sites. two patient identifiers.
◆ Urge the patient to relax the mus- ◆ Place the patient in the lateral posi-
cles to reduce pain and bleeding. tion, exposing the gluteal muscle to be
◆ I.M. injections can damage local used as the injection site. The patient
muscle cells and elevate the serum cre- may also be placed in the prone posi-
atine kinase level. This increase can be tion. Put on gloves.
confused with the elevated levels ◆ Clean an area on the upper outer
caused by a myocardial infarction. Di- quadrant of the patient’s buttock with
agnostic tests can differentiate the two. an alcohol pad.
◆ Displace the skin laterally by pul-
Z-track injection ling it away from the injection site. To
do so, place your finger on the skin
The Z-track I.M. injection method pre- surface and pull the skin and subcu-
vents leakage, or tracking, into the sub- taneous layers out of alignment with
cutaneous tissue. Typically, it’s used to the underlying muscle. In doing so,
administer drugs that irritate and discol- the skin should move about 1⬙
or subcutaneous tissue — primarily iron (2.5 cm).
preparations such as iron dextran. It may ◆ Insert the needle at a 90-degree an-
also be used in elderly patients who gle in the site where you initially
have decreased muscle mass. Lateral displaced your finger, as shown below.
placement of the skin during the injec-
tion helps to seal the drug in the muscle.

◆ two 20G 1⬙ to 3⬙ needles ◆ pre-
scribed medication ◆ gloves ◆ 3- to
5-ml syringe ◆ alcohol pad
Wash your hands. Make sure that
the needle you’re using is long enough
to reach the muscle. As a rule of
thumb, a 200-lb (91-kg) patient re-
quires a 2⬙ needle; a 100-lb (45-kg) ◆ Aspirate for blood return. If none
patient, a 11⁄4⬙ to 11⁄2⬙ needle. appears, inject the drug slowly, fol-
Attach one needle to the syringe lowed by the air. Injecting air after the
and draw up the prescribed medica- drug helps to clear the needle and pre-
tion. Then draw 0.2 to 0.5 cc of air vents tracking the medication through
(depending on facility policy) into the subcutaneous tissues as the needle is
syringe. Remove the first needle and at- withdrawn.
tach the second to prevent tracking the ◆ Wait 10 seconds before withdrawing
medication through the subcutaneous the needle to ensure dispersion of the
tissue as the needle is inserted. medication.
◆ Withdraw the needle slowly. Re- ◆ Discard the needles and syringe in
lease the displaced skin and subcuta- an appropriate biohazard container. To
neous tissues to seal the needle track, avoid needle-stick injuries, don’t recap
as shown below. the needles.
◆ Remove and discard your gloves.
◆ Never inject more than 5 ml of solu-
tion into a single site using the Z-track
method. Alternate gluteal sites for re-
peat injections.
◆ If the patient is on bed rest, encour-
age active range-of-motion (ROM) exer-
cises, or perform passive ROM exercis-
es to facilitate absorption of the drug
from the injection site.
◆ Don’t massage the injection site or
allow the patient to wear a tight-fitting Drug infusion through a secondary
garment over the site because doing ei- I.V. line
ther could force the medication into
subcutaneous tissue. A secondary I.V. line is a complete I.V.
◆ Encourage the patient to walk or set that’s connected to the lower Y-port
move about in bed to facilitate ab- (secondary port) of a primary line in-
sorption of the drug from the injection stead of to the I.V. catheter or needle.
site. It features an I.V. container, long
Extension hook
Slide clamp
Piggyback set
Primary set
Piggyback Y-port
(with backcheck valve)
Flow control clamp
Secondary Y-port (to serve

secondary set)
tubing, and either a microdrip or Implementation

macrodrip system. It can be used for ◆ Verify the order on the patient’s
continuous or intermittent drug infu- medication record by checking it
sion. When used continuously, it per- against the physician’s order. Check
mits drug infusion and titration while the patient’s medication record for
the primary line maintains a constant allergies.
total infusion rate. ◆ Confirm the patient’s identity using
A secondary I.V. line, used only for two patient identifiers.
intermittent drug administration, is ◆ If the drug is incompatible with the
called a piggyback set. In this case, the primary I.V. solution, replace the pri-
primary line maintains venous access mary I.V. solution with a fluid that’s
between drug doses. A piggyback set compatible with both solutions and
includes a small I.V. container, short flush the line before starting the drug
tubing, and usually a macrodrip sys- infusion.
tem. It connects to the upper Y-port ◆ Hang the container of the secondary
(piggyback port) of the primary line, as set, and wipe the injection port of the
shown on previous page. primary line with an alcohol pad.
◆ Insert the needleless adapter from
Equipment and preparation the secondary line into the injection
Patient’s medication record and chart port and tape it securely to the primary
◆ prescribed I.V. medication ◆ diluent, line.
if necessary ◆ prescribed I.V. solution ◆ To run the container of the sec-
◆ administration set with a secondary ondary set by itself, lower the contain-
injection port ◆ needleless adapter ◆ er of the primary set with an extension
alcohol pads ◆ 1⬙ adhesive tape ◆ hook. To run both containers simulta-
time tape ◆ labels ◆ infusion pump ◆ neously, place them at the same
extension hook and solution for inter- height.
mittent piggyback infusion ◆ Open the slide-clamp and adjust the
Wash your hands. Inspect the I.V. drip rate. For continuous infusion, set
container for cracks, leaks, or contami- the secondary solution to the desired
nation and check compatibility with drip rate and then adjust the primary
the primary solution. solution to the desired total infusion
If necessary, add the drug to the rate.
secondary I.V. solution. To do so, re- ◆ For intermittent infusion, wait until
move any seals from the secondary the secondary solution is completely
container and wipe the main port with infused and then adjust the primary
an alcohol pad. Inject the prescribed drip rate, as required. If the tubing for
medication and agitate the solution to the secondary solution is being reused,
mix the medication. Label the I.V. mix- close the clamp on the tubing and fol-
ture. Insert the administration set low facility policy: Either remove the
spike. Open the flow clamp and prime needleless adapter and replace it with
the line. Then close the flow clamp. a new one, or leave it taped in the in-
Some medications come in vials for jection port and label it with the time
hanging directly on an I.V. pole. In this that it was first used. Leave the empty
case, inject the diluent directly into the container in place until you replace it
medication vial. Then spike the vial, with a new dose of medication at the
prime the tubing, and hang the set. prescribed time. If the tubing won’t be
reused, discard it appropriately with
the I.V. container.
Special considerations ◆ Wash your hands and put on

◆ If facility policy allows, use a pump gloves.
for drug infusion. Put a time tape on
the secondary container to help pre- To inject through an existing I.V. line
vent an inaccurate administration rate. ◆ Check the compatibility of the med-
◆ When reusing secondary tubing, ication.
change it according to facility policy, ◆ Close the flow clamp, wipe the in-
usually every 48 to 72 hours. Inspect jection port with an antiseptic pad, and
the injection port for leakage with each inject the drug as you would a direct
use; change it more often, if needed. injection.
◆ Except for lipids, don’t piggyback a ◆ Open the flow clamp and readjust
secondary I.V. line to a total parenteral the flow rate.
nutrition line because of the risk of ◆ If the drug is incompatible with the
contamination. I.V. solution, flush the line with normal
saline solution before and after the in-
I.V. bolus injection jection.
The I.V. bolus injection method allows To use an implanted port

rapid I.V. drug administration to quick- ◆ Wash your hands, put on gloves,
ly achieve peak levels in the blood- and clean the site three times with an
stream. It may be used for drugs that alcohol or antiseptic pad.
can’t be given I.M. because they’re tox- ◆ Palpate for the septum, anchor the
ic or for a patient with a reduced abili- port between your thumb and the first
ty to absorb these drugs. This method two fingers of your nondominant hand,
may also be used to deliver drugs that and give the injection.
can’t be diluted.
Bolus doses may be injected Special considerations
through an existing I.V. line or through ◆ If the existing I.V. line is capped,
an implanted port. making it an intermittent infusion de-
vice, verify the patency and placement
Equipment and preparation of the device before injecting the med-
Patient’s medication record and chart ication. Flush the device with normal
◆ prescribed drug ◆ needleless adap- saline solution, administer the medica-
tor and syringe ◆ diluent, if necessary tion, and follow with the appropriate
◆ antiseptic pad ◆ alcohol pad ◆ flush.
gloves ◆ optional: second syringe (and ◆ Immediately report signs of acute
needleless adaptor) filled with normal allergic reaction or anaphylaxis. If ex-
saline solution travasation occurs, stop the injection,
Draw the drug into the syringe and estimate the amount of infiltration, and
dilute it, if necessary. notify the physician.
◆ When giving diazepam or chlor-
Implementation diazepoxide, flush with normal saline
◆ Verify the order on the patient’s solution to prevent precipitation.
the patient’s medication record for al-
lergies.
Implementation
Special administration ◆ Verify the order on the patient’s
Epidural analgesics against the physician’s order. Check
the patient’s medication record for al-
When giving an epidural analgesic, the lergies.
physician injects or infuses the drug ◆ Confirm the patient’s identity using
into the epidural space, and thus into two patient identifiers.
the cerebrospinal fluid, so that the ◆ Tell the patient that he’ll feel some
medication can bypass the blood–brain pain as the physician inserts the
barrier. catheter.
Epidural analgesia helps to manage ◆ Put the patient on his side in the
pain, including postoperative pain. knee-chest position or have him sit on
the edge of the bed and lean over a
Equipment and preparation bedside table.
Patient’s medication record and chart ◆ After the catheter is in place, as
◆ prescribed epidural solutions ◆ vol- shown below, prime the infusion de-
ume infusion device and epidural infu- vice, confirm the medication and the
sion tubing (depending on facility poli- infusion rate, and adjust the device.
cy) ◆ transparent dressing ◆ epidural ◆ After the infusion tubing is connect-
tray ◆ label for epidural infusion line ed to the epidural catheter, connect the
◆ silk tape ◆ optional: monitoring tubing to the infusion pump. Tape all
equipment for blood pressure and connection sites and apply a label that
pulse, apnea monitor, pulse oximeter. says EPIDURAL INFUSION.
Make sure that the pharmacy has ◆ Tell the patient to report any pain. If
been notified of the medication order pain occurs, the infusion rate may
ahead of time because epidural solu- need to be increased.
tions require special preparation.
L1 interspace
Small-lumen cather
Steel connector Dacron fiber cuff
Large-lumen cather
Filter and
injection cap
Special administration 537
◆ Change the dressing over the exit

site every 24 to 48 hours or as speci-
fied.
◆ After starting the infusion, assess
the patient’s respiratory rate and blood
pressure every 2 hours for 8 hours,
every 4 hours for 8 hours, and then
once per shift, unless ordered other-
wise. Notify the physician if the respi-
ratory rate is below 10 breaths/minute
or if the systolic blood pressure is less
than 90 mm Hg.
◆ Assess the patient’s sedation level
and mental status and the adequacy of
pain relief every hour initially, and
then every 2 to 4 hours, until adequate
pain control is achieved.
◆ If the patient is receiving a local
anesthetic, assess his lower-extremity
motor strength every 2 to 4 hours. If
the patient has sensory and motor loss,
large motor nerve fibers have been af-
fected and the dosage may need to be
decreased.
◆ The patient should always have a
peripheral I.V. line open to allow ad-
ministration of emergency drugs. Have
an opioid antidote, such as naloxone
(Narcan), readily available.
◆ Don’t give an analgesic by another
route because such administration in-
creases the risk of respiratory depres-
sion.
Ensuring effective therapy
Calculating drug dosages 539

Reviewing ratios and proportions 539
Tips for simplifying dosage calculations 539
Determining the number of tablets to
administer 540
Determining the amount of liquid medication to
administer 540
Administering drugs available in varied
concentrations 541
Calculating I.V. drip and flow rates 541
Dimensional analysis 542
Estimating BSA in adults 544
Estimating BSA in children 545
Administering drugs 546
Administering code drugs 546
Infusion flow rates 549
A guide to equianalgesic doses 552
Critical elements of medication teaching 552
538
If the ratios in a proportion are ex-

Calculating drug dosages pressed with colons, the units of the
first term on the left side of the equal
Reviewing ratios and proportions sign must be the same as the units of
the first term on the right side. In other
A ratio is a mathematical expression of words, the units of the mean on one
the relationship between two things. A side of the equal sign must match the
proportion is a set of two equal ratios. units of the extreme on the other side,
A ratio may be expressed as a fraction, and vice versa.
such as 1⁄3, or with a colon, such as
1:3. When ratios are expressed as frac- mg : kg :: mg : kg
tions in a proportion, their cross prod-
ucts are equal.
Tips for simplifying dosage
Proportion calculations
2
__ 5
__
↔↔
4 10 Incorporate units of measure

into the calculation
Cross products Incorporating units of measure into the
2 ⫻ 10 = 4 ⫻ 5 dosage calculation helps to protect you
from one of the most common errors
When ratios are expressed using made in dosage calculation — using the
colons in a proportion, the product of incorrect unit of measure. Keep in
the means equals the product of the mind that the units of measure that ap-
extremes. pear in the numerator and denomina-
tor cancel each other out, leaving the
Proportion correct unit of measure in the answer.
means The following example uses units of
↓ ↓ measure in calculating a drug with a
3 : 30 :: 4 : 40
↓ ↓ usual dose of 4 mg/kg for a 55-kg pa-
extremes tient.
1. State the problem as a proportion.

Product of means and extremes
4 mg : 1 kg :: X : 55 kg
30 ⫻ 4 = 3 ⫻ 40
2. Solve for X by applying the principle
Whether fractions or ratios are used that the product of the means equals
in a proportion, they must appear in the product of the extremes.
the same order on both sides of the
equal sign. When ratios are expressed 1 kg ⫻ X = 4 mg ⫻ 55 kg
as fractions, the units in the numera-
tors must be the same and the units in 3. Divide and cancel out the units of
the denominators must be the same measure that appear in the numerator
(although they don’t have to be the and denominator.
same as the units in the numerators).
4 mg ⫻ 55 kg
X = ____________
mg mg 1 kg
=
kg kg
X = 220 mg
Check the zeros and the 2. Set up the second ratio with the un-
decimal places known quantity.
Suppose that you receive an order to 3. Use these ratios in a proportion.
administer 0.1 mg of epinephrine sub- 4. Solve for X, applying the principle
cutaneously, but the only epinephrine that the product of the means equals
on hand is a 1-ml ampule that contains the product of the extremes.
1 mg of epinephrine. To calculate the For example, suppose that a drug
volume for injection, use the ratio-and- order calls for 100 mg of propranolol
proportion method. P.O. q.i.d., but only 40-mg tablets are
State the problem as a proportion. available. To determine the number of
tablets to administer, follow these
1 mg : 1 ml :: 0.1 mg : X steps:
1. Set up the first ratio with the known
Solve for X by applying the principle tablet (tab) strength.
that the product of the means equals
the product of the extremes. 40 mg : 1 tab
1 ml ⫻ 0.1 mg = 1 mg ⫻ X 2. Set up the second ratio with the de-

sired dose and the unknown number of
Divide and cancel out the units of mea- tablets.
sure that appear in both the numerator
and the denominator, carefully check- 100 mg : X
ing the decimal placement.
3. Use these ratios in a proportion.
1 ml ⫻ 0.1 mg
_____________ =X 40 mg : 1 tab :: 100 mg : X
1 mg
0.1 ml = X 4. Solve for X by applying the principle

the product of the extremes.
Recheck calculations that seem
unusual 1 tab ⫻ 100 mg = 40 mg ⫻ X
If, for example, your calculation indi-
cates that you should administer 25 tab ⫻ 100 mg
1_____________
tablets, you’ve probably made an error. 40 mg ⫻ X
Carefully recheck any figures that seem
unusual. If you still have doubts, re- 21⁄2 tab = X
view your calculations with another
health care professional.
Determining the amount of liquid
Determining the number of medication to administer
tablets to administer
You can also use ratios and proportions
Calculating the number of tablets to to calculate the amount of liquid med-
administer lends itself to the use of ra- ication to administer. Simply follow the
tios and proportions. To perform the same four-step process used in deter-
calculation, follow this process: mining the number of tablets to admin-
1. Set up the first ratio with the known ister.
tablet (tab) strength.
For example, suppose that a patient 1:1,000 epinephrine. Follow these steps
is to receive 750 mg of amoxicillin oral to calculate the correct volume of drug
suspension. The label reads amoxicillin to inject.
(amoxicillin trihydrate ) 250 mg/5 ml. 1. Determine the strength of the solu-
The bottle contains 100 ml. To deter- tion based on its unlabeled ratio.
mine how many milliliters of amoxi-
cillin solution the patient should re- 1:1,000 epinephrine = 1 g/1,000 ml
ceive, follow these steps:
1. Set up the first ratio with the known 2. Set up a proportion with this infor-
strength of the liquid medication. mation and the desired dose.
250 mg : 5 ml 1g : 1,000 ml :: 0.2 mg : X
2. Set up the second ratio with the de- Before you can perform this calcula-
sired dose and the unknown quantity. tion, however, you must convert grams
to milligrams by using the conversion
750 mg : X 1g = 1,000 mg.
3. Restate the proportion with the con-
3. Use these ratios in a proportion. verted units, and solve for X.
250 mg : 5 ml :: 750 mg : X 1,000 mg : 1,000 ml :: 0.2 mg : X
4. Solve for X by applying the principle 1,000 ml ⫻ 0.2 mg = 1,000 mg ⫻ X

the product of the extremes. 1,000 ml ⫻ 0.2 mg
________________ =X
1,000 mg
5 ml ⫻ 750 mg = 250 mg ⫻ X
0.2 ml = X
ml ⫻ 750 mg
5_____________
=X
250 mg
Calculating I.V. drip and flow rates
15 ml = X
To compute the drip and flow rates, set
up a fraction with the volume of solu-
Administering drugs available tion to be delivered over the prescribed
in varied concentrations duration. For example, if a patient is to
receive 100 ml of solution within 1
Because drugs, such as epinephrine, hour, the fraction is:
heparin, and allergy serums, are avail-
able in varied concentrations, you must 100 ml
__________
consider the concentration of the drug 60 minutes
when calculating a drug dosage. Other-
wise, you could make a serious — even Next, multiply the fraction by the
lethal — mistake. To avoid a dosage er- drip factor (the number of drops con-
ror, make sure that drug concentrations tained in 1 ml) to determine the drip
are part of the calculation. rate (the number of drops per minute
For example, a drug order calls for to be infused). The drip factor varies
0.2 mg of epinephrine subcutaneously among I.V. sets and appears on the
stat. The ampule is labeled as 1 ml of package containing the I.V. tubing
administration set. Following the man- Instead of spending the time solving
ufacturer’s directions for the drip factor the equation, you can simply use the
is crucial. Standard sets have drip fac- number assigned to the flow rate as
tors of 10, 15, or 20 gtt/ml. A micro- the drip rate. For sets that deliver 15
drip (minidrip) set has a drip factor of gtt/ml, the flow rate divided by 4
60 gtt/ml. equals the drip rate. For sets with a
Use the following equation to deter- drip factor of 10, the flow rate divided
mine the drip rate: by 6 equals the drip rate.
To determine how many micro-
total ml
_______ grams of a drug are in a milliliter of so-
⫻ drip factor = gtt/minute
total lution, use the following equation:
minutes
mcg/ml = mg/ml ⫻ 1,000
The equation applies to solutions
that are infused over many hours as To express drip rates in micrograms per
well as to small-volume infusions such kilogram per minute (mcg/kg/minute),
as those used for antibiotics, which are you must know the concentration of
given for less than 1 hour. the solution (mcg/ml), the patient’s
You can modify the equation by weight (kg), and the infusion rate
first determining the number of milli- (ml/hour):
liters to be infused over 1 hour (the
flow rate). Then, divide the flow rate
by 60 minutes. Next, multiply the re- mcg/ml ⫻ ml/min
mcg/kg/min = ______________
sult by the drip factor to determine the body weight (kg)
number of drops per minute. You’ll
also use the flow rate when working To find the milliliters per minute
with infusion pumps to set the number (ml/minute), divide the number of mil-
of milliliters to be delivered in 1 hour. liliters per hour (ml/hour) by 60.
You can also convert milliliters per
Quick calculations of drip rates hour (ml/hour) from a dosage given in
In addition to using the equation and micrograms per kilograms per minute
its modified version, quicker computa- (mcg/kg/min) as follows:
tion methods are available. To adminis-
ter solutions ordered at an hourly rate wt (kg) ⫻ mcg/kg/min
ml/hr = _________________ ⫻ 60
using a microdrip set, adjust the flow mcg/ml
rate (ml/hour) to equal the drip rate
(gtt/minute). Using the equation, di-
vide the flow rate by 60 minutes and Dimensional analysis
multiply the result by the drip factor,
which also equals 60. Because the flow Dimensional analysis (also known as
rate and the drip factor are equal, the factor analysis, or factor labeling) is an
two arithmetic operations cancel each alternative method of solving mathe-
other out. For example, if the flow rate matical problems. It eliminates the
is 125 ml/hour, the equation would be: need to memorize formulas and re-
quires only one equation to determine
125 ml
__________ an answer. To compare the ratio-and-
⫻ 60 = drip rate (125)
60 minutes proportion method and dimensional
analysis at a glance, read the following
problem and solutions.
The physician prescribes 0.25 g of memorized or obtained from a conver-

streptomycin sulfate I.M. The vial sion chart. Because the two quantities
reads “2 ml = 1 g.” How many milli- and units of measurement are equiva-
liters should you administer? lent, they can serve as the numerator or
the denominator. Thus, the conversion
Dimensional analysis factor 1 g = 1,000 mg can be written
in fraction form as:
0.25
_____g ⫻ 2___
ml
= 0.5 ml
1,000 mg
_______ 1g
1 1g or _______
1g 1,000 mg
Ratio and proportion
The factors given in the problem
1 g : 2 ml :: 0.25 g : X plus any conversion factors that are
necessary to solve the problem are
2 ml ⫻ 0.25 g = 1 g ⫻ X called knowns. The quantity of the an-
swer, of course, is unknown. When set-
2 ml ⫻ 0.25 g
_____________ ting up an equation in dimensional
=X analysis, work backward, beginning
1g
with the unit of measurement of the
0.5 ml = X answer. After plotting all of the
knowns, find the solution by following
Dimensional analysis involves ar- this sequence:
ranging a series of ratios, called factors, 1. Cancel similar quantities and units
into a single fractional equation. Each of measurement.
factor, written as a fraction, consists of 2. Multiply the numerators.
two quantities and their units of mea- 3. Multiply the denominators.
surement that are related to each other 4. Divide the numerator by the denom-
in a given problem. For instance, if inator.
1,000 ml of a drug should be adminis- Mastering dimensional analysis can
tered over 8 hours, the relationship be- take practice, but you may find your
tween 1,000 ml and 8 hours is ex- efforts well rewarded. To understand
pressed by the fraction more fully how dimensional analysis
works, review the following problem
1,000 ml
_______ and the steps taken to solve it.
8 hours The physician prescribes X grains
(gr) of a drug. The pharmacy supplies
When a problem includes a quanti- the drug in 300-mg tablets (tab). How
ty and its unit of measurement that are many tablets should you administer?
unrelated to any other factor in the 1. Write down the unit of measurement
problem, they serve as the numerator of the answer, followed by an “equal
of the fraction, and 1 (implied) be- to” symbol (=).
comes the denominator.
Some mathematical problems con- tab =
tain all of the information needed to
identify the factors, set up the equation, 2. Search the problem for the quantity
and find the solution. Other problems with the same unit of measurement (if
require the use of a conversion factor. one doesn’t exist, use a conversion fac-
Conversion factors are equivalents (for tor); place this in the numerator and its
example, 1 g = 1,000 mg) that can be related quantity and unit of measure-
ment in the denominator.
1 tab
tab = _______ a multiplication symbol. Repeat this
300 mg step until all known factors are includ-
ed in the equation.
Separate the first factor from the next
with a multiplication symbol (⫻). 1 tab 60 mg 10 gr
tab = _______⫻ ______ ⫻ ____
300 mg 1gr 1
1 tab
tab = _______ ⫻
300 mg Alternatively, you can treat the
equation as a large fraction, using
Place the unit of measurement of the these steps.
denominator of the first factor in the 1. First, cancel similar units of mea-
numerator of the second factor. Search surement in the numerator and the de-
the problem for the quantity with the nominator. What remains should be
same unit of measurement (if there’s what you began with — the unit of
no common measurement, as in this measurement of the answer; if not,
example, use a conversion factor). recheck your equation to find and cor-
Place this in the numerator and its re- rect the error.
lated quantity and unit of measure- 2. Multiply the numerators and then
ment in the denominator; follow with the denominators.
Estimating BSA in adults
Body surface area (BSA) is a critical com- HEIGHT BODY SURFACE WEIGHT
ponent of the calculation of dosages for AREA
drugs (such as chemotherapeutic agents)

that are extremely potent and must be
given in precise amounts. The nomogram
shown here lets you plot the patient’s
height and weight to determine the BSA.
To estimate the BSA of an adult patient,
place a straightedge from the patient’s
height in the left-hand column to his
weight in the right-hand column. The in-
tersection of this line with the center
scale shows the BSA.
Reprinted with permission from Geigy Scienti-

fic Tables, 8th ed., vol. 5, p. 105 ©Novartis,
1990.
Estimating BSA in children
Pediatric drug dosages are calculated on the basis of body weight or body surface area
(BSA). For an average-sized child, find the weight and the corresponding BSA in the box.
Otherwise, to use the nomogram, place a straightedge on the correct height and weight
points for the patient and note the point at which the line intersects on the scale. Don’t
use drug dosages based on BSA in premature or full-term neonates; instead, use body
weight.
3. Divide the numerator by the denom- 30 mg/minute]); then 360 mg I.V. over
inator. the next 6 hours (1 mg/minute), fol-
lowed by a maintenance infusion of
1 tab 60 mg 10 gr
tab = _______ ⫻ ______ ⫻ ____ 540 mg I.V. over the remaining 18
300 mg 1gr 1 hours (0.5 mg/minute).
Nursing considerations
60 ⫻ 10 tab
= ________ ◆ Administer the drug through a cen-
300 tral line whenever possible.
600 tab ◆ Mix initial 150 mg dose in 100 ml
= _____ dextrose 5% in water (D5W); the drug
300 is incompatible with normal saline so-
lution. Mix infusions to be adminis-
= 2 tablets tered over 2 hours or longer in glass or
polyolefin bottles containing D5W.
◆ Monitor the patient for hypotension,
Administering drugs bradycardia, and arrhythmias.
◆ Must be delivered by volumetric in-
Administering code drugs fusion pump.
adenosine atropine
Indicated for patients with paroxysmal Indicated for symptomatic sinus brady-
supraventricular tachycardia, including cardia with hemodynamic compromise,
that associated with accessory bypass atrioventricular (AV) block, pulseless
tracts (Wolff-Parkinson-White syndrome). electrical activity (PEA), and ventricu-
lar asystole.
Dosage
Initially, give 6 mg I.V. as a rapid bolus Dosage
over 1 to 3 seconds; if there’s no re- For bradycardia or AV block, give 0.5 mg
sponse in 1 to 2 minutes, give 12 mg to 1 mg I.V. push, repeated every 3 to 5
I.V. as a rapid bolus (12 mg dose may minutes to a total dose of 0.04 mg/kg. A
be given a second time if required). total dose of 2.5 mg (0.04 mg/kg) results
in full vagal blockade in humans. For
Nursing considerations asystole or PEA, give 1 mg I.V. push, re-
◆ Adverse effects may include flushing peat in 3 to 5 minutes if asystole persists.
or chest pain lasting 1 to 2 minutes.
◆ Flush immediately and rapidly with Nursing considerations
20 ml of normal saline solution to en- ◆ Monitor the patient for paradoxical
sure drug delivery. initial bradycardia, especially if he’s re-
◆ Monitor the cardiac rhythm to de- ceiving 0.4 to 0.6 mg.
tect heart block and transient asystole. ◆ Monitor the patient’s fluid intake
and urine output.
amiodarone ◆ Watch for tachycardia.
Indicated for recurrent hemodynamically
unstable ventricular tachycardia and fre- dobutamine
quently recurring ventricular fibrillation. Indicated for inotropic support in
short-term treatment of adults with
Dosage cardiac decompensation caused by de-
Give 150 mg I.V. over the first 10 min- pressed contractility resulting from or-
utes (15 mg/minute [not to exceed ganic heart disease or surgery.
Dosage Nursing considerations

Give 0.5 to 1 mcg/kg/minute by I.V. in- ◆ If administering the drug by the I.V.
fusion, titrating to an optimal dosage of or intraosseous route isn’t possible, the
2 to 20 mcg/kg/minute. drug may be given endotracheally at 2
to 21⁄2 times the peripheral I.V. dose.
Nursing considerations ◆ Intracardiac injection is indicated
◆ Watch for reflex peripheral vasodila- only during open cardiac massage and
tion. if other routes are unavailable.
◆ Monitor the patient’s heart rate
closely; an increase of 10% or more lidocaine
may worsen myocardial ischemia. Indicated for patients with ventricular
◆ Avoid extravasation; give drug tachycardia (VT), ventricular ectopy,
through a central venous catheter or a and ventricular fibrillation (VF); pro-
large peripheral vein. Use an infusion phylactic administration in patients
pump. with uncomplicated myocardial infarc-
tion isn’t recommended.
dopamine
Indicated for patients with hypotension Dosage
or bradycardia, to treat shock, improve Give 1 to 1.5 mg/kg I.V. bolus as a load-
perfusion to vital organs, and increase ing dose at 25 to 50 mg/minute; repeat
cardiac output. the bolus dose every 3 to 5 minutes un-
til arrhythmias subside or adverse reac-
Dosage tions develop, to a maximum of 3
Initially, give 2 to 5 mcg/kg/minute, mg/kg (300 mg over 1 hour); simultane-
titrated until the desired response is ously, set up a continuous I.V. infusion
achieved. Infusion may be increased by at 1 to 4 mg/minute. (Dilute 1 g of lido-
1 to 4 mcg/kg/minute at 10- to 30- caine in 250 ml of dextrose 5% in water
minute intervals. for a 0.4% solution, or 4 mg/ml.)
Nursing considerations Nursing considerations

◆ Drug effects vary with dosage. At ◆ For an elderly patient, a patient
0.5 to 2 mcg/kg/minute, the drug di- weighing less than 110 lb (50 kg), or a
lates the renal and mesenteric vessels patient with heart failure or hepatic dis-
without increasing heart rate or blood ease, administer half of the bolus dose.
pressure; at 2 to 10 mcg/kg/minute, it ◆ Lidocaine improves the response to
increases cardiac output without pe- defibrillation when the patient is in VF.
ripheral vasoconstriction; at more than
10 mcg/kg/minute, it causes peripheral magnesium sulfate
vasoconstriction. Indicated for the treatment of ventricu-
◆ Use a central line or a large vein. lar fibrillation, ventricular tachycardia,
Monitor for extravasation; if it occurs, cardiac arrest associated with torsades
stop the infusion immediately and call de pointes, and torsades de points with
the physician. pulses.
epinephrine Dosage
Indicated for the patient in cardiac arrest. Give 1 to 2 g in 10 ml of dextrose 5%
in water (D5W) administered I.V. or in-
Dosage traosseously over 5 to 20 minutes for
Give 1 mg I.V. or intraosseously repeat- cardiac arrest associated with torsades
ed every 3 to 5 minutes, if necessary. de pointes. Give 1 to 2 g in 50 to 100 ml
of D5W I.V. over 5 to 60 minutes and Nursing considerations

follow this with 0.5 to 1 g/hour I.V. for ◆ Wrap the container in opaque mate-
torsades de pointes with pulses. rial to prevent deterioration of the drug.
◆ Monitor the patient’s blood pressure
Nursing considerations every 5 minutes for 1 hour and every
◆ Monitor serum magnesium levels. 15 minutes thereafter.
◆ Watch for respiratory depression ◆ Large doses given at fast infusion
and signs and symptoms of heart block. rates increase the risk of cyanide toxici-
◆ If hypotension develops, slow or ty. Measure cyanide levels and monitor
stop the infusion. for acidosis. If a toxic reaction is sus-
pected, start treatment without the test
nitroglycerin results.
Indicated for patients with heart failure
associated with myocardial infarction norepinephrine bitartrate
and for patients with unstable angina. Indicated for the patient with severe
hypotension or low total peripheral re-
Dosage sistance.
Give a 5 mcg/minute I.V. infusion ini-
tially, increasing by 5 mcg/minute Dosage
every 3 to 5 minutes until a response Initially, give an 8 to 12 mcg/minute
occurs. If a 20 mcg/minute rate doesn’t I.V infusion. Titrate to maintain systolic
produce a response, increase the blood pressure at 80 to 100 mm Hg in a
dosage by as much as 20 mcg/minute previously normotensive patient. The
every 3 to 5 minutes. Up to 100 average rate of maintenance infusion is
mcg/minute may be needed. 2 to 4 mcg/minute.

◆ Monitor the patient for hypotension, ◆ Norepinephrine is contraindicated
which could worsen myocardial is- in the patient with hypovolemia.
chemia. ◆ Monitor the patient’s blood pressure
◆ Because up to 80% of the drug with an intra-arterial line because mea-
binds to the plastic in normal I.V. ad- surements obtained with a standard
ministration sets, use the special I.V. cuff may be falsely low.
tubing supplied by the manufacturer. ◆ Cardiac output may increase or de-
◆ Mix in glass bottles and avoid using crease, depending on vascular resis-
I.V. filters. Use an infusion pump. tance, left ventricular function, and re-
flux response.
nitroprusside ◆ Avoid prolonged use; the drug may
Indicated for the patient with heart cause ischemia of vital organs.
failure or in hypertensive crisis. ◆ Use a central venous catheter or a
large vein to minimize the risk of ex-
Dosage travasation. If extravasation occurs,
Dissolve 50 mg in 2 to 3 ml of dextrose stop the infusion and call the physician.
5% in water (D5W); then mix with 250
to 1,000 ml of D5W, depending on the procainamide
desired concentration. Begin the infu- Indicated for the patient with ventricu-
sion at 0.3 mcg/kg/minute and titrate lar arrhythmias, such as premature
every few minutes to a maximum of ventricular contractions or tachycardia,
10 mcg/kg/minute. when lidocaine is contraindicated or
ineffective.
Dosage tion, asystole, or pulseless electrical

Give a loading dose infusion of activity.
20 mg/minute, not to exceed a total
dose of 500 mg, followed by a continu- Dosage
ous infusion of 2 to 6 mg/minute. Give 40 units I.V., one time only.

◆ Lower the dosage as ordered, for ◆ Use as an alternative to epinephrine.
the patient with renal failure.
◆ Rapid infusion will cause acute hy- verapamil
potension. An infusion pump is required. Indicated for the patient with atrial fib-
◆ Monitor electrocardiogram results rillation, atrial flutter, or multifocal
carefully; if the QRS complex widens atrial tachycardia; also used to help
more than 50% or if the QT interval is treat narrow QRS complex paroxysmal
prolonged, notify the physician and supraventricular tachycardia.
discontinue the infusion, as ordered.
Dosage
vasopressin Give 2.5 to 5 mg I.V. over 2 minutes. Re-
Indicated for the treatment of adult peat dose of 5 to 10 mg every 15 to 30
shock-refractory ventricular fibrilla- minutes to a maximum dosage of 20 mg.
Infusion flow rates

The infusion flow rates are based on the concentrations shown at the top of each table.
Be sure to check the label on the medication you’re infusing to verify the correct infu-
sion flow rate.
EPINEPHRINE INFUSION RATES ISOPROTERENOL INFUSION RATES

Mix 1 mg in 250 ml (4 mcg/ml). Mix 1 mg in 250 ml (4 mcg/ml).
Dose Infusion rate Dose Infusion rate

(mcg/min) (ml/hr) (mcg/min) (ml/hr)
1 15 0.5 8
2 30 1 15
3 45 2 30
4 60 3 45
5 75 4 60
6 90 5 75
7 105 6 90
8 120 7 105
9 135 8 120
10 150 9 135
15 225 10 150
20 300 15 225
25 375 20 300
30 450 25 375
35 525 30 450
40 600 (continued)
Infusion flow rates (continued)
NITROGLYCERIN INFUSION RATES

Determine the infusion rate in ml/hr using the ordered dose and the concentration of the
drug solution.
Dose 25 mg/250 ml 50 mg/250 ml 100 mg/250 ml

(mcg/min) (100 mcg/ml) (200 mcg/ml) (400 mcg/ml)
5 3 2 1
10 6 3 2
20 12 6 3
30 18 9 5
40 24 12 6
50 30 15 8
60 36 18 9
70 42 21 10
80 48 24 12
90 54 27 14
100 60 30 15
150 90 45 23
200 120 60 30
DOBUTAMINE INFUSION RATES

Mix 250 mg in 250 ml of D5W (1,000 mcg/ml). Determine the infusion rate in ml/hr using
the ordered dose and the patient’s weight in pounds or kilograms.
Dose lb 88 99 110 121 132 143 154 165 176 187 198 209 220 231 242
(mcg/kg/min) kg 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110
2.5 6 7 8 8 9 10 11 11 12 13 14 14 15 16 17
5 12 14 15 17 18 20 21 23 24 26 27 29 30 32 33
7.5 18 20 23 25 27 29 32 34 36 38 41 43 45 47 50
10 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66
12.5 30 34 38 41 45 49 53 56 60 64 68 71 75 79 83
15 36 41 45 50 54 59 63 68 72 77 81 86 90 95 99
20 48 54 60 66 72 78 84 90 96 102 108 114 120 126 132
25 60 68 75 83 90 98 105 113 120 128 135 143 150 158 165
30 72 81 90 99 108 117 126 135 144 153 162 171 180 189 198
35 84 95 105 116 126 137 147 158 168 179 189 200 210 221 231
40 96 108 120 132 144 156 168 180 192 204 216 228 240 252 264
Infusion flow rates (continued)
DOPAMINE INFUSION RATES

Mix 400 mg in 250 ml of D5W (1,600 mcg/ml). Determine the infusion rate in ml/hr using
Dose lb 88 99 110 121 132 143 154 165 176 187 198 200 220 231
(mcg/kg/min) kg 40 45 50 55 60 65 70 75 80 85 90 95 100 105
2.5 4 4 5 5 6 6 7 7 8 8 8 9 9 10
5 8 8 9 10 11 12 13 14 15 16 17 18 19 20
7.5 11 13 14 15 17 18 20 21 23 24 25 27 28 30
10 15 17 19 21 23 24 26 28 30 32 34 36 38 39
12.5 19 21 23 26 28 30 33 35 38 40 42 45 47 49
15 23 25 28 31 34 37 39 42 45 48 51 53 56 59
20 30 34 38 41 45 49 53 56 60 64 68 71 75 79
25 38 42 47 52 56 61 66 70 75 80 84 89 94 98
30 45 51 56 62 67 73 79 84 90 96 101 107 113 118
35 53 59 66 72 79 85 92 98 105 112 118 125 131 138
40 60 68 75 83 90 98 105 113 120 128 135 143 150 158
45 68 76 84 93 101 110 118 127 135 143 152 160 169 177
50 75 84 94 103 113 122 131 141 150 159 169 178 188 197
NITROPRUSSIDE INFUSION RATES

Mix 50 mg in 250 ml of D5W (200 mcg/ml). Determine the infusion rate in ml/hr using
Dose lb 88 99 110 121 132 143 154 165 176 187 198 209 220 231 242
(mcg/kg/min) kg 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110
0.3 4 4 5 5 5 6 6 7 7 8 8 9 9 9 10
0.5 6 7 8 8 9 10 11 11 12 13 14 14 15 16 17
1 12 14 15 17 18 20 21 23 24 26 27 29 30 32 33
1.5 18 20 23 25 27 29 32 34 36 38 41 43 45 47 50
2 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66
3 36 41 45 50 54 59 63 68 72 77 81 86 90 95 99
4 48 54 60 66 72 78 84 90 96 102 108 114 120 126 132
5 60 68 75 83 90 98 105 113 120 128 135 143 150 158 165
6 72 81 90 99 108 117 126 135 144 153 162 171 180 189 198
7 84 95 105 116 126 137 147 158 168 179 189 200 210 221 231
8 96 108 120 132 144 156 168 180 192 204 216 228 240 252 264
9 108 122 135 149 162 176 189 203 216 230 243 257 270 284 297
10 120 135 150 165 180 195 210 225 240 255 270 285 300 315 330
Nursing considerations
◆ Use cautiously and in lower doses Drug Dose
for the patient receiving a beta blocker.
buprenorphine 0.3 mg I.M.
◆ Monitor the patient for hypotension,
severe bradycardia, and heart failure. butorphanol 2 mg I.M.
◆ Because verapamil may decrease
myocardial contractility, it can aggra- dezocine 10 mg I.M.
vate heart failure in the patient with
morphine 10 mg I.M.
severe left ventricular dysfunction.
nalbuphine 10 mg I.M.
A guide to equianalgesic doses
pentazocine 30 mg I.M.
Opioid agonists
The standard opioid agonist dose,
10 mg of morphine I.M., is used to cal-
culate equally effective (equianalgesic) Critical elements of medication
doses of other opioid agonists. This teaching
method is useful when a patient must
be switched from one opioid agonist to As the patient becomes more responsi-
another with no change in dose effec- ble for his own care, it’s important that
tiveness. This chart lists equianalgesic you supply him with all of the infor-
doses for selected opioid agonists. mation that he needs to comply with
his treatment plan. Accurate written in-
formation is crucial for any patient, but
Drug Dose it’s especially important for young pa-
tients, elderly patients, and those with
codeine 120 mg P.O. cognitive impairments. When preparing
your written medication teaching plan,
fentanyl 0.1 to 0.2 mg I.M. it’s important to include these points:
hydromorphone 1.5 mg I.M. ◆ name, dosage, and action of the
drug
meperidine 75 to 100 mg I.M. ◆ frequency and times of administra-
tion
methadone 8 to 10 mg I.M. ◆ special instructions for storage and
morphine 10 mg I.M.
preparation
◆ drugs (including over-the-counter
oxymorphone 1 to 1.5 mg I.M. products) and foods (including addi-
tives) to avoid
◆ special comfort measures or safety
Mixed opioid agonist-antagonists precautions
This chart lists equianalgesic doses ◆ adverse effects and possible signs
(based on the standard dose of 10 mg and symptoms of a toxic reaction
of morphine I.M.) for mixed opioid ◆ warnings about discontinuing the
agonist-antagonists. medication.
LWBK449-c14_p553-632.qxd 11/16/09 12:57 PM Page 553
14 Drug hazards
Recognizing and responding to them
Adverse or toxic drug reactions 555

Drug reactions and treatments 555
Managing toxic drug reactions 555
Dialyzable drugs 560
Drugs that shouldn’t be crushed 563
Reversing anaphylaxis 566
Adverse reactions misinterpreted as
age-related changes 568
Therapeutic drug monitoring guidelines 570
Identifying the most dangerous drugs 582
Reporting reactions to the FDA 582
What The Joint Commission requires 583
Managing I.V. extravasation 583
Antidotes for extravasation 584
Drug overdoses 585
General guidelines 585
Managing an acute toxic reaction 586
Managing poisoning or overdose 587
Acetaminophen overdose 591
Analeptic overdose (amphetamines, cocaine) 592
Anticholinergic overdose 592
Anticoagulant overdose 592
Antihistamine overdose 593
Barbiturate overdose 593
Benzodiazepine overdose 593
CNS depressant overdose 594
Digoxin overdose 594
Iron supplement overdose 595
NSAID overdose 595
Opiate overdose 596
Phenothiazine overdose 596
Salicylate overdose 596
Tricyclic antidepressant overdose 597
Dangers of uncontrolled I.V. flow 597
553
554 Drug hazards
Interactions 598
Compatibility of drugs combined in a syringe 598
Drug combinations 600
Serious drug interactions 600
Drug-tobacco interactions 604
Selected drug-food interactions 605
Drug-alcohol interactions 608
Compatibility of drugs with tube feedings 609
Effects of mixing drugs and alcohol 609
Drug interference with test results 610
Drug-herb interactions 614
Monitoring patients using herbs 621
Drug additives 624
Drugs with ethanol additives 624
Drugs with sulfite additives 625
Drugs with tartrazine additives 626
How aging increases the risk of drug hazards 626
Substance abuse 627
Acute toxic reactions 627
Managing acute toxicity 627
Adverse or toxic drug reactions The key to successful treatment of tox-

ic drug reactions is to identify the drug
quickly and accurately, then immedi-
Drug reactions and treatments ately begin the appropriate treatment.
Managing toxic drug reactions

TOXIC REACTIONS AND INTERVENTIONS SELECTED
CLINICAL EFFECTS CAUSATIVE DRUGS
Anemia, aplastic ◆ Discontinue the drug, if ◆ altretamine

◆ Bleeding from the mucous possible. ◆ Antineoplastic agents
membranes, ecchymoses, pe- ◆ Order vigorous support- ◆ aspirin (long-term)
techiae ive care, including transfu- ◆ carbamazepine
◆ Fatigue, pallor, progressive sions, neutropenic isolation, ◆ chloramphenicol
weakness, shortness of breath, antibiotics, and oxygen. ◆ co-trimoxazole
tachycardia (progresses to ◆ Colony-stimulating fac- ◆ ganciclovir
heart failure) tors may be given. ◆ Gold salts
◆ Fever, oral and rectal ul- ◆ For severe cases, a bone ◆ hydrochlorothiazide
cers, sore throat without char- marrow transplant may be ◆ mephenytoin
acteristic inflammation needed. ◆ methimazole
◆ penicillamine
◆ Phenothiazines
◆ propylthiouracil
◆ triamterene
◆ zidovudine
Anemia, hemolytic ◆ Discontinue the drug. ◆ carbidopa-levodopa

◆ Chills, fever, back and ab- ◆ Order supportive care, ◆ Cephalosporins
dominal pain (hemolytic crisis) including transfusions and ◆ levodopa
◆ Jaundice, malaise, oxygen. ◆ mefenamic acid
splenomegaly ◆ Consider obtaining a ◆ methyldopa
◆ Signs of shock blood sample for Coombs’ ◆ Penicillins
test. ◆ phenazopyridine
◆ primaquine
◆ quinidine
◆ quinine
◆ Sulfonamides
Bone marrow toxicity ◆ Discontinue the drug. ◆ Angiotensin-convert-

(agranulocytosis) ◆ Begin antibiotic therapy ing enzyme inhibitors
◆ Enlarged lymph nodes, while awaiting the results ◆ aminoglutethimide
spleen, and tonsils of blood culture and sensi- ◆ carbamazepine
◆ Septicemia, shock tivity tests. ◆ choramphenicol
◆ Progressive fatigue and ◆ Order supportive thera- ◆ clomipramine
weakness followed by sudden, py, including neutropenic ◆ clozapine
overwhelming infection with isolation, warm saline gar- ◆ co-trimoxazole
chills, fever, headache, and gles, and oral hygiene. ◆ flucytosine
tachycardia ◆ Gold salts
◆ Pneumonia ◆ penicillamine
◆ Ulcers in the colon, mouth, ◆ Phenothiazines
and pharynx
(continued)
556 Drug hazards
Managing toxic drug reactions (continued)

Bone marrow ◆ phenytoin

toxicity ◆ procainamide
(agranulocytosis) ◆ propylthiouracil
(continued) ◆ Sulfonylureas
Bone marrow ◆ Discontinue the drug or ◆ anistreplase

toxicity reduce the dosage. ◆ ciprofloxacin
(thrombocytopenia) ◆ Order corticosteroids and ◆ cisplatin
◆ Fatigue, weakness, lethar- platelet transfusions. ◆ colfosceril
gy, malaise ◆ Consider ordering ◆ etretinate
◆ Hemorrhage, loss of con- platelet-stimulating factors. ◆ floxuridine
sciousness, shortness of ◆ Monitor the patient for ◆ flucytosine
breath, tachycardia signs of bleeding (bleeding ◆ ganciclovir
◆ Sudden onset of ecchy- gums, melena, hematuria, ◆ Gold salts
moses or petechiae; large, and hematemesis). ◆ heparin
blood-filled bullae in the ◆ Interferons alfa-2a
mouth and alfa-2b
◆ lymphocyte immune
globulin
◆ methotrexate
◆ penicillamine
◆ procarbazine
◆ quinidine
◆ quinine
◆ Tetracyclines
◆ valproic acid
Cardiomyopathy ◆ Discontinue the drug, if ◆ cyclophosphamide

◆ Acute hypertensive reac- possible. ◆ cytarabine
tion ◆ Closely monitor the pa- ◆ daunorubicin
◆ Atrial and ventricular tient who is receiving con- ◆ doxorubicin
arrhythmias current radiation therapy. ◆ idarubicin
◆ Chest pain ◆ Institute cardiac monitor- ◆ mitoxantrone
◆ Heart failure ing at the earliest sign of
◆ Chronic cardiomyopathy problems.
◆ Pericarditis-myocarditis ◆ If the patient is receiving
syndrome doxorubicin, limit the cumu-
lative dose to 550 mg/m2
unless the cardioprotectant
dexrazoxane is used con-
comitantly.

