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CONTENTS

Part One: Disorders

Abdominal Pain, Acute, 3
Acute Coronary Syndrome, 5
Acute Respiratory Distress Syndrome, 13
Addison’s Disease, 18
Alzheimer’s Disease, 21
Amyotrophic Lateral Sclerosis, 27
Anal Cancer, 29
Anemia, 29
Anemia, Aplastic, 35
Anemia, Cobalamin (Vitamin B12) Deficiency, 37
Anemia, Folic Acid Deficiency, 39
Anemia, Iron-Deficiency, 39
Aneurysm, Aortic, 41
Angina, Chronic Stable, 46
Ankylosing Spondylitis, 51
Aortic Dissection, 53
Appendicitis, 56
Asthma, 58
Bell’s Palsy, 67
Benign Paroxysmal Positional Vertigo, 69
Benign Prostatic Hyperplasia, 70
Bladder Cancer, 77
Bone Tumors, 79
Brain Tumors, 82
Breast Cancer, 85
Bronchiectasis, 95
Burns, 97
Cardiomyopathy, 106
Carpal Tunnel Syndrome, 111
Cataract, 113
Celiac Disease, 115
Cervical Cancer, 117
Chlamydial Infections, 122
Cholelithiasis/Cholecystitis, 123
Chronic Obstructive Pulmonary Disease, 127
Cirrhosis, 136
Colorectal Cancer, 143
Conjunctivitis, 148
Constipation, 148
Cor Pulmonale, 152
Coronary Artery Disease, 153
Crohn’s Disease, 158
vi
CONTENTS vii

Cushing Syndrome, 158

Cystic Fibrosis, 162
Dementia, 165
Diabetes Insipidus, 166
Diabetes Mellitus, 168
Diarrhea, 188
Disseminated Intravascular Coagulation, 191
Diverticulosis/Diverticulitis, 194
Dysmenorrhea, 196
Dysrhythmias, 198
Eating Disorders, 207
Encephalitis, 208
Endocarditis, Infective, 211
Endometrial Cancer, 215
Endometriosis, 216
Esophageal Cancer, 218
Fibrocystic Breast Changes, 221
Fibromyalgia, 222
Flail Chest, 225
Fracture, 226
Fracture, Hip, 231
Fracture, Humerus, 235
Fracture, Pelvis, 235
Gastritis, 236
Gastroesophageal Reflux Disease, 238
Gastrointestinal Bleeding, Upper, 242
Glaucoma, 246
Glomerulonephritis, 248
Gonorrhea, 250
Gout, 252
Guillain-Barré Syndrome, 255
Head and Neck Cancer, 258
Head Injury, 261
Headache, 268
Heart Failure, 274
Hemophilia and von Willebrand Disease, 287
Hemorrhoids, 290
Hepatitis, Viral, 292
Hernia, 302
Herpes, Genital, 303
Hiatal Hernia, 306
Hodgkin’s Lymphoma, 308
Human Immunodeficiency Virus Infection, 311
Huntington’s Disease, 319
Hyperparathyroidism, 321
viii CONTENTS

Hypertension, 323
Hyperthyroidism, 332
Hypoparathyroidism, 337
Hypothyroidism, 338
Increased Intracranial Pressure, 342
Inflammatory Bowel Disease, 348
Interstitial Cystitis/Painful Bladder Syndrome, 356
Intervertebral Disc Disease, 358
Intestinal Obstruction, 363
Irritable Bowel Syndrome, 367
Kidney Cancer, 369
Kidney Disease, Chronic, 370
Kidney Injury, Acute, 376
Lactase Deficiency, 384
Leiomyomas, 385
Leukemia, 386
Liver Cancer, 392
Low Back Pain, Acute, 393
Low Back Pain, Chronic, 396
Lung Cancer, 397
Lyme Disease, 401
Macular Degeneration, 402
Malignant Melanoma, 404
Malnutrition, 406
Ménière’s Disease, 409
Meningitis, Bacterial, 410
Metabolic Syndrome, 414
Multiple Myeloma, 416
Multiple Sclerosis, 419
Myasthenia Gravis, 424
Myocardial Infarction, 427
Myocarditis, 427
Nausea and Vomiting, 429
Nephrotic Syndrome, 433
Non-Hodgkin’s Lymphomas, 434
Obesity, 437
Obstructive Sleep Apnea, 442
Oral Cancer, 444
Osteoarthritis, 446
Osteomalacia, 453
Osteomyelitis, 454
Osteoporosis, 459
Ovarian Cancer, 463
Paget’s Disease, 465
Pancreatic Cancer, 467
CONTENTS ix