Dermatologic ◆ Discontinue the drug. ◆ Androgens

toxicity ◆ Topical antihistamines ◆ Barbiturates
◆ May vary from phototoxi- and analgesics may be or- ◆ Corticosteroids
city to acneiform eruptions, dered. ◆ Cephalosporins
alopecia, exfoliative dermati- ◆ Gold salts
tis, lupus erythematosus-like ◆ hydralazine
reactions, and toxic epider- ◆ Interferons
mal necrolysis ◆ Iodides
◆ Penicillins
◆ pentamidine
◆ phenolphthalein
◆ Phenothiazines
◆ procainamide
◆ Psoralens
◆ Quinolones
◆ Sulfonamides
◆ Sulfonylureas
◆ Tetracyclines
◆ Thiazides
Hepatotoxicity ◆ Reduce the dosage or ◆ amiodarone

◆ Abdominal pain, hepato- discontinue the drug. ◆ asparaginase
megaly ◆ Order monitoring of the ◆ carbamazepine
◆ Abnormal levels of ala- patient’s vital signs, blood ◆ chlorpromazine
nine aminotransferase, as- levels, weight, intake and ◆ chlorpropamide
partate aminotransferase, output, and fluids and elec- ◆ cytarabine
serum bilirubin, and lactate trolytes. ◆ dantrolene
dehydrogenase ◆ Promote rest. ◆ erythromycin estolate
◆ Bleeding, low-grade fever, ◆ Perform hemodialysis, if ◆ ifosfamide
mental changes, weight loss needed. ◆ isoniazid
◆ Dry skin, pruritus, rash ◆ Order symptomatic care: ◆ ketoconazole
◆ Jaundice vitamins A, B complex, D, ◆ leuprolide
and K; potassium for alka- ◆ methotrexate
losis; salt-poor albumin for ◆ methyldopa
fluid and electrolyte bal- ◆ mitoxantrone
ance; neomycin for GI flora; ◆ niacin
stomach aspiration for ◆ phenobarbital
blood; reduced dietary pro- ◆ plicamycin
tein; and lactulose for blood ◆ Quinolones
ammonia. ◆ Statins
◆ sulindac
(continued)
558 Drug hazards

Nephrotoxicity ◆ Reduce the dosage or ◆ Aminoglycosides

◆ Increased or decreased discontinue the drug. ◆ amphotericin B
creatinine clearance ◆ Perform hemodialysis, if ◆ Cephalosporins
◆ Blurred vision, dehydra- needed. ◆ cisplatin
tion (depending on the part ◆ Order monitoring of the ◆ Contrast media
of the kidney affected), ede- patient’s vital signs, weight ◆ Corticosteroids
ma, mild headache, pallor changes, and urine volume. ◆ cyclosporine
◆ Casts, albumin, or red or ◆ Give symptomatic care: ◆ furosemide
white blood cells in the urine fluid restriction and loop di- ◆ Gadolinium-based
◆ Dizziness, fatigue, irri- uretics to reduce fluid reten- contrast agents
tability, slowed mental tion and I.V. solutions to ◆ gallium
processes correct an electrolyte imbal- ◆ Gold salts (parenteral)
◆ Electrolyte imbalance ance. ◆ Nitrosoureas
◆ Elevated blood urea nitro- ◆ Nonsteroidal anti-
gen level inflammatory drugs
◆ Oliguria ◆ penicillin
◆ pentamidine isethion-
ate
◆ plicamycin
◆ vancomycin
◆ Vasopressors or vaso-
constrictors
Neurotoxicity ◆ Notify the physician as ◆ Aminoglycosides

◆ Akathisia soon as changes appear. ◆ cisplatin
◆ Bilateral or unilateral ◆ Reduce the dosage or ◆ cytarabine
palsy discontinue the drug. ◆ isoniazid
◆ Muscle twitching, tremor ◆ Monitor the patient care- ◆ nitroprusside
◆ Paresthesia fully for changes in his con- ◆ polymyxin B injection
◆ Seizures dition. ◆ Vinca alkaloids
◆ Strokelike syndrome ◆ Order symptomatic care.
◆ Unsteady gait Remain with the patient, re-
◆ Weakness assure him, and protect him
during seizures. Provide a
quiet environment, draw
the shades, and speak in
soft tones. Maintain the air-
way, and ventilate the pa-
tient as needed.
Ocular toxicity ◆ Notify the physician as ◆ amiodarone

◆ Acute glaucoma soon as changes appear. ◆ Antibiotics such as
◆ Blurred, colored, or flick- ◆ Discontinue the drug, if chloramphenicol
ering vision possible. (Some oculotoxic ◆ Anticholinergics
◆ Cataracts drugs that are used to treat ◆ Cardiac glycosides
◆ Corneal deposits serious conditions may be ◆ chloroquine
◆ Diplopia given again at a reduced ◆ clomiphene
◆ Miosis dosage after the eyes are ◆ Corticosteroids
◆ Mydriasis rested and have returned to ◆ cyclophosphamide
◆ Optic neuritis near normal.) ◆ cytarabine
◆ Scotomata ◆ ethambutol
◆ Vision loss

Ocular toxicity ◆ Monitor the patient care- ◆ hydroxychloroquine

(continued) fully for changes in symp- ◆ lithium carbonate
toms. ◆ methotrexate
◆ Treat the effects sympto- ◆ Phenothiazines
matically. ◆ quinidine
◆ quinine
◆ rifampin
◆ tamoxifen
◆ Vinca alkaloids
Ototoxicity ◆ Notify the physician as ◆ Aminoglycosides

◆ Ataxia soon as changes appear. ◆ Antibiotics, such as
◆ Hearing loss ◆ Discontinue the drug or colistimethate sodium,
◆ Tinnitus reduce the dosage. erythromycin, genta-
◆ Vertigo ◆ Monitor the patient care- micin, kanamycin, and
fully for symptomatic streptomycin
changes. ◆ chloroquine
◆ cisplatin
◆ Loop diuretics
◆ minocycline
◆ quinidine
◆ quinine
◆ Salicylates
◆ vancomycin
Pseudomembranous ◆ Discontinue the drug ◆ Antibiotics

colitis and order another antibiot-
◆ Abdominal pain ic, such as vancomycin or
◆ Colonic perforation metronidazole.
◆ Fever ◆ Maintain the fluid and
◆ Hypotension electrolyte balance.
◆ Severe dehydration ◆ Check the serum elec-
◆ Shock trolyte levels daily. If
◆ Sudden, copious diarrhea pseudomembranous colitis
(watery or bloody) is mild, order an ion ex-
change resin.
◆ Monitor the patient’s vi-
tal signs and hydration sta-
tus.
◆ Immediately report signs
of shock to the physician.
◆ Observe the patient for
signs of hypokalemia, espe-
cially malaise and weak,
rapid, irregular pulse.
560 Drug hazards
Dialyzable drugs
The amount of a drug removed by dialysis differs among patients and depends on sever-
al factors, including the patient’s condition, the drug’s properties, length of dialysis and
dialysate used, rate of blood flow or dwell time, and purpose of dialysis. This table
shows the effect of hemodialysis on selected drugs.
DRUG LEVEL DRUG LEVEL

REDUCED BY REDUCED BY
HEMODIALYSIS HEMODIALYSIS
acebutolol Yes cefotetan Yes (only by 20%)

acetaminophen Yes (may not affect cefoxitin Yes
toxicity) cefpodoxime Yes
acetazolamide No ceftazidime Yes
acyclovir Yes ceftibuten Yes
allopurinol Yes ceftizoxime Yes
alprazolam No ceftriaxone No
amikacin Yes cefuroxime Yes
amiodarone No cephalexin Yes
amitriptyline No cephalothin Yes
amlodipine No cephradine Yes
amoxicillin Yes chloral hydrate Yes
amoxicillin and clavu- Yes chlorambucil No
lanate potassium chloramphenicol Yes (very small
amphotericin B No amount)
ampicillin Yes chlordiazepoxide No
ampicillin and Yes chloroquine No
sulbactam sodium chlorpheniramine No
aprepitant No chlorpromazine No
aspirin Yes chlorthalidone No
atenolol Yes cimetidine Yes
azathioprine Yes ciprofloxacin Yes (only by 20%)
aztreonam Yes cisplatin No
bivalirudin Yes clindamycin No
busulfan Yes clofibrate No
captopril Yes clonazepam No
carbamazepine No clonidine No
carbenicillin Yes clorazepate No
carboplatin Yes cloxacillin No
carmustine No codeine No
cefadroxil Yes colchicine No
cefazolin Yes cortisone No
cefepime Yes co-trimoxazole Yes
cefonicid Yes (only by 20%) cyclophosphamide Yes
cefoperazone Yes diazepam No
cefotaxime Yes diazoxide Yes
Dialyzable drugs (continued)

diclofenac No hydroxyzine No
dicloxacillin No ibuprofen No
didanosine Yes imipenem and Yes
digoxin No cilastatin
diltiazem No imipramine No
diphenhydramine No indapamide No
dipyridamole No indomethacin No
doxazosin No insulin No
doxepin No irbesartan No
doxorubicin No iron dextran No
doxycycline No isoniazid Yes
enalapril Yes isosorbide Yes
erythromycin Yes (only by 20%) isradipine No
ethacrynic acid No kanamycin Yes
ethambutol Yes (only by 20%) ketoconazole No
ethchlorvynol Yes ketoprofen Yes
ethosuximide Yes labetalol No
famciclovir Yes levofloxacin No
famotidine No lidocaine No
fenoprofen No lisinopril Yes
flecainide No lithium Yes
fluconazole Yes lomefloxacin No
flucytosine Yes lomustine No
fluorouracil Yes loracarbef Yes
fluoxetine No loratadine No
flurazepam No lorazepam No
foscarnet Yes mefenamic acid No
fosinopril No meperidine No
furosemide No meprobamate Yes
gabapentin Yes mercaptopurine Yes
ganciclovir Yes meropenem Yes
gemcitabine Yes mesalamine Yes
gemfibrozil No methadone No
gemifloxicin Yes methotrexate Yes
gentamicin Yes methyldopa Yes
glipizide No methylprednisolone No
glyburide No metoclopramide No
haloperidol No metolazone No
heparin No metoprolol No
hydralazine No metronidazole Yes
hydrochlorothiazide No mezlocillin Yes
(continued)
562 Drug hazards
Dialyzable drugs (continued)

miconazole No pyridoxine Yes

midazolam No quinapril No
minocycline No quinidine Yes
minoxidil Yes quinine Yes
misoprostol No ranitidine Yes
morphine No rifampin No
nabumetone No salsalate Yes
nadolol Yes sertraline No
nafcillin No sotalol Yes
naproxen No stavudine Yes
nelfinavir Yes sucralfate No
nifedipine No sulbactam Yes
nimodipine No sulfamethoxazole Yes
nitrofurantoin Yes sulindac No
nitroglycerin No tazobactam Yes
nitroprusside Yes temazepam No
nizatidine No theophylline Yes
nortriptyline No ticarcillin Yes
octreotide Yes ticarcillin and Yes
ofloxacin Yes clavulanate
olanzapine No timolol No
omeprazole No tobramycin Yes
oxacillin No tocainide Yes
paroxetine No tolbutamide No
penicillin G Yes topiramate Yes
pentamidine No triazolam No
pentazocine Yes trimethoprim Yes
perindopril Yes valacyclovir Yes
phenobarbital Yes valproic acid No
phenytoin No valsartan No
piperacillin Yes vancomycin Yes
piperacillin and Yes verapamil No
tazobactam warfarin No
prazosin No zolpidem No
prednisone No
primidone Yes
procainamide Yes
promethazine No
propoxyphene No
propranolol No
protriptyline No
pyrazinamide Yes
Drugs that shouldn’t be crushed
Many drug forms, such as slow-release, enteric-coated, encapsulated beads, wax-matrix,

sublingual, and buccal forms, are designed to release their active ingredients over a cer-
tain period or at preset intervals after administration. The disruptions caused by crush-
ing these drug forms can dramatically affect the absorption rate and increase the risk of
adverse reactions.
Other reasons not to crush these drug forms include such considerations as taste, tis-
sue irritation, and unusual formulation — for example, a capsule within a capsule, a liq-
uid within a capsule, or a multiple-compressed tablet. Avoid crushing the following
drugs, listed by brand name, for the reasons noted beside them.
Accutane (irritant) Choledyl SA (slow release)

Aciphex (delayed release) Cipro XR (extended release)
Adalat CC (sustained release) Claritin-D 12-hour (slow release)
Advicor (extended release) Claritin-D 24-hour (slow release)
Aggrenox (extended release) Cleocin (taste)
Allegra D (extended release) Colace (liquid within a capsule)
Altocor (extended release) Colazal (granules within capsules must
Ambien CR (extended release) reach the colon intact)
Amnesteem (irritant) Colestid (protective coating)
Arthrotec (delayed release) Compazine Spansules (slow release)
Asacol (delayed release) Concerta (extended release)
Aspirin (enteric coated) Congess SR (sustained release)
Augmentin XR (extended release) Contac 12 Hour, Maximum Strength
Avinza (extended release) 12 Hour (slow release)
Azulfidine EN-tabs (enteric coated) Cotazym-S (enteric coated)
Biaxin XL (extended release) Covera-HS (extended release)
Bisacodyl (enteric coated) Creon (enteric coated)
Bontril Slow-Release (slow release) Cytovene (irritant)
Bromfed (slow release) Dallergy, Dallergy-Jr (slow release)
Bromfed-PD (slow release) Deconamine SR (slow release)
Bronkodyl SR (slow release) Depakene (slow release, mucous
Calan SR (sustained release) membrane irritant)
Carbatrol (extended release) Depakote (enteric coated)
Cardizem CD, LA, SR (slow release) Depakote ER (extended release)
Cartia XT (extended release) Desyrel (taste)
Ceclor CD (slow release) Dexedrine Spansule (slow release)
Ceftin (strong, persistent taste) Diamox Sequels (slow release)
CellCept (teratogenic potential) Dilacor XR (extended release)
Chloral Hydrate (liquid within a capsule, Dilatrate-SR (slow release)
taste) Diltia XT (extended release)
Chlor-Trimeton Allergy 8-hour and Dimetapp Extentabs (slow release)
12-hour (slow release) Ditropan XL (slow release)
(continued)
564 Drug hazards
Drugs that shouldn’t be crushed (continued)
Dolobid (irritant) Guaifenex PSE (slow release)

Drisdol (liquid filled) Hydergine LC (liquid within a capsule)
Dristan (protective coating) Hytakerol (liquid filled)
Drixoral (slow release) Iberet (slow release)
Dulcolax (enteric coated) ICAPS Plus (slow release)
Dynabac (slow release) ICAPS Time Release (slow release)
DynaCirc CR (slow release) Imdur (slow release)
Easprin (enteric coated) Inderal LA (slow release)
Ecotrin (enteric coated) Indocin SR (slow release)
Ecotrin Maximum Strength (enteric InnoPran XL (extended release)
coated) Ionamin (slow release)
E.E.S. 400 Filmtab (enteric coated) Isoptin SR (sustained release)
Effexor XR (extended release) Isordil Sublingual (sublingual)
Emend (hard gelatin capsule) Isordil Tembid (slow release)
E-Mycin (enteric coated) Isosorbide Dinitrate Sublingual
Entex LA (slow release) (sublingual)
Entex PSE (slow release) Kaon-Cl (slow release)
Ergostat (sublingual) K-Dur (slow release)
Ery-Tab (enteric coated) Klor-Con (slow release)
Erythrocin Stearate (enteric coated) Klotrix (slow release)
Erythromycin Base (enteric coated) K-Tab (slow release)
Eskalith CR (slow release) Levbid (slow release)
Extendryl JR, SR (slow release) Levsinex Timecaps (slow release)
Feldene (mucous membrane irritant) Lithobid (slow release)
Feosol (enteric coated) Macrobid (slow release)
Feratab (enteric coated) Mestinon Timespans (slow release)
Fergon (slow release) Metadate CD, ER (extended release)
Fero-Folic 500 (slow release) Methylin ER (extended release)
Fero-Grad-500 (slow release) Micro-K Extencaps (slow release)
Ferro-Sequel (slow release) Motrin (taste)
Feverall Children’s Capsules, Sprinkle MS Contin (slow release)
(taste) Mucinex (extended release)
Flomax (slow release) Naprelan (slow release)
Fumatinic (slow release) Nexium (sustained release)
Geocillin (taste) Niaspan (extended release)
Glucophage XR (extended release) Nicotinic acid (slow release)
Glucotrol XL (slow release) Nitroglyn (slow release)
Glumetza (slow release) Nitrostat (sublingual)
Guaifed (slow release) Norflex (slow release)
Guaifed-PD (slow release) Norpace CR (slow release)
Guaifenex LA (slow release) Oramorph SR (slow release)
Drugs that shouldn’t be crushed (continued)
Oruvail (extended release) Slow-Mag (slow release)

OxyContin (slow release) Sorbitrate (sublingual)
Pancrease (enteric coated) Sotret (irritant)
Pancrease MT (enteric coated) Sudafed 12 Hour (slow release)
Paxil CR (controlled release) Sular (extended release)
PCE (slow release) Tegretol-XR (extended release)
Pentasa (controlled release) Ten-K (slow release)
Phazyme (slow release) Tenuate Dospan (slow release)
Phazyme 95 (slow release) Tessalon Perles (slow release)
Phenytex (extended release) Theochron (slow release)
Plendil (slow release) Theoclear LA (slow release)
Prelu-2 (slow release) Theo-Dur (extended release)
Prevacid, Prevacid SoluTab (delayed Theolair-SR (slow release)
release) Theo-24 (extended release)
Prilosec (slow release) Thorazine Spansules (slow release)
Prilosec OTC (delayed release) Tiazac (sustained release)
Pro-Banthine (taste) Topamax (taste)
Procanbid (slow release) Toprol XL (extended release)
Procardia (delayed absorption) T-Phyl (slow release)
Procardia XL (slow release) Trental (slow release)
Propecia (women who are or who may Tylenol Extended Relief (slow release)
become pregnant shouldn’t handle) Uniphyl (slow release)
Proscar (women who are or who may Vantin (taste)
become pregnant shouldn’t handle) Verelan, Verelan PM (slow release)
Protonix (delayed release) Volmax (slow release)
Proventil Repetabs (slow release) Voltaren (enteric coated)
Prozac Weekly (slow release) Voltaren-XR (extended release)
Quibron-T/SR (slow release) Wellbutrin SR (sustained release)
Quinidex Extentabs (slow release) Xanax XR (extended release)
Respaire SR (slow release) Zerit XR (extended release)
Respbid (slow release) Zomig-ZMT (delayed release)
Risperdal M-Tab (delayed release) ZORprin (slow release)
Ritalin-LA, -SR (slow release) Zyban (slow release)
Rondec-TR (slow release) Zyrtec-D 12 hour (extended release)
Sinemet CR (slow release)
Slo-bid Gyrocaps (slow release)
Slo-Niacin (slow release)
Slo-Phyllin GG, Gyrocaps (slow release)
Slow FE (slow release)
Slow-K (slow release)
566 Drug hazards
Reversing anaphylaxis
Anaphylaxis — the sudden, extreme reaction to a foreign antigen — requires immediate

treatment. Generally, the more rapid the onset of symptoms, the more severe the reac-
tion. This table lists drugs that are useful in reversing anaphylactic reactions.
DRUG ACTION NURSING

CONSIDERATIONS
Cimetidine ◆ Competes with histamine for ◆ Know that this drug is

(Tagamet) histamine2-receptor sites incompatible with amino-
Severe anaphylaxis ◆ Treats urticaria phylline.
◆ Reduce the dosage for pa-
tients with impaired renal or
hepatic function.
Diphenhydramine ◆ Competes with histamine for ◆ Administer I.V. doses

(Benadryl) histamine1-receptor sites slowly to avoid hypotension.
◆ Prevents laryngeal edema ◆ Monitor the patient for hy-
◆ Controls localized itching potension and drowsiness.
◆ Give fluids as needed. The
drug causes dry mouth.
Epinephrine Alpha-adrenergic effects ◆ Select a large vein for

(Adrenalin) ◆ Increases blood pressure infusion.
Severe anaphylaxis ◆ Reverses peripheral vasodi- ◆ Use an infusion controller
(drug of choice) lation and systemic hypotension to regulate the drip rate.
◆ Considered the drug of ◆ Check the patient’s blood
choice for treating anaphylaxis pressure and heart rate fre-
◆ Decreases angioedema and quently.
urticaria ◆ Monitor the patient for
◆ Improves coronary blood arrhythmias.
flow by raising diastolic pres- ◆ Check the solution
sure strength, dosage, and label
◆ Causes peripheral vasocon- before administration.
striction
Reversing anaphylaxis (continued)
DRUG ACTION NURSING

CONSIDERATIONS
Epinephrine Beta-adrenergic effects ◆ Watch for signs of ex-

(continued) ◆ Causes bronchodilation travasation at the infusion
Severe anaphylaxis ◆ Causes positive inotropic and site.
(drug of choice) chronotropic cardiac activity ◆ Monitor the patient’s in-
◆ Decreases the synthesis and take and output.
release of chemical mediators ◆ Assess the color and tem-
perature of the extremities.
Hydrocortisone ◆ Prevents neutrophil and ◆ Monitor the patient’s fluid

(Solu-Cortef) platelet aggregation and electrolyte balance, in-
Severe anaphylaxis ◆ Inhibits mediator synthesis take and output, and blood
◆ Decreases capillary perme- pressure closely.
ability ◆ Keep the patient on a pro-
phylactic ulcer and antacid
regimen.
568 Drug hazards
Adverse reactions misinterpreted as age-related changes
In elderly patients, adverse drug reactions can easily be misinterpreted as the typical signs
and symptoms of aging. This table shows common adverse reactions for common drug
classifications and can help you avoid such misinterpretations.
ADVERSE REACTIONS
Constipation
Arrhythmias
Depression
Changes in
Confusion
Agitation
appetite
Anxiety
Ataxia
DRUG CLASSIFICATIONS
Angiotensin-converting enzyme inhibitors 䢇䢇䢇
Alpha1 adrenergic blockers 䢇䢇䢇
Antianginals 䢇䢇䢇䢇
Antiarrhythmics 䢇䢇
Anticholinergics 䢇䢇䢇䢇䢇䢇
Anticonvulsants 䢇䢇䢇䢇䢇䢇䢇
Antidepressants, tricyclic 䢇䢇䢇䢇䢇䢇䢇
Antidiabetics, oral
Antihistamines 䢇䢇䢇
Antilipemics 䢇
Antiparkinsonians 䢇䢇䢇䢇䢇䢇䢇
Antipsychotics 䢇䢇䢇䢇䢇䢇䢇䢇
Barbiturates 䢇䢇䢇䢇
Benzodiazepines 䢇䢇䢇䢇䢇
Beta-adrenergic blockers 䢇䢇䢇
Calcium channel blockers 䢇䢇䢇
Corticosteroids 䢇䢇䢇
Diuretics 䢇
Nonsteroidal anti-inflammatory drugs 䢇䢇䢇䢇
Opioids 䢇䢇䢇䢇䢇
Skeletal muscle relaxants 䢇䢇䢇䢇䢇
Thyroid hormones 䢇䢇
Muscle weakness
Vision changes
Disorientation
Memory loss
Hypotension
Restlessness
Drowsiness
dysfunction
dysfunction
breathing
Insomnia
Dizziness
Difficulty
Tremors
Urinary
Fatigue
Edema
Sexual
䢇䢇䢇䢇䢇䢇
䢇䢇䢇䢇䢇䢇䢇䢇䢇
䢇䢇䢇䢇
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䢇䢇䢇䢇䢇䢇
䢇䢇
570 Drug hazards
Therapeutic drug monitoring guidelines

DRUG LABORATORY TEST THERAPEUTIC
MONITORED RANGES OF TEST
aminoglycoside antibi- Amikacin peak 20 to 30 mcg/ml

otics (amikacin, gen- trough 1 to 4 mcg/ml
tamicin, tobramycin) Gentamicin/tobramycin peak 4 to 12 mcg/ml
trough ⬍ 2 mcg/ml
Creatinine 0.6 to 1.3 mg/dl
angiotensin-converting White blood cell count (WBC) *****

enzyme (ACE) inhibitors with differential
(benazepril, captopril, Creatinine 0.6 to 1.3 mg/dl
enalapril, enalaprilat, Blood urea nitrogen (BUN) 5 to 20 mg/dl
fosinopril, lisinopril, Potassium 3.5 to 5 mEq/L
moexipril, quinapril,
ramipril, trandolapril)
amphotericin B Creatinine 0.6 to 1.3 mg/dl

BUN 5 to 20 mg/dl
Electrolytes (especially potas- Potassium: 3.5 to 5 mEq/L
sium and magnesium) Magnesium: 1.5 to 2.5 mEq/L
Sodium: 135 to 145 mEq/L
Chloride: 98 to 106 mEq/L
Liver function *
Complete blood count (CBC) *****
with differential and platelets
antibiotics WBC with differential

Cultures and sensitivities *****
biguanides (metformin) Creatinine 0.6 to 1.3 mg/dl

Fasting glucose 70 to 110 mg/dl
Glycosylated hemoglobin 4% to 7% of total hemoglobin
CBC *****
carbamazepine Carbamazepine 4 to 12 mcg/ml

CBC with differential *****
Liver function *
BUN 5 to 20 mg/dl
Platelet count 150 to 450 x 103/mm3
Note: *****For those areas marked with asterisks, the following values can be used:
Hemoglobin: Women: 12 to 16 g/dl; Differential: Neutrophils: 45% to 74%
Men: 13 to 18 g/dl Bands: 0% to 8%
Hematocrit: Women: 37% to 48%; Lymphocytes: 16% to 45%
Men: 42% to 52% Monocytes: 4% to 10%
Red blood cell count (RBC): 4 to 5.5 ⫻ 106/mm3 Eosinophils: 0% to 7%
WBC: 5 to 10 ⫻ 103/mm3 Basophils: 0% to 2%
MONITORING GUIDELINES
Wait until the administration of the third dose to check drug levels. Obtain blood for peak
level 30 minutes after I.V. infusion ends or 60 minutes after I.M. administration. For trough
levels, draw blood just before the next dose. Dosage may need to be adjusted accordingly.
Recheck after three doses. Monitor creatinine and BUN levels and urine output for signs of
decreasing renal function. Monitor urine for increased proteins, cells, and casts.
Monitor the WBC with differential before therapy, monthly during the first 3 to 6 months, and
then periodically for the first year. Monitor renal function and potassium level periodically.
Monitor creatinine, BUN, and electrolyte levels at least weekly during therapy. Monitor blood
counts and liver function test results regularly during therapy.
Results of specimen cultures and sensitivities will determine the cause of the infection and the
best treatment. Monitor the WBC with differential weekly during therapy.
Check renal function and hematologic values before starting therapy and at least annually
thereafter. If the patient has impaired renal function, don’t use metformin because it may
cause lactic acidosis. Monitor response to therapy by evaluating fasting glucose and glycosy-
lated hemoglobin levels periodically. A patient’s home monitoring of glucose levels helps
monitor compliance and response.
Monitor blood counts and platelet count before therapy, monthly during the first 2 months,
and then yearly. Liver function, BUN, and urinalysis results should be checked before and pe-
riodically during therapy.
(continued)
* For those areas marked with one asterisk, the following values can be used:
Alanine aminotransferase: 7 to 56 units/L
Aspartate aminotransferase: 5 to 40 units/L
Alkaline phosphatase: 17 to 142 units/L
Lactate dehydrogenase: 60 to 220 units/L
Gamma glutamyl transferase (GGT): ⬍ 40 units/L
Total bilirubin: 0.2 to 1 mg/dl
572 Drug hazards
Therapeutic drug monitoring guidelines (continued)

clozapine WBC with differential Adults: 4,500 to 10,500 mm3
corticosteroids (corti- Electrolytes (especially Potassium: 3.5 to 5 mEq/L

sone, hydrocortisone, potassium) Magnesium: 1.7 to 2.1 mEq/L
prednisone, predni- Sodium: 135 to 145 mEq/L
solone, triamcinolone, Chloride: 98 to 106 mEq/L
methylprednisolone, Calcium: 8.6 to 10 mg/dl
dexamethasone, be- Fasting glucose 70 to 110 mg/dl
tamethasone)
digoxin Digoxin 0.8 to 2 ng/ml

Electrolytes (especially Potassium: 3.5 to 5 mEq/L
potassium, magnesium, and Magnesium: 1.7 to 2.1 mEq/L
calcium) Sodium: 135 to 145 mEq/L
Calcium: 8.6 to 10 mg/dl
diuretics Electrolytes Potassium: 3.5 to 5 mEq/L

Magnesium: 1.7 to 2.1 mEq/L
Calcium: 8.6 to 10 mg/dl
BUN 5 to 20 mg/dl
Uric acid 2 to 7 mg/dl
erythropoietin Hematocrit Women: 36% to 48%

Men: 42% to 52%
Serum ferritin 10 to 383 mg/ml
Transferrin saturation 220 to 400 mg/dl
Platelet count 150 to 450 ⳯ 103/mm3
ethosuximide Ethosuximide 40 to 100 mcg/ml

Liver function *
Red blood cell count (RBC): 4 to 5.5 ⫻ 10 /mm
6 3 Eosinophils: 0% to 7%
Obtain a WBC with differential before starting therapy, weekly during therapy, and 4 weeks
after discontinuing the drug. Discontinue drug for WBC less than 3,500 mm3
Monitor electrolyte and glucose levels regularly during long-term therapy.
Check digoxin levels just before the next dose or a minimum of 6 to 8 hours after the last
dose. To monitor maintenance therapy, check drug levels at least 1 to 2 weeks after therapy is
initiated or changed. Adjust therapy based on the entire clinical picture, not solely based on
drug levels. Also, check electrolyte levels and renal function periodically during therapy.
To monitor fluid and electrolyte balance, perform baseline and periodic determinations of elec-
trolyte, calcium, BUN, uric acid, and glucose levels.
After therapy is initiated or changed, monitor hematocrit twice weekly for 2 to 6 weeks until
it’s stabilized in the target range and a maintenance dose is determined. Monitor hematocrit
regularly thereafter.
Check drug level 8 to 10 days after therapy is initiated or changed. Periodically monitor the
CBC with differential and results of liver function tests and urinalysis.
(continued)
574 Drug hazards

gemfibrozil Lipids Total cholesterol: ⬍ 200 mg/dl

Low-density lipoprotein (LDL):
⬍ 130 mg/dl
High-density lipoprotein (HDL):
Women: 40 to 75 mg/dl
Men: 37 to 70 mg/dl
Triglycerides: 10 to 160 mg/dl
Liver function *
Serum glucose 70 to 100 mg/dl
CBC *****
heparin Partial thromboplastin 1.5 to 2.5 times control

time (PTT)
Hematocrit *****
Platelet count 150 to 450 ⳯ 103/mm3
3-hydroxy-3-methyl- Lipids Total cholesterol: ⬍ 200 mg/dl

glutaryl coenzyme A LDL: ⬍ 130 mg/dl
(HMG-CoA) reductase HDL: Women: 40 to 75 mg/dl
inhibitors (fluvastatin, Men: 37 to 70 mg/dl
lovastatin, pravastatin, Triglycerides: 10 to 160 mg/dl
simvastatin) Liver function *
insulin Fasting glucose 70 to 110 mg/dl

isotretinoin Pregnancy test negative

Liver function *
Lipids Total cholesterol: ⬍ 200 mg/dl
LDL: ⬍ 130 mg/dl
HDL: Women: 40 to 75 mg/dl
Men: 37 to 70 mg/dl
Platelet count 150 to 450 ⫻ 103/mm3
Therapy is usually withdrawn after 3 months if response is inadequate. The patient must
be fasting to measure triglyceride levels. Obtain blood counts periodically during the first
12 months.
When drug is given by continuous I.V. infusion, check PTT every 4 hours in the early stages of
therapy, and daily thereafter. When drug is given by deep subcutaneous injection, check PTT 4
to 6 hours after injection, and daily thereafter. Periodically during therapy, check platelet
counts and hematocrit and test for occult blood in stool.
Perform liver function tests at baseline, 6 to 12 weeks after therapy is initiated or changed,
and approximately every 6 months thereafter. If adequate response isn’t achieved within 6
weeks, consider changing therapy.
Monitor response to therapy by evaluating glucose and glycosylated hemoglobin levels. Glyco-
sylated hemoglobin level is a good measure of long-term control. A patient’s home monitoring
of glucose levels helps measure compliance and response.
Use a serum or urine pregnancy test with a sensitivity of at least 25 mIU/ml. Perform one test
before therapy and a second test during the second day of the menstrual cycle before therapy
begins or at least 11 days after the last unprotected act of sexual intercourse, whichever is lat-
er. Repeat pregnancy tests monthly. Obtain baseline liver function tests and lipid levels; repeat
every 1 to 2 weeks until a response is established (usually 4 weeks).
(continued)
576 Drug hazards

linezolid CBC with differential *****

and platelets
Cultures and sensitivities
Liver function *
Amylase 35 to 118 IU/L
Lipase 10 to 150 units/L
lithium Lithium 0.6 to 1.2 mEq/L

CBC *****
potassium and sodium) Magnesium: 1.7 to 2.1 mEq/L
Thyroid function tests Thyroid-stimulating hormone (TSH):
0.2 to 5.4 microunits/ml
T3: 80 to 200 ng/dl
T4: 5.4 to 11.5 mcg/dl
methotrexate Methotrexate Normal elimination:

⬃ 10 micromol 24 hours postdose
⬃ 1 micromol 48 hours postdose
⬍ 0.2 micromol 72 hours postdose
Liver function *
nonnucleoside reverse Liver function *

transcriptase inhibitors CBC with differential *****
(nevirapine, delavir- and platelets
dine, efavirenz) Lipids (efavirenz) Total cholesterol: ⬍ 200 mg/dl
LDL: ⬍ 130 mg/dl
Men: 37 to 70 mg/dl
Obtain a baseline CBC with differential and platelet count. Repeat weekly, especially if the pa-
tient receives more than 2 weeks of therapy. Monitor liver function test results and amylase
and lipase levels during therapy.
Checking lithium levels is crucial to safe use of the drug. Obtain lithium levels immediately be-
fore the next dose. Monitor levels twice weekly until they are stable. Once at a steady state,
levels should be checked weekly; when the patient is receiving the appropriate maintenance
dose, levels should be checked every 2 to 3 months. Monitor creatinine, electrolyte, and fast-
ing glucose levels; CBC; and thyroid function test results before therapy is initiated and period-
ically during therapy.
Monitor methotrexate levels according to the dosing protocol. Monitor the CBC with differen-
tial, platelet count, and liver and renal function test results more frequently when therapy is
initiated or changed and when methotrexate levels may be elevated, such as when the patient
is dehydrated.
Obtain baseline liver function tests and monitor results closely during the first 12 weeks of
therapy. Continue to monitor them regularly during therapy. Check the CBC with differential
and platelet count before therapy and periodically during therapy. Monitor lipid levels during
efavirenz therapy. Monitor the amylase level during efavirenz and delavirdine therapy.
(continued)
578 Drug hazards

phenytoin Phenytoin 10 to 20 mcg/ml

CBC *****
potassium chloride Potassium 3.5 to 5 mEq/L
procainamide Procainamide 3 to 10 mcg/ml (procainamide)

N-acetylprocainamide 10 to 30 mcg/ml (combined
(NAPA) procainamide and NAPA)
CBC *****
Liver function *
ANA titer Negative
protease inhibitors Fasting glucose 70 to 110 mg/dl

(amprenavir, indinavir, Liver function *
lopinavir, nelfinavir, ri- CBC with differential *****
tonavir, saquinavir) Lipids Total cholesterol: ⬍ 200 mg/dl
LDL: ⬍ 130 mg/dl
Men: 37 to 70 mg/dl
Creatine kinase (CK) Women: 20 to 170 IU/L
Men: 30 to 220 IU/L
quinidine Quinidine 2 to 6 mcg/ml

CBC *****
Liver function *
potassium) Magnesium: 1.7 to 2.1 mEq/L
sulfonylureas Fasting glucose 70 to 110 mg/dl

Monitor phenytoin levels immediately before the next dose and 7 to 10 days after therapy is
initiated or changed. Obtain a CBC at baseline and monthly early in therapy. Watch for toxic
effects at therapeutic levels. Adjust the measured level for hypoalbuminemia or renal impair-
ment, which can increase free drug levels.
After oral replacement therapy is initiated, check the level weekly until it’s stable and every 3
to 6 months thereafter.
Measure procainamide levels 6 to 12 hours after a continuous infusion is started or immedi-

ately before the next oral dose. Combined (procainamide and NAPA) levels can be used as an
index of toxicity in patients with renal impairment. Obtain a CBC, liver function tests, and ANA
titer periodically during longer-term therapy.
Obtain a baseline glucose level, liver function test results, a CBC with differential, and lipid,
CK, and amylase levels. Monitor during therapy.
Obtain levels immediately before the next oral dose and 30 to 35 hours after therapy is initi-
ated or changed. Obtain blood counts, liver and kidney function test results, and electrolyte
levels periodically. With more specific assays, therapeutic levels are ⬍ 1 mcg/1 ml.
Monitor response to therapy by evaluating fasting glucose and glycosylated hemoglobin levels
periodically. The patient should monitor glucose levels at home to help measure compliance
and response.
(continued)
580 Drug hazards

theophylline Theophylline 10 to 20 mcg/ml
thiazolidinediones Fasting glucose 70 to 110 mg/dl

(rosiglitazone, pioglita- Glycosylated hemo- 4% to 7% of total hemoglobin
zone) globin
Liver function *
thyroid hormone Thyroid function tests TSH: 0.2 to 5.4 microunits/ml

T3: 80 to 200 ng/dl
T4: 5.4 to 11.5 mcg/dl
valproate sodium, val- Valproic acid 50 to 100 mcg/ml

proic acid, divalproex Liver function *
sodium Ammonia 15 to 45 mcg/dl
PTT 10 to 14 seconds
BUN 5 to 20 mg/dl
vancomycin Vancomycin 20 to 40 mcg/ml (peak)

Creatinine 5 to 15 mcg/ml (trough)
0.6 to 1.3 mg/dl
warfarin International Normal- For acute myocardial infarction, atrial

ized Ratio (INR) fibrillation, treatment of pulmonary
embolism, prevention of systemic em-
bolism, tissue heart valves, valvular
heart disease, or prophylaxis or treat-
ment of venous thrombosis: 2 to 3
For mechanical prosthetic valves or
recurrent systemic embolism: 3 to 4.5
Obtain theophylline levels immediately before the next dose of sustained-release oral drug
and at least 2 days after therapy is initiated or changed.
Monitor response by evaluating fasting glucose and glycosylated hemoglobin levels. Obtain
baseline liver function test results, and repeat the tests periodically during therapy.
Monitor thyroid function test results every 2 to 3 weeks until the appropriate maintenance
dose is determined, and annually thereafter.
Monitor liver function test results, ammonia level, coagulation test results, renal function test
results, CBC, and platelet count at baseline and periodically during therapy. Monitor liver func-
tion test results closely during the first 6 months of therapy.
Check vancomycin levels with the third dose administered, at the earliest. Obtain peak levels
11⁄2 to 21⁄2 hours after a 1-hour infusion or when I.V. infusion is complete. Obtain trough lev-
els within 1 hour of the next dose administered. Renal function can be used to adjust dosing
and intervals.
Check INR daily, beginning 3 days after therapy is initiated. Continue checking it until the
therapeutic goal is achieved, and monitor it periodically thereafter. Also check levels 7 days
after a change in the warfarin dose or concomitant, potentially interacting therapy.
582 Drug hazards
Identifying the most dangerous The FDA also wants to hear from
drugs nurses whose patients have had seri-
ous reactions associated with drugs —
Almost any drug can cause an adverse especially drugs that have been on the
reaction in some patients, but the fol- market for 3 years or less. After all,
lowing drugs cause about 90% of all you and your colleagues are the ones
reported reactions. who are most likely to see the reac-
tions, so you can give the best clinical
Anticoagulants descriptions. Unlike drug manufactur-
◆ Heparin ers, however, nurses aren’t required by
◆ Warfarin law to make a report.
What constitutes a serious reaction?
Antimicrobials According to the FDA, it’s one that:
◆ Cephalosporins ◆ is life-threatening
◆ Penicillins ◆ causes death
◆ Sulfonamides ◆ leads to or prolongs hospitalization
◆ results in permanent or severe dis-
Bronchodilators ability.
◆ Sympathomimetics The FDA also wants to know about
◆ Theophylline drugs that don’t produce a therapeutic
response. It doesn’t need to hear about
Cardiac drugs inappropriate use of drugs, prescriber
◆ Antihypertensives errors, or administration errors. (How-
◆ Digoxin ever, the U.S. Pharmacopeia does want
◆ Diuretics to know about medication errors —
◆ Quinidine especially those caused by sound-alike
or look-alike drug names. See your
Central nervous system drugs pharmacist for more information.)
◆ Analgesics You can submit a report to the FDA
◆ Anticonvulsants even if you aren’t sure if a patient’s re-
◆ Neuroleptics action was serious or if you suspect —
◆ Sedative-hypnotics but don’t know for certain — that a re-
action is the result of a drug.
Diagnostic agents To file a report, use the MEDWATCH
◆ X-ray contrast media form, which should be available in the
pharmacy. Fill out this form as com-
Hormones pletely as possible. You don’t have to
◆ Corticosteroids include the patient’s name or initials,
◆ Estrogens but you should be able to identify the
◆ Insulin patient if the FDA requests follow-up
information.
Reporting reactions to the FDA Approximately 60,000 reports on
adverse reactions are collected annual-
Drug manufacturers monitor adverse ly; more than 400,000 are currently in
drug reactions and report them to the the FDA database. These reports lead
Food and Drug Administration (FDA). to improved patient safety because the
That’s the law. more reports that are submitted, the
more information the FDA has to alert
health care professionals to these ad- Managing I.V. extravasation

verse reactions.
Extravasation is leakage of infused so-
What The Joint Commission lution from a vein into the surrounding
requires tissue. The result of a needle punctur-
ing the vessel wall or leakage around a
To meet the standards set by The Joint venipuncture site, extravasation causes
Commission, a facility must have a local pain and itching, edema, blanch-
program in place for reporting adverse ing, and decreased skin temperature in
drug reactions. The pharmacy and the affected extremity. Extravasation of
therapeutics committee at the facility is I.V. solution may be referred to as infil-
required to review “all significant unto- tration because the fluid infiltrates the
ward drug reactions” to ensure quality tissues.
patient care. Extravasation of a small amount of
According to The Joint Commission, isotonic fluid or nonirritating drug usu-
a “significant” reaction is one in which: ally causes only minor discomfort.
◆ the drug suspected of causing the Treatment involves routine comfort
reaction must be discontinued measures, such as the application of
◆ the patient requires treatment with warm compresses. However, extravasa-
another drug, such as an antihista- tion of some drugs can severely dam-
mine, a steroid, or epinephrine age tissue through irritative, sclerotic,
◆ the patient’s hospital stay is pro- vesicant, corrosive, or vasoconstrictive
longed — for example, because surgery action. In these cases, emergency mea-
had to be delayed or more diagnostic sures must be taken to minimize tissue
tests had to be done. damage and necrosis, prevent the need
Why is this type of reporting pro- for skin grafts or, rarely, avoid amputa-
gram important? First, the quality of tion.
care improves when you know which
patients are at higher risk for an ad- Equipment and preparation
verse drug reaction and which drugs Three 25G 5⁄8⬙ needles ◆ antidote for
are most likely to cause these reac- extravasated drug in an appropriate sy-
tions. You’ll be more alert for the early ringe ◆ 5-ml syringe ◆ three tuber-
signs and symptoms of problems, and culin syringes ◆ alcohol pad or gauze
you’ll be prepared to intervene prompt- pad soaked in antiseptic cleaning agent
ly. ◆ 4⬙ ⫻ 4⬙ gauze pad ◆ cold and warm
Second, the facility will make better compresses
use of its health care dollars because
the lengthy stays and extra treatments Implementation
associated with adverse drug reactions Facility policy dictates the procedures
will be decreased. for extravasation treatment, which may
Third, reducing drug-induced in- include some or all of these steps:
juries will decrease the number of mal- ◆ Stop the infusion and remove the
practice lawsuits brought against the I.V. needle unless you need the route
facility and staff, saving time, money, to infiltrate the antidote. Carefully esti-
and aggravation. mate the amount of extravasated solu-
tion, and notify the physician.
◆ Disconnect the tubing from the I.V.
needle. Attach the 5-ml syringe to the
584 Drug hazards
needle and try to withdraw 3 to 5 ml drug is a vasoconstrictor, such as nor-

of blood to remove any medication or epinephrine or metaraminol bitartrate,
blood in the tubing or needle and to apply warm compresses only.
provide a path to the infiltrated tissues. ◆ Monitor the I.V. site continuously
◆ Clean the area around the I.V. site for signs of abscess or necrosis.
with an alcohol pad or a 4⬙ ⫻ 4⬙ gauze
pad soaked in an antiseptic agent. Special considerations
Then insert the needle of the empty tu- ◆ If you’re administering a potentially
berculin syringe into the subcutaneous tissue-damaging drug by I.V. bolus or
tissue around the site, and gently aspi- push, first start an I.V. infusion, prefer-
rate as much solution as possible from ably with normal saline solution. In-
the tissue. fuse a small amount of this solution,
◆ Instill the prescribed antidote into and check for signs of infiltration be-
the subcutaneous tissue around the fore injecting the drug.
site. Then, if ordered, slowly instill an ◆ Know the antidote (if any) for an
anti-inflammatory drug subcutaneously I.V. drug that can cause tissue necrosis,
to help reduce inflammation and ede- in case extravasation occurs. Make sure
ma. that you’re familiar with the facility
◆ If ordered, instill the prescribed an- policy for the administration of such
tidote through the I.V. needle. drugs and their antidotes.
◆ Apply cold compresses to the affect- ◆ Tell the patient to report discomfort
ed area for 24 hours, or apply an ice at the I.V. site. During infusion, check
pack for 20 minutes every 4 hours, to the site frequently for signs of infiltra-
cause vasoconstriction that may local- tion.
ize the drug and slow cell metabolism.
After 24 hours, apply warm compress-
es and elevate the affected extremity to
reduce discomfort and promote reab-
sorption of fluid. If the extravasated
Antidotes for extravasation

ANTIDOTE EXTRAVASATED DRUG
Dexrazoxane (Toltect, Totect) ◆ daunorubicin

◆ doxorubicin
◆ epirubicin
◆ idarubicin
Drug overdoses 585
Antidotes for extravasation (continued)
ANTIDOTE EXTRAVASATED DRUG
Hyaluronidase 15 units/ml ◆ aminophylline

◆ Calcium solutions
◆ Contrast media
◆ Dextrose solutions (concentrations of 10%
or more)
◆ nafcillin
◆ Potassium solutions
◆ Total parenteral nutrition solutions
◆ vinblastine
◆ vincristine
◆ vindesine
Hydrocortisone sodium ◆ doxorubicin

succinate 100 mg/ml ◆ vincristine
Usually followed by topical application
of hydrocortisone cream 1%
Phentolamine ◆ dobutamine
◆ dopamine
◆ epinephrine
◆ metaraminol bitartrate
◆ norepinephrine
Sodium bicarbonate 8.4% ◆ carmustine

◆ daunorubicin
◆ doxorubicin
◆ vinblastine
◆ vincristine
Sodium thiosulfate 10% ◆ cisplatin

◆ dactinomycin
◆ mechlorethamine
◆ mitomycin
support measures, as indicated. Admin-

Drug overdoses ister the prescribed antidote, if avail-
able, and institute measures to block
General guidelines absorption and speed elimination of
the drug. Consult with a regional poi-
If the patient has signs of an acute tox- son control center for additional infor-
ic reaction, institute advanced life- mation about treating patients who
586 Drug hazards
ingested specific toxins. The steps be- ◆ Adsorption with activated charcoal
low outline the management of an is used in place of emesis or lavage, if
acute overdose of ingested systemic the drug is well adsorbed by activated
drugs. charcoal, or after emesis or lavage to
adsorb co-ingestants, if the primary
Starting advanced life support toxin isn’t well adsorbed by activated
◆ Establish and maintain an airway. charcoal.
This is usually done by inserting an ◆ A cathartic may be given to speed
oropharyngeal or endotracheal airway. transit of the poison through the GI
◆ If the patient isn’t breathing, start tract. Whole-bowel irrigation with a
ventilation with a bag-valve mask until balanced polyethylene glycol and elec-
a mechanical ventilator is available. trolyte solution may be ordered if the
Check the pulse oximetry results or ar- patient ingested a sustained-release
terial blood gas levels, and administer product.
oxygen as needed.
◆ Maintain circulation. Start an I.V. Speeding drug elimination
infusion, and obtain laboratory speci- ◆ Gastric dialysis uses timed doses of
mens to check for toxic drug levels as activated charcoal for 1 to 2 days. The
well as electrolyte and glucose levels, charcoal binds to the drug, facilitating
as indicated. If the patient has hypo- its removal in stools.
tension, administer fluids and a vaso- ◆ Diuresis is effective for some drug
pressor such as dopamine (Intropin). If overdoses. Forced diuresis uses furose-
the patient has hypertension, prepare mide and an osmotic diuretic, alkaline
to administer an antihypertensive (usu- diuresis uses I.V. sodium bicarbonate,
ally a beta-adrenergic blocker, if a cate- and acid diuresis uses oral or I.V.
cholamine was ingested). Prepare to ascorbic acid or ammonium chloride.
treat arrhythmias as indicated for the ◆ Peritoneal dialysis and hemodialysis
specific toxin. are occasionally used for severe over-
◆ Protect the patient from injury, and dose.
monitor him for seizures. Observe him,
and provide supportive care. Prepare to Managing an acute toxic reaction
administer diazepam, lorazepam, or
phenytoin. If the patient has signs of an acute
toxic reaction, institute advanced life-
Administering the antidote support measures, as indicated. Admin-
The antidote is administered as soon as ister the prescribed antidote, if avail-
possible. Administer the prescribed an- able, and take steps to block absorp-
tidote, which depends on the type of tion and speed elimination of the drug.
drug the patient has taken. Consult with a regional poison control
center for information on how to treat
Blocking drug absorption ingestion of a specific toxin.
◆ Gastric emptying is effective up to 2
hours after drug ingestion. Two meth-
ods are used: syrup of ipecac for a con-
scious patient whose condition isn’t ex-
pected to deteriorate and gastric lavage
for a comatose patient or one who
doesn’t respond to syrup of ipecac.
Drug overdoses 587
Managing poisoning or overdose

ANTIDOTE AND NURSING CONSIDERATIONS
INDICATIONS
acetylcysteine ◆ Use cautiously in an elderly or debilitated patient and

(Mucomyst, Mucosil, in a patient with asthma or severe respiratory insuffi-
Parvolex) ciency.
◆ Treatment of aceta- ◆ Don’t use with activated charcoal.
minophen toxicity ◆ Don’t combine with amphotericin B, ampicillin, chy-
motrypsin, erythromycin lactobionate, hydrogen peroxide,
oxytetracycline, tetracycline, iodized oil, or trypsin. Ad-
minister separately.
activated charcoal ◆ Don’t give to a semiconscious or unconscious patient.

(Actidose-Aqua, Charcoaid, ◆ If possible, administer within 30 minutes of poisoning.
CharcoCaps, Liqui-Char) Administer a larger dose if the patient has food in his
◆ Treatment of poisoning or stomach.
overdose with most orally ◆ Don’t give with syrup of ipecac because charcoal inac-
administered drugs, except tivates ipecac. If a patient needs syrup of ipecac, give
caustic agents and hydrocar- charcoal after he has finished vomiting.
bons ◆ Don’t give in or with ice cream, milk, or sherbet be-
cause these foods reduce the adsorption capacities of
charcoal.
◆ The powder form is the most effective; mix it with tap
water to form a thick syrup. You may add a small
amount of fruit juice or flavoring to make the syrup more
palatable.
◆ You may need to repeat the dose if the patient vomits
shortly after administration.
aminocaproic acid ◆ For infusion, dilute the solution with sterile water for
(Amicar) injection, normal saline solution, dextrose 5% in water
◆ Antidote for alteplase, (D5W), or lactated Ringer’s solution.
anistreplase, streptokinase, ◆ Monitor the patient’s coagulation studies, heart
or urokinase toxicity rhythm, and blood pressure.
amyl nitrite ◆ Amyl nitrite is effective within 30 seconds, but its ef-
◆ Antidote for cyanide poi- fects last only 3 to 5 minutes.
soning ◆ To administer, wrap an ampule in a cloth and crush it.
Hold it near the patient’s nose and mouth so that he can
inhale the vapor.
◆ Monitor the patient for orthostatic hypotension.
◆ The patient may have a headache after administration.
atropine sulfate ◆ Atropine sulfate is contraindicated in patients with

◆ Antidote for anti- glaucoma, myasthenia gravis, obstructive uropathy, or
cholinesterase toxicity and unstable cardiovascular status.
organophosphate poisoning ◆ Monitor the patient’s intake and output to assess for
urine retention.
(continued)
588 Drug hazards
Managing poisoning or overdose (continued)

INDICATIONS
botulism antitoxin, ◆ Obtain an accurate patient history of allergies, espe-

trivalent equine cially to horses, and of reactions to immunizations.
◆ Treatment of botulism ◆ Test the patient for sensitivity (against a control of
normal saline solution in the opposing extremity) before
administration. Read the results after 5 to 30 minutes. A
wheal indicates a positive reaction, and patient desensiti-
zation is required.
◆ Keep epinephrine 1:1,000 available in case of an al-
lergic reaction.
deferoxamine ◆ Don’t administer the drug to a patient who has severe

mesylate renal disease or anuria.
(Desferal) ◆ Monitor the patient for visual or auditory changes.
◆ Adjunctive treatment of ◆ Keep epinephrine 1:1,000 available in case of an al-
acute iron intoxication lergic reaction.
◆ Use the I.M. route if possible. Use the I.V. route only
when the patient is in shock.
◆ To reconstitute the drug for I.M. administration, add
2 ml of sterile water for injection to each ampule. Make
sure that the drug dissolves completely. To reconstitute it
for I.V. administration, dissolve it as for I.M. use but in
normal saline solution, D5W, or lactated Ringer’s solu-
tion.
◆ Monitor the patient’s intake and output carefully.
Warn the patient that his urine may turn red.
◆ Reconstituted solution can be stored for up to 1 week
at room temperature. Protect it from light.
digoxin immune Fab ◆ Use the drug cautiously in a patient who’s allergic to
(ovine) (Digibind) ovine proteins because it’s derived from digoxin-specific
◆ Treatment of potentially antibody fragments obtained from immunized sheep. Per-
life-threatening digoxin or form a skin test before administering.
digitoxin intoxication ◆ Use only for a patient who is in shock or cardiac ar-
rest with ventricular arrhythmias, such as ventricular
tachycardia or fibrillation; with progressive bradycardia,
such as severe sinus bradycardia; or with second- or
third-degree atrioventricular block if he is unresponsive
to atropine.
◆ Infuse the drug through a 0.22-micron membrane fil-
ter, if possible, over 30 minutes.
◆ Refrigerate powder for reconstitution. If possible, use
the reconstituted drug immediately, although you may
refrigerate it for up to 4 hours.
Drug overdoses 589

INDICATIONS
digoxin immune Fab ◆ Drug interferes with immunoassay measurements of

(continued) digoxin, resulting in misleading standard serum digoxin
levels until the drug is cleared from the body (about 2
days).
◆ Total serum digoxin levels may rise after adminis-
tration of the drug, reflecting fat-bound (inactive)
digoxin.
◆ Monitor the patient’s potassium levels closely.
edetate calcium ◆ Don’t give the drug to a patient who has severe renal
disodium disease or anuria.
(Calcium Disodium ◆ Avoid using the I.V. route in a patient who has lead
Versenate, Calcium EDTA) encephalopathy because intracranial pressure may in-
◆ Treatment of lead poison- crease; use the I.M. route.
ing in patients with blood lev- ◆ Avoid rapid infusion; the I.M. route is preferred, espe-
els > 50 mcg/dl cially for children.
◆ If giving a high dose, give the drug with dimercaprol
to avoid a toxic reaction.
◆ Give plenty of fluids to facilitate the excretion of lead,
except in patients with lead encephalopathy.
◆ Before giving the drug, obtain baseline intake and
output, urinalysis, blood urea nitrogen, and serum alka-
line phosphatase, calcium, creatinine, and phosphorus
levels. Then monitor these values on the first, third, and
fifth days of treatment. Monitor the patient’s electrocar-
diogram results periodically.
◆ If procaine hydrochloride has been added to the I.M.
solution to minimize pain, watch the patient for a local
reaction.
nalmefene (Revex) ◆ Use cautiously in patients with known cardiovascular

◆ Treatment of known or risk.
suspected opioid overdose; ◆ If I.V. access is lost or isn’t readily attainable, a single
not recommended for children dose of 1 mg nalmefene I.M. or subcutaneously may be
or neonates effective within 5 to 15 minutes.
◆ Monitor the patient’s respirations. Be prepared to pro-
vide resuscitative measures.
(continued)
590 Drug hazards

INDICATIONS
naloxone ◆ Use cautiously in a patient with cardiac irritability or

hydrochloride narcotic addiction.
(Narcan) ◆ Monitor the patient’s respiratory depth and rate. Be
◆ Treatment of respiratory prepared to provide oxygen, ventilation, and other resus-
depression caused by opi- citative measures.
oids ◆ If the neonatal concentration (0.02 mg/ml) isn’t avail-
◆ Treatment of postopera- able, dilute the adult concentration (0.4 mg) by mixing
tive narcotic depression 0.5 ml of the drug with 9.5 ml of sterile water or normal
◆ Treatment of asphyxia saline solution.
neonatorum ◆ Respiratory rate increases within 2 minutes; the ef-
fects last 1 to 4 hours.
◆ Duration of narcotic may exceed that of naloxone,
causing the patient to relapse into respiratory depression.
◆ Drug may be administered by continuous I.V. infusion
to control the adverse effects of epidurally administered
morphine.
◆ An “overshoot” effect may occur in which the patient’s
respiratory rate after receiving the drug exceeds his rate
before respiratory depression occurred.
◆ Naloxone is the safest drug to use when the cause of
respiratory depression is uncertain.
◆ Naloxone doesn’t reverse respiratory depression
caused by diazepam. Although it’s generally believed to
be ineffective in the treatment of respiratory depression
caused by nonopioids, naloxone may reverse a coma
that’s induced by alcohol intoxication.
pralidoxime chloride ◆ Don’t give to a patient poisoned with carbaryl (Sevin),

(Protopam Chloride) a carbamate insecticide, because it increases the toxic ef-
◆ Antidote for organophos- fects of carbaryl.
phate poisoning and cholin- ◆ Use with caution in a patient with renal insufficiency,
ergic overdose myasthenia gravis, asthma, or peptic ulcer.
◆ Use in a hospitalized patient only, and have respirato-
ry and other supportive equipment available.
◆ Administer the antidote as soon as possible after poi-
soning. Treatment is most effective if started within 24
hours of exposure.
◆ Before administering, suction secretions and make
sure the airway is patent.
◆ Dilute the drug with sterile water without preserva-
tives. Give atropine along with pralidoxime.
◆ If the patient’s skin was exposed, remove his clothing
and wash his skin and hair with sodium bicarbonate,
soap, water, and alcohol as soon as possible. He may
need a second washing. When washing the patient, wear
protective gloves and clothes to avoid exposure.
Drug overdoses 591

INDICATIONS
pralidoxime chloride ◆ Observe the patient for 48 to 72 hours after he ingest-

(continued) ed poison. Delayed absorption may occur. Watch for
signs of rapid weakening in a patient with myasthenia
gravis who is being treated for an overdose of cholinergic
drugs. He may pass quickly from cholinergic crisis to
myasthenic crisis and require more cholinergic drugs to
treat the myasthenia. Keep edrophonium available.
protamine sulfate ◆ Use cautiously after cardiac surgery.

◆ Treatment of heparin ◆ Administer slowly to reduce adverse reactions. Have
overdose equipment available to treat shock.
◆ Monitor the patient continuously, and check his vital
signs frequently.
◆ Watch for spontaneous bleeding (heparin “rebound”),
especially in patients undergoing dialysis and those who
have had cardiac surgery.
◆ Protamine sulfate may act as an anticoagulant in ex-
tremely high doses.
Acetaminophen overdose ◆ Stage 4 (7 to 8 days after ingestion):

recovery
In patients with acute overdose of acet- To treat acetaminophen toxicity, im-
aminophen, plasma levels of 300 mcg/ mediately induce emesis with syrup of
ml 4 hours after ingestion or 50 mcg/ ipecac if the patient is conscious, or
ml 12 hours after ingestion are associ- with gastric lavage if he’s comatose or
ated with hepatotoxicity. Signs and doesn’t respond to syrup of ipecac. Ad-
symptoms of overdose include cyano- minister activated charcoal via a naso-
sis, anemia, jaundice, skin eruptions, gastric tube, and give oral acetylcys-
fever, emesis, central nervous system teine. Monitor the patient’s laboratory
(CNS) stimulation, delirium, and met- results and vital signs closely. Provide
hemoglobinemia progressing to CNS symptomatic and supportive measures,
depression, coma, vascular collapse, including respiratory support and cor-
seizures, and death. Acetaminophen rection of fluid and electrolyte imbal-
poisoning develops in stages. ances.
◆ Stage 1 (12 to 24 hours after inges- Oral acetylcysteine, a specific anti-
tion): nausea, vomiting, diaphoresis, dote for acetaminophen poisoning, is
and anorexia most effective if started within 12
◆ Stage 2 (24 to 48 hours after inges- hours after ingestion, but can help if
tion): clinical improvement, but elevat- started as late as 24 hours after inges-
ed liver function test results tion. Doses vomited within 1 hour of
◆ Stage 3 (72 to 96 hours after inges- administration must be repeated.
tion): peak hepatotoxicity Remove charcoal by lavage before
592 Drug hazards
administering acetylcysteine because it GI evacuation of unabsorbed sustained-

may interfere with absorption of this release drug.
antidote. Acetylcysteine minimizes he-
patic injury by supplying sulfhydryl Anticholinergic overdose
groups that bind with acetaminophen
metabolites. Signs and symptoms of anticholinergic
Hemodialysis may help to remove overdose include peripheral effects,
acetaminophen from the body, and such as dilated, nonreactive pupils;
cimetidine has been used investigation- blurred vision; flushed, hot, dry skin;
ally to block the metabolism of aceta- dry mucous membranes; dysphagia;
minophen to toxic intermediates. De- decreased or absent bowel sounds;
termine plasma levels of acetamino- urine retention; hyperthermia; tachy-
phen at least 4 hours after overdose cardia; hypertension; and increased
occurs. If the levels indicate hepatotox- respiratory rate.
icity, perform liver function tests every Treatment is primarily symptomatic
24 hours for at least 96 hours. and supportive, as needed. If the pa-
tient is alert, induce emesis (or use
Analeptic overdose gastric lavage), and follow with a
(amphetamines, cocaine) saline cathartic and activated charcoal
to prevent further drug absorption. In
Individual responses to overdose with severe cases, physostigmine may be ad-
analeptics vary widely. Toxic doses also ministered to block central antimus-
vary, depending on the drug and the carinic effects. Give fluids as needed to
route of ingestion. treat shock. If urine retention occurs,
Signs and symptoms of overdose in- catheterization may be necessary.
clude restlessness, tremor, hyperreflex-
ia, tachypnea, confusion, aggressive- Anticoagulant overdose
ness, hallucinations, and panic; fatigue
and depression usually follow the ex- Signs and symptoms of oral anticoagu-
citement stage. Other effects include lant overdose vary with the severity of
arrhythmias, shock, altered blood pres- overdose. They may include internal or
sure, nausea, vomiting, diarrhea, and external bleeding and skin necrosis,
abdominal cramps; seizures and coma but the most common sign is hema-
usually precede death. turia.
Treat overdose symptomatically and If the patient has an excessively
supportively: If oral ingestion is recent prolonged prothrombin time, an elevat-
(within 4 hours), use gastric lavage to ed International Normalized Ratio, or
empty the stomach and reduce further minor bleeding, anticoagulant therapy
absorption. Follow with activated char- must be stopped. In some cases, with-
coal. Monitor the patient’s vital signs holding one or two doses may be ade-
and fluid and electrolyte balance. If the quate. Other measures to control bleed-
drug was smoked or injected, focus on ing include oral or subcutaneous phy-
enhancing drug elimination and pro- tonadione (vitamin K1) and, for severe
viding supportive care. Administer a hemorrhage, fresh frozen plasma or
sedative if needed. Urine acidification whole blood. Menadione (vitamin K3)
may enhance excretion. A saline ca- isn’t as effective. The use of phytona-
thartic (magnesium citrate) may hasten dione may interfere with subsequent
Drug overdoses 593
oral anticoagulant therapy and may sary; support cardiac function and cir-
cause an anaphylactic reaction. culation with a vasopressor and I.V.
fluids, as needed. If the patient is con-
Antihistamine overdose scious and the gag reflex is intact, in-
duce emesis (if ingestion was recent).
Drowsiness is the most common sign If emesis is contraindicated, perform
of antihistamine overdose. Seizures, gastric lavage while a cuffed endotra-
coma, and respiratory depression may cheal tube is in place, to prevent aspi-
occur with severe overdose. Certain ration. Then administer activated char-
histamine antagonists, such as diphen- coal and a saline cathartic. Measure
hydramine, also block cholinergic re- the patient’s intake and output, vital
ceptors and produce modest anticholin- signs, and laboratory parameters;
ergic signs and symptoms, such as dry maintain his body temperature. The
mouth, flushed skin, fixed and dilated patient should be rolled from side to
pupils, and GI symptoms, especially in side every 30 minutes to avoid pul-
children. Phenothiazine-type antihista- monary congestion.
mines such as promethazine also block Alkalinization of urine may help re-
dopamine receptors. The patient may move the drug from the body; he-
have movement disorders that mimic modialysis may be useful in severe
Parkinson’s disease. Children may also overdose.
have central nervous system stimula-
tion or seizures. Benzodiazepine overdose
Treat the overdose with gastric
lavage followed by activated charcoal. Benzodiazepine overdose can produce
Syrup of ipecac usually isn’t recom- somnolence, confusion, coma, hypoac-
mended because acute dystonic reactive reflexes, dyspnea, labored breath-
tions may increase the risk of aspira- ing, hypotension, bradycardia, slurred
tion. Also, phenothiazine-type antihist- speech, and unsteady gait or impaired
amines may have antiemetic effects. coordination.
Treat hypotension with fluids or a va- Treatment of overdose involves sup-
sopressor, and treat seizures with porting the patient’s blood pressure
phenytoin or diazepam. Watch the pa- and respiration and monitoring his vi-
tient for arrhythmias, and provide tal signs until the effects of the drug
treatment accordingly. subside. Mechanical ventilatory assis-
tance via an endotracheal tube may be
Barbiturate overdose required to maintain a patent airway
and support adequate oxygenation.
A barbiturate overdose can cause un- Flumazenil, a specific benzodiazepine
steady gait, slurred speech, sustained antagonist, may be useful. Use I.V. flu-
nystagmus, somnolence, confusion, ids or a vasopressor, such as dopamine
respiratory depression, pulmonary ede- and phenylephrine, to treat hypoten-
ma, areflexia, and coma. Typical shock sion, as needed. If the patient is con-
syndrome with tachycardia and hy- scious and his gag reflex is intact, in-
potension, jaundice, hypothermia fol- duce emesis (if ingestion was recent).
lowed by fever, and oliguria may occur. If emesis is contraindicated, perform
To treat barbiturate overdose, main- gastric lavage while a cuffed endotra-
tain and support the patient’s ventila- cheal tube is in place, to prevent
tion and pulmonary function as neces- aspiration. After emesis or lavage,
594 Drug hazards
administer activated charcoal with a may be difficult. Digoxin has caused al-
cathartic as a single dose. Dialysis is of most every kind of arrhythmia; various
limited value. combinations of arrhythmias may oc-
cur in the same patient. Patients with
CNS depressant overdose chronic digoxin toxicity commonly
have ventricular arrhythmias, atrioven-
Signs of central nervous system (CNS) tricular (AV) conduction disturbances,
depressant overdose include prolonged or both. Patients with digoxin-induced
coma, hypotension, hypothermia fol- ventricular tachycardia have a high
lowed by fever, and inadequate ventila- mortality rate because ventricular fib-
tion, even without significant respirato- rillation or asystole may result.
ry depression. Absence of pupillary re- If toxicity is suspected, the drug
flexes, dilated pupils, loss of deep should be discontinued and serum lev-
tendon reflexes, tonic muscle spasms, els of the drug obtained. Usually, the
and apnea may also occur. drug takes at least 6 hours to be dis-
Treatment of overdose involves sup- tributed between plasma and tissue
porting the patient’s respiratory and and to reach equilibrium; plasma levels
cardiovascular function; mechanical obtained earlier may show higher lev-
ventilation may be needed. Maintain els of digoxin than those obtained after
adequate urine output with adequate the drug has distributed into the tis-
hydration while avoiding pulmonary sues.
edema. Empty the gastric contents by Other treatment measures include
inducing emesis. For lipid-soluble inducing emesis immediately, per-
drugs such as glutethimide, charcoal forming gastric lavage, and adminis-
and resin hemoperfusion are effective tering activated charcoal to reduce
in removing the drug; hemodialysis the absorption of the remaining drug.
and peritoneal dialysis are of minimal Multiple doses of activated charcoal
value. Because glutethimide is stored may help reduce further absorption,
in fat tissue, blood levels commonly especially of drugs undergoing en-
show large fluctuations with worsening terohepatic recirculation. Some clini-
symptoms. cians advocate administering
cholestyramine if digoxin was ingest-
Digoxin overdose ed recently; however, this treatment
may not be useful if the patient in-
Signs and symptoms of digoxin over- gested a life-threatening amount. In-
dose are primarily related to the GI, teracting drugs probably should be
cardiovascular, and central nervous discontinued.
systems. Severe overdose may cause Ventricular arrhythmias may be
hyperkalemia, which may develop treated with I.V. potassium (replace-
rapidly and result in life-threatening ment doses, but not in patients with
cardiac effects. Cardiac signs of digoxin significant AV block), I.V. phenytoin,
toxicity may occur with or without oth- I.V. lidocaine, or I.V. propranolol. Re-
er signs of toxic reaction and common- fractory ventricular tachyarrhythmias
ly precede other toxic effects. Because may be controlled with overdrive pac-
cardiotoxic effects can also occur with ing. Procainamide may be used for ven-
heart disease, determining whether tricular arrhythmias that don’t respond
these effects result from underlying to these treatments. For severe AV
heart disease or from digoxin toxicity block, asystole, and hemodynamically
Drug overdoses 595
significant sinus bradycardia, atropine cation and may occur 2 to 6 weeks af-
restores a normal rate. ter overdose. Severe gastric scarring,
Administration of digoxin-specific pyloric stenosis, or intestinal obstruc-
antibody fragments (digoxin immune tion may be present.
Fab [Digibind]) treats life-threatening Patients who have vomiting, diar-
digoxin toxicity. Each 40 mg of digoxin rhea, leukocytosis, or hyperglycemia
immune Fab binds about 0.6 mg of and have an abdominal X-ray that’s
digoxin in the bloodstream. The com- positive for iron within 6 hours of in-
plex is excreted in the urine, rapidly gestion are at risk for a serious toxic
decreasing serum levels and, therefore, reaction. Perform gastric lavage within
cardiac drug concentrations. 1 hour with normal saline or polyethyl-
ene glycol electrolyte solution.
Iron supplement overdose If a patient has had multiple
episodes of vomiting or if the vomitus
Iron supplements are a major source of contains blood, avoid ipecac and per-
poisoning, especially in small children. form lavage. Some clinicians add sodi-
As little as 1 g of ferrous sulfate can um bicarbonate to the lavage solution
kill an infant. Signs and symptoms of to convert ferrous iron to ferrous car-
poisoning result from the acute corro- bonate, which is poorly absorbed. Dis-
sive effects of iron on the GI mucosa as odium phosphate has also been used;
well as the adverse metabolic effects of however, life-threatening hyperphos-
iron overload. These signs and symp- phatemia or hypocalcemia may devel-
toms may occur within the first 10 to op in some children. Other possible
60 minutes of ingestion or may be de- treatments include administration of a
layed for several hours. Four stages of saline cathartic, surgical removal of
acute iron poisoning have been identi- tablets, and chelation therapy with de-
fied. feroxamine mesylate. Hemodialysis is
The first findings reflect acute GI ir- of little value. Supportive treatment in-
ritation and include epigastric pain, cludes monitoring the acid-base bal-
nausea, and vomiting. The patient may ance, maintaining a patent airway, and
have green diarrhea, followed by tarry controlling shock and dehydration with
stools and then melena. Hematemesis appropriate I.V. therapy.
may be accompanied by drowsiness,
lassitude, shock, and coma. Local ero- NSAID overdose
sion of the stomach and small intestine
may further enhance the absorption of Signs and symptoms of nonsteroidal
iron. If death doesn’t occur in the first anti-inflammatory drug (NSAID) over-
phase, a second phase of apparent re- dose include dizziness, drowsiness,
covery may last 24 hours. A third paresthesia, vomiting, nausea, abdomi-
phase, which can occur 4 to 48 hours nal pain, headache, sweating, nystag-
after ingestion, is marked by central mus, apnea, and cyanosis.
nervous system abnormalities, meta- To treat an ibuprofen overdose,
bolic acidosis, hepatic dysfunction, re- empty the stomach at once by inducing
nal failure, and bleeding diathesis. This emesis or using gastric lavage. Admin-
phase may progress to circulatory fail- ister activated charcoal via a nasogas-
ure, coma, and death. If the patient tric tube. Provide symptomatic and
survives, the fourth phase consists of supportive measures, including respira-
late complications of acute iron intoxi- tory support and correction of fluid
596 Drug hazards
and electrolyte imbalances. Monitor the Phenothiazine overdose

patient’s vital signs and the results of
laboratory tests closely. Alkaline diure- Phenothiazine overdose can cause cen-
sis may enhance renal excretion. Dialy- tral nervous system depression, which
sis is of minimal value because ibupro- is characterized by deep sleep — from
fen is strongly protein-bound. which the patient can’t be roused —
and possible coma, hypotension or hy-
Opiate overdose pertension, extrapyramidal symptoms,
abnormal involuntary muscle move-
Rapid I.V. administration of opiates ments, agitation, seizures, arrhythmias,
may result in overdose because of a electrocardiogram changes, hypother-
30-minute delay in the maximum cen- mia or hyperthermia, and autonomic
tral nervous system (CNS) effect. The nervous system dysfunction.
most common signs of morphine over- Treatment is symptomatic and sup-
dose are respiratory depression, with portive; it includes maintaining vital
or without CNS depression and miosis signs, a patent airway, a stable body
(pinpoint pupils). Other acute toxic ef- temperature, and fluid and electrolyte
fects include hypotension, bradycardia, balance. Don’t induce vomiting; phe-
hypothermia, shock, apnea, cardiopul- nothiazines inhibit the cough reflex,
monary arrest, circulatory collapse, so aspiration may occur. Use gastric
pulmonary edema, and seizures. lavage and then activated charcoal
To treat an acute overdose, establish and saline cathartics. Dialysis doesn’t
adequate respiratory exchange via a help. Regulate the patient’s body tem-
patent airway and provide ventilation, perature as needed. Treat hypotension
as needed; then administer an opioid with I.V. fluids. Don’t give epinephrine.
antagonist (naloxone) to reverse respi- Treat seizures with parenteral diaze-
ratory depression. (Because the dura- pam or barbiturates, arrhythmias with
tion of action of morphine is longer parenteral phenytoin, and extrapyrami-
than that of naloxone, repeated doses dal reactions with benztropine or par-
of naloxone are needed.) Naloxone is enteral diphenhydramine.
given only when clinically significant
respiratory or cardiovascular depres- Salicylate overdose
sion is present. Monitor the patient’s
vital signs closely. Signs and symptoms of salicylate over-
In a patient who had an oral overdose include metabolic acidosis with
dose less than 2 hours ago, empty the respiratory alkalosis, hyperpnea, and
stomach immediately by inducing eme- tachypnea as a result of increased pro-
sis or using gastric lavage. Use caution duction of carbon dioxide and direct
to avoid the risk of aspiration. Admin- stimulation of the respiratory center.
ister activated charcoal via a nasogas- To treat the overdose, perform gas-
tric tube to remove more of the drug. tric lavage. Administer activated char-
Provide symptomatic and support- coal via a nasogastric tube. Provide
ive treatment (continued respiratory symptomatic and supportive measures
support and correction of fluid or elec- (respiratory support and correction of
trolyte imbalances). Monitor the pa- fluid and electrolyte imbalances).
tient’s vital signs, neurologic status, Closely monitor the patient’s laboratory
and laboratory test results closely. values and vital signs. Enhance renal
Drug overdoses 597
excretion by administering sodium bi- with parenteral phenytoin or lidocaine,

carbonate to alkalinize urine. Use a and acidosis with sodium bicarbonate.
cooling blanket or sponging if the pa- Don’t give barbiturates; they may en-
tient’s rectal temperature is above hance CNS and respiratory depressant
104° F (40° C). Hemodialysis is effec- effects.
tive in removing aspirin but is used
only with severe poisoning or in pa- Dangers of uncontrolled I.V. flow
tients who are at risk for pulmonary
edema. Suppose that you’re caring for a patient
who’s receiving a drug through an
Tricyclic antidepressant overdose electronic infusion device. His gown
needs to be changed, but it doesn’t
Tricyclic antidepressant overdose is of- have sleeve snaps. Therefore, you must
ten life-threatening, particularly when deactivate the device, clamp and re-
the drug is combined with alcohol. move the tubing, remove the fluid bag
During the first 12 hours after inges- from the I.V. pole, and pull the I.V. bag
tion, a stimulatory phase occurs and is and tubing through the sleeve — a tire-
characterized by excessive anticholiner- some job.
gic activity (agitation, irritation, confu- Actually, this task is more than tire-
sion, hallucinations, hyperthermia, some; it’s dangerous. In one document-
parkinsonian symptoms, seizures, ed case, a nurse deactivated the infu-
urine retention, dry mucous mem- sion device and the patient died. Either
branes, pupillary dilation, constipation, she didn’t secure the roller clamp cor-
and ileus). This phase precedes central rectly or it malfunctioned, causing
nervous system (CNS) depressant ef- rapid, uncontrolled drug flow into the
fects, including hypothermia, decreased patient.
or absent reflexes, sedation, hypoten-
sion, cyanosis, and cardiac irregulari- Standards
ties, including tachycardia, conduction To protect both the patient and your-
disturbances, and quinidine-like effects self, be extremely careful when using
on the electrocardiogram. an infusion set — especially if you’re
The severity of an overdose is best unfamiliar with the facility equipment
indicated by widening of the QRS com- because you’re floating to a temporary
plex, which usually represents a severe assignment. The Joint Commission has
toxic reaction; obtaining serum mea- established a National Patient Safety
surements usually isn’t helpful. Meta- Goal to ensure free-flow protection on
bolic acidosis may follow hypotension, all general-use and patient-controlled
hypoventilation, and seizures. analgesia (PCA) I.V. pumps used in the
Treatment is symptomatic and sup- organization. Follow facility policy and
portive; it includes maintaining a guidelines.
patent airway, a stable body tempera-
ture, and fluid and electrolyte balance.
Induce emesis if the patient is con-
scious; follow with gastric lavage and
activated charcoal to prevent further
absorption. Dialysis is of little use.
Treat seizures with parenteral di-
azepam or phenytoin, arrhythmias
598 Drug hazards
Interactions
Compatibility of drugs combined in a syringe

KEY
dexamethasone sodium phosphate

Y = compatible for at least
30 minutes
P = provisionally compatible;
administer within 15 minutes
diphenhydramine HCl
butorphanol tartrate
metoclopramide HCl
hydromorphone HCl
chlorpromazine HCl
P(5) = provisionally compatible;
codeine phosphate
administer within 5 minutes
hydroxyzine HCl
atropine sulfate
dimenhydrinate
meperidine HCl
fentanyl citrate
cimetidine HCl
glycopyrrolate
N = not compatible
heparin Na
droperidol
* = conflicting data
(A blank space indicates no
available data.)
atropine sulfate Y P Y P P P P Y P(5) Y P* P P

butorphanol tartrate Y Y Y N Y Y Y Y Y Y
chlorpromazine HCl P Y N N P P P Y N Y P P P
cimetidine HCl Y Y N Y Y Y Y P(5)* Y Y Y
codeine phosphate P(5) Y Y
dexamethasone sodium phosphate N* N N* Y
dimenhydrinate P N N P(5) P P P N P(5)* Y N P P
diphenhydramine HCl P Y P Y N* P P P Y Y P P Y
droperidol P Y P Y P P P Y N P P P
fentanyl citrate P Y P Y P P P P(5) Y P P P
glycopyrrolate Y Y Y Y N N Y Y Y Y Y
heparin Na P(5) N P(5)* P(5)* N P(5) N N Y
hydromorphone HCl Y Y Y N* Y Y Y Y N Y
hydroxyzine HCl P* Y P Y Y N P P P Y Y P P
meperidine HCl P Y P Y P P P P Y N P P
metoclopramide HCl P Y P Y P Y P P Y P P
midazolam HCl Y Y Y Y N Y Y Y Y N Y Y Y Y
morphine sulfate P Y P Y P P P P Y N* P N P
nalbuphine HCl Y Y N Y Y Y Y
pentazocine lactate P Y P Y P P P P N N Y P P P
pentobarbital Na P* N N N N N N N N Y N N
perphenazine Y Y Y Y Y Y Y Y Y Y P
phenobarbital Na P(5) N
prochlorperazine edisylate P Y P Y N P P P Y N* P P P
promazine HCl P P Y N P P P Y P P P
promethazine HCl P Y P Y N P P P Y N Y P P P
ranitidine HCl Y N* Y Y Y Y Y Y N Y Y
scopolamine HBr P Y P Y P P P P Y Y P P P
secobarbital Na N N
sodium bicarbonate N N N
thiethylperazine maleate Y Y
thiopental Na N N N N
Interactions 599
prochlorperazine edisylate
thiethylperazine maleate
sodium bicarbonate
pentazocine lactate
promethazine HCl
phenobarbital Na
scopolamine HBr
pentobarbital Na
morphine sulfate
secobarbital Na
nalbuphine HCl
midazolam HCl
promazine HCl
thiopental Na
ranitidine HCl
perphenazine
Y P Y P P* Y P P P Y P atropine sulfate
Y Y Y N Y Y Y Y Y butorphanol tartrate
Y P P N Y P P P N* P N chlorpromazine HCl
Y Y Y Y N Y Y Y Y Y N cimetidine HCl
codeine phosphate
Y dexamethasone sodium phosphate
N P N P N Y N N N Y P N dimenhydrinate
Y P Y P N Y P P P Y P N diphenhydramine HCl
Y P Y P N Y P P P P droperidol
Y P P N Y P P P Y P fentanyl citrate
Y Y Y N N Y Y Y Y Y N N N glycopyrrolate
N N* N P(5) N heparin Na
Y Y Y N N* Y Y Y Y hydromorphone HCl
Y P Y P N Y P P P N P hydroxyzine HCl
Y N P N Y P P P Y P meperidine HCl
Y P P P P P P Y P N metoclopramide HCl
Y Y N N N Y Y N Y Y midazolam HCl
Y P N* Y P* P P* Y P N morphine sulfate
Y N Y N* Y Y Y nalbuphine HCl
P N Y P P* P* Y P pentazocine lactate
N N* N N N N N N N P Y Y pentobarbital Na
N Y Y N Y Y Y Y N perphenazine
N phenobarbital Na
N P* Y P N Y P P Y P N prochlorperazine edisylate
Y P P* N P P P promazine HCl
Y P* N* P* N Y P P Y P N promethazine HCl
N Y Y Y N Y N Y Y Y Y ranitidine HCl
Y P Y P P Y P P P Y Y scopolamine HBr
secobarbital Na
Y N sodium bicarbonate
Y Y N Y thiethylperazine maleate
N Y N N Y N thiopental Na
600 Drug hazards
Drug combinations
Drugs can interact to produce undesir-

able, even hazardous, effects. These in-
teractions can decrease therapeutic effi-
cacy or cause a toxic reaction.
Serious drug interactions

When administering these combinations, monitor the patient to prevent serious drug in-
teractions.
DRUG INTERACTING DRUG POSSIBLE EFFECT
Aminoglycosides Parenteral cephalosporins May enhance nephrotoxicity

amikacin ◆ ceftizoxime
gentamicin
kanamycin
neomycin I.V. loop diuretics May enhance ototoxicity
netilmicin ◆ bumetanide
streptomycin ◆ ethacrynic acid
tobramycin ◆ furosemide
Amphetamines Urine alkalinizers Decreases urinary excretion of

amphetamine ◆ potassium citrate amphetamine
benzphetamine ◆ sodium acetate
dextroamphetamine ◆ sodium bicarbonate
methamphetamine ◆ sodium citrate
◆ sodium lactate
◆ tromethamine
Angiotensin- indomethacin Decreases or abolishes the ef-

converting Nonsteroidal anti- fectiveness of the antihyper-
enzyme (ACE) inflammatory drugs (NSAIDs) tensive action of ACE inhibitors
inhibitors
captopril
enalapril
lisinopril
benazepril
fosinopril
ramipril
quinapril
Barbiturate Opiate analgesics Enhances central nervous sys-

anesthetics tem and respiratory depres-
methohexital sion
thiopental
Interactions 601
Serious drug interactions (continued)
Barbiturates valproic acid Increases serum barbiturate

amobarbital levels
aprobarbital
butabarbital
mephobarbital
phenobarbital
primidone
secobarbital
Beta-adrenergic verapamil Enhances the pharmacologic

blockers effects of both beta-adrenergic
acebutolol blockers and verapamil
atenolol
betaxolol
carteolol
esmolol
levobunolol
metoprolol
nadolol
penbutolol
pindolol
propranolol
timolol
carbamazepine erythromycin Increases the risk of carba-

mazepine toxicity
Cardiac Loop and thiazide diuretics Increases the risk of cardiac

glycosides arrhythmias as a result of hy-
pokalemia
Thiazide-like diuretics Increases the therapeutic or

toxic effects
carmustine cimetidine Enhances the risk of bone mar-

row toxicity
ciprofloxacin Antacids that contain magne- Decreases plasma levels as

sium or aluminum hydroxide, well as the effectiveness of
iron supplements, sucralfate, ciprofloxacin
multivitamins that contain
iron or zinc
clonidine Beta-adrenergic blockers Enhances rebound hyperten-

sion after rapid withdrawal of
clonidine
cyclosporine carbamazepine, isoniazid, Reduces plasma levels of cy-

phenobarbital, phenytoin, closporine and may decrease
rifabutin, rifampin immunosuppressant effect
(continued)
602 Drug hazards
digoxin amiodarone Decreases the renal clearance of

digoxin, which increases digoxin
level
quinidine Elevates serum levels of digoxin
verapamil Elevates serum levels of digoxin
dopamine phenytoin Hypertension, bradycardia, and

cardiac arrest
epinephrine Beta-adrenergic blockers Increases systolic and diastolic

pressures; causes a marked de-
crease in heart rate
erythromycin astemizole Increases the risk of arrhythmia
carbamazepine Decreases carbamazepine clearance
theophylline Decreases hepatic clearance of

theophylline
ethanol disulfiram Causes an acute alcohol intoler-

furazolidone ance reaction
metronidazole
furazolidone Amine-containing foods Inhibits MAO, possibly leading to

Anorexiants a hypertensive crisis
heparin Salicylates Enhances the risk of bleeding

NSAIDs
levodopa furazolidone Enhances the toxic effects of lev-

odopa and may cause severe hy-
pertension
lithium Thiazide diuretics Decreases the excretion of lithium

NSAIDs
meperidine MAO inhibitors Causes cardiovascular instability

and increases toxic effects
methotrexate probenecid Decreases the elimination of

methotrexate
Salicylates Increases the risk of methotrexate

toxicity
Interactions 603
Monoamine Amine-containing foods Risk of hypertensive crisis

oxidase (MAO) Anorexiants
inhibitors meperidine
Nondepolarizing Aminoglycosides Enhances neuromuscular

muscle relaxants Inhaled anesthetics blockade
Potassium Potassium-sparing diuretics Increases the risk of hyper-

supplements kalemia
quinidine amiodarone Increases the risk of quinidine

toxicity
Sympatho- MAO inhibitors Increased the risk of hyperten-

mimetics sive crisis
Tetracyclines Antacids containing magne- Decreases plasma levels as

sium, aluminum, or bismuth well as the effectiveness of
salts tetracyclines
Iron supplements
theophylline carbamazepine Reduces theophylline levels
cimetidine Increases theophylline levels
ciprofloxacin Increases theophylline levels
erythromycin Increases theophylline levels
phenobarbital Reduces theophylline levels
rifampin Reduces theophylline levels
warfarin testosterone May enhance bleeding caused

by increased hypoprothrom-
binemia
Barbiturates Reduces the effectiveness of

carbamazepine warfarin
amiodarone Increases the risk of bleeding

certain Cephalosporins
chloral hydrate
cholestyramine
cimetidine
clofibrate
co-trimoxazole
dextrothyroxine
disulfiram (continued)
604 Drug hazards
warfarin erythromycin Increases the risk of bleeding

(continued) glucagon
metronidazole
phenylbutazone
quinidine
quinine
Salicylates
sulfinpyrazone
Thyroid drugs
Tricyclic antidepressants
ethchlorvynol Decreases the pharmacologic

glutethimide effect
griseofulvin
rifampin Decreases the risk of bleeding

trazodone
methimazole Increases the risk of bleeding

propylthiouracil
Drug-tobacco interactions Chlordiazepoxide hydrochloride,

chlorpromazine hydrochloride,
Smoking — or living and working in a diazepam
smoke-filled environment — can affect Possible effects
a patient’s drug therapy, especially if ◆ Increased drug metabolism, which
he’s taking one of the drugs listed here. results in reduced plasma levels
For a patient who is using any of these ◆ Decreased sedative effects
drugs, monitor plasma drug levels
closely and watch for possible adverse Nursing considerations
reactions. ◆ Watch for a decrease in the effec-
tiveness of the drug.
Ascorbic acid (vitamin C) ◆ Adjust the patient’s drug dosage, if
Possible effects ordered.
◆ Low serum levels of vitamin C
◆ Decreased oral absorption of vita- Propoxyphene hydrochloride
min C Possible effect
◆ Increased drug metabolism and di-
Nursing considerations minished analgesic effects
◆ Tell the patient to increase his vita-
min C intake. Nursing considerations
◆ Watch for a decrease in the effec-
tiveness of the drug.
Interactions 605
Propranolol hydrochloride Selected drug-food interactions

Possible effects
◆ Increased metabolism, which de- acebutolol hydrochloride (Sectral):
creases the effectiveness of the drug Food in general. Slightly decreases drug
◆ Reduced effectiveness of the drug absorption and peak levels.
(Smoking increases the heart rate,
stimulates the release of catecholamine amiloride hydrochloride (Midamor):
from the adrenal medulla, raises arteri- Potassium-rich diet. May rapidly in-
al blood pressure, and increases myo- crease serum potassium levels.
cardial oxygen consumption.)
antihypertensives: Licorice. Decreases
Nursing considerations the antihypertensive effect.
◆ Monitor the patient’s blood pressure
and heart rate. bacampicillin hydrochloride (Spectro-
◆ To reduce the interaction between bid powder for oral suspension): Food
the drug and tobacco, the physician in general. Decreases drug absorption.
may order a selective beta-adrenergic
blocker such as atenolol. buspirone hydrochloride (BuSpar):
Food in general. May decrease presys-
Hormonal contraceptives that temic drug clearance. Grapefruit juice.
contain estrogen and progestogen May increase serum drug levels.
Possible effects
◆ Increased risk of adverse reactions, caffeine (NoDoz): Caffeine-containing
such as headache, dizziness, depres- beverages and food. May cause sleep-
sion, changes in libido, migraine, hy- lessness, irritability, nervousness, and
pertension, edema, worsening of astig- rapid heartbeat.
matism or myopia, nausea, vomiting,
and gallbladder disease calcium glubionate (Neo-Calglucon
syrup): Large quantities of bran,
Nursing considerations whole-grain cereals, dairy products,
◆ Inform the patient of increased risk rhubarb, spinach. Interferes with calci-
of myocardial infarction and stroke. um absorption.
◆ Suggest that the patient stop smok-
ing or use a different birth control captopril (Capoten): Food in general.
method. Reduces drug absorption by 30% to 40%.
Theophylline cefuroxime axetil (Ceftin tablets):

Possible effects Food in general. Increases drug absorp-
◆ Increased metabolism of theo- tion.
phylline as a result of the induction of
liver microsomal enzymes demeclocycline hydrochloride (De-
◆ Lower plasma levels of theophylline clomycin): Dairy products, food in
general. Interferes with the absorption
Nursing considerations of oral forms of demeclocycline.
◆ Monitor plasma theophylline levels,
and watch for a decreased therapeutic dextroamphetamine sulfate (Dexe-
effect. drine elixir): Fruit juice. Lowers blood
◆ Increase the drug dosage, if ordered. drug levels and efficacy.
606 Drug hazards
dicumarol: Diet high in vitamin K. De- ferrous sulfate (Feosol, Slow FE):
creases prothrombin time. Dairy products, eggs. Inhibits iron ab-
sorption.
digoxin (Lanoxin tablets, Lanoxi-
caps): Food high in bran fiber. May re- fluoroquinolone antibiotics, such as
duce the bioavailability of oral digoxin. ciprofloxacin (Cipro), norfloxacin
Food in general. Slows the drug absorp- (Noroxin), ofloxacin (Floxin): Food in
tion rate. general (particularly dairy products).
May decrease the absorption of oral flu-
dyclonine hydrochloride (Dyclone oroquinolones.
0.5% and 1% topical solutions, USP):
Food in general. Topical anesthesia flurbiprofen (Ansaid): Food in gener-
may impair swallowing, enhancing the al. Alters the rate of absorption, but not
risk of aspiration; food shouldn’t be in- the extent of drug availability.
gested for 60 minutes.
fosinopril sodium (Monopril): Food in
erythromycin base (PCE Dispertab general. May slow the rate, but not the
tablets): Food in general. Optimum extent, of drug absorption.
blood levels are obtained on a fasting
stomach; administration is preferable glipizide (Glucotrol): Food in general.
30 minutes before or 2 hours after Delays absorption by about 40 minutes.
meals. Give an immediate-release tablet about
30 minutes before meals.
estramustine phosphate sodium (Em-
cyt): Dairy products, calcium-rich hydralazine hydrochloride (Apreso-
foods. Impairs drug absorption. line tablets): Food in general. Increases
plasma levels.
etodolac (Lodine): Food in general. Re-
duces peak levels by about 50% and in- hydrochlorothiazide (Esidrix, Hydro-
creases the time to peak levels by 1.4 to DIURIL): Food in general. Enhances GI
3.8 hours. drug absorption.
etretinate (Tegison capsules): Dairy ibuprofen (Advil, Children’s Advil

products, high-lipid diet. Increases drug suspension, Motrin, Nuprin, Chil-
absorption. dren’s Motrin suspension, Rufen):
Food in general. Reduces the rate, but
famotidine (Pepcid oral suspension): not the extent, of absorption.
Food in general. Slightly increases
bioavailability. isotretinoin (Accutane): Dairy prod-
ucts, food in general. Increases the ab-
felodipine (Plendil): Grapefruit juice. sorption of oral isotretinoin.
Increases bioavailability more than
twofold. isradipine (DynaCirc): Food in gener-
al. Significantly increases the time to
fenoprofen calcium (Nalfon Pulvules peak levels by about 1 hour, with no ef-
and tablets): Dairy products, food in fect on bioavailability.
general. Delays and diminishes peak
blood levels.
Interactions 607
ketoprofen (Orudis capsules): Food in misoprostol (Cytotec): Food in general.