Pancreatitis, Acute, 469

Pancreatitis, Chronic, 473
Parkinson’s Disease, 475
Pelvic Inflammatory Disease, 481
Pelvic Pain, Chronic, 483
Peptic Ulcer Disease, 484
Pericarditis, Acute, 490
Peripheral Artery Disease, 494
Peritonitis, 498
Pneumonia, 500
Pneumothorax, 504
Polycystic Kidney Disease, 507
Polycythemia, 508
Pressure Ulcer, 511
Prostate Cancer, 516
Psoriatic Arthritis, 522
Pulmonary Embolism, 523
Pulmonary Hypertension, 526
Pyelonephritis, 528
Raynaud’s Phenomenon, 530
Reactive Arthritis, 531
Refractive Errors, 532
Respiratory Failure, Acute, 533
Restless Legs Syndrome, 540
Retinal Detachment, 542
Rheumatic Fever and Heart Disease, 543
Rheumatoid Arthritis, 546
Scleroderma, 552
Seizure Disorders, 555
Sexually Transmitted Infections, 562
Shock, 565
Sickle Cell Disease, 580
Sjögren’s Syndrome, 583
Spinal Cord Injury, 584
Spinal Cord Tumors, 593
Spleen Disorders, 595
Stomach Cancer, 596
Stroke, 598
Syphilis, 613
Systemic Exertion Intolerance Disease, 615
Systemic Inflammatory Response Syndrome (SIRS) and Multiple
Organ Dysfunction Syndrome (MODS), 617
Systemic Lupus Erythematosus, 621
Testicular Cancer, 626
Thalassemia, 627
x CONTENTS

Thromboangiitis Obliterans, 628

Thrombocytopenia, 629
Thyroid Cancer, 633
Trigeminal Neuralgia, 635
Tuberculosis, 638
Ulcerative Colitis, 643
Urethritis, 643
Urinary Incontinence, 644
Urinary Retention, 647
Urinary Tract Calculi, 648
Urinary Tract Infections, 653
Vaginal, Cervical, and Vulvar Infections, 657
Valvular Heart Disease, 661
Varicose Veins, 669
Venous Thrombosis, 671
Warts, Genital, 677

Part Two: Treatments and Procedures

Amputation, 681
Artificial Airways: Endotracheal Tubes, 683
Basic Life Support for Health Care Providers, 689
Chemotherapy, 694
Chest Tubes and Pleural Drainage, 699
Dialysis, 704
Enteral Nutrition, 706
Immunotherapy and Targeted Therapy, 708
Mechanical Ventilation, 712
Ostomies, 713
Oxygen Therapy, 718
Pacemakers, 727
Parenteral Nutrition, 731
Radiation Therapy, 733
Tracheostomy, 735
Urinary Catheterization, 739

Part Three: Reference Appendix

Abbreviations, 745
The Joint Commission Official “Do Not Use” List, 752
Blood Gases, 753
Blood Products, 755
Breath Sounds, 758
Commonly Used Formulas, 760
Characteristics of Common Dysrhythmias, 761
Electrocardiogram (ECG) Monitoring, 764
Glasgow Coma Scale, 767
CONTENTS xi

Heart Sounds, 768

Intracranial Pressure Monitoring, 770
Laboratory Values, 771
Lung Volumes and Capacities, 773
Medication Administrations, 774
Temperature Equivalents, 780
TNM Classification System, 781
English/Spanish Common Medical Terms, 781
Urinalysis, 785
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PART ONE
A
Disorders
This page intentionally left blank
Abdominal Pain, Acute 3

ABDOMINAL PAIN, ACUTE A

Description
Acute abdominal pain is pain of recent onset. It may signal a life-
threatening problem and therefore requires immediate attention.
Causes include damage to organs in the abdomen and pelvis, which
may lead to inflammation, infection, obstruction, bleeding, or per-
foration. Common causes of acute abdominal pain are listed in
Table 1.