general. Slows the absorption rate and Diminishes maximum plasma concen-
delays and reduces peak levels. trations.
levodopa-carbidopa (Sinemet tablets): monoamine oxidase (MAO) inhibi-

High-protein diet. May impair levodopa tors, such as isocarboxazid (Marplan
absorption. Food in general. Increases tablets), phenelzine sulfate (Nardil),
the extent of availability and peak lev- or tranylcypromine sulfate (Parnate
els of sustained-release levodopa- tablets); drugs that also inhibit MAO,
carbidopa. such as amphetamines, furazolidone
(Furoxone), isoniazid (Laniazid), or
levothyroxine sodium (Synthroid in- procarbazine (Matulane capsules):
jection): Soybean formula (infants). Anchovies, avocados, bananas, beans
May cause excessive fecal loss. (broad, fava), beer (including alcohol-
free and reduced-alcohol types), caviar,
lidocaine hydrochloride (Xylocaine): cheese (especially aged, strong, and
Food in general. Topical anesthesia unpasteurized types), chocolate, sour
may impair swallowing, enhancing the cream, canned figs, pickled herring,
risk of aspiration; avoid ingestion of liver, liqueurs, meat extracts, meat pre-
food for 60 minutes. pared with tenderizers, raisins, sauer-
kraut, sherry, soy sauce, red wine,
liotrix (Thyrolar): Soybean formula yeast extract, yogurt. Can cause hyper-
(infants). May cause excessive fecal tensive crisis.
loss.
moricizine hydrochloride (Eth-
lovastatin (Mevacor): Grapefruit juice. mozine): Food in general. Administra-
Increases serum levels. tion 30 minutes after a meal delays the
rate, but not the extent, of drug absorp-
meclofenamate (Meclomen): Food in tion.
general. Decreases the rate and extent
of drug absorption. nifedipine (Procardia XL tablets):
Grapefruit juice. May increase bioavail-
methenamine mandelate (Mande- ability and drug levels.
lamine granules): Food that raises uri-
nary pH. Reduces essential antibacterial nitrofurantoin (Macrodantin cap-
activity. sules): Food in general. Increases drug
bioavailability.
methotrexate sodium (Rheumatrex):
Food in general. Delays absorption and pancrelipase (Cotazym capsules):
reduces peak levels of oral methotrexate Food with a pH greater than 5.5. Dis-
sodium. solves the protective enteric coating.
minocycline hydrochloride pentoxifylline (Trental): Food in gen-

(Minocin): Dairy products. Slightly de- eral. Delays drug absorption, but
creases peak plasma levels and delays doesn’t affect total absorption.
them by 1 hour.
608 Drug hazards
phenytoin (Dilantin): Enteral tube late, cola. Large quantities increase the
feedings. May interfere with the absorp- adverse effects of theophylline. High-
tion of oral phenytoin. Enteral feedings lipid diet. Reduces plasma levels and
should be stopped for 2 hours before delays the time of peak plasma levels.
and 2 hours after administration. Charcoal-broiled foods, especially
meats; cruciferous (cabbage family)
polyethylene glycol electrolyte solu- vegetables; low-carbohydrate, high pro-
tion (GoLYTELY, NuLYTELY): Food in tein diets. Large quantities may in-
general. For best results, no solid food crease the hepatic metabolism of theo-
should be eaten for 3 to 4 hours before phylline.
the solution is consumed.
tolmetin sodium (Tolectin): Dairy
propafenone hydrochloride (Ryth- products. Decreases total tolmetin
mol): Food in general. Increased peak bioavailability by 16%. Food in gener-
blood levels and bioavailability in a al. Decreases total tolmetin bioavailabil-
single-dose study. ity by 16% and reduces peak plasma
levels by 50%.
propranolol hydrochloride (Inderal):
Food in general. May increase the trazodone hydrochloride: Food in gen-
bioavailability of oral propranolol. eral. May affect bioavailability, includ-
ing the amount of drug absorbed and
ramipril (Altace): Food in general. Re- peak plasma levels.
duces the rate, but not the extent, of
drug absorption. triazolam (Halcion): Grapefruit juice.
May increase serum levels.
salsalate (Disalcid, Mono-Gesic,
Salflex): Food that lowers urinary pH. verapamil hydrochloride (Calan SR,
Decreases urinary excretion and in- Isoptin SR): Grapefruit juice. Increases
creases plasma levels. Food that raises absorption.
urinary pH. Increases renal clearance
and urinary excretion of salicylic acid. warfarin sodium (Coumadin, Pan-
warfin): Diet high in vitamin K. De-
selegiline hydrochloride (Eldepryl): creases prothrombin time. Charcoal-
Food with a high concentration of tyra- broiled meats. May decrease blood drug
mine. May precipitate hypertensive cri- levels.
sis if the daily dosage exceeds the rec-
ommended maximum. Drug-alcohol interactions
sodium fluoride (Luride): Dairy prod- Drug-alcohol interactions are more

ucts. Forms calcium fluoride, which is than just potentiated central nervous
poorly absorbed. system depression. Combined with
nonsteroidal anti-inflammatory drugs,
tetracycline hydrochloride alcohol is highly irritating to the stom-
(Achromycin V): Dairy products, food ach; combined with some diuretics and
in general. Interferes with the absorp- cardiac medications, it may cause a
tion of oral tetracycline. steep drop in blood pressure.
theophylline (Theo-24, Uniphyl):

Caffeine-containing beverages, choco-
Interactions 609
Compatibility of drugs with tube ◆ Infuse 30 ml of water before and af-

feedings ter giving a single drug dose through
the tube.
Some feeding formulas such as Ensure ◆ Flush the feeding tube with 5 ml of
may break down chemically when water between drug doses if you’re giv-
combined with a drug such as Dimetapp ing more than one drug.
Elixir. Increased formula viscosity, and ◆ Dilute highly concentrated liquids
a clogged tube, can occur as a result of with 60 ml of water before administer-
giving Klorvess or Phenergan Syrup ing them.
with a feeding formula. ◆ Instill drugs in liquid form when
Drug preparations, such as ferrous possible. If you must crush a tablet,
sulfate or potassium chloride liquids, crush it into fine dust and dissolve it in
are incompatible with some formulas, warm water. (Never crush and liquefy
causing clumping and other problems enteric-coated tablets or timed-release
when mixed in a tube. Still other com- capsules.)
binations may alter the bioavailability ◆ Time the intervals for drug and for-
of some drugs, such as phenytoin. mula administration appropriately. You
To avoid problems with incompati- may need to withhold tube feeding and
bility, follow these guidelines: supply medication by mouth to an
◆ Never add a drug to a feeding for- empty stomach or with food.
mula container.
◆ Always check the compatibility of
an ordered drug and the feeding for-
mula before administering.
Effects of mixing drugs and alcohol

DRUG EFFECTS
◆ Analgesics Deepened central nervous system (CNS) depression

◆ Anxiolytics
◆ Antidepressants
◆ Antihistamines
◆ Antipsychotics
◆ Hypnotics
◆ Monoamine oxidase in- Deepened CNS depression; possible hypertensive crisis

hibitors with certain types of beer and wine that contain tyramine
(Chianti, Alicante)
◆ Oral antidiabetics Disulfiram-like effects (facial flushing, headache), especial-

ly with chlorpropamide; inadequate food intake may trig-
ger increased antidiabetic activity
◆ Cephalosporins Facial flushing, headache

◆ metronidazole
◆ disulfiram
610 Drug hazards
Drug interference with test results
Drugs can interfere with the results of blood or urine tests in two ways. A drug in a
blood or urine specimen may interact with the chemicals used in the laboratory test,
causing a false result. Alternatively, a drug may cause a physiologic change in the pa-
tient, resulting in an actual increase or decrease in the blood or urine level of the sub-
stance being tested. This chart identifies drugs that can cause these two types
of interference in common blood and urine tests.
TEST AND DRUGS DRUGS THAT CAUSE PHYSIOLOGIC INTERFERENCE

THAT CAUSE
CHEMICAL Increase test values Decrease test values
INTERFERENCE
Alkaline ◆ Anticonvulsants ◆ clofibrate

phosphatase ◆ Hepatotoxic drugs ◆ Estrogens
◆ albumin ◆ ticlopidine ◆ prednisone
◆ Fluorides ◆ vitamin D
Ammonia, blood ◆ acetazolamide ◆ kanamycin, oral

◆ ammonium chloride ◆ lactulose
◆ asparaginase ◆ neomycin, oral
◆ Barbiturates ◆ Potassium salts
◆ Diuretics, loop and thiazide ◆ Tetracyclines
◆ ethanol
Amylase, serum ◆ asparaginase ◆ somatostatin

◆ Chloride salts ◆ Cholinergic agents ◆ zidovudine
◆ Fluorides ◆ Contraceptives, hormonal
◆ contrast media with iodine
◆ Drugs that induce acute
pancreatitis: azathioprine, cor-
ticosteroids, loop and thiazide
diuretics
◆ methyldopa
◆ Opioids
Aspartate ◆ Cholinergic agents ◆ interferon

aminotransferase ◆ Hepatotoxic drugs ◆ naltrexone
◆ erythromycin ◆ Opium alkaloids ◆ prednisone
◆ methyldopa
Bilirubin, serum ◆ Hemolytic agents ◆ Barbiturates

◆ ascorbic acid ◆ Hepatotoxic drugs ◆ Sulfonamides
◆ dextran ◆ methyldopa ◆ theophylline
◆ epinephrine ◆ rifampin
◆ pindolol
◆ propanolol
◆ levodopa
◆ theophylline
Interactions 611
Drug interference with test results (continued)

THAT CAUSE
INTERFERENCE
Blood urea ◆ Angiotensin-converting ◆ amikacin

nitrogen enzyme (ACE) inhibitors ◆ levodopa
◆ chloral hydrate ◆ Anabolic steroids ◆ streptomycin
◆ chloramphenicol ◆ Nephrotoxic drugs
◆ streptomycin ◆ pentamidine
Calcium, serum ◆ Calcium salts ◆ acetazolamide

◆ aspirin ◆ Diuretics, loop and thiazide ◆ Anticonvulsants
◆ heparin ◆ lithium ◆ calcitonin
◆ hydralazine ◆ Thyroid hormones ◆ cisplatin
◆ sulfisoxazole ◆ vitamin D ◆ Contraceptives, hormonal
◆ Anabolic steroids ◆ Corticosteroids
◆ Laxatives
◆ Magnesium salts
◆ plicamycin
Chloride, serum ◆ acetazolamide ◆ Corticosteroids

◆ Androgens ◆ Diuretics, loop and thiazide
◆ Estrogens ◆ Laxatives
◆ Nonsteroidal anti-
inflammatory drugs (NSAIDs)
Cholesterol, ◆ alcohol ◆ Androgens

serum ◆ Beta-adrenergic blockers ◆ captopril
◆ Androgens ◆ Contraceptives, hormonal ◆ chlorpropamide
◆ aspirin ◆ Corticosteroids ◆ cholestyramine
◆ Corticosteroids ◆ cyclosporine ◆ clofibrate
◆ Nitrates ◆ Diuretics, thiazide ◆ colestipol
◆ Phenothiazines ◆ Phenothiazines ◆ haloperidol
◆ vitamin D ◆ Sulfonamides ◆ neomycin, oral
◆ ticlopidine
Creatine kinase ◆ aminocaproic acid ◆ aspirin

◆ amphotericin B ◆ amikacin
◆ chlorthalidone ◆ calcium
◆ ethanol (long-term use) ◆ prednisone
◆ gemfibrozil
Creatinine, serum ◆ cimetidine ◆ amikacin

◆ cefoxitin ◆ flucytosine ◆ captopril
◆ cephalothin ◆ Nephrotoxic drugs ◆ ibuprofen
◆ flucytosine ◆ prednisone
(continued)
612 Drug hazards

THAT CAUSE
INTERFERENCE
Glucose, serum ◆ Antidepressants, tricyclic ◆ acetaminophen

◆ acetaminophen ◆ Beta-adrenergic blockers ◆ Anabolic steroids
◆ ascorbic acid ◆ Corticosteroids ◆ clofibrate
(urine) ◆ cyclosporine ◆ disopyramide
◆ Cephalosporins ◆ dextrothyroxine ◆ ethanol
(urine) ◆ diazoxide ◆ gemfibrozil
◆ Diuretics, loop and thiazide ◆ Monoamine oxidase
◆ epinephrine inhibitors
◆ Estrogens ◆ pentamidine
◆ isoniazid
◆ lithium
◆ Phenothiazines
◆ phenytoin
◆ Salicylates
◆ somatostatin
Magnesium, ◆ lithium ◆ albuterol

serum ◆ Magnesium salts ◆ Aminoglycosides
◆ amphotericin B
◆ Calcium salts
◆ cisplatin
◆ Cardiac glycosides
◆ Diuretics, loop and thiazide
◆ ethanol
Phosphates, ◆ Anabolic steroids ◆ Antacids, phosphate-

serum ◆ aspirin binding
◆ vitamin D (excessive ◆ lithium
amounts) ◆ mannitol
Potassium, ◆ aminocaproic acid ◆ Aminoglycosides

serum ◆ ACE inhibitors ◆ ammonium chloride
◆ Antineoplastics ◆ amphotericin B
◆ cyclosporine ◆ Corticosteroids
◆ Diuretics, potassium- ◆ Diuretics, potassium-
sparing wasting
◆ isoniazid ◆ glucose
◆ lithium ◆ insulin
◆ mannitol ◆ Laxatives
◆ succinylcholine ◆ Penicillins, extended-
spectrum
◆ Salicylates
Interactions 613

THAT CAUSE
INTERFERENCE
Protein, serum ◆ Anabolic steroids ◆ Contraceptives, hormonal

◆ Corticosteroids ◆ Estrogens
◆ phenazopyridine ◆ Hepatotoxic drugs
Protein, urine ◆ ACE inhibitors ◆ Not applicable

◆ Aminoglycosides ◆ Cephalosporins
◆ Cephalosporins ◆ contrast media with iodine
◆ contrast media ◆ Corticosteroids
◆ magnesium sulfate ◆ nafcillin
◆ miconazole ◆ Nephrotoxic drugs
◆ nafcillin ◆ Sulfonamides
◆ phenazopyridine
◆ Sulfonamides
◆ tolbutamide
◆ tolmetin
Prothrombin ◆ Anticoagulants ◆ Anabolic steroids

time ◆ asparaginase ◆ Contraceptives, hormonal
◆ aspirin ◆ Estrogens
◆ azathioprine ◆ vitamin K
◆ Certain cephalosporins
◆ chloramphenicol
◆ cholestyramine
◆ colestipol
◆ cyclophosphamide
◆ Hepatotoxic drugs
◆ propylthiouracil
◆ quinidine
◆ quinine
◆ Sulfonamides
Sodium, serum ◆ carbamazepine ◆ ammonium chloride

◆ clonidine ◆ carbamazepine
◆ diazoxide ◆ desmopressin
◆ Estrogens ◆ Diuretics
◆ guanabenz ◆ lithium
◆ guanadrel ◆ lypressin
◆ guanethidine ◆ vasopressin
◆ methyldopa ◆ vincristine
◆ NSAIDs
(continued)
614 Drug hazards

THAT CAUSE
INTERFERENCE
Uric acid, serum ◆ acetazolamide ◆ acetohexamide

◆ ascorbic acid ◆ cisplatin ◆ allopurinol
◆ caffeine ◆ cyclosporine ◆ clofibrate
◆ hydralazine ◆ diazoxide ◆ contrast media with iodine
◆ isoniazid ◆ Diuretics ◆ diflunisal
◆ levodopa ◆ epinephrine ◆ Glucose infusions
◆ theophylline ◆ ethambutol ◆ guaifenesin
◆ ethanol ◆ Phenothiazines
◆ levodopa ◆ Salicylates (small doses)
◆ niacin ◆ Uricosuric agents
◆ phenytoin
◆ propranolol
◆ spironolactone
Drug-herb interactions
The use of herbs is becoming more prevalent. It’s important to ask the patient if he’s us-
ing any herbs. Certain herb and drug combinations have potential adverse effects. Moni-
tor the patient closely, and watch for possible effects.
HERB DRUG POSSIBLE EFFECT
aloe Cardiac glycosides, anti- May lead to hypokalemia, which

arrhythmics may potentiate cardiac glycosides
and antiarrhythmics
Thiazide diuretics, licorice, Increases the effects of potassium

and other potassium- wasting with thiazide diuretics and
wasting drugs other potassium-wasting drugs
Orally administered drugs May decrease the absorption of

drugs because GI transit time is
more rapid
capsicum Antiplatelets, anticoagu- Decreases platelet aggregation and

lants increases fibrinolytic activity, pro-
longing bleeding time
Interactions 615
Drug-herb interactions (continued)
capsicum Nonsteroidal anti- Stimulates GI secretions to help pro-

(continued) inflammatory drugs tect against NSAID-induced GI irrita-
(NSAIDs) tion
Angiotensin-converting May cause cough

enzyme inhibitors
theophylline Increases the absorption of theoph-

ylline, possibly leading to higher
serum levels or toxicity
Monoamine oxidase (MAO) Decreases the effects of MAO in-

inhibitors hibitors as a result of increased cate-
cholamine secretion
Central nervous system Increases the sedative effect

(CNS) depressants (such as
opioids, benzodiazepines,
or barbiturates)
Histamine-2 (H2) blockers, May decrease effectiveness because

proton pump inhibitors of increased acid secretion
chamomile Drugs that require GI May delay drug absorption

absorption
Anticoagulants May enhance anticoagulant therapy

and prolong bleeding time
iron May reduce iron absorption because

of the tannic acid content
echinacea Immunosuppressants May counteract immunosuppressant

drugs
Hepatotoxics May increase hepatotoxicity with

drugs that elevate liver enzyme
levels
warfarin Increases bleeding time without an

increased International Normalized
Ratio (INR)
evening primrose Anticonvulsants Lowers the seizure threshold
(continued)
616 Drug hazards
feverfew Antiplatelets, anticoagu- May decrease platelet aggregation

lants and increase fibrinolytic activity
methysergide May potentiate methysergide
garlic Antiplatelets, anticoagu- Enhances platelet inhibition, leading

lants to increased anticoagulation
insulin, other drugs that May increase serum insulin levels,

cause hypoglycemia causing hypoglycemia, an additive
effect with antidiabetics
Antihypertensives May increase hypotension
Antihyperlipidemics May have additive lipid-lowering

properties
ginger Chemotherapeutic drugs May reduce nausea associated with

chemotherapy
H2 blockers, proton pump May decrease effectiveness because

inhibitors of increased acid secretion by ginger
Antiplatelets, anticoagu- Inhibits platelet aggregation by an-

lants tagonizing thromboxane synthase
and enhancing prostacyclin, leading
to prolonged bleeding time
Calcium channel blockers May increase calcium uptake by

myocardium, leading to altered drug
effects
Antihypertensives May antagonize the antihypertensive

effect
ginkgo Antiplatelets, anticoagu- May enhance platelet inhibition,

lants leading to increased anticoagulation
Anticonvulsants May decrease the effectiveness of

anticonvulsants
Drugs that lower the May further reduce the seizure

seizure threshold threshold
Interactions 617
ginseng Stimulants May potentiate the stimulant effects
warfarin May antagonize warfarin, resulting

in a decreased INR
Antibiotics May enhance the effects of some

antibiotics (Siberian ginseng)
Anticoagulants, anti- Decreases platelet adhesiveness

platelets
digoxin May falsely elevate digoxin levels
MAO inhibitors Potentiates the action of MAO in-

hibitors
Hormones, anabolic May potentiate the effects of hor-

steroids mone and anabolic steroid therapies
(estrogenic effects of ginseng may
cause vaginal bleeding and breast
nodules)
alcohol Increases alcohol clearance, possibly

by increasing the activity of alcohol
dehydrogenase
furosemide May decrease the diuretic effect of

furosemide
Antipsychotics May stimulate CNS activity
goldenseal Antidiabetic agents May alter glucose regulation
heparin May counteract the anticoagulant

effect of heparin
Diuretics Increases the diuretic effect
H2 blockers, proton pump May decrease effectiveness because

inhibitors of increased acid secretion by gold-
enseal
General anesthetics May potentiate the hypotensive

action of general anesthetics
CNS depressants (such as Increases the sedative effect

opioids, barbiturates, or
benzodiazepines) (continued)
618 Drug hazards
glucosamine insulin and antidiabetic Insulin and oral antidiabetic agents

agents may be less effective
grapeseed warfarin Increases the effects and the INR as

a result of the tocopherol content of
grapeseed
green tea warfarin Decreases effectiveness as a result of

the vitamin content of green tea
hawthorn berry digoxin Causes an additive positive inotropic

effect, with the potential for digoxin
toxicity
kava CNS stimulants or depres- May interfere with CNS stimulant

sants therapy
Benzodiazepines May result in comalike states
alcohol, other CNS depres- Potentiates the depressant effect of

sants alcohol and other CNS depressants
levodopa Decreases the effectiveness of levo-

dopa
licorice digoxin Causes hypokalemia, which predis-

poses the patient to digoxin toxicity
Hormonal contraceptives Increases fluid retention and the po-

tential for increased blood pressure
as a result of fluid overload
Corticosteroids Causes additive and enhanced effects

of corticosteroids
spironolactone Decreases the effects of spironolac-

tone
melatonin CNS depressants (such as Increases the sedative effect

benzodiazepines)
Interactions 619
milk thistle Drugs that cause diarrhea Increases bile secretion and com-
monly causes loose stools; may in-
crease the effects of other drugs that
commonly cause diarrhea; also caus-
es liver membrane stabilization and
antioxidant effects, leading to protec-
tion from liver damage from various
hepatotoxic drugs, such as aceta-
minophen, phenytoin, ethanol, phe-
nothiazines, and butyrophenones
nettle Anticonvulsants May increase sedative adverse ef-

fects and the risk of seizure
Opioids, anxiolytics, hyp- May increase sedative adverse ef-

notics fects
warfarin Decreases effectiveness as a result of

the vitamin K content of the aerial
parts of nettle

passionflower CNS depressants (such as Increases the sedative effect

benzodiazepines)
St. John’s wort Selective serotonin reup- Causes additive effects with SSRIs,
take inhibitors (SSRIs), MAO inhibitors, and other antide-
MAO inhibitors, nefa- pressants, potentially leading to
zodone, trazodone serotonin syndrome, especially when
combined with SSRIs
indinavir; human immun- Induces the cytochrome P450 meta-

odeficiency virus protease bolic pathway, which may decrease
inhibitors (PIs); nonnucle- the therapeutic effects of drugs that
oside reverse transcrip- use this pathway for metabolism
tase inhibitors (NNRTIs) (use of St. John’s wort and PIs or
NNRTIs should be avoided because
of the potential for subtherapeutic
antiretroviral levels and insufficient
virologic response that could lead to
resistance or class cross-resistance)
Opioids, alcohol Enhances the sedative effects of opi-

oids and alcohol
(continued)
620 Drug hazards
St. John’s wort Photosensitizing drugs Increases photosensitivity

(continued)
Sympathomimetic amines Causes additive effects
(such as pseudoephed-
rine)
digoxin May reduce serum digoxin concen-

trations, decreasing the therapeutic
effects
reserpine Antagonizes the effects of reserpine
Hormonal contraceptives Increases breakthrough bleeding

when taken with hormonal contra-
ceptives; also decreases the effective-
ness of the contraceptive
theophylline May decrease serum theophylline

levels, making the drug less effective
Anesthetics May prolong the effect of anesthetic

drugs
cyclosporine Decreases cyclosporine levels to less

than therapeutic levels, threatening
the rejection of transplanted organs

warfarin May alter the INR; reduces the effec-

tiveness of anticoagulant, requiring
increased dosage of the drug
valerian Sedative hypnotics, CNS Enhances the effects of sedative hyp-

depressants notic drugs
alcohol Increases sedation with alcohol (al-

though this is debated)

Interactions 621
Monitoring patients using herbs

Altered laboratory values and changes in a patient’s condition can help target your
assessments and better meet the needs of a patient who uses herbs.
HERB WHAT TO MONITOR EXPLANATION
aloe ◆ Serum electrolyte level Aloe has cathartic properties that in-
◆ Weight pattern hibit water and electrolyte reabsorp-
◆ Blood urea nitrogen (BUN) tion, which may lead to potassium de-
and creatinine levels pletion, weight loss, and diarrhea.
◆ Heart rate Long-term use may lead to nephritis,
◆ Blood pressure albuminuria, hematuria, and cardiac
◆ Urinalysis disturbances.
capsicum ◆ Liver function Oral administration of capsicum may

◆ BUN and creatinine levels lead to gastroenteritis and hepatic or
renal damage.
cat’s claw ◆ Blood pressure Cat’s claw may cause hypotension

◆ Lipid panel through inhibition of the sympathetic
◆ Serum electrolyte level nervous system and its diuretic prop-
erties. It may also lower the choles-
terol level.
chamomile ◆ Menstrual changes Chamomile may cause changes in the

(German, ◆ Pregnancy menstrual cycle and is a known terato-
Roman) ◆ Prothrombin time (PT) and gen in animals. It also enhances the ef-
partial thromboplastin time fects of anticoagulants, making chamo-
(PTT) mile unsafe to use with these drugs.
echinacea ◆ Temperature When echinacea is used parenterally,

dose-dependent, short-term fever,
nausea, and vomiting can occur.
evening ◆ Pregnancy Evening primrose elevates plasma

primrose ◆ Complete blood count lipid levels and reduces platelet aggre-
(CBC) gation. It may increase the risk of
◆ Lipid profile pregnancy complications, including
premature rupture of the membranes,
the need for oxytocin augmentation,
arrest of descent, and the need for
vacuum extraction.
fennel ◆ Liver function Fennel contains trans-anethole and es-

◆ Blood pressure tragole. Trans-anethole has estrogenic
◆ Serum calcium level activity, and estragole is a procarcino-
◆ Blood glucose level gen that can cause liver damage. Ad-
verse effects include photodermatitis
and allergic reactions, particularly in
patients who are sensitive to carrots,
celery, and mugwort.
(continued)
622 Drug hazards
Monitoring patients using herbs (continued)
feverfew ◆ CBC Feverfew may inhibit blood platelet

◆ Pregnancy aggregation and decrease neutrophil
◆ Sleep pattern and platelet secretory activity. It can
cause uterine contractions in full-term,
pregnant women. Adverse effects in-
clude mouth ulceration, tongue irrita-
tion and inflammation, abdominal
pain, indigestion, diarrhea, flatulence,
nausea, and vomiting. Post Feverfew
syndrome includes nervousness,
headache, insomnia, joint pain, stiff-
ness, and fatigue.
flaxseed ◆ Lipid panel Flaxseed has weak estrogenic and

◆ Blood pressure antiestrogenic activity. It may reduce
◆ Serum calcium level platelet aggregation and the serum
◆ Blood glucose level cholesterol level. Oral administration
◆ Liver function with inadequate fluid intake can cause
intestinal blockage.
garlic ◆ Blood pressure Garlic is associated with hypotension,

◆ Lipid panel leukocytosis, inhibition of platelet ag-
◆ Blood glucose level gregation, and decreased blood glu-
◆ CBC cose and cholesterol levels. Postopera-
◆ PT and PTT tive bleeding and prolonged bleeding
time can occur.
ginger ◆ Blood glucose level Ginger contains gingerols, which have

◆ Blood pressure positive inotropic properties. Adverse
◆ Heart rate effects include platelet inhibition, hypo-
◆ Respiratory rate glycemia, hypotension, hypertension,
◆ Lipid panel and stimulation of respiratory centers.
◆ Electrocardiogram Overdoses cause central nervous sys-
tem (CNS) depression and arrhythmias.
ginkgo ◆ Respiratory rate Consumption of ginkgo seed may

◆ Heart rate cause difficulty breathing, weak pulse,
◆ PT and PTT seizures, loss of consciousness, and
shock. Ginkgo leaf is associated with
infertility as well as GI upset, head-
ache, dizziness, palpitations, restless-
ness, lack of muscle tone, weakness,
bleeding, subdural hematoma, sub-
arachnoid hemorrhage, and a bleeding
iris.
Interactions 623
ginseng ◆ BUN and creatinine levels Ginseng contains ginsenosides and

(American, ◆ Blood pressure eleutherosides that can affect blood
Panax, ◆ Serum electrolyte levels pressure, CNS activity, platelet aggre-
Siberian) ◆ Liver function gation, and coagulation. Reduced glu-
◆ Serum calcium level cose and glycosylated hemoglobin lev-
◆ Blood glucose level els have also been reported. Adverse
◆ Heart rate effects include drowsiness, mastalgia,
◆ Sleep pattern vaginal bleeding, tachycardia, mania,
◆ Menstrual changes cerebral arteritis, Stevens-Johnson syn-
◆ Weight pattern drome, cholestatic hepatitis, amenor-
◆ PT, PTT, and International rhea, decreased appetite, diarrhea,
Normalized Ratio (INR) edema, hyperpyrexia, pruritus, hy-
potension, palpitations, headache, ver-
tigo, euphoria, and neonatal death.
goldenseal ◆ Respiratory rate Goldenseal contains berberine and hy-

◆ Heart rate drastine. Berberine improves bile se-
◆ Blood pressure cretion, increases coronary blood flow,
◆ Liver function and stimulates or inhibits cardiac activ-
◆ Mood pattern ity. Hydrastine causes hypotension, hy-
pertension, increased cardiac output,
exaggerated reflexes, seizures, paraly-
sis, and death as a result of respiratory
failure. Other adverse effects include GI
upset and constipation, excitatory
states, hallucinations, delirium, ner-
vousness, depression, dyspnea, and
bradycardia.
kava ◆ Weight pattern Kava contains arylethylene pyrone

◆ Lipid panel constituents that have CNS activity. It
◆ CBC also has antianxiety effects. Long-term
◆ Blood pressure use may lead to weight loss, increased
◆ Liver function high-density lipoprotein cholesterol
◆ Urinalysis levels, hematuria, increased red blood
◆ Mood changes cell count, decreased platelet count, de-
creased lymphocyte levels, reduced
protein levels, and pulmonary hyper-
tension.
milk thistle ◆ Liver function Milk thistle contains flavonolignans,

which have liver-protective and antiox-
idant effects.
(continued)
624 Drug hazards
nettle ◆ Blood glucose level Nettle contains significant amounts of

◆ Blood pressure vitamin C, vitamin K, potassium, and
◆ Weight pattern calcium. Nettle may cause hyper-
◆ BUN and creatinine glycemia, decreased blood pressure,
levels decreased heart rate, weight loss, and
◆ Serum electrolyte level diuretic effects.
◆ Heart rate
◆ PT and INR
passionflower ◆ Liver function Passionflower may contain cyanogenic

◆ Amylase level glycosides, which can cause liver and
◆ Lipase level pancreas toxicity.
St. John’s wort ◆ Vision St. John’s wort may cause changes in
◆ Menstrual changes menstrual bleeding and reduced fertili-
◆ Excessive response to ty. Other adverse effects include GI up-
other medications adminis- set, fatigue, dry mouth, dizziness,
tered concomitantly headache, delayed hypersensitivity,
phototoxicity, and neuropathy. St.
John’s wort may also increase the risk
of cataracts. St John’s wort interferes
with the metabolism of many drugs.
saw palmetto ◆ Liver function Saw palmetto inhibits the conversion of

testosterone to dihydrotestosterone and
may inhibit growth factors. Adverse ef-
fects include cholestatic hepatitis, erec-
tile or ejaculatory dysfunction, and al-
tered libido.
formulations. Check with the pharma-

Drug additives cist for more information.)
◆ acetaminophen, acetaminophen
Drugs with ethanol additives with codeine elixir
◆ bitolterol mesylate
Many oral liquid drug preparations ◆ brompheniramine maleate elixir
contain ethanol, which produces a ◆ butabarbital sodium
slight sedative effect, but isn’t harmful ◆ chlorpheniramine maleate elixir
to most patients and can in fact be ◆ chlorpromazine hydrochloride
beneficial. However, ingesting ethanol ◆ clemastine fumarate
can be undesirable and even dangerous ◆ co-trimoxazole
in some circumstances. The following ◆ cyproheptadine hydrochloride
list identifies generic drugs that com- ◆ dexchlorpheniramine maleate
monly contain ethanol. (Note that ◆ dextroamphetamine sulfate
some manufacturers of these drugs ◆ diazepam
also produce ethanol-free [alcohol-free] ◆ diazoxide
Drug additives 625
◆ digoxin ◆ carisoprodol with aspirin and

◆ dihydroergotamine mesylate injection codeine phosphate
◆ diphenhydramine hydrochloride ◆ chlorpromazine, chlorpromazine hy-
◆ epinephrine drochloride
◆ ergoloid mesylates ◆ dexamethasone acetate, dexametha-
◆ esmolol hydrochloride sone sodium phosphate
◆ ferrous sulfate elixirs ◆ dobutamine hydrochloride
◆ fluphenazine hydrochloride ◆ dopamine hydrochloride
◆ hydromorphone hydrochloride ◆ epinephrine, epinephrine bitartrate,
cough syrup epinephrine bitartrate with pilocarpine
◆ hyoscyamine sulfate hydrochloride, epinephrine hydrochlo-
◆ indomethacin suspension ride
◆ isoproterenol hydrochloride ◆ etidocaine hydrochloride with epi-
◆ methadone hydrochloride oral solu- nephrine bitartrate 1:200,000
tion ◆ heparin calcium, heparin sodium
◆ methyldopa suspension ◆ hydralazine hydrochloride
◆ minocycline hydrochloride ◆ hydrocortisone sodium phosphate
◆ molindone hydrochloride ◆ hyoscyamine sulfate
◆ nitroglycerin infusion ◆ imipramine hydrochloride
◆ nystatin ◆ influenza virus vaccine
◆ opium alkaloids hydrochlorides ◆ isoetharine hydrochloride,
◆ oxycodone hydrochloride isoetharine mesylate
◆ paramethadione ◆ isoproterenol hydrochloride, isopro-
◆ pentobarbital sodium elixir, pento- terenol sulfate
barbital sodium injection ◆ lidocaine hydrochloride with epi-
◆ perphenazine nephrine hydrochloride
◆ phenobarbital injection ◆ mafenide acetate
◆ phenytoin sodium injection ◆ metaraminol bitartrate
◆ promethazine hydrochloride ◆ methotrimeprazine hydrochloride
◆ pyridostigmine bromide ◆ methyldopa, methyldopate hy-
◆ thioridazine hydrochloride drochloride
◆ metoclopramide hydrochloride
Drugs with sulfite additives ◆ orphenadrine citrate, orphenadrine
hydrochloride
Used as a drug preservative, sulfites can ◆ oxycodone hydrochloride with ac-
cause allergic reactions in certain pa- etaminophen
tients. The following list identifies gener- ◆ pentazocine hydrochloride, penta-
ic drugs that commonly contain sulfites. zocine hydrochloride with aceta-
(A pharmacist can provide definitive in- minophen
formation on brand-name drugs.) ◆ perphenazine
◆ amikacin sulfate ◆ phenylephrine hydrochloride
◆ aminophylline ◆ procainamide hydrochloride
◆ amrinone lactate ◆ procaine hydrochloride
◆ atropine sulfate with meperidine hy- ◆ prochlorperazine, prochlorperazine
drochloride edisylate, prochlorperazine maleate
◆ betamethasone sodium phosphate ◆ propoxycaine hydrochloride with
◆ bupivacaine hydrochloride and epi- procaine hydrochloride 2% and lev-
nephrine 1:200,000 onordefrin 1:20,000
626 Drug hazards
◆ scopolamine hydrobromide with ◆ methysergide maleate (Sansert

phenylephrine hydrochloride 10% tablets)
◆ tetracycline hydrochloride 0.22% ◆ niacin (Nicolar)
topical ◆ paramethadione (Paradione)
◆ theophylline ◆ penicillin G potassium (Pentids
◆ thiethylperazine maleate syrup, Pentids 400 syrup, Pentids 800)
◆ tinzaparin sodium ◆ penicillin V potassium (Veetids 125
oral solution)
Drugs with tartrazine additives ◆ pentobarbital sodium (Nembutal
Sodium)
Also known as FD&C Yellow No. 5, tar- ◆ procainamide hydrochloride (Pron-
trazine is a dye that’s used as an addi- estyl)
tive in certain drugs. It can provoke a ◆ promazine hydrochloride (Sparine)
severe allergic reaction in some people, ◆ rauwolfia serpentina (Raudixin)
especially those who are also allergic
to aspirin. The following list identifies How aging increases the risk of
some drugs that contain tartrazine. drug hazards
However, not all dosage forms contain
the dye. (Check with the pharmacist The physiologic changes associated
for more information.) with aging make older adults more sus-
◆ benzphetamine hydrochloride ceptible than younger adults to drug-
(Didrex tablets) induced illnesses, adverse effects, toxi-
◆ butabarbital sodium (Butisol elixir city, and interactions. Other conditions
and tablets) that are common to older adults also
◆ carisoprodol (Rela) increase the risk of these problems.
◆ chlorphenesin carbonate (Maolate) To help prevent these problems or
◆ chlorprothixene (Taractan) detect them early, check the patient’s
◆ clindamycin hydrochloride (Cleocin history for the following risk factors
capsules) when developing a teaching plan:
◆ desipramine hydrochloride (Nor- ◆ altered mental status
pramin) ◆ financial problems
◆ dextroamphetamine sulfate ◆ frail health
(Dexedrine elixir, spansule, and tablets) ◆ history of allergies
◆ dextrothyroxine hydrochloride ◆ history of previous adverse effects
(Choloxin) ◆ multiple chronic illnesses
◆ fluphenazine hydrochloride (Prolixin) ◆ female gender
◆ haloperidol (Haldol tablets) ◆ living alone
◆ hydralazine hydrochloride (Apreso- ◆ polypharmacy or complex medica-
line tablets) tion regimen
◆ hydromorphone hydrochloride (Di- ◆ poor nutritional status
laudid cough syrup) ◆ renal failure
◆ imipramine (Janimine, Tofranil-PM) ◆ small frame
◆ mepenzolate bromide (Cantil tablets) ◆ treatment by several physicians.
◆ methamphetamine hydrochloride
(Desoxyn Gradumets)
◆ methenamine hippurate (Hiprex
tablets)
Substance abuse 627
lapses. You must understand the signs

Substance abuse and symptoms of a toxic reaction be-
fore you can take steps to help the
Acute toxic reactions patient recover from his addiction.
Treatment of substance abuse is a long-
term process that’s often beset with re-
Managing acute toxicity

SUBSTANCE SIGNS AND INTERVENTIONS
SYMPTOMS
alcohol ◆ Ataxia ◆ Induce vomiting or perform gastric

(ethanol) ◆ Seizures lavage if ingestion occurred in the previ-
◆ Beer and wine ◆ Coma ous 4 hours. Give activated charcoal and a
◆ Distilled spirits ◆ Hypothermia saline cathartic.
◆ Other prepara- ◆ Alcohol breath ◆ Start I.V. fluid replacement and admin-
tions, such as odor ister dextrose 5% in water, thiamine, B-
cough syrup, af- ◆ Respiratory de- complex vitamins, and vitamin C to pre-
tershave, or pression vent dehydration and hypoglycemia and
mouthwash ◆ Bradycardia or correct nutritional deficiencies. Monitor
tachycardia the magnesium level.
◆ Hypotension ◆ Pad the bed rails and apply cloth re-
◆ Nausea and vomit- straints to protect the patient from injury.
ing ◆ Give an anticonvulsant such as di-
azepam to control seizures.
◆ Watch the patient for signs and symp-
toms of withdrawal, such as hallucinations
and alcohol withdrawal delirium. If these
occur, consider giving chlordiazepoxide or
benzodiazepines.
◆ Auscultate the patient’s lungs frequent-
ly to detect crackles or rhonchi, which
may indicate aspiration pneumonia. If you
note these breath sounds, consider antibi-
otics.
◆ Monitor the patient’s neurologic status
and vital signs every 15 minutes until his
condition is stable. Assist with dialysis if
his vital functions are severely depressed.
(continued)
628 Drug hazards
Managing acute toxicity (continued)

SYMPTOMS
Amphetamines ◆ Dilated reactive ◆ If the drug was taken orally, induce

◆ Amphetamine pupils vomiting or perform gastric lavage; give
sulfate ◆ Altered mental activated charcoal and a sodium or magne-
(Benzedrine): status (from confu- sium sulfate cathartic.
bennies, greenies, sion to paranoia) ◆ Lower the patient’s urine pH to 5 by
cartwheels ◆ Hallucinations adding ammonium chloride or ascorbic
◆ Dextroamphet- ◆ Tremors and acid to his I.V. solution.
amine sulfate seizure activity ◆ Force diuresis by giving the patient
(Dexedrine): dexies, ◆ Hyperactive deep mannitol.
hearts, oranges tendon reflexes ◆ Give a short-acting barbiturate such as
◆ Methampheta- ◆ Exhaustion pentobarbital to control stimulant-induced
mine: speed, meth, ◆ Coma seizures.
crystal ◆ Dry mouth ◆ Place the patient in a protective envi-
◆ Shallow respira- ronment, especially if he’s paranoid or hal-
tions lucinating, so he doesn’t injure himself or
◆ Tachycardia others.
◆ Hypertension ◆ Give haloperidol I.M. or I.V. to treat
◆ Hyperthermia agitation or assaultive behavior.
◆ Diaphoresis ◆ Give an alpha-adrenergic blocker such
as phentolamine for hypertension.
◆ Watch the patient for cardiac arrhyth-
mias. If these develop, consider propra-
nolol or lidocaine to treat tachyarrhyth-
mias or ventricular arrhythmias, respec-
tively.
◆ Treat hyperthermia with tepid sponge
baths or a hypothermia blanket.
◆ Provide a quiet environment to avoid
overstimulation.
◆ Be alert for signs and symptoms of
withdrawal, such as abdominal tenderness,
muscle aches, and long periods of sleep.
◆ Observe suicide precautions, especially
if the patient shows signs of withdrawal.
Substance abuse 629

SYMPTOMS
Antipsychotics ◆ Constricted pupils ◆ Expect to perform gastric lavage if the

◆ Chlorpromazine ◆ Photosensitivity patient ingested the drug within the previ-
(Thorazine) ◆ Extrapyramidal ous 6 hours. (Don’t induce vomiting be-
◆ Phenothiazines effects (dyskinesia, cause phenothiazines have an antiemetic
◆ Thioridazine opisthotonos, muscle effect.) Consider activated charcoal and a
(Mellaril) rigidity, ocular devia- cathartic.
tion) ◆ Give diphenhydramine to treat ex-
◆ Dry mouth trapyramidal effects.
◆ Decreased level of ◆ Give physostigmine salicylate to reverse
consciousness (LOC) anticholinergic effects in severe cases.
◆ Decreased deep ◆ Replace fluids I.V. to correct hypoten-
tendon reflexes sion; monitor the patient’s vital signs often.
◆ Seizures ◆ Monitor the patient’s respiratory rate,
◆ Hypothermia or and give supplemental oxygen to treat res-
hyperthermia piratory depression.
◆ Dysphagia ◆ Give an anticonvulsant such as diaze-
◆ Respiratory de- pam or a short-acting barbiturate such as
pression pentobarbital sodium to control seizures.
◆ Hypotension ◆ Keep the patient’s room dark to avoid
◆ Tachycardia exacerbating photosensitivity.
Anxiolytic ◆ Confusion ◆ Induce vomiting or perform gastric

sedative- ◆ Drowsiness lavage; consider activated charcoal and a
hypnotics ◆ Stupor cathartic.
◆ Benzodiazepines ◆ Decreased reflexes ◆ Give supplemental oxygen to correct
(Ativan, Valium, ◆ Seizures hypoxia-induced seizures and insert an en-
Librium, Xanax) ◆ Coma dotracheal tube, if neccessary.
◆ Shallow respira- ◆ Replace fluids I.V. to correct hypoten-
tions sion; monitor the patient’s vital signs often.
◆ Hypotension ◆ For benzodiazepine overdose or to re-
verse the effect of benzodiazepine-induced
sedation or respiratory depression, give
flumazenil (Romazicon).
Barbiturate ◆ Poor pupillary re- ◆ Induce vomiting or perform gastric

sedative- action to light lavage if the patient ingested the drug
hypnotics ◆ Nystagmus within the previous 4 hours; consider acti-
◆ Amobarbital ◆ Depressed LOC vated charcoal and a saline cathartic.
sodium (Amytal): (from confusion to ◆ Maintain the patient’s blood pressure
blue angels, blue coma) with I.V. fluid challenges and vasopressors.
devils, blue birds ◆ Flaccid muscles ◆ If the patient took an overdose of phe-
◆ Phenobarbital and absent reflexes nobarbital, give him sodium bicarbonate
(Luminal): phen- ◆ Hyperthermia or I.V. to alkalinize his urine and speed elimi-
nies, purple hearts, hypothermia nation of the drug.
goofballs ◆ Cyanosis ◆ Maintain the patient’s airway and moni-
tor his respiratory status.
(continued)
630 Drug hazards

SYMPTOMS
Barbiturate ◆ Respiratory ◆ Apply a hyperthermia or hypothermia

sedative- depression blanket to help return the patient’s tem-
hypnotics ◆ Hypotension perature to normal.
(continued) ◆ Blisters or bullous ◆ Prepare the patient for hemodialysis or
◆ Secobarbital lesions hemoperfusion if the toxic reaction is se-
sodium (Seconal): vere.
reds, red devils ◆ Perform frequent neurologic assess-
ments, and check the patient’s pulse rate,
temperature, skin color, and reflexes often.
◆ Notify the physician if you see signs of
respiratory distress or pulmonary edema.
◆ Watch the patient for signs and symp-
toms of withdrawal, such as hyperreflexia,
tonic-clonic seizures, and hallucinations.
Provide symptomatic relief of withdrawal
symptoms.
◆ Protect the patient from injuring him-
self.
Cocaine ◆ Dilated pupils ◆ Maintain the patient’s airway and mon-

◆ Cocaine hy- ◆ Confusion itor his respiratory status.
drochloride: ◆ Alternating ◆ Calm the patient by talking to him in a
crack, freebase euphoria and appre- quiet room.
hension ◆ If the patient ingested cocaine, induce
◆ Hyperexcitability vomiting or perform gastric lavage; give
◆ Visual, auditory, activated charcoal followed by a saline
and olfactory halluci- cathartic.
nations ◆ Give the patient a tepid sponge bath
◆ Spasms and and administer an antipyretic to reduce
seizures fever.
◆ Coma ◆ Monitor his blood pressure and heart
◆ Tachypnea rate. Expect to give propranolol for symp-
◆ Hyperpnea tomatic tachycardia.
◆ Pallor or cyanosis ◆ Administer an anticonvulsant such as
◆ Respiratory arrest diazepam to control seizures.
◆ Tachycardia ◆ Scrape the inside of his nose to remove
◆ Hypertension or hy- residual amounts of the drug.
potension ◆ Monitor the patient’s cardiac rate and
◆ Fever rhythm. Ventricular fibrillation and cardiac
◆ Nausea and standstill can occur as a direct cardiotoxic
vomiting result of cocaine ingestion. Defibrillate the
◆ Abdominal pain patient and initiate cardiopulmonary re-
◆ Perforated nasal suscitation, if indicated.
septum or mouth
sores
Substance abuse 631

SYMPTOMS
Hallucinogens ◆ Dilated pupils ◆ Reorient the patient repeatedly to time,

◆ Lysergic acid di- ◆ Intensified percep- place, and person.
ethylamide (LSD): tions ◆ Place the patient in a protective envi-
hawk, acid, sun- ◆ Agitation and ronment.
shine anxiety ◆ Calm the patient by talking to him in a
◆ Mescaline (pey- ◆ Synesthesia quiet room.
ote): mese, cactus, ◆ Impaired judgment ◆ If the drug was taken orally, induce
big chief ◆ Hyperactive move- vomiting or perform gastric lavage; give
ment activated charcoal and a cathartic.
◆ Flashbacks ◆ Give diazepam I.V. to control seizures.
◆ Hallucinations
◆ Depersonalization
◆ Moderately in-
creased blood pressure
◆ Increased heart rate
◆ Fever
Opioids ◆ Constricted pupils ◆ Give naloxone until the depressant ef-

◆ Codeine ◆ Depressed LOC (al- fects of the drug on the central nervous
◆ Heroin: junk, though the patient is system are reversed.
smack, H, snow usually responsive to ◆ Replace fluids I.M. to increase the cir-
◆ Hydromorphone persistent verbal or culatory volume.
hydrochloride (Di- tactile stimuli) ◆ Correct hypothermia by applying extra
laudid): D, lords ◆ Seizures blankets; if the patient’s body temperature
◆ Morphine: Mort, ◆ Hypothermia doesn’t increase, use a hyperthermia blan-
M, monkey, Emma ◆ Slow, deep respira- ket.
◆ Oxycodone tions ◆ Reorient the patient often.
(OxyContin): OCs, ◆ Hypotension ◆ Auscultate the lungs often for crackles,
ox, and oxy. ◆ Bradycardia which may indicate pulmonary edema.
◆ Skin changes (pruri- Onset may be delayed.
tus, urticaria, flushing) ◆ Administer oxygen with a nasal cannu-
la, a mask, or mechanical ventilation to
correct hypoxemia caused by hypoventila-
tion.
◆ Monitor the patient’s cardiac rate and
rhythm. Be alert for atrial fibrillation,
which should resolve when hypoxemia is
corrected.
◆ Watch the patient for signs of with-
drawal, such as piloerection (gooseflesh),
diaphoresis, and hyperactive bowel
sounds.
◆ Institute safety measures to prevent
patient injury.
(continued)
632 Drug hazards

SYMPTOMS
phencyclidine ◆ Blank stare ◆ If the drug was taken orally, induce

(PCP) ◆ Nystagmus vomiting or perform gastric lavage; instill
◆ Angel dust, ◆ Amnesia and remove activated charcoal repeatedly.
peace pill, hog ◆ Decreased aware- ◆ Acidify the patient’s urine with ascorbic
ness of surroundings acid to increase excretion of the drug.
◆ Recurrent coma ◆ Expect to continue to acidify the urine
◆ Violent behavior for 2 weeks because signs and symptoms
◆ Hyperactivity may recur when fat cells release PCP
◆ Seizures stores.
◆ Gait ataxia ◆ Give diazepam and haloperidol to con-
◆ Muscle rigidity trol agitation or psychotic behavior.
◆ Drooling ◆ Institute safety measures to protect the
◆ Hyperthermia patient from injury.
◆ Hypertensive ◆ Administer diazepam to control seizures.
◆ Institute seizure precautions.
◆ Provide a quiet environment and
dimmed light.
◆ Give propranolol for hypertension and
tachycardia, and give nitroprusside for se-
vere hypertension.
◆ Closely monitor the patient’s urine out-
put and the results of serial renal function
tests. Rhabdomyolysis, myoglobinuria, and
renal failure may occur in severe intoxica-
tion.
◆ If renal failure develops, prepare the
patient for hemodialysis.
15 Complications
Spotting and correcting life-threatening
conditions
Air embolism 634

Atelectasis 635
Bone marrow suppression 636
Nursing interventions in bone marrow
suppression 637
Brain herniation 639
Cardiac tamponade 640
Disseminated intravascular coagulation 641
Hyperglycemic crisis 642
Hypoglycemia 643
Hypovolemic shock 644
Pneumothorax 646
Septic shock 647
Spinal cord compression 648
Functional loss from spinal cord injury 650
Syndrome of inappropriate antidiuretic
hormone secretion 650
Thyroid storm 652
Tracheal erosion 653
633
634 Complications
and cardiac symptoms may develop.

Air embolism The patient may have dyspnea, vertigo,
anxiety, or a sense of impending doom.
Air embolism is the migration of a bo- He may also experience a “gasp” reflex
lus of gas from the systemic circulation (cough, short exhalation, and pro-
into the microvasculature. Obstruction longed inhalation).
occurs when the gas reaches the capil- Other signs include tachycardia,
lary system. Besides impairing blood tachypnea, hypoxemia, and elevated
flow, an air embolus causes a physio- central venous and pulmonary artery
logic response as fibrin, platelets, and pressures. Electrocardiogram results
red blood cells congregate at the site of show ST-segment changes that reflect
occlusion. This further restricts blood ischemia. A transient churning heart
flow and contributes to an inflammato- murmur has been noted. Hypotension
ry vasospasm of the affected vessel. and decreased peripheral vascular resis-
Arterial air emboli may lodge in the tance indicate progressive shock. Crepi-
small vessels that supply major organs tus occasionally is palpable, and
or the peripheral circulation. Venous wheezes and crackles may be auscultat-
air emboli commonly occlude pulmo- ed when pulmonary edema is present.
nary blood flow; they may also ob-
struct arterial circulation if the patient Treatment
has an intracardiac defect or a micro- The goal of treatment is to promote re-
vascular shunt between the arterioles absorption of trapped air and mitigate
and venules of the lungs. life-threatening signs and symptoms. In
the event of cardiac arrest, cardiopul-
Causes monary resuscitation (CPR) is initiated
A bolus of air may enter the blood- immediately. External cardiac massage
stream during positive-pressure ventila- improves circulation and may help
tion if the patient has a lung tear, or break up large right ventricular bub-
when air enters an artery or vein during bles, increasing blood flow to the pul-
insertion, maintenance, or removal of monary vasculature.
the arterial or venous line. Air emboli An air embolus may be removed
have also been associated with oral- through a central venous catheter or by
vaginal sex, laser surgery, and pneu- needle aspiration. The size of the bub-
moperitoneum. They may also occur as ble may be reduced by administering
a complication of needle biopsy or preg- 100% oxygen, which reduces the
nancy. Air emboli also result from rapid amount of nitrogen in the bubble, or
decompression after underwater diving. by administering hyperbaric oxygen;
Venous air emboli may occur as a the latter approach may also improve
complication of surgery or blunt or the patient’s signs and symptoms by
penetrating trauma to the head, neck, oxygenating ischemic tissue.
chest, heart, or abdomen.
Signs and symptoms ◆ Preventing air embolism is the key
The first sign of a venous air embolism to nursing care. Make sure that all air
may be cardiopulmonary collapse, es- is purged from catheters and I.V. lines
pecially in the presence of a rapid infu- before connecting them.
sion of a large volume of air. ◆ Keep closed systems as airtight as
If the embolus moves into the arter- possible; tape all tubing connections, or
ial circulation, central nervous system use luer-lock devices for all connections.
Atelectasis 635
◆ Place the patient in Trendelenburg’s Lung collapse or reduced expansion

position when inserting all central ve- may accompany prolonged immobility
nous line catheters. Have the patient or mechanical ventilation. Central ner-
perform Valsalva’s maneuver during vous system depression eliminates pe-
catheter insertion and tubing changes. riodic sighing and predisposes the pa-
◆ Position the patient on his left side tient to progressive atelectasis.
in Trendelenburg’s position so that air
can enter the right atrium and be dis- Signs and symptoms
persed by the pulmonary artery. Clinical effects vary with the causes of
◆ Initiate CPR immediately if cardiac lung collapse, the degree of hypoxia,
collapse occurs. and the underlying disease. If atelecta-
sis affects a small area of the lung,
symptoms may be minimal and tran-
Atelectasis sient; however, if atelectasis affects a
large area, symptoms may be severe
In atelectasis, alveolar clusters (lob- and may include dyspnea, tachypnea,
ules) or lung segments don’t expand tachycardia, anxiety, and pleuritic chest
completely during respiration, causing pain.
all or part of the affected lung to col- Inspection may show decreased
lapse. This condition can be acute or movement of the chest wall, cyanosis,
chronic. Because the collapsed lung tis- diaphoresis, and substernal or inter-
sue is effectively isolated from gas ex- costal retractions. Palpation may show
change, unoxygenated blood is shunted decreased fremitus and a mediastinal
and passes unchanged through these shift to the affected side. Percussion
tissues, producing hypoxia. may show dullness or flatness over the
lung fields. Auscultation may show
Causes crackles during the last part of inspira-
Atelectasis can result from bronchial tion and decreased (or absent) breath
occlusion by mucus plugs — a problem sounds with major lung involvement;
for patients with chronic obstructive auscultation may also disclose tachy-
pulmonary disease, bronchiectasis, or cardia.
cystic fibrosis. Atelectasis may also re- A chest X-ray is the primary diag-
sult from occlusion caused by foreign nostic tool. Other diagnostic tests in-
bodies, bronchogenic cancer, or inflam- clude bronchoscopy to rule out an ob-
matory lung disease. structing neoplasm or a foreign body,
Other causes include idiopathic res- arterial blood gas (ABG) analysis to de-
piratory distress syndrome of the neo- tect respiratory acidosis and hypoxemia
nate, oxygen toxicity, and pulmonary resulting from atelectasis, and pulse
edema. oximetry, which may show deteriorat-
External compression, which in- ing arterial oxygen saturation levels.
hibits full lung expansion, or any con-
dition that makes deep breathing Treatment
painful may also cause atelectasis. Incentive spirometry, chest percussion,
Compression or pain may result from postural drainage, mucolytics, and fre-
surgical incisions in the upper ab- quent coughing and deep-breathing ex-
domen, rib fractures, pleuritic chest ercises may improve oxygenation. If
pain, tight chest dressings, or obesity these measures are unsuccessful, bron-
(which elevates the diaphragm and choscopy may help to remove secre-
reduces tidal volume). tions. Humidity and a bronchodilator
636 Complications
can improve mucociliary clearance and

dilate the airways. Bone marrow suppression
To minimize the risk of atelectasis
after thoracic and abdominal surgery, Bone marrow suppression is character-
the patient may require an analgesic ized by reduced numbers of hemato-
to facilitate deep breathing. If the pa- poietic (blood-forming) stem cells in the
tient has atelectasis as a result of an bone marrow. Impaired hematopoiesis
obstructing neoplasm, he may need leads to reduced numbers of peripheral
surgery or radiation therapy. blood leukocytes and neutrophils (neu-
tropenia), thrombocytes (thrombocy-
Nursing interventions topenia), and erythrocytes (anemia).
◆ Offer the patient reassurance and
emotional support because he may be Causes
frightened by his limited ability to Many chemotherapeutic agents injure
breathe. the rapidly proliferating stem cells.
◆ Encourage a patient who is recover- Other drugs, such as sulfa compounds,
ing from surgery to perform coughing anticonvulsants, and immunosuppres-
and deep-breathing exercises and in- sants, also may suppress bone marrow.
centive spirometry every 1 to 2 hours Radiation to large marrow-bearing
while splinting the incision. Encourage areas — such as the pelvis, ribs, spine,
these procedures in any patient who is and sternum — may produce significant,
at increased risk for atelectasis. permanent bone marrow damage. Bone
◆ Assess the patient’s breath sounds marrow suppression and depressed pe-
and respiratory status frequently. Re- ripheral blood cell counts occur in pa-
port changes immediately; monitor tients with tumor replacement of the
pulse oximetry readings and ABG val- bone marrow (leukemia, myeloma, or
ues for evidence of hypoxia. metastatic deposits from solid tumors).
◆ Gently reposition the patient often, Additional causes of bone marrow sup-
and help him walk as soon as possible. pression include autoimmune disorders,
Administer adequate analgesics to con- certain congenital disorders, and expo-
trol his pain. sure to pesticides, benzene-containing
◆ If the patient is receiving mechani- solvents, and other toxins.
cal ventilation, maintain the tidal vol-
ume at 10 to 15 cc/kg of body weight Signs and symptoms
to ensure adequate lung expansion. Clinical effects of bone marrow sup-
Use the sigh mechanism on the ventila- pression are related to its severity. A
tor, if appropriate, to increase the tidal patient with neutropenia is at risk for
volume intermittently at the rate of 10 infection from bacteria, viruses, or fun-
to 15 sighs per hour. gi. He may have fever, chills, malaise,
◆ Humidify inspired air, and encour- or other localized signs of infection.
age adequate fluid intake to mobilize Thrombocytopenia is associated
secretions. Use postural drainage and with bleeding (especially from the
chest percussion to remove secretions. gums and nose), bruising, petechiae,
Suction as needed. ecchymoses, hematuria and, possibly,
◆ Administer sedatives cautiously. hematochezia. Spontaneous bleeding is
They depress respirations and the likely to occur if the platelet count
cough reflex and suppress sighs. drops below 20,000/mm3.
Signs and symptoms of anemia in-
clude fatigue, weakness, pallor, tachy-
Bone marrow suppression 637
cardia, palpitations, dizziness, exertion- to increase platelet production.

al dyspnea, and headache. Platelet transfusions may be used to
stop episodic abnormal bleeding
Treatment caused by a low platelet count; how-
Improved antimicrobial therapy has ever, if platelet destruction is caused
dramatically reduced the rates of mor- by an immune disorder, platelet infu-
bidity and mortality in patients with sions may have only a minimal effect
neutropenia. Chemotherapy-induced and may be reserved for life-threaten-
neutropenia can be reduced by the use ing bleeding.
of myeloid growth factors (granulocyte Recombinant erythropoietin may
colony-stimulating factor [filgrastim] help improve anemia caused by chron-
or granulocyte-macrophage colony- ic disease or renal dysfunction. Packed
stimulating factor [sargramostim]). red blood cells and platelets are admin-
In patients with drug-induced istered to support the patient until
thrombocytopenia, removal of the bone marrow function recovers.
causative agents or proper treatment
of the underlying cause (when possi- Nursing interventions
ble) is essential. A corticosteroid, lithi- See Nursing interventions in bone mar-
um carbonate, or folate may be used row suppression.
Nursing interventions in bone marrow suppression
This table summarizes the essential nursing interventions for patients who have ane-
mia, neutropenia, or thrombocytopenia.
CONDITIONS INTERVENTIONS
Anemia
(Hemoglobin ⬍ 14 g/dl in men ◆ Monitor the patient’s complete blood count (CBC)
and boys; ⬍ 12 g/dl in women at least daily.
and girls) ◆ Monitor the patient for signs of inadequate oxy-
(Severe anemia, hemoglobin genation, such as pallor, tachypnea, and increased
⬍ 8 g/dl) capillary refill time.
◆ Teach the patient about nutritional supplementa-
tion (such as iron or folic acid).
◆ Assess the patient for source of blood loss, if ap-
plicable.
◆ Teach the patient energy conservation measures.
◆ Teach the patient to avoid driving or participating
in hazardous activities if he’s dizzy.
◆ Teach the patient to change positions slowly to
avoid syncope and orthostatic hypotension.
◆ Administer transfusions of packed red blood cells
as ordered. Monitor the patient for transfusion reac-
tions.
◆ Administer recombinant erythropoietin or other
blood replacement alternatives, as ordered.
(continued)
638 Complications
Nursing interventions in bone marrow suppression (continued)
CONDITIONS INTERVENTIONS
Neutropenia
(Neutrophil count ◆ Monitor the patient’s temperature and vital signs.
⬍ 1,500/mm3) Report fever ⬎ 101º F (38º C).
(Severe neutropenia, neutrophil ◆ Monitor the patient’s CBC, differential, and blood
count ⬍ 500/mm3) chemistry results.
◆ Assess the patient for localized signs of infection.
◆ Assess the patient for symptoms of sepsis.
◆ Obtain cultures of the patient’s blood, urine,
throat, sputum, and stool, as ordered. Obtain blood
cultures if the patient has a temperature spike
⬎ 101º F (38º C).
◆ Avoid invasive procedures or rectal manipulation.
◆ Avoid contact with persons with viral or bacterial
infections.
◆ Administer broad-spectrum antibiotics as indicat-
ed.
◆ Explain to the patient or caregiver the rationale
for the use of hematopoietic growth factors and
demonstrate self-administration, if indicated.
◆ Teach proper storage and precautions for
hematopoietic growth factors.
◆ Teach the patient to avoid fresh flowers and to
refrain from eating raw fruits and vegetables.
Thrombocytopenia
(Platelet count ⬍ 100,000/mm3) ◆ Teach the patient to avoid injury and sharp ob-
(Severe thrombocytopenia, jects.
platelet count ⬍ 20,000/mm3) ◆ Teach the patient to avoid straining and to avoid
performing Valsalva’s maneuver.
◆ Avoid invasive procedures, such as I.M. injections,
enemas, or suppositories.
◆ Apply direct pressure for 5 minutes to needle
puncture sites.
◆ Assess the patient for signs of bleeding, increased
petechiae, or increased bruising.
◆ Monitor the patient for signs of internal bleeding
(such as blood in the stool and hematuria) and signs
and symptoms of intracranial bleeding (such as
headache, restlessness, decreased level of conscious-
ness, pupillary changes, and seizures).
◆ Administer platelet transfusions, as ordered.
◆ Monitor the patient for transfusion reactions.
Check the posttransfusion platelet count.
Brain herniation 639
paresis; and Cheyne-Stokes respirations.

Brain herniation Signs of transtentorial herniation include
ipsilateral pupil dilation, paralysis of eye
Brain herniation is caused by distortion movements, restlessness progressing to
and displacement of brain tissue loss of consciousness, contralateral hemi-
through a natural opening in the in- paresis, decorticate or decerebrate pos-
tracranial cavity. turing, and bilateral Babinski’s sign. Late
Five types of brain herniation syn- in the syndrome, altered vital signs be-
drome occur: central, uncal, tonsillar, come evident, such as widening pulse
cingulate, and extracranial. Central pressure and bradycardia.
herniation—also known as transtentori-
al herniation—is an upward or down- Treatment
ward displacement of the temporal lobe If herniation is caused by a space-
and diencephalon through the tentori- occupying lesion, such as a hematoma
um. In uncal herniation, the inner part or tumor, surgical removal of the lesion
of the temporal lobe passes the tentori- will relieve the pressure and allow ad-
um and presses on the brain stem. In jacent structures to resume their nor-
tonsillar herniation, the tonsils of mal shape. If herniation is related to
the cerebellum pass down through the increased intracranial pressure (ICP) as
foramen magnum and press on the a result of cerebral edema, treatment
brain stem and spinal cord, possibly involves reducing the edema with an
causing respiratory and cardiac dysfunc- osmotic diuretic or a corticosteroid,
tion. Cingulate, or subfalcine, herniation CSF drainage, hyperventilation and, in
involves displacement of the frontal extreme cases, barbiturate therapy.
lobe of the brain under the falx cerebri. Maintaining temperature control and a
Finally, in extracranial herniation, the normal fluid balance is also important.
brain is displaced through a cranial de- In some situations, such as cerebral
fect, such as a fracture or a craniotomy. edema caused by traumatic injury, the
patient may have an ICP monitor in
Causes place to help guide treatment.
Brain herniation is caused by space-
occupying lesions, cerebral edema as Nursing interventions
a result of trauma or stroke, or hydro- ◆ Perform a neurologic assessment at
cephalus. It can also be caused by ex- least hourly.
cessive drainage of cerebrospinal fluid ◆ Institute precautionary measures to
(CSF) from a ventricular catheter or decrease ICP, including elevating the
lumbar puncture. head of the bed at 15 to 30 degrees to
promote venous drainage. Place the
Signs and symptoms patient in a neutral position, avoiding
Signs and symptoms vary with the type extreme hip and neck flexion.
of herniation. General early signs include ◆ Institute seizure precautions, and
decreasing level of consciousness, pupil- assess the patient frequently for signs
lary abnormalities, impaired motor func- of seizures.
tion, and impaired brain stem reflexes. ◆ Monitor the patient’s vital signs fre-
Signs of central herniation include small, quently to ensure adequate cerebral
reactive pupils (early phase); roving eye perfusion.
movements with loss of upward gaze; in- ◆ If the patient underwent a cranioto-
termittent agitation and drowsiness pro- my for a hematoma or tumor, provide
gressing to stupor; contralateral hemi- postoperative craniotomy care.
640 Complications
◆ Observe the patient carefully for pulse pressure, restlessness, and hepa-
other postoperative complications, tomegaly, but the lung fields will be
such as infection, thrombophlebitis, or clear. The patient typically sits upright
diabetes insipidus. and leans forward.
Chest X-rays show a slightly
widened mediastinum and an enlarged
Cardiac tamponade cardiac silhouette. Electrocardiography
is performed to rule out other cardiac
In cardiac tamponade, a rapid, un- disorders. Pulmonary artery pressure
checked increase in intrapericardial monitoring detects increases in right
pressure impairs diastolic filling of the atrial pressure, right ventricular dias-
heart. The increased pressure usually tolic pressure, and central venous pres-
results from the accumulation of blood sure (CVP). Echocardiography records
or fluid in the pericardial sac. If fluid pericardial effusion with signs of right
accumulates rapidly, as little as 250 ml ventricular and atrial compression.
can create an emergency situation.
Gradual accumulation of fluid, as in Treatment
pericardial effusion associated with The goal of treatment is to relieve in-
cancer, may not produce immediate trapericardial pressure and cardiac
signs and symptoms because the fi- compression by removing accumulated
brous wall of the pericardial sac can blood or fluid. Pericardiocentesis (nee-
stretch to accommodate as much as dle aspiration of the pericardial cavity)
1 to 2 L of fluid. or surgical creation of an opening dra-
matically improves systemic arterial
Causes pressure and cardiac output with the
Cardiac tamponade may be idiopathic aspiration of as little as 25 ml of fluid.
(Dressler’s syndrome), or it may result In a patient with hypotension, trial
from effusion (in lung cancer, bacterial volume loading with normal saline so-
infection, tuberculosis, lupus and, lution I.V. with albumin — and perhaps
rarely, acute rheumatic fever), hemor- an inotropic drug such as dopamine —
rhage as a result of trauma, hemor- is necessary to maintain cardiac out-
rhage from nontraumatic causes (with put. Depending on the cause of tam-
pericarditis), acute myocardial infarc- ponade, additional treatment may be
tion, chronic renal failure during dialy- needed.
sis, drug reaction, or a connective tis-
sue disorder. Nursing interventions
◆ Infuse I.V. solutions and inotropic
Signs and symptoms drugs (such as dopamine), as ordered,
Cardiac tamponade classically produces to maintain the patient’s blood pressure.
increased venous pressure, with jugu- ◆ Administer oxygen therapy as
lar vein distention, reduced arterial needed.
blood pressure, muffled heart sounds ◆ Prepare the patient for pericardio-
on auscultation, and paradoxical pulse centesis, thoracotomy, or central ve-
(an abnormal inspiratory drop in sys- nous line insertion, as indicated.
temic blood pressure greater than ◆ Check for signs of increasing tam-
15 mm Hg). ponade, increasing dyspnea, and
Cardiac tamponade may also cause arrhythmias.
dyspnea, diaphoresis, pallor or cyano- ◆ Watch for a decrease in CVP and a
sis, anxiety, tachycardia, narrowed concomitant rise in blood pressure
Disseminated intravascular coagulation 641
after treatment; these indicate relief of venous thrombosis, and purpura ful-
cardiac compression. minans.
◆ Monitor the patient’s respiratory
status for signs of respiratory distress, Signs and symptoms
such as severe tachypnea or changes in The most significant sign of DIC is ab-
the level of consciousness. normal bleeding without an accompa-
nying history of a hemorrhagic disor-
der. Principal signs of such bleeding in-
Disseminated intravascular clude cutaneous oozing, petechiae,
coagulation ecchymoses, and hematomas caused
by bleeding into the skin. Bleeding at
Also known as consumption coagu- the sites of surgical or invasive proce-
lopathy or defibrination syndrome, dis- dures and from the GI tract are equally
seminated intravascular coagulation significant indications, as are acro-
(DIC) complicates conditions that ac- cyanosis and signs of acute tubular
celerate clotting — thereby causing necrosis.
small vessel occlusion, organ necrosis, Related signs and symptoms and
depletion of circulating clotting factors other possible effects include nausea,
and platelets, and activation of the fib- vomiting, dyspnea, oliguria, seizures,
rinolytic system — which can provoke coma, shock, failure of major organ
severe hemorrhage. systems, and severe muscle, back, and
Clotting in the microcirculation usu- abdominal pain.
ally affects the kidneys and extremities, The following initial laboratory find-
but can occur in the brain, lungs, pitu- ings suggest a tentative diagnosis of
itary and adrenal glands, and GI mu- DIC: decreased platelet count, reduced
cosa. Other conditions — such as vita- fibrinogen levels, prolonged prothrom-
min K deficiency, hepatic disease, and bin time, prolonged partial thrombo-
anticoagulant therapy — can cause a plastin time, and increased fibrin
similar hemorrhage. degradation products.
Although usually acute, DIC may be
chronic in patients with cancer. The Treatment
prognosis depends on early detection Successful management of DIC requires
and treatment, the severity of the hem- prompt recognition and adequate treat-
orrhage, and treatment of the underly- ment of the underlying disorder. If the
ing condition. patient isn’t actively bleeding, support-
ive care alone may reverse DIC. How-
Causes ever, active bleeding may require the
DIC results when tissue factor, a lipo- administration of blood, fresh frozen
protein that helps initiate blood coagu- plasma, platelets, or packed red blood
lation, is introduced into the blood- cells.
stream as a result of pathologic states, Heparin therapy is controversial,
such as infections, obstetric complica- but is usually mandatory if thrombosis
tions, neoplastic disease, and disorders occurs. Drugs such as antithrombin III
that produce necrosis. Other causes in- and gabexate are being considered for
clude heatstroke, shock, poisonous use as antithrombins to inhibit the
snakebite, cirrhosis, fat embolism, in- clotting cascade.
compatible blood transfusion, cardiac
arrest, surgery requiring cardiopulmo-
nary bypass, giant hemangioma, severe
642 Complications
◆ Administer prescribed analgesics for Hyperglycemic crisis
pain, as needed.
◆ Administer oxygen therapy as or- Diabetic ketoacidosis (DKA) and hyper-
dered. osmolar hyperglycemic nonketotic syn-
◆ To prevent clots from dislodging drome (HHNS) are acute complications
and causing fresh bleeding, don’t rub of hyperglycemic crisis that may occur
these areas vigorously when washing. in a patient with diabetes. Quick and
If bleeding occurs, use pressure, cold effective treatment is required to pre-
compresses, and topical hemostatic vent coma and possibly death. DKA
agents to control it. usually occurs in patients with type 1
◆ After giving an I.V. injection or re- diabetes; DKA may be the first sign of
moving a catheter or needle, apply previously unrecognized diabetes.
pressure to the injection site for at least HHNS usually occurs in patients with
10 minutes. Alert other staff members type 2 diabetes, but may also occur in
to the patient’s tendency to hemor- patients whose insulin tolerance is
rhage. Limit venipunctures whenever stressed and in those who have under-
possible. gone certain therapeutic procedures,
◆ Protect the patient from injury. En- such as peritoneal dialysis, hemodialy-
force complete bed rest during bleeding sis, total parenteral nutrition, or tube
episodes. If the patient is very agitated, feedings.
pad the bed rails.
◆ Reposition the patient every 2 hours, Causes
and provide meticulous skin care to Acute insulin deficiency (absolute in
prevent skin breakdown. DKA; relative in HHNS) precipitates
◆ If the patient can’t tolerate activity both conditions. Causes include illness,
because of blood loss, provide frequent trauma, stress, infection, and failure to
rest periods. take insulin (only in a patient with
◆ Monitor the patient’s intake and DKA).
output hourly. Watch for transfusion
reactions and signs of fluid overload. Signs and symptoms
◆ Weigh dressings and linens, and Signs and symptoms of DKA and
record drainage. Weigh the patient HHNS result primarily from extremely
daily. elevated blood glucose levels. They in-
◆ Watch for bleeding from the GI and clude fluid loss, dehydration, shock,
genitourinary tracts. If you suspect coma and, possibly, death. Acetone
intra-abdominal bleeding, measure the breath, dehydration, Kussmaul’s respi-
patient’s abdominal girth at least every rations, and a weak, rapid pulse are ev-
4 hours, and observe him closely for ident in patients with DKA. Polyuria,
signs of shock. thirst, neurologic abnormalities, and
◆ Monitor the results of serial blood stupor are seen in patients with HHNS.
studies. The patient with DKA also shows evi-
◆ Test all stools and urine for occult dence of metabolic acidosis. Acidosis
blood. may start a cycle that leads to addition-
◆ Inform the family of the patient’s al breakdown of tissue, followed by
progress, and provide emotional sup- more ketosis, more acidosis, and even-
port and encouragement. tually shock, coma, and death.
Hypoglycemia 643
Treatment ous. It occurs when glucose burns up

Both DKA and HHNS are treated with too rapidly, when the glucose release
fluid and electrolyte replacement and rate falls behind tissue demands, or
supportive care. Normal or half-normal when too much insulin enters the
saline solution is given I.V. at 1 L/hour bloodstream.
until blood pressure is stabilized and Hypoglycemia is classified as reac-
urine output reaches 60 ml/hour. Then tive or fasting. Reactive hypoglycemia
regular insulin is started, initially as an is caused by a reaction to a meal or the
I.V. bolus dose, followed by continuous administration of too much insulin.
infusion. The rate is adjusted until the Fasting hypoglycemia causes discom-
patient’s serum glucose levels decrease fort during periods of abstinence from
by 80 to 100 mg/dl/hour. food (for example, in the early morning
When renal blood flow and urine hours before breakfast).
output are established, potassium is
given I.V. If acidosis is severe (pH less Causes
than 7.1), sodium bicarbonate may Reactive hypoglycemia may occur in
also be infused. several forms. In a patient with dia-
betes, it may result from the adminis-
Nursing interventions tration of too much insulin or, less
◆ When you recognize the signs and commonly, from the administration of
symptoms of DKA or HHNS, notify the too much of an oral antidiabetic. Reac-
physician immediately and prepare the tive hypoglycemia may result from de-
patient for transfer to the intensive care layed and excessive production of in-
unit. sulin after carbohydrate ingestion, or
◆ Monitor the patient’s vital signs, from a sharp increase in insulin output
level of consciousness, intake and out- after a meal. Sometimes called post-
put, electrocardiogram results, and ar- prandial hypoglycemia, this form usu-
terial blood gas, electrolyte, glucose, ally can be prevented by reducing sim-
and osmolarity levels frequently, as or- ple sugars and increasing protein in a
dered. Also check the patient’s urine meal.
for ketones. In some patients, reactive hypo-
◆ Begin I.V. fluid replacement therapy glycemia has no known cause or may
as soon as possible. Monitor elderly result from hyperalimentation as a re-
and very young patients for indications sult of gastric dumping syndrome or
of fluid overload. impaired glucose tolerance.
◆ Expect to administer an injection of Fasting hypoglycemia usually results
regular insulin immediately — either from an excess of insulin or insulin-like
I.M. or I.V. — followed by a continuous substances, or from a decrease in
I.V. insulin drip. counterregulatory hormones. It may
◆ Provide supportive care as indicated also be exogenous (such as from the
by the patient’s condition. ingestion of alcohol or drugs) or en-
◆ Prepare to administer potassium re- dogenous (from organic problems such
placements, as ordered. as tumors, liver disease, or small islet
cell tumors).
Other endocrine causes include de-
Hypoglycemia struction of the pancreatic islet cells,
adrenocortical insufficiency, and pitu-
Hypoglycemia, which is an abnormally itary insufficiency. Nonendocrine caus-
low blood glucose level, can be danger- es include severe liver disease, such as
644 Complications
hepatitis, liver cancer, cirrhosis, and calculated at 5 to 10 ml/kg of body

liver congestion associated with heart weight, administered I.V. over
failure. 10 minutes and followed by 4 to
8 mg/kg/minute for maintenance,
Signs and symptoms should reduce the chance of hypo-
Reactive and fasting hypoglycemia glycemia. To reduce the chance of hy-
cause fatigue, malaise, nervousness, ir- poglycemia in high-risk neonates,
ritability, trembling, tension, headache, feedings of either breast milk or a so-
hunger, diaphoresis, and rapid heart lution of dextrose 5% to 10% in wa-
rate. ter should begin as soon after birth as
Fasting hypoglycemia may also possible. Infants and children older
cause central nervous system (CNS) than age 1 should receive 1 ml/kg of
disturbances, such as altered level of dextrose 25% in water.
consciousness, blurry or double vision, For severe hypoglycemia (producing
confusion, motor weakness, hemiple- confusion or coma), initial treatment is
gia, seizures, or coma. usually I.V. administration of a bolus of
Age alert In infants and chil- 25 or 50 g of glucose as a 50% solu-
dren, signs and symptoms are tion. This treatment is followed by a
vague. A neonate’s refusal to feed constant infusion of glucose until the
may be the primary clue to underly- patient can eat a meal. A patient who
ing hypoglycemia. Associated effects has adrenergic reactions without CNS
include tremors, twitching, a weak or symptoms may receive oral carbohy-
high-pitched cry, diaphoresis, limp- drates; parenteral therapy isn’t re-
ness (or weakness), seizures, and quired.
coma.
Treatment ◆ Administer medications, as ordered.
Reactive hypoglycemia requires dietary ◆ Avoid delays in mealtimes, and pro-
modification to help delay glucose ab- vide a proper diet.
sorption and gastric emptying. Usually, ◆ Correct hypoglycemic episodes
this includes small, frequent, high- quickly. Measure the patient’s blood
protein meals with added fiber and glucose level to verify the presence and
avoidance of simple carbohydrates. The severity of hypoglycemia before taking
patient may also receive an anticholin- steps to correct it.
ergic to slow gastric emptying and in- ◆ Monitor I.V. infusion of hypertonic
testinal motility and inhibit vagal stim- glucose, circulatory overload, and cel-
ulation of insulin release. lular dehydration.
For fasting hypoglycemia, surgery ◆ Measure blood glucose levels, as or-
and drug therapy may be required. For dered.
patients with insulinoma, removal of ◆ Assess the effects of drug therapy,
the tumor is the treatment of choice. and watch the patient for adverse reac-
Drug therapy may include a nondiuret- tions.
ic thiazide (such as diazoxide) to in-
hibit insulin secretion, streptozocin and
hormones (such as a glucocorticoid), Hypovolemic shock
and long-acting glycogen.
Age alert For neonates who Potentially life-threatening hypovolemic
have hypoglycemia, a hypertonic shock is caused by reduced intravascu-
solution of dextrose 10% in water, lar blood volume, which leads to de-
Hypovolemic shock 645
creased cardiac output and inadequate count; elevated serum potassium, sodi-
tissue perfusion. The subsequent tissue um, lactate dehydrogenase, creatinine,
anoxia prompts a shift in cellular me- and blood urea nitrogen levels; in-
tabolism from aerobic to anaerobic creased urine specific gravity (greater
pathways, resulting in an accumulation than 1.020) and urine osmolality; de-
of lactic acid that produces metabolic creased urine creatinine levels; de-
acidosis. Without immediate treatment, creased pH and partial pressure of arte-
hypovolemic shock can cause adult rial oxygen; and increased partial pres-
respiratory distress syndrome, acute sure of arterial carbon dioxide.
tubular necrosis and renal failure, dis- X-rays, gastroscopy, aspiration of
seminated intravascular coagulation, gastric contents through a nasogastric
and multisystem organ dysfunction tube, and tests for occult blood are
syndrome. used to identify internal bleeding sites.
Coagulation studies may detect coagu-
Causes lopathy caused by disseminated intra-
Hypovolemic shock usually results vascular coagulation.
from acute blood loss — about 20% of
total volume. Massive blood loss may Treatment
result from GI bleeding, internal or ex- Emergency treatment relies on prompt
ternal hemorrhage, or any condition and adequate blood and fluid replace-
that reduces circulating intravascular ment to restore intravascular volume
volume or causes significant loss of and raise blood pressure and maintain
other body fluids. it above 60 mm Hg. Rapid infusion of
Other causes include intestinal ob- normal saline or lactated Ringer’s solu-
struction, peritonitis, acute pancreatitis, tion and possibly albumin or other
ascites, and dehydration as a result of plasma expanders may expand volume
excessive perspiration, severe diarrhea adequately until packed cells can be
or protracted vomiting, diabetes in- matched.
sipidus, diuresis, and inadequate fluid Other measures include administra-
intake. tion of oxygen, control of bleeding, ad-
ministration of dopamine or another
Signs and symptoms inotropic drug and, possibly, surgery.
The patient’s history includes a condi- (To be effective, dopamine and other
tion that reduces blood volume, such inotropic drugs must be used with vig-
as GI hemorrhage, trauma, or severe orous fluid resuscitation.)
diarrhea and vomiting. A patient with
cardiac disease may have anginal pain. Nursing interventions
Examination may show pale skin, ◆ Check for a patent airway and ade-
decreased sensorium, and rapid, shal- quate circulation. If the patient experi-
low respirations. Urine output is usual- ences cardiac or respiratory arrest, start
ly less than 25 ml/hour. Palpation may cardiopulmonary resuscitation.
show rapid, thready peripheral pulses ◆ Begin an I.V. infusion with normal
and cold, clammy skin. Auscultation of saline or lactated Ringer’s solution.
blood pressure usually detects a mean ◆ Monitor the patient’s central venous
arterial pressure of less than 60 mm Hg pressure, right atrial pressure, pulmo-
and a narrowing pulse pressure. nary artery pressure, pulmonary artery
Laboratory findings may include wedge pressure (PAWP), and cardiac
low hematocrit; decreased hemoglobin output at least once hourly or as
level, red blood cell count, and platelet ordered.
646 Complications
◆ Monitor urine output hourly. If out- Causes

put falls below 30 ml/hour in an adult, Open pneumothorax may be caused by
increase the fluid infusion rate, but penetrating chest injury (such as a
watch for signs of fluid overload such gunshot or knife wound), insertion of a
as elevated PAWP. Notify the physician central venous catheter, chest surgery,
if urine output doesn’t increase. transbronchial or closed pleural biopsy,
◆ Obtain arterial blood gas (ABG) or thoracentesis. Closed pneumothorax
samples, as ordered. Administer oxy- may be caused by blunt chest trauma,
gen by face mask or through an estab- air leakage (from ruptured, congenital
lished airway to ensure adequate tissue blebs adjacent to the visceral pleural
oxygenation. Adjust the oxygen flow space), rupture of emphysematous bul-
rate according to the ABG measure- lae, barotrauma as a result of mechani-
ments. cal ventilation, tubercular or cancerous
◆ Record the patient’s blood pressure, lesions that erode into the pleural
pulse and respiratory rates, and periph- space, or interstitial lung disease. Ten-
eral pulse rates every 15 minutes until sion pneumothorax may be caused by
they are stable. Monitor the patient’s a penetrating chest wound treated with
cardiac rhythm continuously. an airtight dressing, puncture of the
◆ Notify the physician and increase lung or airway by a fractured rib, me-
the infusion rate if the patient has a chanical ventilation, high-level positive
progressive drop in blood pressure ac- end-expiratory pressure that causes
companied by a thready pulse. alveolar blebs to rupture, or occlusion
◆ Obtain a complete blood count, or malfunction of a chest tube.
electrolyte levels, typing and cross-
matching, and coagulation studies, as Signs and symptoms
ordered. The patient history shows sudden,
◆ During therapy, assess the patient’s sharp, pleural pain. The patient may
skin color and temperature, and note report that the pain is exacerbated by
changes. chest movement, breathing, and cough-
◆ Watch the patient for signs of iming. He may also report shortness of
pending coagulopathy. breath.
Examination shows asymmetrical
movement of the chest wall, with over-
Pneumothorax expansion and rigidity on the affected
side. The patient may appear cyanotic.
Pneumothorax is characterized by an If he has tension pneumothorax, he
accumulation of air or gas between may have distended jugular veins and
the parietal and visceral pleurae. The pallor, and he may exhibit anxiety.
amount of air or gas trapped in the Palpation may show crackling be-
intrapleural space determines the de- neath the skin, indicating subcuta-
gree of lung collapse. The most com- neous emphysema and decreased vocal
mon types of pneumothorax are open, fremitus. If the patient has tension
closed, and tension. Many factors pneumothorax, palpation may show
contribute to pneumothorax. If left tracheal deviation away from the af-
untreated, extensive pneumothorax fected side (a late sign) and a weak
and tension pneumothorax can lead and rapid pulse. Percussion may show
to fatal pulmonary and circulatory hyperresonance on the affected side,
collapse. and auscultation may disclose de-
creased or absent breath sounds over
Septic shock 647
the collapsed lung. The patient may ◆ Monitor the patient for complica-
also be hypotensive. Spontaneous tions signaled by pallor, gasping respi-
pneumothorax that releases only a rations, and chest pain.
small amount of air into the pleural ◆ Carefully monitor the patient’s vital
space may not cause any signs or signs at least once every hour for indi-
symptoms. cations of shock, increasing respiratory
distress, or mediastinal shift. Auscul-
Treatment tate breath sounds over both lungs.
Chest X-rays confirm the diagnosis. ◆ Make sure the suction setup is func-
Other supportive diagnoses include an tioning appropriately. Monitor the pa-
early decline in pulse oximetry read- tient for signs of tension pneumotho-
ings and hypoxemia and respiratory rax. If he doesn’t have a chest tube to
acidosis, as shown by arterial blood suction, monitor him for recurrence of
gas studies. Treatment is conservative pneumothorax and recollapse of the
(bed rest, oxygen administration, aspi- lung.
ration of air with a large-bore needle
and, possibly, insertion of a Heimlich
valve) for patients with spontaneous Septic shock
pneumothorax and no signs of in-
creased pleural pressure, lung collapse Usually caused by a bacterial infection,
of less than 30%, and no dyspnea or septic shock causes inadequate blood
other indications of physiologic com- perfusion and circulatory collapse. Un-
promise. less treated promptly (preferably before
For patients with lung collapse of symptoms fully develop), it progresses
more than 30%, treatment to reexpand to multisystem organ dysfunction syn-
the lung includes placing a thoracosto- drome or death within a few hours in
my tube in the second or third inter- up to 80% of cases. Septic shock usu-
costal space in the midclavicular line. ally occurs in hospitalized patients, es-
The tube is then connected to an un- pecially men older than age 40 and
derwater seal or low-pressure suction. women ages 25 to 45.
Recurring spontaneous pneumotho-
rax requires thoracotomy and pleurec- Causes
tomy. Traumatic pneumothorax and Many gram-positive and gram-negative
tension pneumothorax require chest bacteria as well as actinomycetes can
tube drainage; traumatic pneumothorax cause septic shock. Preexisting infec-
may also require surgical repair. An tions caused by viruses, rickettsiae,
analgesic may be prescribed. chlamydiae, and protozoa may be com-
plicated by septic shock. Other predis-
Nursing interventions posing factors include immunodeficien-
◆ Listen to the patient’s fears and cy, advanced age, cirrhosis, trauma,
concerns, and offer reassurance, as burns, diabetes mellitus, and dissemi-
appropriate. nated intravascular coagulation.
◆ Keep the patient as comfortable as
possible, and administer an analgesic, Signs and symptoms
if necessary. Clinical effects of septic shock vary ac-
◆ Help the patient to a comfortable cording to the stage of the shock, the
position. Many patients with pneu- causative organism, and the age of the
mothorax feel most comfortable sitting patient. Early signs and symptoms in-
upright. clude oliguria, sudden fever (higher
648 Complications
than 101º F [38.3º C]), chills, nausea, ◆ Measure hourly urine output. Watch
vomiting, diarrhea, and prostration. the patient for signs of fluid overload
Late signs and symptoms include rest- such as increased PAWP.
lessness, apprehension, irritability, ◆ If urine output is less than 30 ml/
thirst as a result of reduced perfusion hour, increase the fluid infusion rate.
of cerebral tissue, hypothermia, anuria, Notify the physician if urine output
tachycardia, and tachypnea. doesn’t improve. A diuretic may be or-
Age alert Hypotension, altered dered to increase renal blood flow and
level of consciousness, and hy- urine output.
perventilation may be the only signs ◆ Monitor arterial blood gas (ABG)
of septic shock in infants and elderly studies. Administer oxygen by face
patients. mask or through an airway. Adjust the
oxygen flow rate according to ABG
Treatment measurements.
The first goal of treatment is to moni- ◆ If the patient’s blood pressure drops
tor and reverse shock through volume below 80 mm Hg, increase the oxygen
expansion. I.V. fluids are administered, flow rate and notify the physician im-
and a pulmonary artery catheter is in- mediately.
serted. Whole blood or plasma may be ◆ Record the patient’s blood pressure,
administered to raise the pulmonary pulse and respiratory rates, and periph-
artery wedge pressure (PAWP) to a sat- eral pulses every 5 minutes until his
isfactory level. An I.V. antibiotic is giv- condition is stabilized. Record hemody-
en, and a urinary catheter is inserted namic pressure readings every 15 min-
to monitor hourly output. Mechanical utes. Monitor cardiac rhythm continu-
ventilation may be necessary. ously.
If shock persists after fluid infusion, ◆ Provide emotional support to the
a vasopressor is given to help the pa- patient and his family.
tient maintain adequate blood perfu- ◆ Document the occurrence of a noso-
sion. Other treatments may include comial infection, and report it to the
giving I.V. bicarbonate to correct acido- infection-control nurse.
sis and administering drotrecogin alfa
(activated) (Xigris) in progressing mod-
erate or severe sepsis. Other treatments Spinal cord compression
to combat infection include surgery to
drain and excise abscesses and de- Compression of the spinal cord can af-
bridement. fect the patient’s ability to perform ac-
tivities of daily living. The onset and
Nursing interventions severity of symptoms vary with the eti-
◆ Remove I.V., intra-arterial, or uri- ology of the compression; onset may
nary drainage catheters, and send them be acute (traumatic injury) or insidious
to the laboratory for culture for (tumor growth). Outcome depends on
causative organisms. the nature of the compression and how
◆ Start an I.V. infusion of normal saline promptly the diagnosis is made.
solution or lactated Ringer’s solution.
◆ Administer an antibiotic I.V. to Causes
achieve effective blood levels rapidly. Traumatic injury is the most common
Monitor serum drug levels. cause of spinal cord compression. Hy-
perflexion injuries usually result from
Spinal cord compression 649
sudden deceleration and usually affect Specific treatment depends on the type
the cervical region. Hyperextension in- of injury; treatment may be surgical,
juries cause more damage because the nonsurgical, or a combination. If
spine swings through a larger arc, surgery is indicated, it’s usually to de-
making cord compression more likely. crease compression and stabilize the
Rotational injuries result from extreme spine.
lateral flexion. Compression injuries re- Treatment of spinal tumors — which
sult from extreme vertical pressure, may include radiation, chemotherapy,
usually caused by a long fall. and surgery — depends on the type and
Spinal cord tumors are less common location of the tumor as well as the ra-
than other types of tumors. They are pidity of onset of symptoms.
usually benign, located in the thoracic
region, and extradural. Nursing interventions
◆ In patients with traumatic injury,
Signs and symptoms perform physical assessments each
Clinical effects of spinal cord compres- time the vital signs are assessed and
sion are related to the level of the in- each time the patient is moved. Hy-
jury. Usually, sudden, complete com- potension is common if the patient’s
pression causes loss of movement, head is raised above the level of his
spinal reflexes, and pain sensation be- heart.
low the level of the lesion. Bowel and ◆ Pay special attention to the patient’s
bladder dysfunction may also occur, respiratory status, especially if he has a
along with inability to perspire and cervical lesion; measure the patient’s
regulate body temperature below the vital capacity and tidal volume fre-
level of the lesion. Incomplete, acute quently.
traumatic compression may result in ◆ Maintain a patent airway and suc-
any combination of these symptoms. tion as needed; perform chest physio-
(For more information, see Functional therapy frequently.
loss from spinal cord injury, pages 650 ◆ Instruct the patient to cough and
and 651.) perform deep-breathing exercises every
With spinal cord tumors, the loca- 2 hours.
tion of symptoms is related to the level ◆ Provide range-of-motion exercises,
of the lesion. Pain is the most common and encourage the patient to partici-
initial symptom, along with coldness pate as much as his function allows.
and numbness. Motor weakness usual- ◆ Reposition the patient every 2
ly occurs along with sensory loss. Loss hours, and provide meticulous skin
of sphincter control may occur; bladder care.
control is usually affected before bowel ◆ Administer an analgesic and a mus-
control. cle relaxant, as ordered. Monitor the
patient for oversedation.
Treatment ◆ Monitor the patient’s intake and
For traumatic injury, treatment begins output to assess the fluid balance. En-
with immediate stabilization followed sure adequate oral intake.
by the basic goals of decompression, ◆ Provide emotional support and en-
realignment, and further stabilization. couragement to the patient and his
A 24-hour regimen of high-dose methyl family. Help enhance the patient’s ca-
prednisolone (Medrol) is currently rec- pabilities.
ommended to improve motor function ◆ Assist with arrangements and
and sensation by decreasing edema. follow-up for rehabilitation.
650 Complications
Functional loss from spinal cord injury
Functional losses as a result of spinal cord Level C6

injury include variable losses of motor ◆ Loss of all function below the shoulders;
function, deep tendon reflexes, sensory no elbow, forearm, or hand control
function, respiratory function, and bowel ◆ Loss of deep tendon reflexes in the
and bladder function, depending on which biceps
vertebral level is affected. ◆ Loss of sensation below the clavicle and
in most of the chest, abdomen, and upper
Level C1 to C4 and lower extremities
◆ Complete loss of motor function below ◆ Phrenic nerve intact, but not the inter-
the neck costal and abdominal muscles
◆ No reflex loss ◆ Loss of bowel and bladder control
◆ Loss of sensory function in the neck and
below Level C7
◆ Loss of involuntary and voluntary respi- ◆ Loss of motor control to portions of the
ratory function arms and hands
◆ Loss of bowel and bladder control ◆ Loss of deep tendon reflexes in the tri-
ceps
Level C5 ◆ Loss of sensation below the clavicle and
◆ Loss of all motor function below the up- in portions of the arms and hands
per shoulders ◆ Phrenic nerve intact, but not the inter-
◆ Loss of deep tendon reflexes in the bi- costal and abdominal muscles
ceps ◆ Loss of bowel and bladder function
◆ Loss of sensation below the clavicle and
in most of the chest, abdomen, and upper Level C8
and lower extremities ◆ Loss of motor control to portions of the
◆ Phrenic nerve intact, but not the inter- arms and hands
costal and abdominal muscles ◆ Loss of deep tendon reflexes in the tri-
◆ Loss of bowel and bladder control ceps
Causes
Syndrome of inappropriate Most commonly, SIADH results from
antidiuretic hormone secretion bronchogenic carcinoma of the lung;
the tumor secretes excessive ADH or
Syndrome of inappropriate antidiuretic vasopressor-like substances. Other neo-
hormone (SIADH) secretion is marked plastic diseases (such as pancreatic
by excessive release of antidiuretic hor- and prostatic cancer, Hodgkin’s dis-
mone (ADH), which disturbs the fluid ease, and thymoma) may also trigger
and electrolyte balance. Such distur- SIADH.
bances result from an inability to ex- Additional causes include central
crete dilute urine, retention of free wa- nervous system disorders, pulmonary
ter, expansion of extracellular fluid vol- disorders, positive-pressure ventilation,
ume, and hyponatremia. The syndrome drugs, and miscellaneous conditions,
occurs as a result of diseases that affect such as myxedema and psychosis.
the osmoreceptors of the hypothala-
mus.
Syndrome of inappropriate antidiuretic hormone secretion 651
◆ Loss of sensation below the chest and in Level L1 to L3

portions of the hands ◆ Loss of control of most of the leg and
◆ Phrenic nerve intact, but not the inter- pelvis
costal and abdominal muscles ◆ Loss of the knee-jerk reflex
◆ Loss of bowel and bladder function ◆ Loss of sensation to portions of the
lower legs, ankles, and feet
Level T1 to T6 ◆ No interference with respiratory function
◆ Loss of all motor function below the mid- ◆ Loss of bowel and bladder control
chest region, including the trunk muscles
◆ No reflex loss Level L3 to L4
◆ Loss of sensation below the midchest ◆ Loss of control of portions of the lower
area legs, ankles, and feet
◆ Independent function of the phrenic ◆ Loss of the knee-jerk reflex
nerve ◆ Loss of sensation to portions of the low-
◆ Some impairment of the intercostal and er legs, ankles, and feet
abdominal muscles ◆ No interference with respiratory function
◆ Loss of bowel and bladder function ◆ Loss of bowel and bladder control
Level T6 to T12 Level L4 to L5

◆ Loss of motor control below the waist ◆ Varying extent of loss of motor control
◆ No reflex loss ◆ Loss of the ankle-jerk reflex (S1, S2)
◆ Loss of all sensation below the waist ◆ Loss of sensation in the upper legs and
◆ No interference with respiratory function portions of the lower legs (lumbar sensory
◆ Impairment of the abdominal muscles, nerves) and in the lower legs, feet, and per-
leading to diminished cough ineum (sacral sensory nerves)
◆ Loss of bowel and bladder control ◆ No interference with respiratory function
◆ Possible impairment of bowel and blad-
der control
Signs and symptoms than 20 mEq/L) without a diuretic.