Clinical Manifestations
Pain is the most common symptom of an acute abdominal problem.
Patients may have nausea, vomiting, diarrhea, constipation, flatu-
lence, fatigue, fever, rebound tenderness, and bloating.

Diagnostic Studies
Diagnosis begins with a complete history and physical examina-
tion. Description of the pain (frequency, timing, duration, location),
accompanying symptoms, and sequence of symptoms (e.g., pain
before or after vomiting) provide vital clues about the problem.
Physical examination should include both rectal and pelvic exami-
nations in addition to an abdominal examination.
■ Complete blood count (CBC), urinalysis, abdominal x-ray, and
an electrocardiogram (ECG) are done initially, along with an
ultrasound or CT scan.
■ A pregnancy test is performed in women of childbearing age to
rule out ectopic pregnancy.

Interprofessional Care
The goal of management is to identify and treat the cause and
monitor and treat complications, especially shock. Table 42-10 in

TABLE 1 Causes of Acute Abdominal Pain

• Abdominal compartment • Pelvic inflammatory disease
syndrome • Perforated gastric or
• Acute pancreatitis duodenal ulcer
• Appendicitis • Peritonitis
• Bowel obstruction • Ruptured abdominal
• Cholecystitis aneurysm
• Diverticulitis • Ruptured ectopic pregnancy
• Gastroenteritis
4 Abdominal Pain, Acute

Lewis et al, Medical-Surgical Nursing, ed 10, p. 939, outlines

emergency management of the patient with acute abdominal pain.
■ A diagnostic laparoscopy may be performed to inspect the
surface of abdominal organs, obtain biopsy specimens, perform
laparoscopic ultrasounds, and remove organs.
■ A laparotomy is used when laparoscopic techniques are inad-
equate. If the cause of the acute abdomen can be surgically
removed (e.g., inflamed appendix) or surgically repaired (e.g.,
ruptured abdominal aneurysm), surgery is considered definitive
therapy.

Nursing Management
Goals
The patient will have resolution of inflammation, relief of abdomi-
nal pain, freedom from complications (especially hypovolemic
shock), and normal nutritional status.
Nursing Interventions
General care involves management of fluid and electrolyte imbal-
ances, pain, and anxiety. Assess the quality and intensity of pain at
regular intervals, and provide medication and other comfort mea-
sures. Maintain a calm environment and provide information to
help allay anxiety. Conduct ongoing assessments of vital signs,
intake and output, and level of consciousness, which are key indi-
cators of hypovolemic shock.
Preoperative care includes the emergency care of the patient and
general care of the preoperative patient (Chapter 17 and Table
42-10 in Lewis et al, Medical-Surgical Nursing, ed 10, p. 939).
Postoperative care depends on the type of surgical procedure
performed. Laparoscopic procedures result in lower rates of post-
operative complications (e.g., poor wound healing, paralytic ileus),
earlier diet advancement, and shorter hospital stays compared with
open surgical procedures. A general nursing care plan (eNursing
Care Plan 19-1) for the postoperative patient is available on the
website for Chapter 19.
A nasogastric (NG) tube with low suction may be used to empty
the stomach and prevent gastric dilation. If the upper gastrointes-
tinal (GI) tract was entered, drainage from the NG tube may be
dark brown to dark red for the first 12 hours. Later it should be
light yellowish brown or greenish. If a dark red color continues or
if bright red blood is observed, notify the surgeon of the possibility
of hemorrhage. “Coffee ground” granules in the drainage indicate
blood that has been changed by acidic gastric secretions.
■ Nausea and vomiting are common after a laparotomy and may
result from the surgery, decreased peristalsis, or pain medica-
tion. Antiemetics such as ondansetron (Zofran), promethazine,
Acute Coronary Syndrome 5