SIADH may cause weight gain despite Other diagnostic studies show normal
appetite loss, nausea and vomiting, renal function and no evidence of de-
muscle weakness, restlessness and, hydration.
possibly, seizures and coma. Edema is
rare unless water overload exceeds 4 L, Treatment
because much of the excess free water Treatment begins with restricted fluid
exists within cellular boundaries. intake (17 to 34 oz [503 to 1,005 ml]/
SIADH is suggested by a complete day). With severe water intoxication,
medical history that shows a positive administration of 200 to 300 ml of 3%
water balance. The diagnosis is con- to 5% sodium chloride solution may
firmed by the finding of serum osmo- be needed to increase the serum sodi-
lality of less than 280 mOsm/kg of wa- um level. If fluid restriction is ineffec-
ter and a serum sodium level of less tive, demeclocycline or lithium may be
than 123 mEq/L. Other laboratory val- given to help block the renal response
ues that support the diagnosis include to ADH. When possible, treatment
high urine sodium secretion (more should include correcting the root
652 Complications
cause of SIADH. If the syndrome is re- acidosis, stroke, myocardial infarction,

lated to cancer, the water retention pulmonary embolism, sudden discon-
may be relieved by surgery, irradiation, tinuation of antithyroid medication,
or chemotherapy. initiation of 131I therapy, preeclampsia,
and subtotal thyroidectomy with excess
Nursing interventions intake of synthetic thyroid hormone.
◆ Restrict fluids, and provide comfort
measures for thirst, including ice chips, Signs and symptoms
mouth care, lozenges, and staggered Initially, the patient may have marked
water intake. tachycardia, vomiting, and stupor. Oth-
◆ Reduce unnecessary environmental er findings include irritability and rest-
stimuli, and orient the patient as need- lessness, visual disturbances such as
ed. diplopia, tremors and weakness, angi-
◆ Provide a safe environment for the na, shortness of breath, cough, and
patient who has an altered level of swollen extremities. Palpation may
consciousness (LOC). Take seizure pre- show warm, moist, flushed skin and a
cautions, as needed. high fever (101º F [38º C] or greater)
◆ Monitor the patient’s serum osmo- that begins insidiously and rises rapid-
lality and serum and urine sodium lev- ly to a lethal level.
els.
◆ Closely monitor and record the pa- Treatment
tient’s intake and output, vital signs, Treatment of thyroid storm includes ad-
and daily weight. ministration of an antithyroid drug I.V.,
◆ Perform neurologic checks at least propranolol to block the sympathetic
every 2 to 4 hours, depending on the effects, a corticosteroid to inhibit con-
patient’s status. Look for and report version of the thyroid hormone thyrox-
early changes in LOC. ine (T4) to triiodothyronine (T3) and to
◆ Observe the patient for signs and replace depleted cortisol levels, and io-
symptoms of heart failure, which may dide to block the release of T4. Sup-
occur as a result of fluid overload. portive measures include administra-
tion of nutrients, vitamins, fluids, and
a sedative.
Thyroid storm
Also known as thyrotoxic crisis, thy- ◆ Monitor the patient’s vital signs,
roid storm is an acute manifestation of electrocardiogram readings, and car-
hyperthyroidism. It usually occurs in diopulmonary status continuously. As-
patients with preexisting (although typ- sess the patient for changes in level of
ically unrecognized) thyrotoxicosis. If consciousness.
thyroid storm isn’t treated promptly, ◆ Expect to administer an antithyroid
hypotension, vascular collapse, coma, medication and a beta-adrenergic
and death may occur. blocker to inhibit sympathetic effects.
Monitor the patient’s response to med-
Causes ications.
Onset is almost always abrupt and is ◆ Administer a corticosteroid to inhib-
evoked by a stressful event, such as it the conversion of T4 and to replace
trauma, surgery, or infection. Less depleted cortisol, as ordered. Antici-
common causes include insulin- pate administering iodide to block the
induced hypoglycemia or diabetic keto- release of thyroid hormones.
Tracheal erosion 653
◆ Monitor the patient’s temperature vessels are injured; it may be severe

closely. Apply cooling measures, if in- and can result in death if erosion pene-
dicated, and administer acetamino- trates the adjacent neck vessels. In pa-
phen, as ordered. Never administer as- tients receiving mechanical ventilation,
pirin because it may increase the pa- a persistent air leak may indicate tra-
tient’s metabolic rate further. cheal dilation and possible erosion.
◆ Institute safety measures, including Tracheal erosion should be suspected
seizure precautions, to protect the pa- when the patient aspirates food or flu-
tient from injury. id, especially during prolonged tracheal
◆ Provide supportive care, and admin- and NG intubation.
ister vitamins, nutrients, fluids, and a
sedative, as ordered. Treatment
Treatment is primarily limited to allow-
ing the affected area to heal sponta-
Tracheal erosion neously. For injury caused by traumatic
intubation, removal of the tube is de-
Tracheal erosion is damage to the tra- sirable. Otherwise, pressure on the ero-
cheal lumen that occurs through me- sion site can be reduced by deflation of
chanical or chemical irritation. Tissue the cuff, recannulation with a smaller
destruction usually progresses from in- airway, or replacement of a standard
terior to exterior tracheal structures, tracheostomy tube with a dual cuffed
but it also may be caused or abetted by or longer tube. Removal of an NG tube
external pressure, especially to the pos- limits friction on the trachea. A gastric
terior tracheal wall. tube may be inserted to promote de-
compression or provide nutrition. An
Causes antibiotic may be given to treat infec-
Chemical injury to the tracheal tissues tion and promote healing.
occurs as epithelial cells and submucos-
al structures are destroyed by inhala- Nursing interventions
tion of toxic substances (such as smoke ◆ Make sure that the endotracheal or
and corrosive gases) and by direct burn tracheal tube is the correct size, to
injury. Edema and inflammation also avoid placing unnecessary pressure on
occur. Mechanical injury occurs when a the tracheal wall.
foreign body is lodged in the airway; it ◆ Stabilize airway tubes to prevent ir-
may be accompanied by inflammation. ritation caused by movement.
In the clinical setting, tracheal ero- ◆ Maintain lateral wall pressures for
sion usually results from traumatic nonatmospheric tubes at less than
intubation with a cuffed or uncuffed 18 mm Hg.
tracheal or endotracheal tube. High- ◆ Suction only as necessary, using a
pressure, low-volume cuffed tubes are vacuum with less than 120 mm Hg of
most likely to cause damage. pressure. Never force a suction catheter
Concomitant use of a nasogastric against resistance.
(NG) tube places additional friction on ◆ Use small-bore NG or gastric tubes
the tracheal muscle, internally and ex- to prevent erosion.
ternally, increasing the risk of tracheo- ◆ If a fistula is suspected, discontinue
esophageal fistula. NG intubation and notify the physi-
cian.
Signs and symptoms
Hemoptysis is the most common sign.
Bleeding may be scant if only surface
16 End-of-life care
Caring for the dying patient
and his family
The dying process 655

Cardiovascular system 655
Integumentary system 655
Respiratory system 655
Musculoskeletal system 655
Renal system 655
Other signs and symptoms 655
Five signs of impending death 655
Meeting patient and family needs 656
Meeting patient needs 656
Meeting family needs 657
654
The dying process 655
The experience of dying is unique for ◆ Dyspnea or air hunger

each patient and family. Nurses must ◆ Tachypnea
discover what each dying patient and ◆ Irregular breathing, or Cheyne-
his family need. What are they afraid Stokes respirations
of? What do they need to know? What
will help them? It’s important to help Musculoskeletal system
both the patient and his family prepare
for the dying process. ◆ Muscle weakness
◆ Drooping of the mouth
◆ Difficulty swallowing
The dying process ◆ Relaxation of the tissues of the soft
palate
The dying process is a total body sys- ◆ Decline in the gag reflex and reflex-
tem failure. Although each patient’s ive clearing of the oropharynx
death progresses differently, the dying
process usually occurs over 10 to 14 Renal system
days, but can take as little as 24 hours.
The following is a summary of the ef- ◆ Decreased urine output
fect of the dying process on each body ◆ Urinary incontinence
system.
Other signs and symptoms
Cardiovascular system
◆ Moaning and grunting with breathing
◆ Decreasing need for food and drink ◆ Agitation and restlessness
◆ Dehydration ◆ Decreased communication (“transi-
◆ Initial increase in the heart rate, tional withdrawal” as a result of the
followed by a decrease as hypoxia body failing)
develops ◆ Decreased hearing and vision
◆ Decrease in blood pressure and the ◆ Confusion
volume of Korotkoff sounds ◆ Difficulty rousing the patient
◆ Visions of people and things not
Integumentary system visible to others
◆ Bowel incontinence
◆ Perspiration
◆ Cold, clammy skin Five signs of impending death
◆ Pale, ashen, or mottled skin
◆ Darkened skin at the sacrum and ◆ Clouding of consciousness
lower back ◆ Death rattle
◆ Blanching of the skin when touched, ◆ Mandibular movement on respiration
with little or no return of color ◆ Cyanosis of the extremities
◆ No pulse in the radial artery
Respiratory system
◆ Diminished or adventitious breath

sounds
◆ Moist-sounding respirations
656 End-of-life care
Meeting patient and family

needs
Meeting patient needs
Care of the dying patient should be individualized to meet each patient’s unique
needs. This chart identifies some specific interventions to help the patient during the
dying process.
INTERVENTIONS RATIONALES
◆ Keep the blankets and ◆ The patient’s slowing metabolic rate decreases the
sheets loose and untucked. amount of heat coming from the body. The patient feels
Don’t apply extra blankets. cold to the touch, but the core temperature stays normal
(unless infection is present).
◆ For acute air hunger or ◆ Morphine changes the patient’s perception of breath-
tachypnea, morphine or an- lessness and decreases anxiety. It dilates the pulmonary
other opioid is indicated. vessels, decreases oxygen consumption, and decreases
pulmonary congestion.
◆ Don’t routinely apply ◆ Air hunger associated with the dying process usually
oxygen. Instead, promote doesn’t respond to oxygen, and the cannula may not stay
air movement with a fan or on because of the patient’s restlessness. However, air
open windows. Provide movement can stimulate trigeminal nerve receptors in
space around the bed for air the cheek and nasopharynx that cause the brain stem to
to move freely. inhibit the sensation of difficulty breathing.
◆ Assess the dying patient ◆ Secretions accumulate in the oropharynx or bronchi as

before suctioning. Reposi- death approaches. Suctioning may not relieve the loud,
tion the patient on his side, gurgling sound, or “death rattle.” These secretions are
and elevate the head of the hard to reach, and suctioning may cause discomfort.
bed. Anticholinergics and
antispasmodics may help
decrease secretions.
◆ Perform frequent pain ◆ Opioid requirements are unique for each patient and
assessment, even during the situation. Pain must be assessed and managed through-
patient’s last hours. If possi- out the dying process. Titrate analgesics according to the
ble, ask the patient what his goals of care, the severity of pain, the need for supple-
goal is for pain relief. mental analgesics, the adverse side effects, the patient’s
functional abilities (sleep, mobility, interaction with oth-
ers), the patient’s emotional state, and the effect of pain
on the patient’s quality of life.
◆ Identify the cause of agi- ◆ The team must identify the cause of agitated behavior.
tation or restlessness. Anxiety, depression, and delirium can all occur in the dy-
ing patient and require different interventions.
Meeting patient and family needs 657
Meeting patient needs (continued)
INTERVENTIONS RATIONALES
◆ When assessing the pa- ◆ In many cases, delirium is reversible if the cause is
tient for delirium, review the identified. Medications are a common cause of delirium.
onset of symptoms of deliri- Other causes include sepsis, encephalopathy, involve-
um with family members. ment of the central nervous system by a tumor, metabol-
ic changes, and organ system failure. Delirium can be
treated with cause-specific interventions, pharmacologi-
cally, or with palliative sedation, as appropriate.
◆ Accommodate changes in ◆ Hearing is believed to be the last sense that’s lost as

hearing and vision. Don’t dying occurs. Whispering may cause increased strain on
say anything near the pa- the patient as his hearing diminishes. Changes in vision
tient that you don’t want include increased sensitivity to light and loss of visual
him to hear. Avoid whisper- acuity.
ing. Provide dim lighting,
but ensure that it’s bright
enough to allow the patient
to recognize faces.
Meeting family needs Teaching

◆ Discuss the signs of imminent death
Meeting family needs is as important as with the family before they occur.
meeting the needs of the dying patient. ◆ Encourage family members to stay
In many cases they may not be pre- with the patient if they wish.
pared to be losing their loved one, par- ◆ Support family members who don’t
ticularly in instances of sudden acci- wish to be present.
dents or the death of a young person. ◆ Teach the family simple techniques
In other cases, such as with long ill- to help keep the patient comfortable,
nesses, the family may be more pre- such as helping to turn the patient, us-
pared. Regardless, ask the family mem- ing pillows for positioning, giving
bers what their specific needs are. Do mouth care, and performing gentle
this early, and be sure to include all massage. Offer this teaching only if the
family members. family is comfortable with it.
◆ Does the family have questions ◆ When the patient’s words and state-
about the benefits and disadvantages ments are unclear, work with the fami-
of artificial nutrition and hydration? ly members to determine what the pa-
◆ Do they have concerns about pain tient is trying to communicate.
relief for the patient? ◆ Explain to the family that some dy-
◆ Do they want to be present at the ing patients appear to see and hear
time of death? someone or something that isn’t visible
◆ How involved do they want to be or audible to others in the room. Often,
with the patient’s physical care? dying patients see visions of someone
◆ What do they need to know? who has died or of comforting figures.
658 End-of-life care
Care after death

◆ Ask if the family needs the support
of a clergy member.
◆ Express sympathy for the family.
◆ Bathe and handle the body accord-
ing to the family’s wishes. Some cul-
tures have rules and rituals for treat-
ment of the body.
◆ Always treat the body with respect.
◆ Don’t remove the body until the
family is ready.
◆ Ask if the family needs assistance in
contacting the funeral director.
◆ Ensure that the patient’s personal
possessions and valuables are given to
the family.
Documentation
17 systems
Completing forms fully and concisely
Traditional narrative charting 660

Problem-oriented medical record 662
Problem-intervention-evaluation system 663
FOCUS charting 665
Charting-by-exception 666
FACT documentation 667
Core charting 670
Outcome documentation 671
Computerized charting 673
Nursing Minimum Data Set program 674
Nursing Outcomes Classification system 674
Voice-activated systems 674
659
Documentation refers to the prepara- medical record (POMR), problem-

tion and maintenance of records that intervention-evaluation (PIE), FOCUS,
describe a patient’s care. If you docu- charting-by-exception (CBE), FACT, core,
ment with attention to detail, you’ll and outcome documentation systems. In
clearly show the quality of care your addition, many heath care facilities use
patient received, the outcome of that computerized charting systems.
care, and the treatment he still needs.
The detailed information you as- Traditional narrative charting
semble will be scrutinized by many re-
viewers, including other health care Narrative charting is a straightforward
team members; accrediting, certifying, chronological account of the patient’s
and licensing organizations; perfor- status, the nursing interventions per-
mance improvement monitors; peer re- formed, and the patient’s response to
viewers; and Medicare and insurance those interventions that is suitable in
company reviewers. Attorneys and any clinical setting. Documentation is
judges may also examine your docu- usually included in the progress notes
mentation. Researchers and educators and is supplemented by flow sheets.
may use it to improve patient care and The Joint Commission standards re-
to provide continuing education. quire all health care facilities to set
Although each health care facility policies on how frequently patients
determines its own requirements for should be assessed. Document patient
documentation and evaluation, those assessments as often as your institution
requirements must comply with legal, requires and more frequently when you
accreditation, and professional stan- observe any of the following:
dards. ◆ change in the patient’s condition
Similarly, a nursing department can ◆ patient’s response to a treatment or
select the documentation system it medication
wants to use as long as the system ◆ lack of improvement in the patient’s
demonstrates adherence to standards condition
and care requirements. Regardless of ◆ patient’s or family member’s re-
the documentation system used, specif- sponse to teaching.
ic policies and procedures for docu- Document exactly what you hear,
mentation must be in place and observe, inspect, do, or teach. Include
known. Understanding them will help as much specific, descriptive informa-
you document care accurately. It will tion as possible. Always document
also serve you well when evaluating or how your patient responds to care,
modifying your documentation system treatments, and medications and his
or when selecting a new one. progress toward the desired outcome.
Depending on the policies of your Also include notification to the physi-
health care facility, you’ll use one or cian for changes that have occurred.
more documentation systems to record Document this communication, the
your nursing interventions and evalua- physician’s response, new orders that
tions and the patient’s response. are followed, and the patient’s response.
Health care facilities may use tradi- You can organize your notes by us-
tional narrative charting or an alterna- ing a head-to-toe approach or by refer-
tive system, such as problem-oriented
Traditional narrative charting 661
ring to the care plan and documenting narrative note, be specific and
the patient’s progress in relation to the document chronologically, recording
plan and any unresolved problems. Re- exact times.
gardless of the way you organize your
__________________________________________________________________
11/26/09 2255 Patient 4 hr postop; awakens easily, oriented X 3 but
__________________________________________________________________
groggy, incision site in front of Ø ear extending down
__________________________________________________________________
and around the ear and into neck — approximately 6Ç in
__________________________________________________________________
length — without dressing. No swelling or bleeding,
__________________________________________________________________
bluish discoloration below Ø ear noted, sutures intact.
__________________________________________________________________
Jackson-Pratt drain in Ø neck below ear with 20-ml
__________________________________________________________________
bloody drainage measured. Drain remains secured in
__________________________________________________________________
place with suture and anchored to Ø anterior chest
__________________________________________________________________
wall with tape. Pt. denied pain but stated she felt
__________________________________________________________________
nauseated and promptly vomited 100 ml of clear fluid.
__________________________________________________________________
Pt. attempted to get OOB to ambulate to bathroom with
__________________________________________________________________
assistance, but felt dizzy upon standing. Assisted to lie
__________________________________________________________________
down in bed. Voided 200 ml clear, yellow urine in
__________________________________________________________________
bedpan. Pt. encouraged to deep breathe and cough qhr,
__________________________________________________________________
and turn frequently in bed. Lungs sound clear
__________________________________________________________________
bilaterally. Antiembolism stockings applied to both lower
__________________________________________________________________
extremities. Explanations given regarding these
__________________________________________________________________
preventive measures. Pt. verbalized understanding.
______________________ Bridget Smith, RN
__________________________________________________________________
__________________________________________________________________
2300 Pt. continues to feel nauseated. Compazine 1 mg I.V.
______________________ Bridget Smith, RN
__________________________________________________________________
__________________________________________________________________
2335 Pt. states she’s no longer nauseated. No further
__________________________________________________________________
vomiting. Rating pain in incisional areas as 7/10, on a
__________________________________________________________________
scale of 0 to 10. Medicated with morphine 2 mg I.V.
______________________ Bridget Smith, RN
__________________________________________________________________
__________________________________________________________________
2355 Pt. states pain as 1/10. Demonstrated taking deep
breaths and coughing effectively. _____________
__________________________________________________________________
_______________________Bridget Smith, RN
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Problem-oriented medical record Progress notes

Typically you must write a note for
The POMR system focuses on specific each current problem every 24 hours or
patient problems. Developed by physi- when the patient’s condition changes.
cians and later adapted by nurses, SOAP, SOAPIE, or SOAPIER is used to
POMR has five components: the data- structure progress notes. If you have
base, problem list, initial plan, progress nothing to record for a component,
notes, and discharge summary. simply omit the letter from the note.
The components of SOAPIER include:
Database ◆ Subjective data: chief complaint or
Subjective and objective data about other information the patient or family
the patient form the initial care plan. members tell you
These data are collected during the ini- ◆ Objective data: factual, measurable
tial assessment of the patient and in- data, such as observable signs and
clude such information as reason for symptoms, vital signs, or test values
hospitalization or treatment, medical ◆ Assessment data: conclusions based
history, allergies, medications, physical on subjective and objective data and
and psychosocial findings, self-care formulated as patient problems or
abilities, educational needs, and dis- nursing diagnoses
charge planning concerns. ◆ Plan: strategy for relieving the pa-
tient’s problems, including short- and
Problem list long-term actions
A numbered list of the patient’s current ◆ Interventions: measures you’ve tak-
problems in chronological order ac- en to achieve expected outcomes
cording to the date each was identified ◆ Evaluation: analysis of the effective-
provides an overview of the patient’s ness of your interventions
health status. You can refer to it by ◆ Revision: changes from the original
number when writing your notes. care plan.
When a problem is resolved, note the
date and time and highlight the prob- Discharge summary
lem with a felt-tip pen. This covers each problem on the list
and notes whether it was resolved. Dis-
Initial plan cuss any unresolved problems and
This includes expected outcomes and specify plans for dealing with the prob-
plans for further data collection, pa- lems after discharge. Also record com-
tient care, and teaching. Involve pa- munications with other facilities, home
tients and significant others in plan- health agencies, and the patient.
ning and setting goals.
Problem-intervention-evaluation system 663
11/26/09 2400 #1 Nausea related to anesthetic. _______________

_________________________________________________________________
S: Pt. states, åI feel nauseated.Ç _______________
_________________________________________________________________
O: Pt. vomited 100 ml of clear fluid at 2255. ______
_________________________________________________________________
A: Pt. is nauseated. ______________________
_________________________________________________________________
P: Monitor nausea and give antiemetic as necessary. ___
_________________________________________________________________
I: Pt. given Compazine 1 mg. I.V. at 2300. ________
_________________________________________________________________
E: Pt. states she’s no longer nauseated at 2335. _____
_________________________________________________________________
#2 Risk for infection related to incision sites. _____
_________________________________________________________________
_________________________________________________________________
O: Incision site in front of Ø ear extending down and
_________________________________________________________________
around the ear and into neck — approximately 6Ç in length
_________________________________________________________________
— without dressing. No swelling or bleeding, bluish
_________________________________________________________________
discoloration below Ø ear noted, sutures intact. Jackson-
_________________________________________________________________
Pratt drain in Ø neck below ear with 20-ml bloody
_________________________________________________________________
drainage. Drain remains secured in place with suture.
A: No infection at present. _________________
_________________________________________________________________
_________________________________________________________________
P: Monitor incision sites for redness, drainage, and
_________________________________________________________________
swelling. Monitor JP drain output. Teach pt. S&S of
_________________________________________________________________
infection prior to discharge. Monitor temperature.
#3 Delayed surgical recovery. ________________
_________________________________________________________________
_________________________________________________________________
O: Pt. oriented x 3 but groggy. Pt. attempted to get OOB
_________________________________________________________________
at 2245 to ambulate to bathroom but felt dizzy upon
standing. Lungs sound clear bilaterally. ___________
_________________________________________________________________
_________________________________________________________________
A: Pt. is dizzy when getting OOB. Pt. needs post-op edu-
_________________________________________________________________
cation about mobility and coughing and deep-breathing
exercises. ____________________________
_________________________________________________________________
_________________________________________________________________
P: Allowed pt. to use bedpan. Assist in getting OOB in 1
_________________________________________________________________
hour by dangling legs on side of bed for a few minutes
_________________________________________________________________
before attempting to stand. Monitor blood pressure.
_________________________________________________________________
Teach patient how to get out of bed slowly to prevent
_________________________________________________________________
dizziness and to ask for assistance. Teach coughing and
_________________________________________________________________
deep breathing, turning, use of antiembolism stockings.
_________________________________________________________________
I: Allowed pt. to lie down in bed after feeling dizzy. Pt.
_________________________________________________________________
used bedpan and voided 200 ml clear, yellow urine at
_________________________________________________________________
2245. Assisted in coughing and deep-breathing exercises
_________________________________________________________________
and taught about turning, use of antiembolism stockings.
E: Lungs remain clear bilaterally. ______________
_________________________________________________________________
#4 Acute pain related to surgical incision. ________
_________________________________________________________________
_________________________________________________________________
S: 2245 pt. states åNoÇ when asked if she has pain. At
2335 pt. states åIt hurts.Ç __________________
_________________________________________________________________
_________________________________________________________________
O: Pt. reports incisional pain as 7/10 on scale of 0 to 10.
A: Pt. is in pain and needs pain medication. _______
_________________________________________________________________
P: Give pain meds as ordered. _______________
_________________________________________________________________
I: Pt. given morphine 2 mg I.V. at 2335. ________
_________________________________________________________________
E: Pt. states pain as 1/10. ________ Bridget Smith, RN
_________________________________________________________________
Problem-intervention-evaluation progress notes eliminates the need for

system a separate care plan and provides a
record that has a nursing — rather than
The PIE system organizes information medical — focus.
according to patients’ problems. It re- The daily assessment flow sheet in-
quires that you keep a daily assess- cludes areas for documenting assess-
ment flow sheet and progress notes. In- ment of major categories, such as res-
tegrating the care plan into the nurses’ piration or pain, along with routine
care and monitoring. It usually pro- menting a problem in the progress

vides spaces to document times treat- notes, label it as P and number it; for
ments were given as well as continued example, P#1. This way you can refer
assessments of a specific area such as to it later by number without having to
neurologic checks every hour. Progress re-document the problem statement.
notes are organized according to PIE:
Intervention
Problem Document the nursing actions you take
Use data collected from your initial as- for each nursing diagnosis. Label each
sessment to identify pertinent nursing entry as I followed by P and the prob-
diagnoses. Use the list of nursing diag- lem number; for example, IP#1.
noses accepted by your facility, which
usually corresponds to the diagnoses Evaluation
approved by the North American Nurs- The patient’s response to treatment
ing Diagnosis Association (NANDA). makes up your evaluation. Use the la-
Some facilities use a separate problem bel E followed by P and the problem
list such as in the POMR. When docu- number; for example, EP#1.
11/26/09 2400 P#1: Nausea related to anesthetic. _____________

__________________________________________________________________
IP#1: Pt. given Compazine 1 mg I.V. at 2300. ______
__________________________________________________________________
__________________________________________________________________
EP#1: Pt. vomited 100-ml clear fluid at 2255. Pt. now
states no nausea after given Compazine. _________
__________________________________________________________________
P#2: Risk for infection related to incision sites. ____
__________________________________________________________________
__________________________________________________________________
IP#2: Drainage from Jackson-Pratt drain measured. Site
__________________________________________________________________
monitored for redness, drainage, and swelling.
Temperature monitored. __________________
__________________________________________________________________
__________________________________________________________________
EP#2: Incision site in front of Ø ear extending down
__________________________________________________________________
and around the ear and into neck — approximately 6Ç in
__________________________________________________________________
length — without dressing. No swelling or bleeding, bluish
__________________________________________________________________
discoloration below Ø ear noted, sutures intact. JP drain
__________________________________________________________________
in Ø neck below ear with 20 ml of bloody drainage. Drain
__________________________________________________________________
remains secured in place with suture.
P#3: Delayed surgical recovery. ______________
__________________________________________________________________
__________________________________________________________________
IP#3: At 2245 assisted patient getting back in bed and
__________________________________________________________________
using bedpan after attempting to get up. Explained to pt.
__________________________________________________________________
how to dangle legs and get OOB slowly. Assisted with and
__________________________________________________________________
taught about coughing and deep-breathing exercises,
__________________________________________________________________
turning, and use of antiembolism stockings. Assessed
breath sounds. ________________________
__________________________________________________________________
__________________________________________________________________
EP#3: Pt. reported feeling dizzy after first attempt to
__________________________________________________________________
get OOB. Pt. did coughing and deep-breathing exercises
effectively, and lungs sound clear bilaterally. ______
__________________________________________________________________
P#4: Acute pain related to surgical incision._______
__________________________________________________________________
__________________________________________________________________
IP#4: Assessed pain as 7 on scale of 0 to 10. Gave pt.
morphine 2 mg I.V. at 2335. _______________
__________________________________________________________________
__________________________________________________________________
EP#4: Prior to med. administration, pt. reported pain as
7/10. Now pt. reports pain as 1/10. __________
__________________________________________________________________
_______________________ Bridget Smith, RN
__________________________________________________________________
FOCUS charting 665
FOCUS charting the data category, include subjective

and objective information that de-
FOCUS charting is organized into scribes the focus. In the action catego-
patient-centered topics, or foci. It en- ry, include immediate and future nurs-
courages you to use assessment data ing actions based on your assessment
to evaluate these concerns. of the patient’s condition and any
Use a progress sheet with columns changes to the care plan you deem
for the date, time, focus, and progress necessary based on your evaluation. In
notes. In the focus column, write each the response category, describe the pa-
focus as a nursing diagnosis, a sign or tient’s response to nursing or medical
symptom, a patient behavior, a special care. Using all three categories ensures
need, an acute change in the patient’s concise documentation based on the
condition, or a significant event. In the nursing process. All other routine
progress notes column, organize infor- nursing tasks and assessment data can
mation using three categories: data be documented on flow sheets and
(D), action (A), and response (R). In checklists.
__________________________________________________________________
Date Time Focus Progress notes
__________________________________________________________________
11/26/09 2400 Nausea D: Pt. states she’s nauseated. Vomited 100-ml clear
related to fluid at 2255. _____________________
__________________________________________________________________
__________________________________________________________________
anesthetic. A: Given Compazine 1 mg I.V. at 2300.
__________________________________________________________________
R: Pt. reports no further nausea at 2335. No
further vomiting. ___________________
__________________________________________________________________
__________________________________________________________________
Risk for D: Incision site in front of Ø ear extending down
__________________________________________________________________
infection and around the ear and into neck — approximately
__________________________________________________________________
related to 6Ç in length — without dressing. Jackson-Pratt
__________________________________________________________________
incision drain in Ø neck below ear secured in place with
suture. __________________________
__________________________________________________________________
sites.
__________________________________________________________________
A: Assessed site and emptied drain. Taught patient
S&S of infection. ____________________
__________________________________________________________________
__________________________________________________________________
R: No swelling or bleeding; bluish discoloration
__________________________________________________________________
below Ø ear noted. JP drained 20-ml bloody
drainage. Pt. states understanding of teaching.___
__________________________________________________________________
__________________________________________________________________
Delayed D: Pt. reported dizziness after trying to get OOB
to use the bathroom. _________________
__________________________________________________________________
surgical
__________________________________________________________________
recovery A: Assisted patient back in bed and with use of
__________________________________________________________________
bedpan. Taught pt. how to dangle legs and get
__________________________________________________________________
OOB slowly. Also taught coughing and deep-
__________________________________________________________________
breathing exercises, turning in bed, and use of
antiembolism stockings. ________________
__________________________________________________________________
__________________________________________________________________
R: Pt. voided 200 ml in bedpan. Did coughing and
__________________________________________________________________
deep breathing appropriately. Lungs clear
bilaterally. Using antiembolism stockings. ______
__________________________________________________________________
Acute pain D: Pt. reports pain as 7/10 on 0 to 10 scale.___
__________________________________________________________________
related to A: Given morphine 2 mg I.V. at 2335. _______
__________________________________________________________________
R: Pt. reports pain as 1/10 at 2355. ________
__________________________________________________________________
surgical
___________________ Bridget Smith, RN
__________________________________________________________________
incision.
Charting-by-exception ment, you can check mark the category

and add your initials. If your findings
CBE radically departs from traditional aren’t within normal limits or don’t
systems by requiring documentation of match the previous assessment, put an
only significant or abnormal findings in asterisk in the box and document your
the narrative portion of the record. To findings in the comment section or other
use CBE documentation effectively, you designated area such as the progress
must know and adhere to established notes. (See Nursing care flow sheet for
guidelines for nursing assessments and charting-by-exception.)
interventions and follow written stan-
dards of practice that identify the Graphic record
nurse’s basic responsibilities. You docu- This flow sheet is used to document
ment only deviations from the stan- trends in vital signs, weight, intake and
dards. Guidelines for interventions come output, and activity level. As with the
from nursing diagnosis-based standard- nursing care flow sheet, use check
ized care plans, patient care guidelines, marks and initials to indicate expected
physician’s orders, incidental orders, findings and use asterisks to indicate
and standards of nursing practice. abnormal findings. Record abnormali-
The CBE format involves the use of ties in the nurses’ progress notes.
a nursing diagnosis–based standardized
care plan and several types of flow Patient-teaching record
sheets: Use this form to track and document
patient teaching, including who and
Nursing diagnosis–based what is being taught, and document
standardized care plans outcomes. Include teaching resources,
These preprinted care plans are used social and behavioral measures, dates
when you identify a nursing diagnosis. when goals are met, and other perti-
They allow members of the nursing nent observations.
team to share information about the
patient’s care needs, which helps to en- Patient discharge note
sure that those needs are met. The care This form may be used to document on-
plans document changes in a patient’s going discharge planning. A typical dis-
condition, adjustments or additions to charge form includes places to document
nursing diagnoses, and the patient’s re- patient instructions, appointments for
sponse to treatment. Individualize your follow-up care, medication and diet in-
plan in the blank spaces provided. structions, signs and symptoms to report,
level of activity, and patient education.
Nursing care flow sheet
This form is used to document your as- Progress notes
sessments and interventions and is usu- The progress notes are used to docu-
ally designed for a 24-hour period. Af- ment revisions to the care plan and in-
ter completing an assessment, compare terventions that don’t lend themselves
your findings with the normal parame- to any of the flow sheets. Since most
ters defined in the printed guidelines on flow sheets should have areas in which
the form. Also compare your assess- to document abnormal findings, the
ment findings with the previous nurse’s progress notes typically contain few as-
notes to see if the patient’s condition sessment and intervention data. In ad-
has changed. If your findings are within dition, you may need to supplement
normal parameters and haven’t your CBE documentation with nurses’
changed since the last nursing assess- progress notes.
FACT documentation sheets documenting the patient’s con-

dition and responses, and Timely en-
The FACT documentation system, which tries recorded when care is given.
incorporates many CBE principles, has FACT requires that you document only
four key elements: Flow sheets, Assess- exceptions to the norm or significant
ments with baseline parameters, Con- information about the patient. (See
cise integrated progress notes and flow Documenting with FACT, page 669.)
Nursing care flow sheet for charting-by-exception
Hour 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400
Bed rest BS BS BS
OOB BS*
Ambulate (assist)
Ambulatory
ACTIVITY
Sleeping
BRP
HOB elevated
Cough, deep-breathe, turn BS BS BS BS BS BS
ROM:
Bath
Shave
HYGIENE
Oral
Skin care
Active
Perianal care Passive
Diet Sips of liquid

NUTRITION
% Eating
Feeding
Supplemental
S=Self, A=Assist, F=Feed
Catheter
BLADDER
Incontinent
Voiding Clear yellow at 2245
Intermittent cath.
Stools (OB+, OB–)
BOWEL
Incontinent
Normal
Enema
Special mattress
SPECIAL TREATMENTS
Special bed
Heel and elbow pads
Antiembolism stockings BS BS BS BS BS BS
Traction: + = on, – = off
Isolation type
(continued)
Nursing care flow sheet for charting-by-exception (continued)
ASSESSMENT FINDINGS
Key:
Day Evening Night ✓ = normal findings
* = significant finding
Neurologic ✓
BS
Cardiovascular ✓
BS
Pulmonary ✓
BS
Gastrointestinal * vomited X 1 at 2255. Given Compazine 1mg I.V.
º relief. ___________________
Genitourinary ✓
BS
Surgical dressing * Incision Ø ear around ear into neck 6Ç
and incision BS Jackson-Pratt drain, 20-ml bloody drainage.
Skin integrity ✓
BS
Psychosocial ✓
BS
Educational * Taught C&DB, use of antiembolism stockings,
BS and OOB slowly º legs dangling first. ___
Peripheral ✓
vascular BS
Signatures Bridget Smith, RN
NORMAL ASSESSMENT FINDINGS

Neurologic Gastrointestinal Skin integrity
• Alert and oriented to time, • Abdomen soft and nondis- • Skin color normal
place, and person tended • Skin warm, dry, and intact
• Speech clear and understand- • Tolerates prescribed diet • Moist mucous membranes
able without nausea or vomiting Psychosocial
• Memory intact • Bowel movements within own • Interacts and communicates in
• Behavior appropriate to normal pattern and consisten- an appropriate manner with
situation and accommodation cy others
• Active range of motion (ROM) Genitourinary
of all extremities; symmetri- Educational
• No indwelling catheter in use • Patient or significant others
cally equal strength • Urinates without pain
• No paresthesia communicate understanding
• Undistended bladder after of the patient’s health status,
Cardiovascular urination care plan, and expected re-
• Regular apical pulse • Urine clear yellow to amber sponse
• Palpable bilateral peripheral color • Patient or significant others
pulses Surgical dressing and incision demonstrate ability to perform
• No peripheral edema • Dressing dry and intact health-related procedures and
• No calf tenderness • No evidence of redness, in- behaviors as taught
Pulmonary creased temperature, or ten- Peripheral vascular
• Resting respirations 10 to 20 derness in surrounding tissue • Affected extremity pink, warm,
per minute, quiet and regular • Sutures, staples, Steri-Strips and movable within average
• Clear sputum intact ROM
• Pink nail beds and mucous • Sound edges well approximat- • Capillary refill time < 3 sec-
membranes ed onds
• No drainage present • Peripheral pulses palpable
• No edema: sensation intact
without numbness or pares-
thesia
• No pain on passive stretch
Documenting with FACT
Developed in 1987 at Abbott Northwestern Hospital in Minneapolis, the FACT documen-

tation system records nursing assessment findings and interventions that are exceptions
to the norm. This sample shows portions of an assessment flow sheet and a postopera-
tive flow sheet using the FACT format.
ASSESSMENT AND ACTION RECORD
Date 11/26/09 11/26/09 11/26/09

Time 2245 2335 2355
Neurologic
Alert and oriented to time, place, and person. PEARL.
Symmetry of strength in extremities. No difficulty with ✓ ✓ ✓
coordination. Behavior appropriate to situation. groggy
Sensation intact without numbness or paresthesia.
Orient patient.
Refer to neurologic flow sheet.
Pain
No report of pain. If present, include patient statements ✓ 7/10 1/10
about intensity (0 to 10 scale), location, description,
duration, radiation, precipitating and alleviating factors.
Location incision incision
Relief measures MSO4 2 mg
I.V.
Pain relief: Y = Yes N = No Y
Cardiovascular
Apical pulse 60 to 100. S1 and S2 present. Regular rhythm.
Peripheral (radial, pedal) pulses present. No edema or calf
✓ ✓ ✓
tenderness. Extremities pink, warm, movable within
patient’s range of motion (ROM).
I.V. solution and rate
Respiratory
Respiratory rate 12 to 20 at rest, quiet, regular, and ✓ ✓
nonlabored. Lungs clear and aerated equally in all lobes.
No abnormal breath sounds. Mucous membranes pink.
O2 therapy
TCDB/Incentive spirometer ✓ ✓
Musculoskeletal
Extremities pink, warm, and without edema; sensation OOB dizzy
}
and motion present. Normal joint ROM, no swelling or BR ✓

}
tenderness. Steady gait without aids. Pedal, radial puls-

es present. Rapid capillary refill.
Activity (describe) BR BR
Nurse’s signature and title Bridget Smith, RN Bridget Smith, RN Bridget Smith, RN
Key: ✓ = Meets assessment criteria

FACT documentation begins with a

complete initial baseline assessment on ______________________________
11/26/09 2400 D: Pt. states she’s
______________________________
nauseated. Vomited
each patient using standardized para- ______________________________
100-ml clear fluid at
meters. This format involves an assess- 2255.___________
______________________________
ment-action flow sheet, a frequent as- ______________________________
A: Given Compazine 1 mg
sessment flow sheet, and progress I.V. at 2300. ______
______________________________
notes. Flow sheets cover 24- to 72-hour ______________________________
R: Pt. reports no further
______________________________
nausea at 2335. No
periods. Always include the date and ______________________________
further vomiting.
time and sign all entries. ____ Bridget Smith, RN
______________________________
Assessment-action flow sheet
Use this form to document ongoing as-
sessments and interventions. Normal Core charting
assessment parameters for each body
system are printed on the form along Core charting focuses on the nursing
with planned interventions. Individual- process — the core, or most important
ize the flow sheet according to patient part of documentation. It consists of a
need. In the appropriate place on the database, a care plan, flow sheets,
form (next to “normal”), check off as- progress notes, and a discharge sum-
sessment or interventions done, or use mary. Core charting requires that you
the space provided to document abnor- assess and record a patient’s functional
malities or completed interventions and cognitive status within 8 hours of
that are different from those printed on admission. The database and care plan
the form. are used as the initial assessment and
focus on the patient’s body systems
Frequent assessment flow sheet and activities of daily living. They in-
Use this form to chart vital signs and clude a summary of the patient’s prob-
frequent assessments. For example on lems and appropriate nursing diag-
a surgical unit this form would include noses. Flow sheets are used to docu-
a postoperative assessment section. ment the patient’s activities and
response to nursing interventions, diag-
Progress notes nostic procedures, and patient teach-
This form includes an integrated ing. Progress notes contain information
progress record on which you’ll use for each problem organized in a DAE
narrative notes to document the pa- (data, action, evaluation or response)
tient’s progress and any significant in- format. Finally, the discharge summary
cidents. As with FOCUS charting, write includes information related to nursing
narrative notes using the data-action- diagnosis, patient teaching, and follow-
response method. Update progress up care.
notes related to patient outcomes every
48 hours or as required by your facility.
Outcome documentation 671
__________________________________________________________________
11/26/09 2400 D: Pt. states being nauseated. Vomited 100-ml clear fluid at
2255. _________________________________
__________________________________________________________________
A: Given Compazine 1 mg I.V. at 2300. _____________
__________________________________________________________________
__________________________________________________________________
E: Pt. reports no further nausea at 2335. No further
vomiting. _______________________________
__________________________________________________________________
__________________________________________________________________
D: Incision site in front of Ø ear extending down and around
__________________________________________________________________
the ear and into neck — approximately 6Ç in length — without
__________________________________________________________________
dressing. Jackson-Pratt drain in Ø neck below ear secured in
place with suture. __________________________
__________________________________________________________________
__________________________________________________________________
A: Assessed site and emptied drain. Taught patient S&S of
infection. _______________________________
__________________________________________________________________
__________________________________________________________________
E: No swelling or bleeding; bluish discoloration below Ø ear
__________________________________________________________________
noted. JP drained 20-ml bloody drainage. Pt. states
understanding of teaching. ____________________
__________________________________________________________________
__________________________________________________________________
D: Pt. reported dizziness after trying to get OOB to use the
bathroom. ______________________________
__________________________________________________________________
__________________________________________________________________
A: Assisted patient back in bed and with use of bedpan. Taught
__________________________________________________________________
pt. how to dangle legs and get OOB slowly. Also taught
__________________________________________________________________
coughing and deep-breathing exercises, turning in bed, and use
of antiembolism stockings.______________________
__________________________________________________________________
__________________________________________________________________
E: Pt. voided 200 ml in bedpan. Did coughing and deep
__________________________________________________________________
breathing appropriately. Lungs clear bilaterally. Using
antiembolism stockings. _______________________
__________________________________________________________________
D: Pt. reports pain as 7/10 on 0 to 10 scale. __________
__________________________________________________________________
A: Given morphine 2 mg I.V. at 2335. ______________
__________________________________________________________________
E: Pt. reports pain as 1/10 at 2345. _____ Bridget Smith, RN
__________________________________________________________________
Outcome documentation Care plan

The care plan establishes priorities,
Outcome documentation presents the identifies expected outcomes and nurs-
patient’s condition in relation to prede- ing interventions, and documents the
termined outcomes on the plan of care, plan. Traditional handwritten plans,
focusing on desired outcomes rather preprinted standardized plans, clinical
than problems. This system uses pathways, and patient care guidelines
progress notes, flow sheets, and plans can be used.
of care. Some facilities use a separate
teaching plan. (See Multidisciplinary Expected outcome statements
patient-family education record, page Expected outcomes describe the de-
672.) Outcome documentation features sired results of nursing actions. Be spe-
these components: cific and use outcome criteria that are
measurable and include target dates or
Database times. Learning outcomes focus on pa-
This includes subjective and objective tient behaviors that are measurable
data identifying the patient’s problems and observable. Outcomes are evaluat-
and learning needs, and is a founda- ed; if problems are resolved, outcomes
tion for ongoing evaluation. are met. When outcomes aren’t met,
the plan is reevaluated. (See Writing
expected outcomes and outcome crite-
ria, page 673.)
Multidisciplinary patient-family education record

This sample shows the features of a typical multidisciplinary patient-family ed-
ucation record.
INITIAL EDUCATIONAL EVALUATION

Date/Time 11/21/09 2255
Motivational level: P = Patient F = Family

P/F Asks questions
____ P/F
____ Eager to learn ____ Very anxious
____ Uninterested ____ Denies need for education ____ Not appropriate for education
Barrier to education: ✓ No barrier identified

____
____ Visual deficit ____ Auditory deficit ____ Physical deficit
____ Religious barrier ____ Cultural barrier ____ Dexterity deficit
____ Language barrier ____ Language spoken
Care after surgery

Special learning needs ________________________________________________
Community resources discussed:

____ Cardiac support ____ Twelve-step program ____ Cancer support
____ Hospice ____ Achievement center ____ Diabetic support
____ Other ________________________________________________________
DATE/INITIAL TOPIC PT FAM RESPONSE

CODE
11/22/09 BS Pt. oriented to room postoperatively.________ ✓ ✓ 2, 6
11/22/09 BS Explained purpose of Jackson-Pratt drain.____ ✓ ✓ 2, 6
11/22/09 BS Instructed pt. on use of pain scale to report pain. ✓
11/22/09 BS Instructed pt. on coughing and deep-breathing ✓ ✓ 1, 3, 5
exercises. _________________________
11/22/09 BS Instructed pt. on use of antiembolism stockings, ✓ 5, 6
turning, & getting OOB slowly. ____________
11/23/09 DR Instructed pt. on how to empty JP drain herself.___ ✓ ✓ 2, 6

11/23/09 DR Instructed pt. on S&S of infection to report to MD. ✓ ✓ 2, 6
Response codes:
1 Received literature 4 Prior experience 7 Referral indicated
2 Communicates understanding 5 Returned demo 8 Refused/Uninterested
3 Requires reinforcement 6 Education achieved 9 Inappropriate for education
Initials Signature - Status Initials Signature - Status

BS Bridget Smith, RN
DR Daniella Reams, RN
Computerized charting 673
Writing expected outcomes and outcome criteria
Here are two examples of how to develop patient-focused outcomes and outcome crite-
ria based on selected nursing diagnoses.
NURSING EXPECTED OUTCOME

DIAGNOSIS OUTCOMES CRITERIA
Risk for infection Patient won’t develop ◆ Patient states signs and symptoms to
related to incision postoperative wound report to MD on discharge.
infection ◆ Patient demonstrates incision care.
◆ Patient demonstrates emptying of JP
drain.
Acute pain related Pain will be reduced by ◆ Patient rates less pain using a numer-
to effects of sur- time of discharge. ical scale (for example, if patient had rat-
gery ed pain as 8 on scale of 1 to 10, any re-
duction in pain would be a rating of less
than 8).
◆ Patient expresses pain relief.
◆ Patient can perform self-care activities
without assistance.
◆ Patient shows no facial mask of pain.
◆ Patient doesn’t guard incision site.
Computerized charting tient data, such as health status, histo-

ry, chief complaint, and other assess-
Computerized nursing information sys- ment data, the computer system can
tems (NISs) can increase efficiency and flag an entry if the data are outside the
accuracy in all phases of the nursing acceptable range.
process and can help nurses meet stan-
dards set by the American Nurses Asso- Nursing diagnosis
ciation and The Joint Commission. Cur- Most current programs list standard
rent NISs not only collect, transmit, and diagnoses with associated signs and
organize the information, but they can symptoms and can suggest one for
also suggest nursing diagnoses and pro- your patient. You still need to use clini-
vide standardized patient status and cal judgment to determine if the sug-
nursing interventions that you can use gested diagnosis is right for your pa-
for care plans and progress notes. They tient.
are also interactive, prompting you with
questions and suggestions about the in- Planning
formation you enter. Depending on your To help nurses begin writing a care
institution’s software, you might use plan, computer programs can display
computers for these nursing processes: recommended expected outcomes and
interventions for the selected diag-
Assessment noses. You can also use computers to
Admission data can be collected via compare and track patient outcomes
computer terminals. After entering pa- for a selected group of patients.
Implementation prehensive standardized method of

Use the computer to record actual in- measuring nursing-sensitive patient
terventions and patient-processing in- outcomes. The NOC has major implica-
formation, such as discharge or trans- tions for nursing administrative prac-
fer instructions. Progress notes, med- tices and the patient care delivery sys-
ication administration, vital signs, and tem. This system allows the nurse to
treatments can also be documented compare patients’ outcomes to the out-
with the computer. comes of larger groups according to pa-
rameters, such as age, diagnosis, or
Evaluation health care setting.
Use the computer to record evaluations
and reevaluations and your patient’s Voice-activated systems
response to nursing care.
Voice-activated systems are also avail-
Nursing Minimum Data Set able. They are most useful in hospital
program departments, such as the operating
room, that have a high volume of
The Nursing Minimum Data Set structured reports. These software pro-
(NMDS) program attempts to standard- grams use a specialized knowledge
ize nursing information. It contains base, nursing words, phrases, and re-
three categories: nursing care, patient port forms, combined with automated
demographics, and service elements. speech recognition (ASR) technology.
The NMDS allows you to collect nurs- ASR systems require little or no key-
ing diagnosis and intervention data board use and allow the user to record
and identify the nursing needs of vari- prompt and complete nursing notes by
ous patient populations. It also lets you speaking into a telephone handset. The
track patient outcomes. This system system displays the text on the com-
helps establish accurate estimates for puter screen. These systems increase
nursing service costs and provides data the speed of reporting and free the
about nursing care that may influence nurse from paperwork.
health care policy and decision mak-
ing. With the NMDS, you can compare
nursing trends locally, regionally, and
nationally using data from various clin-
ical settings, patient populations, and
geographic areas. By comparing trends,
you can set realistic outcomes for an
individual patient as well as formulate
accurate nursing diagnoses and plan
interventions. Also, NANDA assigns
numerical codes to all nursing diag-
noses so those diagnoses can be used
with the NMDS.
Nursing Outcomes Classification

system
The Nursing Outcomes Classification

(NOC) system provides the first com-
LWBK449-BM_p675-682.qxd 11/16/09 7:44 PM Page 675
Appendices
Selected references
Index
675
Cultural considerations
in patient care
As a health care professional, you in- ◆ Identify any biases and possible
teract with a diverse, multicultural pa- prejudices you may have.
tient population. If not handled proper- ◆ Seek and obtain information about
ly, culture and language differences different cultures and ethnic groups,
can lead to misunderstandings and a including:
lack of compliance and can negatively – nonverbal and verbal communica-
affect patient outcomes. tion practices
To make sure that you give all your – activities of daily living
patients the best care, remember that a – food practices
patient’s cultural behaviors and beliefs – symptom management
may differ from yours. Learn the facts – birth rituals and child care
about diverse population groups, and – death rituals
keep your awareness of cultural differ- – family relationships
ences and your skill with handling – spiritual and religious beliefs
these differences up to date. Doing so – illness beliefs
will help avoid dangerous misunder- – health practices.
standings and ensure that you deliver ◆ Look for opportunities to interact
effective, respectful care to all your with patients from various cultures.
patients. ◆ Perform a cultural-needs assessment
at admission.
– Determine the patient’s ability to
Cultural competence speak and read English, find out what
his native language is, assess his abili-
ty to read lips (if appropriate), and de-
Cultural competence requires sensitivi- cide if you’ll need an interpreter.
ty to issues related to diverse cultures. – Ask the patient how he wants to be
You don’t have to be an expert in other addressed.
cultures to have cultural competence, – Observe the patient’s nonverbal
but you must be willing to learn about communication style, assessing his eye
and interact with patients and families contact, expressiveness, and ability to
from different cultures, social groups, understand common signs and ges-
and races. tures.
Following these guidelines can help – Determine the patient’s social orien-
you provide culturally competent care: tation, including culture, race, ethnici-
◆ Identify your own values and be- ty, family role, work, and religion.
liefs. – Establish the patient’s special com-
◆ Realize that you may have stereo- fort level, particularly in light of his
types about people from countries you conversation, proximity to others, body
aren’t familiar with as well as people movement, and sense of personal
who speak a different primary lan- space.
guage. – Ask about food preferences, family
health history, religious and cultural
676
Cultural considerations in patient care 677
health practices, and definitions of ◆ During the interaction, look at and

health and illness. speak directly to the patient, not the
– Identify the patient’s major support interpreter. Look at and listen to the
people. patient as he speaks.
– Determine if the patient is past- ◆ Avoid body language or gestures
oriented, present-oriented, or future- that may cause offense or be misinter-
oriented. preted.
◆ Periodically assess the patient’s un-
derstanding of what you’ve been dis-
The interpreter’s role cussing by asking him to repeat it back
to you. Avoid asking, “Do you under-
stand?”
Language assistance services should al-
ways be readily available to patients
with limited English proficiency, often
at all points of contact and during all
hours of facility operation. Whenever
possible, use a trained interpreter
rather than a patient’s family member
or friend, according to your facility’s
policy. A family member or friend may
have role conflicts or lack the neces-
sary medical vocabulary; he may also
change the message you’re trying to
convey based on his own perception of
the situation or withhold vital informa-
tion because it might be embarrassing.
Consider these tips when using an
interpreter:
◆ Before beginning, meet with the in-
terpreter to explain the purpose of the
session.
◆ If appropriate, have the interpreter
speak briefly with the patient before-
hand to learn his educational level and
needs.
◆ Instruct the interpreter to interpret
exactly what the patient says and not
to edit or summarize any information.
◆ Expect the session to move more
slowly than a usual interchange be-
cause careful interpretation requires
time.
◆ Speak in short sentences, and avoid
using complex medical terms, slang,
and jargon.
◆ Speak clearly and a little more slow-
ly than normal, but don’t speak more
loudly.
Potential agents of bioterrorism

Listed below are examples of biological agents that may potentially be used as
biological weapons and the major signs and symptoms associated with each.
MAJOR ASSOCIATED SIGNS AND SYMPTOMS
Diarrhea, bloody
Diarrhea, watery
Abdominal pain
Blood pressure,
Dysphagia
Dysarthria
Chest pain
decreased
Back pain
Headache
Dyspnea
Diplopia
Cough
POTENTIAL
Chills
Fever
AGENTS
Anthrax (cutaneous) 䢇䢇
Anthrax (GI) 䢇䢇䢇
Anthrax (inhalation) 䢇䢇䢇䢇䢇䢇
Botulism 䢇䢇䢇䢇
Cholera 䢇䢇
Plague (septicemic) 䢇䢇
Plague (pneumonic) 䢇䢇䢇䢇䢇䢇
Smallpox 䢇䢇䢇䢇
Tularemia 䢇䢇䢇䢇䢇䢇
678
䢇
Hematemesis
䢇
Hemoptysis
䢇
䢇
Lymphadenopathy
䢇
䢇
Malaise
LWBK449-BM_p675-682.qxd
Muscle spasms or
䢇
muscle cramps
䢇
䢇
Myalgias
11/16/09
䢇
Nausea
䢇
Oliguria
䢇
䢇
Slin lesions
7:44 PM
䢇
Ptosis
Skin turgor,
䢇
decreased
Stridor,
Page 679
䢇
decreased
䢇
Tachycardia
Tachypnea
䢇
Vomiting
䢇
䢇
Potential agents of bioterrorism
䢇
䢇
䢇
Weakness
679
Web sites of selected organizations

Agency for Healthcare Research and National Institute of Neurological
Policy Disorders and Stroke
www.ahrq.gov www.ninds.nih.gov
American Association of Critical National Kidney Foundation

Care Nurses www.kidney.org
www.aacn.org
National League for Nursing
American Burn Association www.nln.org
www.ameriburn.org
PubMed
American Cancer Society www.ncbi.nlm.nih.gov/PubMed
www.cancer.org
Sigma Theta Tau International
American Diabetes Association www.nursingsociety.org
www.diabetes.org
U.S. Department of Health and Human
American Heart Association Services
www.americanheart.org www.hhs.gov
American Holistic Nurses’ Association Wound Ostomy and Continence Nurses

www.ahna.org Society
www.wocn.org
American Lung Association
www.lungusa.org
American Nurses Association

www.nursingworld.org
American Pain Society

www.ampainsoc.org
Centers for Disease Control and

Prevention
www.cdc.gov
Centers for Medicare &

Medicaid Services
www.cms.hhs.gov
Intravenous Nurses Society

www.ins1.org
680
Dangerous abbreviations
The Joint Commission approved the following “minimum list” of dangerous ab-
breviations, acronyms, and symbols. Using this list should help protect patients
from the effects of miscommunication in clinical documentation.
ABBREVIATION POTENTIAL PREFERRED TERM

PROBLEM
U (for “unit”) Mistaken as “zero,” “four,” or Write “unit.”

“cc.”
IU (for “international unit”) Mistaken as “I.V.” (intravenous) Write “international unit.”

or “10” (ten).
Q.D., QD, q.d., qd (daily) Mistaken for each other. The Write “daily” and “every other
Q.O.D., QOD, q.o.d., qod period after the Q can be mis- day,” respectively.
(every other day) taken for “I,” and the “O” can
be mistaken for “I.”
Trailing zero (X.0 mg), lack Decimal point is missed. Never write a zero by itself af-
of leading zero (.X mg) ter a decimal point (X mg), and
always use a zero before a
decimal point (0.X mg).
MS, MSO4, MgSO4 Mistaken for each other. Can Write “morphine sulfate” or
mean “morphine sulfate” or “magnesium sulfate.”
“magnesium sulfate.”
© The Joint Commission, 2009. Reprinted with permission.
681
682 Appendices
Selected references
American Association of Critical Care (Supplement) 29(1S):S1-S92, Janu-

Nurses. AACN Procedure Manual for ary/February 2006.
Critical Care, 5th ed. Edited by Lynn- The Joint Commission. National Patient
McHale, D.J., and Carlson, K.K. Safety Goals, 2009. http://www.
Philadelphia: W.B. Saunders, 2005. jointcommission.org/PatientSafety/
American Association of Critical Care NationalPatientSafetyGoals/
Nurses. Advanced Critical Care accessed 5/1/09.
Nursing. Edited by Carlson, K.K. The Joint Commission. Official “Do
Philadelphia: W.B. Saunders, 2008. Not Use” List. http://www.
Baranoski, S., and Ayello, E. Wound jointcommission.org/NR/
Care Essentials: Practice Principles, rdonlyres/2329F8F5-6EC5-
2nd ed. Philadelphia: Lippincott 4E21-B932-54B2B7D53F00/0/dnu_
Williams & Wilkins, 2007. list.pdf accessed 5/5/09.
Berman, A., et al. Kozier & Erb’s Fun- Judge, N.L. “Neurovascular Assess-
damentals of Nursing: Concepts, ment,” Nursing Standard
Process, and Practice, 8th ed. Up- 21(45):39-44, July 2007.
per Saddle River, N.J.: Prentice Karch, A.M. Focus on Nursing Pharma-
Hall Health, 2008. cology, 5th ed., Philadelphia: Lip-
Bickley, L.S. Bates’ Guide to Physical pincott Williams & Wilkins, 2010.
Examination and History Taking, Lilly, L.S., ed. Pathophysiology of Heart
10th ed. Philadelphia: Lippincott Disease, 4th ed. Philadelphia: Lip-
Williams & Wilkins, 2009. pincott Williams & Wilkins, 2006.
Bolton, L. “Compression in Venous Ulcer Lippincott’s Nursing Procedures, 5th
Management,” Journal of Wound, ed. Philadelphia: Lippincott
Ostomy and Continence Nursing Williams & Wilkins, 2008.
35(1):40-49, January/February 2008. McPhee, S.J., and Papadakis, M.A.
Craven, R.F., and Hirnle, C.J. Fundamen- Current Medical Diagnosis and
tals of Nursing: Human Health and Treatment 2010. New York:
Function, 6th ed. Philadelphia: Lip- McGraw-Hill, 2009.
pincott Williams & Wilkins, 2009. Nursing 2010 Drug Handbook.
Fauci, A.S., et al. Harrison’s Principles Philadelphia: Lippincott Williams
of Internal Medicine, 17th ed. New & Wilkins, 2009.
York: McGraw-Hill, 2008. Perioperative Standards and Recom-
Fox, S.I. A Laboratory Guide to Human mended Practices. Denver: Associ-
Physiology: Concepts and Clinical ation of periOperative Registered
Applications, 12th ed. New York: Nurses, Inc., 2009.
McGraw-Hill, 2007. Porth, C.M. Essentials of Pathophysiol-
Fishbach, F.A., and Dunning III, M.B. A ogy: Concepts of Altered Health
Manual of Laboratory and Diagnos- States, 2nd ed. Philadelphia: Lip-
tic Tests, 8th ed. Philadelphia: Lip- pincott Williams & Wilkins 2006.
pincott Williams & Wilkins, 2009. Professional Guide to Diseases, 9th ed.
Hadaway, L. “Infiltration and Extrava- Philadelphia: Lippincott Williams
sation,” AJN 107(8):64-72, August & Wilkins, 2008.
2007. Smeltzer, S.C., et al. Brunner and Sud-
Infusion Nurses Society. “Infusion darth’s Textbook of Medical-Surgical
Nursing Standards of Practice,” Nursing, 11th ed. Philadelphia: Lip-
Journal of Infusion Nursing pincott Williams & Wilkins, 2008.
682
LWBK449-IND_p683-698.qxd 11/16/09 7:44 PM Page 683
Index
A Aerosol spray application, 511

Age/aging
Abbreviations, dangerous, 687
Abdomen, 34–38, 36i, 88–90, 425. See also automated external defibrillation and, 271
specific conditions; specific organs. bed-wetting questions, 39
Abdominal aortic aneurysm, dissecting, 89, 91 blood pressure measurements and, 17
Abdominal reflex, 28, 28i breath sounds and, 21
Abducens nerve (CN VI), 30t hypoglycemia and, 644
Abrasions, wound care, 460t impact on vital signs, 3
Accelerated idioventricular rhythm, 124, 124i interpretation of drug reactions, 568t–569t
Accelerated junctional rhythm, 117, 117i manual ventilation and, 328
Accommodation, assessment of, 22 preoperative care and, 407
Acebutolol hydrochloride (Sectral), 605 response to pain and, 436
Aceta with Codeine, 446t risk of drug hazards and, 626
Acetaminophen (Acephen, Anacin, Tylenol), skin and, 54
228, 440t–441t, 591–592 toilet training questions, 39
Acetylcysteine (Mucomyst, Mucosil, Parv- Agranulocytosis, 555t–556t
olex), 587t, 591–592 Air emboli, 476t, 478t, 503t, 634–635
Achilles reflex, 28 Air-fluidized beds, 454t
Acid-base disorders, 152t, 158–159, 179–180 Airborne precautions, 464
Acid perfusion test, 219 Airways, 3, 74, 76, 283–284
Acne vulgaris, 96, 97 Alanine aminotransferase (ALT), 147
Acoustic nerve (CN VIII), 31t AlaSTAT test, 321
Acquired immunodeficiency syndrome Albumin, transfusion of, 388t–389t
(AIDS), 224–225 Alcohol (ethanol)
Acromegaly, 100 alcoholism, 177, 178
Activities of daily living, assessment of, as drug additive, 624–625
5, 10 drug interactions, 602t, 608, 609t
Acute angle-closure glaucoma, 77, 82 managing acute toxicity, 627t
Acute anxiety attacks, 94 questions on use of, 10
Acute myocardial infarction, 137–139, rubs, 467t
159–161, 161i Aldesleukin (Proleukin), 76
Acute otitis media, 70 Aldosterone, serum, 147–148
Acute pain. See Pain, acute. Aldosterone antagonists, 226
Acute respiratory distress syndrome (ARDS), Aldosteronism, 181
75–76 Alfa-2b interferon, 223
Addison’s disease, 181 Alginate dressings, 456, 457t
Adenosine (Adenocard), 113, 546 Alkaline phosphatase (ALP), 148–149, 610t
Adrenal insufficiency, 102, 177 Alkylating drugs, in MS, 233
Adverse drug reactions, 555–585. See also Allergic reactions, 73, 476t–477t
specific drugs. Alloallergosorbent tests, 321
aging and risk of, 626 Aloe, 614t, 621t
anaphylaxis, reversal of, 566t–567t Alpha-adrenergic blockers, 568t–569t
dizziness and, 74 Alpha-receptor antagonists, 226
drug removal by dialysis, 560t–562t Alternating-pressure air mattresses, 454t
fevers and, 80–81 Alzheimer’s disease, 201–202
interventions, 555t–559t Amantadine, 228
misinterpretation of, 568t–569t Ambulation, postoperative, 424
monitoring for, 509 Amikacin, 410t, 570t–571t
most dangerous drugs, 582 Amiloride hydrochloride (Midamor), 605
nausea and, 88 Amino acid supplements, 250
palpitations and, 94 Aminocaproic acid (Amicar), 587t
papular rash in, 96 Aminoglycosides, interactions, 600t
proteinuria in, 183 Aminosalicylic acid, 258
reporting to the FDA, 582–583 Amiodarone (Cordarone), 113, 114, 115,
substance abuse and, 627–632 120i, 121i, 122, 546
surgery-related risks, 409t–412t heart failure and, 76
vision loss and, 98–99 Ammonia, blood, test interference, 610t
i refers to an illustration; t refers to a table.

683
684 Index
Amobarbital sodium, 629t Anticholinesterase agents, 202

Amoxicillin, 241 Anticoagulant therapy
Amphetamines, 81, 102, 592, 600t, 628t adverse drug reactions, 582
Amphotericin B, 570t–571t for arterial occlusive disease, 203
Amyl nitrate, 587t in embolism prophylaxis, 365
Amylase, serum, 149, 610t in heart failure, 221
Anacin, 444t INR monitoring of, 174–175
Analeptics, overdoses, 592 overdoses, 592–593
Analgesics in pulmonary emboli, 246
adverse drug reactions, 582 in stroke, 256
epidural, 536–537 surgery-related risks, 411t
equianalgesic doses, 552 in thrombophlebitis, 257
interactions with alcohol, 609t Anticonvulsants, 202, 254, 256, 411t,
nonopioid combination drugs, 444t–446t 568t–569t, 582
in osteoarthritis, 237 Antidepressants, 81, 202, 256, 568t–569t, 609t
for pneumonia, 244 Antidotes, administration of, 586
in stroke, 256 Antiembolism stockings, 365
in thrombophlebitis, 257 Antiemetics, 223, 250
Anaphylaxis, reversal of, 566t–567t Antiestrogen therapy, 208
Anemia Antifungal creams, 511
aplastic, 555t Antihistamines, 240, 568t–569t, 593, 609t.
dizziness and, 74 See also specific drugs.
dyspnea and, 77 Antihyperglycemic drugs, oral, 214–215,
fatigue and, 79 568t–569t, 609t
hemolytic, 555t Antihypertensives
iron-deficiency type, 186, 187t adverse drug reactions, 582
nursing interventions, 637t food interactions, 605
palpitations and, 94 surgery-related risks, 411t
in peptic ulcers, 241 Antilipemics, 213
pernicious, 186, 187t Antimalarials, 252
total hemoglobin tests, 168 Antimetabolics, in MS, 233
Anesthetics, review of, 414t–419t Antineoplastic agents, 225, 252. See also
Anexsia, 446t Chemotherapeutic agents.
Angina, chest pain and, 92 Antinuclear antibodies, 150
Angiotensin-converting enzyme inhibitors, Antiparkinsonians, reactions, 568t–569t
221, 226, 235, 568t–569t, 570t–571t, Antiplatelet medications, 203, 213, 256
600t Antipruritics, 250
Angiotensin receptor blockers, 221, 226 Antipsychotics, 568t–569t, 609t, 629t
Ankles, range of motion, 50–51 Antiseptics, hand washing, 467t
Anorexia nervosa, 102 Antitussives, 244
Antacids, 219, 241 Antiviral agents, in Parkinson’s disease, 240
Anterior tibialis muscle, 52 Anxiety, 67–69, 77
Anthrax, cutaneous, 678t–679t Anxiolytics, 202, 609t, 629t
Anthrax, GI, 71, 678t–679t Aortic aneurysms, 92–93
Anthrax, inhalation, 678t–679t Aortic stenosis, arterial waveform, 270i
Anti-inflammatory drugs, 84, 202 Appendicitis, 88, 90
Antianginals, 235, 568t–569t Argyle system, 375
Antianxiety drugs, risks, 409t Arms, 16–17, 22, 67
Antiarrhythmics, 235, 246, 410t, 568t–569t. Arrhythmias. See Cardiac arrhythmias.
See also specific drugs. Arterial blood gas analysis (ABG), 150–152,
Antibiotics, 230–232, 260–262, 410t, 208–209, 216, 243, 246
570t–571t. See also specific antibiotics; Arterial lines, 492t–494t, 495
specific conditions. Arterial occlusive disease, 95, 202–203
Anticholinergics Arterial pressure monitoring, 265–271
adverse reactions, 568t–569t Arterial waveforms, 268i, 270i
in asthma management, 206 Arteriography, 203
in emphysema, 216 Arteriosclerosis, 54
fevers in response to, 80 Arthritis, paresthesia and, 95
heartburn and, 84 Arthroscopy, 237
overdoses, 592 Ascorbic acid (vitamin C), 604
in Parkinson’s disease, 240 Ascriptin, 444t
in peptic ulcers, 241 Aspartate aminotransferase, 152–153, 610t
surgery-related risks, 410t Aspiration pneumonia, 243

Index 685
Aspirin (ASA, Ascriptin, Bufferin), 213, 228, Beta-adrenergic blockers (continued)

229, 235, 407, 440t–441t in heart failure, 221
Aspirin Free Anacin PM, 444t for hypertension, 226
Assessments, 1–61 in myocardial infarction, 235
10-minute, 3–4 Betamethasone, 411t
findings, 62–102 Biceps muscle strength, 51
of pain, 437–439, 437t Biceps reflex, 26, 26i
preoperative, 403–406 Biguanides (metformin), 570t–571t
Asthma, 68, 69–70, 76, 204–206 Bilirubin, serum, 153–154, 610t
Atelectasis, 425, 635–636 Biohazards, disposal, 469–470
Atrioventricular blocks, 125–129, 125i–128i Biologic response modifiers, 233
Atracurium besylate, 420t Bioterrorism, agents of, 678t–679t
Atrial fibrillation, 115, 115i Bispectral index monitoring, 506i
Atrial flutter, 114, 114i Bite wounds, 460t
Atrial tachycardia, 113, 113i Bladder cancer, 85
Atrioventricular (AV) node, 104 Bladder irrigation, continuous, 273–275, 274i
Atropine Blastomycosis, 97
administration of, 546 Blepharitis, 77
for arrhythmias, 108, 109i, 111, 116, 123, 129 Blind finger-sweep, 340
in digoxin overdose, 595 Blood
overdoses, 587t cultures, 243
surgery-related risks, 410t exposures to, 463–464
Auscultation, 8i–9i, 12i–13i, 20–21, 35, 63, transfusion of, 81, 384–393, 386t–387t
65–66 Blood counts, complete, 241
Automated external defibrillators (AEDs), Blood pressure measurement, 16–18, 485t
271–273 Blood urea nitrogen (BUN), 154, 226, 248, 611t
Axilla, examination of, 44–45 Body fluids, 463–464, 470
Body surface area (BSA), 544t, 545t
Bolus thermodilution technique, 280–281
B Bone marrow, 555t–556t, 636–638, 637t
B-type natriuretic peptide, 220 Bone scans, 237, 238, 245
Babinski’s reflex, 28–29, 81, 639 Borrelia burgdorferi, 176
Bacampicillin hydrochloride, 605 Botulism, 678t–679t
Bacillus anthracis, 71 Botulism antitoxin, 588t
Back pain, assessment of, 90–91 Bowel, 35, 89, 314
Bacteremia, 475t–476t Brachial pulse, palpation, 14i, 17
Bacterial conjunctivitis, 78 Brachioradialis reflex, 27
Balance, assessment of, 23 Brain abscesses, 81–82
Ballottement, 6i Brain herniation, 639–640
Barbiturates Brain tumors, 82, 95
adverse reactions, 568t–569t Brawny edema, 15i
drug interactions, 600t–601t Breast cancer, 206–208
hypersensitivity to, 80 Breasts, examination of, 44–45
managing acute toxicity, 629t–630t Breathing
overdoses, 593 assessment of, 3, 20–21, 284
in phenothiazine overdose, 596 deep-breathing exercises, 408–409
review, 416t–417t Bronchial challenge testing, 206
Bariatric surgery, 404t–405t, 422t–423t Bronchiectasis, 71, 86
Barium enemas, 210 Bronchiolitis, 71
Barium swallow testing, 218 Bronchitis, 86, 208–209
Bartholin’s glands, 45 Bronchodilators, 206, 209, 216, 244, 582
Battle’s sign, 81 Bronchogenic carcinoma, 650
Bed-wetting, 39 Bronchoscopy, 243, 258
Bence Jones protein, 183 Brudzinksi’s sign, 22, 82
Benign prostatic hyperplasia, 85 Buccal administration, 524–525
Benzodiazepines, 416t–417t, 593–594, 629t Bundle of His, 104
Benztropine, 596 Burn injuries, 77, 98, 181
Bernstein test, 219 Buspirone hydrochloride (BuSpar), 605
Beta-adrenergic blockers
adverse reactions, 568t–569t
for arrhythmias, 110, 112, 113, 114, 115 C
for coronary artery disease, 213 C-reactive protein, 229
drug interactions, 601t Caffeine (NoDoz), 605

686 Index
Calcitonin (Miacalcin), 519 Cerebral emboli, 255

Calculi, 85, 90 Cerebral hemorrhage, 255
Calcium, serum, 154–155, 238, 611t Cerebral thrombosis, 254–255
Calcium channel blockers, 112, 113, 114, Cerebral vasodilators, 202
115, 213, 226, 235, 568t–569t Cerebrospinal fluid analysis, 156–158,
Calcium glubionate (Neo-Calglucon syrup), 157t–158t, 233
605 Cervical traction, 83
Cancer Chalazion, 77
carcinoembryonic antigen tests, 155–156 Chamomile, 615t, 621t
erythrocyte sedimentation rate in, 163 Charcoal, activated (Acidose-Aqua,
fatigue and, 79 Charcoaid, CharcoCaps, Liqui-Char),
SIADH in, 650 587t, 594, 596–597
spinal cord compression and, 648–649 Charting, 660–666, 667i–668i, 670–674. See
weight loss and, 102 also Documentation.
Candida esophagitis, 75 Chemotherapeutic agents. See also specific
Capital with Codeine, 446t agents; specific cancers.
Capreomycin, 258 bone marrow suppression and, 636, 637
Capsicum, 614t–615t, 621t extravasation antidote, 584t–585t
Captopril (Capoten), 605 fevers in response to, 80
Carbamazepine, 570t–571t, 601t hematuria and, 85
Carcinoembryonic antigen, 155–156, 210 nausea and, 88
Carcinoid syndrome, 71 paresthesia and, 95
Cardiac arrhythmias, 73–74, 77, 94, 108, for prostate cancer, 245
108i, 368–375 weight loss and, 102
Cardiac glycosides, 98, 221, 250, 601t Chest, inspection of, 18–19
Cardiac index, normal, 282 Chest drains, 502t–503t
Cardiac monitoring, 275–280, 277i–278i, Chest pain, assessment of, 92–93
486t–487t Chest physiotherapy, 297–300, 299i
Cardiac output measurement, 280–282 Chest X-rays. See Specific conditions.
Cardiac tamponade, 270i, 640–641 Children
Cardiomyopathies, 159–161, 556t automated external defibrillation in, 271
Cardiopulmonary resuscitation (CPR), blood pressure measurement in, 17
282–286 cardiac index, 282
Cardiovascular devices, troubleshooting, diarrhea in, 73
485t–495t dizziness in, 73
Cardiovascular system eardrop administration, 517
assessments, 11–18, 405–406 estimation of BSA, 545t
care after bariatric surgery, 422t fevers in, 80
cough and, 70 hypoglycemia in, 644
in the dying process, 655 manual ventilation in, 328
Cardioversion, 113, 114, 307, 368–370 needle sizes, 527
Care plans, charting, 666, 667i–668i preoperative care, 407
Carmustine, 601t response to pain by, 436
Carotid Doppler, 256 weight gain in, 101
Carotid pulse, palpation of, 14i Chlordiazepoxide hydrochloride, 604
Catechol-O-methyltransferase inhibitors, 240 Chloride, serum, 158–159, 611t
Cat’s claw, 621t Chlorpromazine, 604, 629t
Cefuroxime axetil (Ceftin), 605 Cholecystitis, 88, 93
Celecoxib, 412t Cholera, 71–72, 678t–679t
Centers for Disease Control and Prevention Cholesterol, serum, 611t
(CDC), 463, 465t–466t Cholesterol, total, 159
Central nervous system depressants, 411t, 594 Cholesterol-lowering drugs, 229
Central venous access devices (CVAD), Cholestyramine, 223, 594
286–291, 290i, 345, 477t–480t Cholinergics, 219
Central venous pressure (CVP) monitoring, Chronic infection, fatigue and, 79
291–297, 293i, 294t–296t Chronic pain. See Pain, chronic.
Cephalosporins, 582, 609t Chylothorax, 477t
Cerebellar function, 23–24 Cimetidine (Tagamet), 411t, 566t
Cerebral aneurysms, 82 Ciprofloxacin (Cipro), 601t, 606
Cerebral angiography, 255 Circulation, assessment of, 3, 284–285
Cerebral blood flow studies, 201, 256 Circulatory overload, 475t
Cerebral degenerative disease, 29 Cirrhosis, nausea and, 88
Cerebral edema, 639 Clarithromycin (Biaxin), 242

Index 687
Click-murmur syndrome, 68
Clindamycin, 231
D
D-zone disk diffusion tests, 231
Clonidine, 512, 601t Daptomycin, 231
Clostridium difficile infection, 72 Darvocet-N, 446t
Clozapine, 572t–573t Death, 655, 656t–657t, 658
Coagulation disorders, 86 Decerebrate posturing, 22, 23i
Cocaine, 76, 592, 630t Decorticate posturing, 22, 23i
Codeine, 440t–441t, 631t Deep-breathing exercises, 408–409, 424
Colds, common, 71 Deep tendon reflexes, 25–28
Colonoscopy, 210–211 Deep vein thrombosis (DVT), 364–367
Colorectal cancer, 210–211 Deferoxamine mesylate (Desferal), 588t
Colostomy care, 300–307, 303i Defibrillation, 307–310
Communications, 4, 5, 677–678 Dehiscence, surgical wounds, 431–433
Complete blood counts, 243 Dehydration, 54, 73, 168, 395
Complications, management, 633–653 Delirium, features of, 24t–27t
Computed tomography (CT), 201, 210, 238, Deltoid muscle strength, 51
246, 255, 258 Demecarium, risks, 412t
Computerized nursing information systems, Demeclocycline hydrochloride (Declomycin),
673–674 605
Congenital rubella, 98 Dementia, features of, 24t–27t
Conjunctivae, 56–57 Depression, features of, 24t–27t, 79, 102
Conjunctivitis, 77–78 Dermatitis, 98
Conn’s syndrome, 148 Dermatologic toxicity, 557t
Constipation, postoperative, 425 Dermatomyositis, 160
Contact lenses, 78–79 Desflurane (Suprane), 416t–417t
Contact precautions, 465 Dexamethasone, 411t
Contaminated equipment, 469 Dexrazoxane (Toltect, Totect), 584t
Continuous mixed venous oxygen satura- Dextroamphetamine sulfate (Dexedrine
tion, 496t–497t elixir), 605, 628t
Contrast media, hypersensitivity, 81 Dextrocardia, 134
Conversion disorder, 68 Dextrose, I.V., 363
Cor pulmonale, 77 Dextrothyroxine sodium (Choloxin), 76
Corneal abrasions, 77, 78 Diabetes mellitus, 79–80, 100, 102, 164–168,
Corneal reflex, assessment, 22 213–214
Coronary angiography, 212 Diabetic ketoacidosis (DKA), 181, 642–643
Coronary artery disease (CAD), 159, 176, Dialysis, 560t–562t, 586
211–213 Diarrhea, 71–73
Corticosteroids. See also specific Diazepam (Valium), 363, 409t, 416t–417t,
conditions. 596, 604
adverse drug reactions, 582 Dicumarol, 606
surgery-related risks, 411t Diet, questions on, 5
therapeutic drug monitoring, 572t–573t Digital rectal examinations, 211, 245
weight gain and, 101 Digoxin (Lanoxin, Lanoxicaps), 83, 113, 115,
Cortisone, risks, 411t 572t–573t, 582, 594–595, 602t, 606
Cough, assessment of, 69–71 Digoxin immune Fab (Digibind), 588t–589t,
Coumadin, risks, 411t 595
Cranial nerve assessment, 29t–32t Dimensional analysis, 542–546
Creams, vaginal, 519–520 Dimetapp Elixir, 609
Creatine kinase, 159–161, 235, 611t Diphenhydramine (Benadryl), 566t, 596
Creatinine, serum, 611t Discharge planning, 433–434
Creatinine clearance, 162–163, 248 Discharge summaries, 662
Cremasteric reflex, 28 Disease transmission, 464–465, 465t–466t
Crohn’s disease, 72, 102 Disseminated intravascular coagulation,
Croup, 87 641–642
Cryoprecipitate transfusion, 390t–391t Disulfiram, 609t
Cryptoheptadine, 101 Diuresis, in drug overdose, 586
Cultural competence, 677–678 Diuretics. See also specific conditions;
Cushing’s syndrome, 181 specific drugs.
Cyclophosphamide, 85, 207 adverse reactions, 568t–569t, 582
Cycloserine, 259 surgery-related risks, 411t
Cyclosporine, 601t therapeutic drug monitoring, 572t–573t
Cystic fibrosis, 71, 86 Divalproex sodium, 580t–581t
Cytomegalovirus, 392

688 Index
Dizziness, 73–74 Drug administration (continued)

Dobutamine, 546–547, 550t nasogastric tube, 523–524
Documentation. See also specific interventions. overdose guidelines, 585–586
charting by exception, 666, 667i–668i pain management, 439, 440t–445t
computerized charting, 673–674 parenteral, 527–535
core charting, 670 patient teaching, 552
FACT system, 667, 669i, 670 precautions, 507–509
FOCUS charting, 665 rectal, 525–529
narrative charting, 660–661 respiratory, 520–522
nursing minimum data set program, 674 sublingual, 524–525
Nursing Outcomes Classification (NOC) tablets, 540
system, 674 topical drugs, 510–511
by outcome, 671–673 transdermal drugs, 511–513
patient-family education record, 672i translingual, 524–525
problem-intervention-evaluation system, vaginal medications, 519–520
663–664 varied concentrations, 541
problem-oriented medical record, Z-track injections, 532–533
662–663 Drug interactions
systems of, 659–674 with alcohol, 608, 609t
voice-activated systems, 674 drug combinations, 600t–604t
Doll’s eye reflex, 22s eye reflex, 22 drugs combined in syringes,
Dopamine, 127, 129, 547, 551t, 593, 602t 598t–624t
Dopamine replacement drugs, 240 with food, 605–608
Doppler use, 310 with herbs, 614t–624t
Dorsal interosseous muscles, 52 interference with tests, 610t–614t
Dorsalis pedis pulse, palpation, 14i monitoring for, 509
Dosage calculations, 538–552 with tobacco, 604–605
Doxorubicin, 207 Duplex ultrasonography, 203, 246, 257
Doxycycline, 231 Dyclonine hydrochloride (Dyclone), 606
Drainage systems, 375–378, 376i Dye dilution test, 280
Dressings Dying, process of, 655, 656t–657t
central venous, 290i Dysphagia, assessment of, 74–75
changing, 290i Dyspnea, 18, 75–77
disposal of, 469–470
for I.V. lines, 352–353
peripheral catheters, 343–345 E
for pressure ulcers, 454–457 Eardrops, 516–517
selection of, 457t Ears, 56–61, 59, 64, 559t
soiled, 469 ECGs. See Electrocardiograms (ECGs).
for surgical wounds, 429–430 Echinacea, 615t, 621t
wound care, 456t Echocardiograms, 203, 212, 235, 246, 256
Dressler’s syndrome, 640 Echothiophate, 412t
Droperidol (Inapsine), 418t–419t Economic function, interview questions, 11
Droplet precautions, 464–465 Ectopic pregnancy, 90
Drug administration. See also specific drugs. Edema, evaluation of, 15i
buccal, 524–525 Edetate calcium disodium, 589t
for code drugs, 546–549, 552 Elbows, range of motion, 47
crushing of drug forms, 563t–565t Elderly patients
dosage calculations, 538–552 eyedrops for, 514–515
drug-alcohol interactions, 608, 609t glaucoma in, 79
drug combinations, 600t–604t needle sizes, 527
drug compatibility in syringes, 598t–624t preventing skin tears, 458t
eardrops, 516–517 response to pain by, 436
enteral, 522–523 septic shock in, 648
equianalgesic doses, 552 skin assessment in, 54
eye medications, 514–515 Electrical axis of the heart, 131, 132i,
guidelines, 507–509 133–134, 133i
intramuscular injections, 530–532 Electrocardiograms (ECGs). See also specific
I.V. bolus injections, 535 conditions.
I.V. drug infusion, 533–535 12-lead, 129–144, 130i, 235
managing drug reactions, 555t–559t 8-step method, 104–106
methods of, 507–537 interpretation of, 103–144, 134–137
nasal medications, 517–519 normal, 104–105, 135i–137i

Index 689
Electrocardiograms (ECGs) (continued) Extremities, assessment of, 403, 405

posterior-lead, leads V7-V9, 140, 140i Eyedrops, 514–515
right-sided, leads V1R-V6R, 140, 140i Eyelids, 56–57
Electrolyte imbalances, 88, 177–178, 314 Eyes
Elimination, interview questions on, 5 assessment of, 56–61
Emphysema, 215–217 interview questions, 56
Emprin with Codeine, 446t medications, 514–516
Encephalitis, 82 movement, 21–22, 57–58, 57i–58i
End-of-life care, 654–658 normal findings, 63–64
End-stage renal disease, 355–359 ocular toxic drugs, 558t–559t
Endotracheal tubes, 379, 500 ophthalmoscopic examination, 58–59
Enflurane (Ethrane), 414t–415t pain, related to, 77–79
Ensure, 609 trauma, 98
Enteral administration, 522–523
Enzyme-inhibiting drugs, 240
Ephedra, 83, 94 F
Epicardial pacing, 370, 373, 374 FACES scale, 437–438
Epididymis, 43 Facial nerve (CN VII), 31t
Epidural analgesics, 536–537 FACT documentation, 667, 669i, 670
Epidural hemorrhages, 82 Factor analysis, 542–546
Epinephrine (adrenalin), 122, 127, 129, 547, Factor labeling, 542–546
549t, 566t–567t, 602t Families, 10–12, 657–658, 672i
Equianalgesic doses, 552 Famotidine (Pepcid oral suspension), 606
Equipment Fat metabolism, 159, 189–190
contaminated, 469 Fatigue, assessment of, 79–80
disposable, 470 FD&C Yellow No. 5, 626
troubleshooting, 471–506 Fecal occult blood, 178
Ergotamine tartrate, 514 Feeding tubes, 311–313, 609
Erythrocyte sedimentation rate, 163 Feet, range of motion, 50–51
Erythrocytes. See Red blood cell count (RBC). Felodipine (Plendil), 606
Erythromycin (Erythrocin, E-Mycin), 410t, Femoral pulse, 14i
602t, 606 Fennel, 621t
Erythropoietin, 250, 572t–573t, 637 Fenoprofen calcium (Nalfon), 606
Escherichia coli 0157:H7, 72 Fentanyl citrate (Sublimaze, Duragesic),
Esgic-Plus, 445t 418t–419t, 442t–443t, 512
Esophageal acidity test, 218 Ferrous sulfate (Feosol, Slow FE), 606
Esophageal cancer, 74, 84 Fever, 54, 76, 80–81
Esophageal manometry, 219 Feverfew, 616t, 622t
Esophagitis, 75 Fick method, 280
Estradiol, transdermal, 512 Filgrastim, 637
Estramustine phosphate sodium (Emcyt), Finger-to-finger movements, 23–24
76, 606 Fingers, range of motion, 48
Estrogens, 163–164, 582 First-degree atrioventricular block, 125, 125i
Ethambutol (Myambutol), 99, 258 Fioricet with Codeine, 446t
Ethanol. See Alcohol (ethanol). Fiorinal, 445t
Ethosuximide, 572t–573t Fiorinal with Codeine, 447t
Etodolac (Lodine), 606 Fiortal, 445t
Etretinate (Tegison capsules), 606 Flaxseed, 622t
Evening primrose, 615t, 621t Flecamide, 115
Evisceration, surgical wounds, 431–433 Flumazenil, 593
Evoked potential studies, 233 Fluoroquinolone antibiotics, 606
Excedrin Extra Strength, 445t Fluorouracil, 207
Excedrin Migraine, 445t Flurbiprofen (Ansaid), 606
Excedrin P.M. Caplets, 445t Foam dressings, 456, 457t
Excretory urography, 210, 226, 245 Foam mattresses, 454t
Exercise FOCUS charting, 665
interview questions on, 10 Folate supplements, 250
postoperative, 408–409 Folliculitis, 97
postoperative complications and, 424 Food, drug interactions, 605–608
Exercise testing, 212 Food and Drug Administration (FDA), 582–583
Extensor hallucis longus strength, 53 Foot cradles, 454t
Extra Strength Tylenol PM, 444t Forearm strength testing, 52
Extravasation, 473t, 503t, 583–585, 584t–585t Foreign bodies, eye, 78