and prochlorperazine may be ordered (see Nausea and Vomit- A

ing, p. 429).
■ Monitor fluid and electrolyte status along with BP, heart rate,
and respirations.
■ Swallowed air and decreased peristalsis from decreased mobil-
ity, manipulation of abdominal organs during surgery, and anes-
thesia can lead to abdominal distention and gas pains. Early
ambulation helps to restore peristalsis, expel flatus, and reduce
gas pain.
▼ Patient and Caregiver Teaching
Preparation for discharge begins soon after surgery. Teach the
patient and caregiver about any modifications in activity, care of
the incision, diet, and drug therapy.
■ Clear liquids are given initially after surgery, and if tolerated,
the patient progresses to a regular diet.
■ Normal activities should be resumed gradually, with planned
rest periods.
■ Both patient and caregiver should be aware of possible compli-
cations after surgery. Teach them to notify the surgeon imme-
diately if fever is higher than 101° F (38.3° C) or if pain, weight
loss, incisional drainage, or changes in bowel function occur.

ACUTE CORONARY SYNDROME

Description
Acute coronary syndrome (ACS) develops when myocardial
ischemia is prolonged and not immediately reversible. ACS
encompasses the spectrum of unstable angina (UA), non–ST-
segment-elevation myocardial infarction (NSTEMI), and ST-
segment-elevation myocardial infarction (STEMI) (Fig. 1).

Pathophysiology
ACS is associated with deterioration of an atherosclerotic plaque
in a coronary artery. The previously stable plaque ruptures, releas-
ing substances into the vessel. This stimulates platelet aggregation
and thrombus formation. The unstable lesion may be partially
occluded by a thrombus (manifesting as UA or NSTEMI) or totally
occluded by a thrombus (manifesting as STEMI).
Unstable Angina
The patient with chronic stable angina may develop UA, or UA
may be the first clinical manifestation of coronary artery disease
(CAD). Unlike chronic stable angina, UA is unpredictable and
must be treated immediately.
6 Acute Coronary Syndrome

Coronary artery disease

Chronic stable angina Acute coronary syndrome

• Unstable angina ST-segment-

• Non–ST-segment- elevation MI
elevation MI

Fig. 1 Relationships among coronary artery disease, chronic stable

angina, and acute coronary syndrome.

■ The patient with previously diagnosed chronic stable angina

describes a significant change in the pattern of angina. It occurs
with increasing frequency and is easily provoked by minimal
or no exertion, during sleep, or even at rest.
■ The patient without previously diagnosed angina describes
anginal pain that has progressed rapidly in the past few hours,
days, or weeks, often culminating in pain at rest.
Myocardial Infarction: ST-Elevation (STEMI) and
Non–ST-Elevation (NSTEMI)
■ A myocardial infarction (MI) occurs because of abrupt stoppage
of blood flow through a coronary artery from a thrombus caused
by platelet aggregation. This causes irreversible myocardial cell
death (necrosis). Most MIs occur in the setting of preexisting
CAD. When a thrombus develops, blood flow to the heart
muscle beyond the blockage stops, resulting in necrosis.
■ A STEMI caused by an occlusive thrombus creates ST elevation
in the electrocardiogram (ECG) leads facing the area of infarc-
tion. A STEMI is an emergency situation. To limit infarct size,
the artery must be opened within 90 minutes of presentation.
This can be done either by percutaneous coronary intervention
(PCI) or with thrombolytic (fibrinolytic) therapy. PCI is the
preferred treatment if a hospital is capable of performing PCI.
■ NSTEMI, caused by a non-occlusive thrombus, does not cause
ST elevation on the 12-lead ECG. Patients may or may not
develop ST-T wave changes in the leads affected by the infarc-
tion. NSTEMI patients do not go to the catheterization labora-
tory emergently, but usually undergo the procedure within 12
to 72 hours if there are no contraindications. Thrombolytic
therapy is not indicated for NSTEMI patients.
Acute Coronary Syndrome 7