690 Index
Fosinopril sodium (Monopril), 606 Grip strength, 22, 52

Fremitus, tactile, 19 Guaifenesin, 228
Fresh frozen plasma (FFP) transfusion, Guarding, involuntary, 36
388t–389t
Frontal sinuses, inspection, 60
Fungal conjunctivitis, 78 H
Furazolidone, 602t Hallucinogens, toxicity, 631t
Furosemide (Lasix), 411t Halothane, review of, 414t–415t
Furunculosis, 97 Hand hygiene, 467t
Hand rubs, 467t
Hand strength testing, 52
G Hand washing, 463, 467t
Gait, heel-to-toe walking, 23 Hawthorn berry, 618t
Garlic, 616t, 622t Head, assessment of, 63, 403
Gastric acid pump inhibitors, 241 Head-tilt, chin-lift maneuver, 283, 340
Gastric bypass procedures, 229 Headaches, assessment of, 81–83
Gastric lavage, 313–316, 315i Health, quick assessment, 5
Gastrin, fasting serum, 241 Health care function, 11
Gastritis, 88 Health history questions, 3–4
Gastrocnemius strength, 52 Heart. See also Cardiac arrhythmias.
Gastroenteritis, 102 12-lead ECG, 130i
Gastroesophageal reflux, 84, 218–219 dextrocardia, 134
Gastroesophageal scintillation testing, 218 electrical axis of, 131–134
Gastrointestinal system, 34–39, 83–84, 406, infarction, 139
559t. See also specific conditions; injury to, 138i, 139
specific organs. ischemia, 138–139
Gastrostomy buttons, 317–319, 318i, 523–524 normal findings, 65–66
Gauze dressings, 454, 457t palpitations, 93–94
Gaze, positions of, 57–58, 57i–58i Heart failure, 76, 80, 100, 220–221
Gel pads, 454t Heart rates, calculation, 105
Gemfibrozil, 574t–575t Heart sounds, auscultation, 66
General anesthetics, 414t–419t Heartburn, 83–84
Generalized anxiety disorder, 74 Heel-to-toe walking, 23
Generalized seizures, 362t Helicobactor pylori, 241
Genitourinary system, assessment of, 406 Heliox, 206
Gentamicin, 410t, 570t–571t Hematocrit (HCT), 167, 248
Ginger, 616t, 622t Hematomas, I.V. lines and, 474t
Ginko biloba, 85, 88, 616t, 622t Hematuria, assessment of, 84–85
Ginseng, 83, 94, 617t, 623t Hemodialysis, 560t–562t, 586, 597
Glabellar reflex, 29 Hemoglobin, glycosylated, 167–168, 214
Glasgow Coma Scale, 34 Hemoglobin, total, 168
Glaucoma, 77, 78, 79, 82, 98 Hemolytic uremic syndrome (HUS), 72
Glipizide (Glucotrol), 606 Hemoptysis, 85–86
Glomerulonephritis, 85 Hemothorax, 477t
Glossopharyngeal nerve (CN IX), 32t Heparin, 235, 411t, 574t–575t, 582, 602t
Gloves, 463, 468–469, 511 Hepatitis, 90, 221–224
Glucosamine, 618t Hepatitis B surface antigen, 168–169
Glucose, 2-hr postprandial plasma, 165–166, 214 Hepatitis C virus, 392
Glucose, fasting plasma, 164–165, 214, 229 Hepatotoxicity, drug reactions, 557t
Glucose, random levels, 214 Herbs, drug interactions, 614t–624t
Glucose, serum, 612t Herniated disks, 95
Glucose-lowering drugs, 229. See also Anti- Heroin, acute toxicity, 631t
hyperglycemic drugs, oral. Herpes simplex, 98
Glucose tolerance test, 166–167 Herpes zoster, 95, 98
Glycopyrrolate (Robinul), 410t Hiatal hernia, 75
Gold salts, 252 High-density lipoproteins, 229
Goldenseal, 617t, 623t Highly active antiretroviral therapy, 225
Gowns, 463, 467 Hips, range of motion, 49–50
Grapeseed, 618t His-Purkinje repolarization, 104, 124
Grasp reflex, 29 Histamine antagonists, 206, 219, 411t
Graves’ disease, 190–191 Histamine-receptor antagonists, 241
Graves speculum, 45 HIV/AIDS, 171–173
Green tea, interactions, 618t Hoarseness, 87

Index 691
Home therapies, 291, 345, 396 Ileostomy care, 300–304

Hormonal contraceptives, 101, 605 Iliopsoas sign, 37–38
Hormonal receptor assays, 207 Immune globulin transfusion, 390t–391t
Hormonal therapy, 208, 245 Immunomodulary agents, 225
Hospital Infection Control Practices Advisory Immunosuppressants, 233, 636
Committee (HICPAC), 463 Implantable cardioverter-defibrillator (ICD),
Human chorionic gonadotropin, 169–171 307, 308i
Human immunodeficiency virus (HIV), Incentive spirometry, 319–321, 409
171–173, 172t–173t, 224–225, 392 Indirect inguinal hernias, 39
Human leukocyte antigen (HLA) test, 174 Indomethacin (Indocin), 83, 98–99
Hyaluronidase, 585t Infants
Hycor assay, 321 blood pressure measurement in, 17
Hydralazine hydrochloride (Apresoline), 606 cardiac index, 282
Hydration, 422t–423t, 424. See also Dehydra- developmental milestones, 46
tion. eardrop administration, 517
Hydrochlorothiazide (Esidrix, Hydro- fevers in, 80
DIURIL), 606 hypoglycemia in, 644
Hydrocolloid dressings, 454, 457t inspection of ears, 59
Hydrocortisone (Solu-Cortef), 411t, 567t manual ventilation in, 328
Hydrocortisone sodium succinate, 585t needle sizes, 527
Hydrogel dressings, 457, 457t septic shock in, 648
Hydromorphone hydrochloride (Dilaudid), Infection control, 462–470, 465t–466t
442t–443t, 631t Infections
Hydrothorax, 477t central venous lines and, 479t–480t
3-hydroxy-3-methyl-glutaryl coenzyme A diarrhea and, 72
reductase inhibitors, 574t–575t fatigue and, 79
Hydroxyzine hydrochloride (Vistaril), 409t fevers and, 80
Hypercholesteremia, 159 peripheral I.V. lines and, 475t–476t
Hypercortisolism, 100 of pressure ulcers, 459
Hyperextension injuries, 648–649 reportable, 465t–466t
Hyperglycemia, 503t Infectious mononucleosis, 96, 150
Hyperglycemic crisis, 642–643 Inferior palpebral conjunctivae, 56–57
Hyperinsulinism, 100 Inflammation, 54, 80, 163, 196–197
Hyperkalemia, 181, 248 Influenza, 227–228
Hypernatremia, 187 Infusion control devices, 480t–481t, 549t–551t
Hyperosmolar hyperglycemic nonketotic Inguinal hernias, indirect, 39
syndrome (HHNS), 642–643 Inhalation agents, 414t–417t
Hyperphosphatemia, 180 Inhalation injury, 77, 87
Hypertension, 74, 82, 225–227 Inhalers, 520–522
Hyperthyroidism, 68, 189, 190–191 Inotropic drugs, 221, 235
Hyperventilation syndrome, 68 Insect bites, 96, 98
Hypnotics, interactions, 609t Insulin, 214–215, 229, 574t–575t, 582, 642–643
Hypoglossal nerve (CN XII), 32t Insulin tolerance tests, 229
Hypoglycemia, 503t, 643–644 Integumentary system, 655. See also Skin.
Hypoglycemic agents, 203 International Normalized Ratio, 174–175
Hypogonadism, 100 Interpreters, 678
Hypokalemia, 181 Interstitial lung disease, 70
Hypomagnesemia, 177–178 Intervertebral disks, herniated, 95
Hyponatremia, 187–188 Interviews, guidelines for, 4–5
Hypophosphatemia, 180 Intestinal obstruction, 72, 90
Hypotension, 270i, 648 Intra-aortic balloon pumps, 488t–490t
Hypothalamic dysfunction, 100 Intracranial pressure, 505t–506t
Hypothermia, 54 Intramuscular injections, 530–532, 531i
Hypothyroidism, 80, 87, 100–101, 189 Intravenous therapy
Hypovolemia, postoperative, 426 bolus injections, 535
Hypovolemic shock, 644–646 calculations, 541–542
drug infusion, 533–535, 533i
extravasation management, 583–585
I flow rates, 549t–551t, 597
Ibuprofen (Advil, Motrin, Nuprin, Rufen), infusion interruptions, 483–484
412t, 442t–443t, 595–596, 606 patient teaching, 345
Ibutilide (Corvert), 115 risks of, 346t–353t
Idioventricular rhythm, 123, 123i troubleshooting flow rates, 481t–482t

692 Index
Ipecac, syrup of, 591 Lesions, exudative, 464

Iritis (acute), 78 Leukemia, 102
Iron-deficiency anemia, 187t Leukocyte counts, 196–197
Iron supplements, 250, 595 Leukocyte-poor red blood cells, 386t–387t
Irritable bowel syndrome (IBS), 72 Leukotriene antagonists, 206
Ischemic bowel disease, 72 Leuprolide (Lupron), 85
Isoflurane (Forane), 414t–415t Levels of consciousness (LOC), 21, 34,
Isoflurophate, 412t 81–82, 648
Isoniazid, 258 Levin tubes, 334, 335i
Isoproterenol, 549t Levodopa, drug interactions, 602t
Isoretinoin (Accutane), 574t–575t, 606 Levodopa-cardiodopa (Sinemet), 607
Isosorbide (Isodil), 83, 514 Levothyroxine sodium (Synthroid), 607
Isradipine (DynaCirc), 606 Licorice, 605, 618t
Lidocaine hydrochloride (Xylocaine), 120i,
121i, 122, 547, 594, 607
J Life support, in overdoses, 586
Ligament damage, 475t
Jaw-thrust maneuver, 283–284
Jendrassik’s maneuver, 26 Light, pupillary response, 22
Joint Commission reports, 583 Linens, contaminated, 463–464, 469
Junctional rhythm, 116, 116i Linezolid, 231, 261, 576t–577t
Junctional tachycardia, 118, 118i Liotrix (Thyrolar), 607
Lipid-lowering agents, 203, 256
Lipoprotein-cholesterol fractionation, 176
Lithium, 101, 576t–577t, 602t
K Liver, 38–39, 67, 557t
Kanamycin, 410t Liver function tests, 147, 148, 152–154
Kaposi’s sarcoma, 96 Loop diuretics, 250
Kardex, 509 Lorazepam, 363
Kava, 618t, 623t Lorcet 10/650, 447t
Kernig’s sign, 22, 82 Lorcet Plus, 446t
Ketamine hydrochloride, 418t–419t Lortab, 447t
Ketoprofen (Orudis), 607 Low-air-loss beds, 454t
Ketorolac tromethamine, 444t–445t Low-density lipoproteins, 229
Kidneys Lower esophageal sphincter (LES) pressure,
normal findings, 67 219t
palpation of, 41–42 Lumbar puncture, 83, 156–158, 324–327, 325i
percussion of, 41 Lung ventilation-perfusion scans, 246
protein, urine, 182–183 Lungs. See also pulmonary entries.
stones, 85 abscesses, 70–71, 86
toxic drug reactions and, 558t angiography, 246
Klorvess, 609 cancer, 77, 86
Knees, range of motion, 50 normal findings, 65
Korokoff sounds, 265 percussion of, 75
Lyme disease serology, 176–177
Lysergic acid diethylamide (LSD), 631t
L
Label verification, 507
Laboratory tests, 145–198. See also specific M
tests. Magnaprin, 444t
Lacerations, wound care, 460t Magnesium, 121i, 122, 206, 411t, 547–548,
Lactate dehydrogenase, 175, 235 612t
Lactose intolerance, 72 Magnetic resonance imaging. See specific
Lamivudine, 223 conditions.
Language assistance services, 678 Malabsorption syndrome, 73
Large-bowel cancer, 72 Mammography, 207
Laryngeal cancer, 87 Manual ventilation, 327–329, 328i
Laryngitis, 87 Marfan’s syndrome, 98
Laryngotracheobronchitis, 87 Masks, 465, 468
Latex allergy, 321–324, 322t, 323t, 324t Mattresses, 454t
Laurence-Moon-Biedl syndrome, 100 Maxillary sinuses, 60
Laxative abuse, 73, 102 Mean corpuscular hemoglobin concentration
Left bundle-branch block, 142, 142i (MCHC), 186, 187t
Legionella-soluble antigen, 243 Mean corpuscular hemoglobin (MCH), 186,
Legs, normal findings, 67 187t

Index 693
Mean corpuscular volume (MCV), 186, 187t

Mechanical ventilation, 329–333
N
N-95 respirators, 565
Meclofenamate (Meclomen), 607 Nalmefene (Revex), 589t
Medical records. See Charting; Documentation. Naloxone hydrochloride (Narcan), 590t, 596
Medication administration records (MARs), Naproxen, 412t
509 Narrative charting, 660–661
Medications. See Drug administration; Drug Nasal inhalers, 521–522
interactions. Nasal medications, 517–519
Melatonin, 618t Nasogastric-decompression tubes, 502
Meloxicam, 412t Nasogastric tubes, 334–338, 335i, 523–524,
Menadione (vitamin K3), 592–593 653
Meningitis, 22, 82 Nausea, assessment of, 87–88
Mental status, sudden changes in, 23 Neck, assessment of, 63, 403
Meperidine hydrochloride, 412t, 602t Needles, 464, 527–533
Mescaline, 631t Negative air pressure rooms, 464
Metabolic acidosis, 152t Neomycin, 410t
Metabolic alkalosis, 152t Neonates, hypoglycemia in, 644
Metabolic syndrome, 228–230 Nephritis, 85
Metered-dose inhalers, 520–521, 520i Nephroblastoma, pediatric, 36
Methanol, vision loss and, 99 Nephrotic syndrome, 101
Methenamine mandelate (Mandelamine), 607 Nephrotoxic reactions, 558t
Methicillin-resistant Staphylococcus aureus Nerve damage, I.V. lines and, 475t
(MRSA), 230–232 Nettle, 619t, 624t
Methotrexate sodium (Rheumatrex), 207, Neuroleptics, reactions, 582
576t–577t, 602t, 607 Neurologic monitors, 505t–506t
N-methyl-D-aspartate antagonists, 202 Neurologic system, assessment, 21–34, 403
Methyldopa (Aldomet), 80 Neurolytics, 202
Methylprednisolone, 411t Neuromuscular blockers, 420t
Methyltestosterone, 514 Neurotoxic drug reactions, 558t
Metronidazole, 609t Neutropenia, 636, 638t
Midazolam hydrochlorine, 409t, 416t–417t Niacin, 203
Migraine headaches, 78, 83, 95 Nicotine, transdermal, 512, 513–514
Milk thistle, 619t, 623t Nifedipine (Procardia XL), 607
Minocycline (Minocin), 231, 607 Nitrates, 213, 514
Misoprostol (Cytotec), 607 Nitrofurantoin (Microdantin), 607
Mitral valve prolapse, 68 Nitroglycerin (Nitrostat), 83, 511–514, 548,
Mixed opioid agonist-antagonists, 552 550t
Monoamine oxidase (MAO) inhibitors, 603t, Nitroprusside, 548, 551t
607, 609t Nitrous oxide, 414t–415t
Mood disorders, 68 Nonnucleoside reverse transcriptase
Moricizine hydrochloride (Ethmozine), inhibitors, 576t–577t
607 Nonopioid combination drugs, 444t–446t
Morphine (Astramorph, Avinza, Demerol, Nonopioid drugs, 439
Duramorph, Infumorph, Kadian, MS Nonsteroidal anti-inflammatory drugs, 237,
Contin, Oramorph), 235, 412t, 252, 407, 412t, 568t–569t, 595–596
444t–445t, 631t Norepinephrine bitartrate, 548
Moss tube, 334, 335i Norfloxacin (Noroxin), 606
Motor function, evaluation of, 22 Nose, assessment of, 56–61, 65, 403
Motor neuron disease, 28 Nostrils, inspection of, 60
Mouth, assessment of, 56, 64–65, 403 Nuclear medicine scans, 235, 237, 238, 245
Mucolytics, 216 Numeric rating scales, 438t
Multiple-gated acquisition scanning, 212 Nursing Minimum Data Set (NMDS)
Multiple sclerosis, 95, 232–234, 233t program, 674
Mupirocin, 231 Nursing Outcomes Classification (NOC)
Muscle relaxants, 568t–569t, 603t system, 674
Musculoskeletal system, 46–51, 46–53, Nutrition, 422t–423t, 424, 503t–504t. See
655 also Tube feedings.
Myasthenia gravis, 80
Mycobacterium tuberculosis, 258–260
Myocardial infarction, 76, 93, 234–236 O
Myocardial perfusion imaging, 212 Obesity, 84, 339–340
Myoglobin levels, 178, 235 Obsessive-compulsive disorder (OCD), 68
Myotics, 412t Obstructed airway, adult, 339–340

694 Index
Obturator sign, 38 Palpation, assessments using, 6i, 14i, 16i,

Occult blood, fecal, 178, 210, 241 17i, 19, 36–46, 39i, 46i, 53–54, 60–67,
Ocular lacerations, 78 60i
Ocular toxicity, drugs, 558t–559t Palpebral conjunctivae, 56–57
Oculocephalic reflex, 22 Palpitations, 93–94
Oculomotor nerve (CN III), 30t Pancreatic islet cell tumors, 101
Odynophagia, 218 Pancreatitis, 90, 91, 149
Ofloxacin (Floxin), 606 Pancrelipase (Cotazym), 607
Ohio system, 375 Pancuronium bromide, 420t
Ointments, 511, 515, 519–520, 525–529 Panic disorder, 74
Olfactory nerve (CN I), 29t Paradoxical pulse, 270i
Omeprazole (Prilosec), 241 Paralytic ileus, 425
One-person rescue, 283 Parathyroid hormone levels, 238
Operating room procedures, 407–408 Parenteral administration, 529–535
Ophthalmalgia, 77–79 Paresthesia, 94–95
Ophthalmodynamometry, 203 Parkinson’s disease, 239–241
Ophthalmoscopic examination, 58–59 Partial thromboplastin time (PTT),
Opiates, 412t, 596. See also specific drugs. 179
Opioid agonists, 552 Passionflower, 619t, 624t
Opioids, 418t–419t, 439, 446t–448t, Patellar reflex, 27–28, 28i
568t–569t, 631t Paternity testing, 174
Optic nerve (CN II), 29t Patient education record, 672i
Optic neuritis, 78 Patient teaching record, 672i
Oral antidiabetics, 609t Patient verification, 385, 390–391, 507
Orlistat, 229 Pedersen speculum, 45
Oropharyngeal inhalers, 520–522 Pemphigus, 98
Orthostatic hypotension, 74 Penetrating wounds, 460t
Osteoarthritis, 236–238 Penicillamine, 252
Osteoporosis, 238–239 Penicillins, reactions to, 582
Ostomy pouching systems, 300–304, 301i, 303i Penis, 43
Otoscopic examination, 59 Pentobarbital sodium (Nembutal), 412t
Ototoxic reactions, drugs, 559t Pentoxifylline (Trental), 607
Outcome documentation, 671–673 Peptic ulcers, 84, 93, 241–242
Overdoses, management of, 585–586, Percocet, 447t
587t–591t Percodan, 447t
Oxycodone (OxyContin), 631t Percodan-Demi, 447t
Oxygen, supplemental, 206, 209, 216, 221, Percussion techniques, 7i
235, 244, 246 abdomen, 35–36, 66
chest physiotherapy, 298, 299i
identifying sounds produced by, 8t
P liver examination, 38
P-A-C analgesic tablets, 444t lungs, 65
P waves, 104, 106 thorax inspection, 19–20
Pacemakers, 116, 123, 124, 370–375, 490t–491t for urinary organs, 40–41
Packed red blood cells, 386t–387t Pericarditis, 144, 144i, 426
Paclitaxel, 207 Peripheral I.V. catheters, 340–355,
Padding, pressure reduction by, 454t 346t–353t, 472t–477t
Pain Peripheral neuropathies, 95
abdominal, 88–90 Peripherally-inserted central catheter (PICC),
acute, 436, 436t 286
acute vs. chronic, 436t Peritoneal dialysis (CAPD), continuous
assessment of, 437–439, 437t ambulatory, 355–359
back, 90–91 Peritonitis, 36, 358
behavior checklist, 439t Pernicious anemia, 187t
chest, 92–93 Persantine thallium stress test, 404
chronic, 436, 436t Petechiae, 54, 55
measurement of, 408, 437–438 Pharmacia Cap test, 321
numeric rating scales, 438t Phencyclidine (PCP), 632t
postoperative, 408 Phenegran Syrup, 609
visual analog scale, 438t Phenobarbital (Luminal), 363, 629t
Wong-Baker FACES scale, 438t Phenothiazines, 101, 596, 629t
Pain behavior checklist, 439t Phentolamine, 585t
Pain management, 435–448, 440t–448t, 552 Phenylephrine, 593

Index 695
Phenytoin (Dilantin), 80, 363, 578t–579t, Pressure ulcers, 96, 450–459, 451i,
594, 596, 608 452i–453i, 457t
Phlebitis, 473t Primitive reflexes, 29
Phlebography, 257 Privacy, interview, 4
Phobias, 68 Problem-intervention-evaluation system,
Phosphate, serum, 179–180, 612t 663–664
Physical examination, 10-min, assessment, 4 Problem-oriented medical record, 662–663
Physician orders, 507 Procainamide
Physiotherapy (PT), 297–300 administration of, 548–549
Phytonadione (vitamin K1), 592–593 for arrhythmias, 113, 114, 120i, 121i, 122
Pitting edema, 15i in digoxin overdose, 594
Plague, 678t–679t hypersensitivity to, 80
Plantar reflex, 22, 28–29 surgery-related risks, 410t
Platelets, 180, 388t–389t therapeutic drug monitoring, 578t–579t
Pleur-evac system, 375 Proctoscopy, 210
Pleural effusion, 77 Progesterone, transdermal, 512
Pneumonia, 76, 242–245 Promethazine hydrochloride (Phenegran), 412t
Pneumonitis, 71 Propacet, 446t
Pneumothorax, 93, 477t, 646–647 Propafenone hydrochloride (Rythmol), 608
Poisoning, management of, 587t–591t Propofol (Diprivan), 418t–419t
Polamine, transdermal, 511 Proportions, review of, 539
Polycythemia, 168 Propoxyphene hydrochloride, 604
Polyethylene glycol electrolyte solution Propranolol (Inderal), 410t, 594, 605, 652–653
(GoLYTELY, NuLYTELY), 608 Prostaglandin analogues, 241
Popliteal pulse, 14i Prostate cancer, 181–182, 244–245
Ports, implanted, 484t Prostate gland, examination of, 43–44
Positron emission tomography, 201, 256 Prostate-specific antigen (PSA), 181–182, 245
Postanesthesia care units (PACUs), 421–423 Protamine sulfate, 591t
Postconcussion syndrome, 68, 74 Protease inhibitors, 578t–579t
Posterior tibial pulse, 14i Protein, serum, 613t
Posterior uveitis, 99 Protein, urine, 613t
Postoperative care, 421–434 Protein electrophoresis, serum, 183–184, 184t
Postoperative psychosis, 426 Proteinuria, 182–183, 248
Posttraumatic stress disorder, 68–69 Prothrombin time (PT), 174–175, 185, 613t
Potassium, I.V., 594 Proton pump inhibitors, 219, 241
Potassium, serum, 226, 612t Pseudomembranous colitis, 559t
Potassium supplementation, 221, 578t–579t, Psoas muscle strength, 52
603t Psoriasis, 96, 97
Potassium-wasting diuretics, 411t Psychological status, 406
Powders, application of, 511 Psychostimulators, 202
PR intervals, 104, 106 Pulmonary angiography, 246
Pralidoxime chloride (Protopam Chloride), Pulmonary artery catheterization, 235
590t–591t Pulmonary artery pressure monitoring,
Prednisolone, 411t 220–221
Prednisone, 207, 411t Pulmonary edema, 71, 76, 86
Preeclampsia, 101 Pulmonary emboli, 76–77, 93, 245–247
Pregnancy Pulmonary function testing, 205, 209, 216
abdomen inspection in, 35 Pulmonary hypertension, 86
abdominal pain and, 89 Pulse oximetry, 243, 359–361, 361t, 495–497
chorionic gonadotropin levels, 169–170, Pulses, palpation of, 14i
170–171 Pupils, assessment of, 21–22, 33i, 57
in diabetic mothers, 214 Pyelonephritis, 85, 91
ectopic, 90 Pyramidal tract disorders, 28–29
nausea and, 88 Pyrazinamide, 258
obstructed airway in, 339–340
Premature atrial contractions (PACs), 112, 112i
Premature junctional contractions (PJCs), Q
119, 119i Q waves, 235
Premature labor, 164 QRS complex, 104, 106
Premature ventricular contractions, 120, 120i QT intervals, 104, 106
Preoperative care, 314, 403–409, 405t, Quadriceps muscle strength, 52
409t–412t Quinidine, 80, 578t–579t, 582, 603t
Pressure reduction devices, 454t Quinupristin/dalfopristin, 261

696 Index
R Scopolamine bromide, 410t

Scrotum, 43
Radial pulse, 14i
Radiation therapy, 75, 88, 95, 636 Secobarbital sodium (Seconal), 630t
Ramipril (Altace), 608 Second-degree aterioventricular block, 126,
Range of motion (ROM), 46–51, 424 126i, 127, 127i
Ranitidine (Zantac), 411t Sedative-hypnotics, 412t, 582, 629t
Rapid skilled movements, 24 Sedatives, 241
Rapport, establishment of, 4 Segmental limb pressures, 203
Rashes, 95–98 Seizure disorders, 253–254, 362t
Ratios, review of, 539 Seizure management, 361–364
Rebound tenderness, 37 Selegiline hydrochloride (Eldepryl), 608
Recreation, interview questions, 10 Semi-Fowler’s position, 18–19, 294
Rectal ointments, 525–529 Sepsis, 77, 504t
Rectal suppositories, 525–529 Septic shock, 647–648
Red blood cell count (RBC), 185–186, 216 Septicemia, 427, 475t–476t
Red blood cell indices, 186, 187t Sequential compression therapy, 364–367
Reference values. See Specific tests. Sevoflurane (Ultane), 416t–417t
Reflexes, assessment of, 25–29 Shampoos, medicated, 511
Renal arteriography, 226 Sharps, handling of, 464
Renal calculi, 90 Sheehan’s syndrome, 101
Renal failure, 177, 179–181, 247–250 Shock, skin temperature in, 54. See also
Renal function tests, 154, 162–163 Hypovolemic shock; Septic shock.
Renal infarction, 85 Shoulders, range of motion, 47
Renal system, dying process, 655 Sibutramine, 229
Reproductive system, female, 44–46 Sigmoidoscopy, 210
Reproductive system, male, 42–44 Sinus arrest, 111, 111i
Resource Web sites, 680 Sinus bradycardia, 109, 109i
Respirators, N-95, 565 Sinus rhythm, 107, 107i, 108, 108i
Respiratory acidosis, 152t Sinus tachycardia, 110, 110i
Respiratory administration, 520–522 Sinuses, inspection of, 60
Respiratory alkylosis, 152t Sinusitis (acute), 83
Respiratory monitors, 495–502 Sinutab Regular, 445t
Respiratory protection, 464 Skeletal muscle relaxants, 568t–569t
Respiratory system Skene’s glands, 45
arterial blood gas analysis, 150–152 Skin. See also Integumentary system;
assessment of, 18–21, 69, 405 Pressure ulcers.
care after bariatric surgery, 422t assessment of, 53–55, 55t, 403, 405
in the dying process, 655 care after bariatric surgery, 423t
preventing complications, 424 dark, 54–55
Retinal detachment, 99 in the dying process, 655
Retrolental fibroplasia, 98 layers of, 452i
Rheumatoid arthritis, 250–253, 253t preparation for surgery, 314
Rhomberg’s test, 23 preventing complications, 423–424, 458t
Ribavirin, 223 topical medications and, 510–511
Rifampin, 258 toxic drug reactions and, 557t
Right bundle-branch block, 143, 143i transdermal medication and, 511–513
Rofecoxib, 412t Skin testing, 205, 258
Roxicet, 447t Sleep, interview questions on, 10
Roxilox, 447t Sleep studies, 405
Roxiprin, 447t Smallpox, 678t–679t
Smoke inhalation, 653
Smoking, 10, 405, 604–605. See also Tobacco use.
Snout reflex, 29
S Soaps, hand washing with, 467t
Salem sump tube, 334 Social structure, questions on, 11
Salicylates, 81, 252, 596–597 Socialization, questions on, 11
Salsalate (Disalcid, Mono-Gesic, Salflex), 608 Societal placement, questions on, 11
Sarcoidosis, 96 Sodium, serum, 186–188, 613t
Sargramostim, 637 Sodium, urine, 248
Saw palmetto, 624t Sodium bicarbonate, 585t
Scabies, 97 Sodium fluoride (Luride), 608
Scleroderma, 84, 150 Sodium thiosulfate, 585t
Scopolamine, transdermal, 512 Somatoform disorders, 69

Index 697
Sominex Pain Relief, 444t Temporary pacemakers, 370–375

Sotalol, 115 Tendon damage, I.V. lines and, 475t
Speculums, 45 Testicles, 43
Speed shock, 476t Tetracycline (Achromycin V), 603t, 608
Spermatic cord, 43 Theophylline (Theo-24, Uniphyl), 580t–581t,
Spinal accessory nerve (CN XI), 32t 582, 603t, 605, 608
Spinal cord compression, 648–649 Therapeutic drug monitoring, 570t–581t
Spinal cord injury, 95, 650t–651t Thiabendazole (Mintezol), 85
Spiral chest computed tomography, 246 Thiamine, 363
Spleen, 67 Thiazolidinediones, 580t–581t
Sputum cultures, 209, 243 Thiopental sodium, 416t–417t
St. John’s wort, 83, 88, 619t–620t, 624t Thioridazine (Mellaril), 629t
ST segments, 235, 275–276 Third-degree atrioventricular block,
Standard Ig, 223 128–129, 128i
Standard precautions, 463–464 Thora-Klex systems, 375
Staphylococcus aureus, methicillin-resistant, Thoracic drainage, 375–378
230–232 Thorax, assessment of, 16i, 17i, 19–20, 20i
Statistics, review of, 539 Throat, 56–61
Status epilepticus, 363 Thrombocytopenia, 180, 556t, 636, 638t
Steroid therapy, in MS, 233 Thrombocytosis, platelet count, 180
Stethoscope, 17 Thrombolytics, 203, 235, 246, 257
Stool softners, 235, 256 Thrombophlebitis, 257–258, 427, 475t
Strength testing, 22, 51–53 Thrombosis, 474t, 478t–479t
Streptomycin, 258, 410t Thumbs, range of motion, 48–49
Stress echocardiography, 212 Thyroid gland, palpation of, 61, 61i
Stroke, 95, 254–256 Thyroid hormones, 412t, 568t–569t,
Subarachnoid hemorrhages, 83 580t–581t
Subcutaneous injections, 527–528 Thyroid-stimulating hormone (TSH), 188
Subdural hematoma, 83 Thyroid-stimulating immunoglobulin (TSI), 188
Sublingual administration, 524–525 Thyroid storm, 652–653
Substance abuse, 627–632 Thyrotoxic crisis, 652–653
Succinylcholine chloride (Anectine, Thyrotoxicosis, 94, 102, 190–191
Quelicin), 420t Thyroxine (FT4), free, 189
Sucking reflex, 29 Thyroxine (T4), 188–189
Sulfamethoxazole/trimethoprim, 231 Thyroxine (T4)-binding globulin (TBG), 188
Sulfites, additive, 625 Tilting devices, mechanical, 454t
Sulfonamides, 582 Tinea pedis, 98
Sulfonylureas, 578t–579t Tobacco use, 10, 604–605. See also Smoking.
Superficial reflexes, 28–29 Tobramycin, 410t, 570t–571t
Superior palpebral conjunctivae, 57 Toddlers, 46, 59, 80, 517
Suppositories, 519, 525–529 Toes, range of motion, 50
Surgical site verification, 367–368 Toilet training, questions, 39
Surgical wounds, caring for, 428–433 Tolmetin sodium (Tolectin), 608
Sympathomimetics, 582, 603t Tongue-jaw lift, 340
Synchronized cardioversion, 368–370 Topical drugs, 510–511
Syndrome of inappropriate antidiuretic Total parenteral nutrition, 503t–504t
hormone secretion (SIADH), 650–652 Tourniquets, 345
Syphilis, 98 Toxic epidermal necrolysis, 98
Systemic lupus erythematosus (SLE), 150 Tracheal erosion, 653
Tracheal suction, 379–384, 382t
Tracheal trauma, 86
T Tracheobronchitis, 71
T tubes, 502 Tracheostomy tubes, 500
T waves, 104, 106 Tranquilizers, 241, 412t, 418t–419t
Tablets, dosage calculations, 540 Transcranial Doppler, 256
Tactile fremitis, 19 Transcutaneous pacing, 370, 371–372, 374
Tail of Spence, 44–45 Transdermal medications, 511–513, 529–530
Talacen, 447t Transfusions, 384–393, 637
Talwin Compound, 447t Transient ischemic attacks, 74
Tartrazine, 626 Translingual administration, 524–525
Tecnal, 446t Transmission-based precautions, 464–467
Telemetry, 275, 276, 277i–278i, 279 Transparent dressings, 455–456, 457t
Temperature, of skin, 54. See also Fever. Transplantation, HLA testing, 174

698 Index
Transrectal prostatic ultrasonography, 245 Venipuncture (continued)

Transthoracic pacemaker, 370, 373, 374 implementation, 399–400
Transtrachealaspiration specimens, 243 indications, 398
Transvenous pacing, 370, 372–373, 374 sites, 340–342, 399i
Trazodone hydrochloride, 608 special considerations, 400–401
Treatments, assessment of, 226 taping, 344t
Triamcinolone, 411t tourniquet application, 345
Triazolam (Halcion), 608 Venous spasm, 474t
Triceps muscle strength, 51 Ventilation, 330, 333
Triceps reflex, 27, 27i Ventilators, 329–330, 331t, 498t–500t
Tricyclic antidepressants, 101, 240, Ventricular bigeminy, 270i
568t–569t, 597 Ventricular fibrillation, 122, 122i, 307–310
Trigeminal nerve (CN V), 30t Ventricular tachycardia (VT), 121, 121i,
Triglycerides, 189–190, 229 368–370
Triiodothyronine (FT3), 189, 190–192 Verapamil hydrochloride (Calan SR, Isoptin
Trochlear nerve (CN IV), 30t SR), 118, 549, 552, 608
Troponin levels, 192, 235 Vibration techniques, 298, 299i
Troubleshooting equipment problems, Vibrio cholerae, 71–72
471–506 Vicodin, 448t
Tube feedings, 393–398, 397t, 504t, 609 Vicodin ES, 448t
Tuberculosis, 258–260, 260t Vincristine, 207
Tularemia, 678t–679t Viral conjunctivitis, 78
Turbo-inhalers, 521, 521i Vision loss, 98–99
Two-person rescue, 285 Visual analog scale, 438t
Tylenol with Codeine, 446t, 447t–448t Visual floaters, 99
Tylox, 448t Vital signs, 3, 21–23, 436. See also specific signs.
Vitamin B complex, 203
Vitamin B12 deficiency, 95
U Vitamin E, 202
U waves, 104 Vitamin supplements, 229, 248, 250
Ulcerative colitis, 72 Vitreous hemorrhage, 99
Ultrasonography, 207, 231, 405 Vocal cord polyps, 87
Urea breath tests, 241 Voice-activated documentation systems, 674
Urethral meatus, 40
Uric acid, serum, 192–193, 614t
Urinalysis, routine, 193–196, 194t, 226, 248 W
Urinary bladder, 41, 42 Warfarin sodium (Coumadin, Panwarfin),
Urinary meatus, 84–85 411t, 580t–581t, 582, 603t–604t, 608
Urinary system, 39–42 Waste disposal, 469–470
Urine, assessments, 40t, 427–428 Water mattresses, 454t
Uterus, palpation of, 46, 46i Web sites, resources, 680
Weight gain, assessment of, 99–101
Weight loss, assessment of, 101–102
V Weight-loss drugs, 556t
Vaccines, 223 White blood cell transfusion, 386t–387t
Vagal stimulation, 115 White blood cell (WBC) counts, 196–198,
Vaginal medications, 519–520 197t, 235, 241
Vagus nerve (CN X), 32t Wong-Baker FACES scale, 437, 438t
Valerian, 620t Wound care, 455t, 456t, 457t, 459–461, 460t
Valproate sodium, 580t–581t Wound infections, postoperative, 428
Valproic acid, 580t–581t Wrists, range of motion, 48
Vancomycin, 231, 580t–581t
Vancomycin-resistant enterococci (VRE),
260–262 X
Vanquish, 446t X-ray studies, 237, 238
Vasodilators, 221, 226
Vasopressin, 122, 549
Vasopressors, 246 Y
Vasovagal reactions, 474t Yellow No. 5, FD&C, 626
Vecuronium bromide, 420t
Venipuncture
documentation, 401 Z
dressings, 343–345 Z-track injections, 532–533
equipment, 398–399 Zydone, 448t

LWBK449-Endpaper.qxd 11/15/09 9:20 AM Page 2
English-Spanish quick reference guide

anemia la anemia heartburn
angina la angina heart disease
appendicitis la apendicitis heart failure
arteriosclerosis la arteriosclerosis heart murmur
arthritis la artritis hemorrhage
asthma el asma hemorrhoids
backache el dolor de espalda hepatitis
blindness la ceguera hernia
bronchitis la bronquitis herpes
burn (first, second, or third la quemadura (de primer, high blood pressure
degree) segundo, o tercer grado) hives
bursitis la bursitis hoarseness
cancer el cáncer ill
chickenpox la varicela, las viruelas locas illness
chills los escalofrios immunization
cold el catarro, el resfriado infarct
cold sores lasúlceras de la boca infection
constipation el estreñimiento inflammation
convulsion la convulsión injury
cough la tos itch
cramps los calambres jaundice
deafness la sordera kidney stone
diabetes la diabetes
diarrhea la diarrea laryngitis
discharge el flujo lesion
dizziness el vértigo, el mareo leukemia
eczema el eccema lice
emphysema el enfisema lump
epilepsy la epilepsia malignancy
fainting spell el desmayo malignant
fatigue la fatiga measles
fever la fiebre meningitis
flu la influenza, la gripe menopause
food poisoning el envenenamiento por metastasis
comestibles migraine
fracture la fractura multiple sclerosis
gallbladder attack el ataque de la vesícula biliar mumps
gallstone el cálculo biliar muscular dystrophy
gastric ulcer la úlcera gástrica mute
glaucoma el glaucoma obese
gonorrhea la gonorrea overdose
headache el dolor de cabeza overweight
heart attack el ataque al corazón pain
heartbeat el latido growing pain
irregular irregular labor pain
rhythmical riftmico phantom limb pain
slow lento referred pain
fast (tachycardia) taquicardia sharp pain
las agruras (el ardor), acedía shooting pain el dolor punzante

la enfermedad del corazón burning pain el dolor que arde
el fallo cardíaco intense pain el dolor intenso
el soplo del corazón severe pain el dolor severo
la hemorragia intermittent pain el dolor intermitente
las almorranas, las hemorroides throbbing pain el dolor palpitante
la hepatitis palpitation la palpitación
la hernia paralysis la parálisis
el herpes Parkinson’s disease la enfermedad de Parkinson
la presión alta pneumonia la pulmonía
la urticaria psoriasis la psoriasis
la ronquera pus el pus
enfermo(a) rash la roncha, el salpullido,
la enfermedad la erupción
la inmunización relapse la recaída
el infarto renal renal
la infección rheumatic fever la fiebre reumitáca
la inflamación roseola la roséola
el daño la lastimadura, la herida rubella la rubéola
la picazón, la comezón rupture la ruptura
la piel amarilla, la ictericia scab la costra
el cálculo en el riñón, la piedra scar la cicatriz
en el riñón scratch el rasguño
la laringitis senile senil
la lesión, el daño shock el choque
la leucemia sore la llaga
los piojos spasm el espasmo
el bulto sprain la torcedura
el tumor, la malignidad stomachache el dolor del estómago
maligno(a) stomach ulcer la úlcera del estómago
el sarampión suicide el suicidio
la meningitis swelling la hinchazón
la menopausia syphilis la sífilis
la metástasis tachycardia la taquicardia
la migrañia, la jaqueca toothache el dolor de muela
la esclerosis múltiple toxemia la toxemia
las paperas trauma el trauma
la distrofia muscular tuberculosis la tuberculosis
mudo(a) tumor el tumor
obeso(a) ulcer la úlcera
la sobredosis unconsciousness la pérdida del conocimiento
el sobrepeso virus el virus
el dolor vomit el vómito, los vómitos
el dolor de crecimiento wart la verruga
el dolor de parto weakness la debilidad
el dolor de miembro fantasma wheeze el jadeo, la silba
el dolor referido wound la herida
el dolor agudo yellow fever la fiebre amarilla
Crisis values of laboratory tests

TEST LOW COMMON CAUSES HIGH COMMON CAUSES
VALUE AND EFFECTS VALUE AND EFFECTS
Calcium, serum ⬍ 6 mg/dl Vitamin D or parathy- ⬎ 13 mg/dl Hyperparathyroidism:

(SI, ⬍ 1.5 roid hormone deficien- (SI, ⬎ 3.2 mmol/L) coma
mmol/L) cy: tetany, seizures
Carbon dioxide ⬍ 6 mEq/L Complex pattern of ⬎ 40 mEq/L Complex pattern of

(SI, ⬍ 6 mmol/L) metabolic and respira- (SI, ⬎ 40 mmol/L) metabolic and
tory factors respiratory factors
Creatinine, ⬎ 4 mg/dl (SI, Renal failure: coma

serum ⬎ 353.6 ␮mol/L)
Glucose, blood ⬍ 40 mg/dl Excess insulin adminis- ⬎ 400 mg/dl Diabetes: diabetic
(SI, 2.2 mmol/L) tration: brain damage (SI, ⬎ 22.2 mmol/L) ketoacidosis
Hemoglobin Hemorrhage, vitamin ⬎ 20 g/dl Chronic obstructive pul-

⬍ 5 g/dl B12 or iron deficiency: (SI, ⬎ 200 g/L) monary disease: throm-
(SI, ⬍ 50 g/L) heart failure bosis, polycythemia vera
International ⬎ 3.6 Disseminated intravascu-

Normalized lar coagulation: uncon-
Ratio trolled oral anticoagula-
tion
Partial pressure ⬍ 20 mm Hg Complex pattern of ⬎ 70 mm Hg Complex pattern of

of arterial (SI, ⬍ 2.7 kPa) metabolic and respira- (SI, ⬎ 9.3 kPa) metabolic and respirato-
carbon dioxide tory factors ry factors
Partial pressure ⬍ 50 mm Hg Complex pattern of

of arterial (SI, ⬍ 6.7 kPa) metabolic and respira-
oxygen tory factors
Partial thrombo- ⬎ 40 sec (SI, ⬎ 40 s) Anticoagulation factor

plastin time ⬎ 70 sec (SI, ⬎ 70 s) deficiency: hemorrhage
(for patient on heparin)
pH, blood ⬍ 7.2 (SI, ⬍ 7.2) Complex pattern of ⬎ 7.6 (SI, ⬎ 7.6) Complex patterns of
metabolic and respira- metabolic and respirato-
tory factors ry factors
Platelet count ⬍ 50,000/␮l Bone marrow suppres- ⬎ 500,000/␮l Leukemia, reaction to

sion: hemorrhage acute bleeding: hemor-
rhage
Potassium, ⬍ 2.5 mEq/L Vomiting and diarrhea, ⬎ 8 mEq/L Renal disease, diuretic
serum (SI, ⬍ 2.5 mmol/L) diuretic therapy: car- (SI, ⬎ 8 mmol/L) therapy: cardiotoxicity,
diotoxicity, arrhythmia, arrhythmia
cardiac arrest
Prothrombin ⬎ 14 sec (SI, ⬎ 14 s) Anticoagulant therapy,

time ⬎ 20 sec (SI, ⬎ 20 s) anticoagulation factor
(for patient on warfarin) deficiency: hemorrhage
Sodium, serum ⬍ 125 mEq/L Diuretic therapy: pro- ⬎ 160 mEq/L Dehydration: vascular
(SI, ⬍ 125 mmol/L) fuse sweating, GI suc- (SI, ⬎ 160 mmol/L) collapse
tioning, diarrhea, vom-
iting, burns
White blood cell ⬍ 2,000/␮l Bone marrow suppres- ⬎ 20,000/µl Leukemia: infection
count (SI, ⬍ 2 ⫻ 109/L) sion: infection (SI, 20 ⫻ 109/L)
Table of equivalents
METRIC SYSTEM EQUIVALENTS
Metric weight Household Metric

1 kilogram (kg or Kg) = 1,000 grams (g or gm) 1 teaspoon (tsp) = 5 ml
1 gram = 1,000 milligrams (mg) 1 tablespoon (T or tbs) = 15 ml
1 milligram = 1,000 micrograms (µg or mcg) 2 tablespoons = 30 ml
0.6 g = 600 mg 8 ounces = 236.6 ml
0.3 g = 300 mg 1 pint (pt) = 473 ml
0.1 g = 100 mg 1 quart (qt) = 946 ml
0.06 g = 60 mg 1 gallon (gal) = 3,785 ml
0.03 g = 30 mg
0.015 g = 15 mg
0.001 g = 1 mg
Metric volume
1 liter (l or L) = 1,000 milliliters (ml)*
1 milliliter = 1,000 microliters (µl)
TEMPERATURE CONVERSIONS
Fahrenheit Celsius Fahrenheit Celsius Fahrenheit Celsius

degrees degrees degrees degrees degrees degrees
106.0 41.1 100.6 38.1 95.2 35.1
105.8 41.0 100.4 38.0 95.0 35.0
105.6 40.9 100.2 37.9 94.8 34.9
105.4 40.8 100.0 37.8 94.6 34.8
105.2 40.7 99.8 37.7 94.4 34.7
105.0 40.6 99.6 37.6 94.2 34.6
104.8 40.4 99.4 37.4 94.0 34.4
104.6 40.3 99.2 37.3 93.8 34.3
104.4 40.2 99.0 37.2 93.6 34.2
104.2 40.1 98.8 37.1 93.4 34.1
104.0 40.0 98.6 37.0 93.2 34.0
103.8 39.9 98.4 36.9 93.0 33.9
103.6 39.8 98.2 36.8 92.8 33.8
103.4 39.7 98.0 36.7 92.6 33.7
103.2 39.6 97.8 36.6 92.4 33.6
103.0 39.4 97.6 36.4 92.2 33.4
102.8 39.3 97.4 36.3 92.0 33.3
102.6 39.2 97.2 36.2 91.8 33.2
102.4 39.1 97.0 36.1 91.6 33.1
102.2 39.0 96.8 36.0 91.4 33.0
102.0 38.9 96.6 35.9 91.2 32.9
101.8 38.8 96.4 35.8 91.0 32.8
101.6 38.7 96.2 35.7 90.8 32.7
101.4 38.6 96.0 35.6 90.6 32.6
101.2 38.4 95.8 35.4 90.4 32.4
101.0 38.3 95.6 35.3 90.2 32.3
100.8 38.2 95.4 35.2 90.0 32.2
WEIGHT CONVERSIONS
1 oz = 30 g 1 lb = 453.6 g 2.2 lb = 1 kg
* 1 ml = 1 cubic centimeter (cc); however, ml is the preferred measurement term used today.

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LWBK449-FM_pi-vi.

qxd 11/15/09 9:20 AM Page i

STAFF The clinical procedures described and recom-

Contributors and consultants v

Common laboratory tests

Surgical patient care

Pressure ulcers and

Helen C. Ballestas, RN, PhD, CRRN Merita Konstantacos, RN, MSN

Reviewing assessment techniques 3

Assessing the GI system 34

Reviewing assessment techniques 3

tient’s current symptom is related to

or if the patient can’t respond, obtain Create a pleasant interviewing

Reviewing assessment techniques 5

Set the tone and focus Assessing overall health

Performing palpation techniques

Palpation uses pressure to assess struc-

Reviewing assessment techniques 7

Performing percussion techniques

Percussion has two basic purposes: to

Identifying percussion sounds

SOUND INTENSITY PITCH DURATION

Resonance Moderate to loud Low Moderate to long

Tympany Loud High Moderate

Dullness Soft to moderate High Long

Hyperresonance Very loud Very low Long

Flatness Soft High Short

Assessing high-pitched sounds

Reviewing assessment techniques 9

Hollow Normal lung

Drumlike Gastric air bubble or intestinal air

Thudlike Liver, full bladder, pregnant uterus, or spleen

Booming Hyperinflated lung (as in emphysema)

Flat Muscle, bone, or tumor

Assessing low-pitched sounds

Exercise and sleep ◆ Do you drink more when you’re un-

Assessing the cardiovascular system 11

Family and social structure Inspecting the precordium

Positioning the patient for cardiac auscultation

Auscultating heart sounds

Assessing the cardiovascular system 13

Left-lateral decubitus position

Aortic area Pulmonic area

Midsternal line Midclavicular line

Palpating arterial pulses

Assessing the cardiovascular system 15

Palpating the thorax

Palpation of the anterior and posterior

examining an obese patient or one Measuring blood pressure

Assessing the cardiovascular system 17

Generally, you’ll use the easy-to- minish or become muffled — phase IV

Assessing the respiratory system 19

Palpating for tactile fremitus Percussing the thorax

Auscultating breath sounds

Auscultating breath sounds is an im-

Assessing the neurologic system 21

Age alert If the patient is a ty, and level of orientation to time,

Assessing the neurologic system 23

Comparing decerebrate and decorticate postures

Especially check pulse pressure — the Romberg’s test

tip of his index finger to the tip of Rapid skilled movements

Comparing delirium, dementia, and depression

This table highlights the distinguishing characteristics of delirium, dementia, and