■ Cardiac cells can withstand ischemic conditions for approxi- A

mately 20 minutes before cellular death (necrosis) begins. If
ischemia persists, it takes approximately 4 to 6 hours for the
entire thickness of the heart muscle to become necrosed. MIs
are usually described by the location of damage (anterior, infe-
rior, lateral, or posterior wall). The location correlates with the
involved coronary circulation. For example, inferior wall
infarctions result from occlusions in the right coronary artery.
The majority of MIs affect the left ventricle. Damage can occur
in more than one location (e.g., anterolateral MI, anteroseptal
MI).
■ The degree of preestablished collateral circulation also influ-
ences the severity of the infarction. An individual with a long
history of CAD may have developed good collateral circulation
to provide the area surrounding the infarction site with a blood
supply.
The body’s response to cell death is the inflammatory process.
Within 24 hours, leukocytes infiltrate the area. Enzymes are
released from the dead cardiac cells and are important diagnostic
indicators (markers) of MI. Proteolytic enzymes from neutrophils
and macrophages remove necrotic tissue by the fourth day.
■ The necrotic zone is identifiable by ECG changes (e.g.,
ST-segment elevation, pathologic Q wave) and by nuclear scan-
ning after the onset of symptoms.
At 10 to 14 days after an MI, the new scar tissue is still weak.
The myocardium is vulnerable to increased stress because of the
unstable state of the healing heart wall. Changes in the infarcted
heart muscle also cause changes in the unaffected areas. In an
attempt to compensate for the damaged muscle, the normal myo-
cardium hypertrophies and the ventricle dilates. This process of
ventricular remodeling can lead to the development of late heart
failure (HF), especially in a person with atherosclerosis of other
coronary arteries and/or an anterior MI.

Clinical Manifestations
Unstable Angina
The chest pain associated with UA is new in onset, occurs at rest,
or has a worsening pattern. Women seek medical attention for
symptoms of UA more often than men. Despite national efforts to
increase awareness, women’s symptoms (fatigue, shortness of
breath, indigestion, anxiety) often go unrecognized as related to
heart problems.
Myocardial Infarction
Severe and persistent chest pain not relieved by rest or nitrate
administration is the hallmark of an MI.
8 Acute Coronary Syndrome

■ Pain is usually described as a heaviness, pressure, burning,

crushing, tightness, or constriction. The persistent pain is unlike
any other pain.
■ Common locations are epigastric, substernal, or retrosternal.
The pain may radiate to the neck, jaw, and arms or to the back.
It may occur while the patient is active or at rest, asleep or
awake, and commonly occurs in the early morning hours.
■ The pain usually lasts for 20 minutes or more and is more severe
than usual anginal pain. When epigastric pain is present, the
patient may take antacids without relief.
■ Some patients may not have pain but may report having “dis-
comfort,” weakness, fatigue, nausea, indigestion, or shortness
of breath. Women may experience atypical discomfort, short-
ness of breath, or fatigue.
■ An older patient may experience a change in mental status (e.g.,
confusion), shortness of breath, pulmonary edema, dizziness, or
a dysrhythmia.
Additional manifestations may include vomiting, and the
patient’s skin may be ashen, clammy, and cool (cold sweat). Fever
occurs within the first 24 hours (up to 100.4° F [38° C]) and may
continue for 1 week. BP and pulse rate are elevated initially. The
BP may then drop, with decreased urine output, lung crackles,
hepatic engorgement, and peripheral edema. Jugular veins may be
distended, with obvious pulsations.

Complications
■ Dysrhythmias are the most common complication after an MI
and are the most common cause of death in patients in the
prehospital period. Dysrhythmias are caused by any condition
that affects the myocardial cell’s sensitivity to nerve impulses,
such as ischemia, electrolyte imbalances, and sympathetic
nervous system stimulation. The intrinsic rhythm of the heart
is disrupted, causing either a very fast heart rate (HR) (tachy-
cardia), a very slow HR (bradycardia), or irregular HR. Life-
threatening dysrhythmias occur most often with anterior wall
infarction, heart failure, and shock. Complete heart block is
seen in a massive infarction (see Dysrhythmias, p. 198).
■ Ventricular tachycardia and ventricular fibrillation are lethal
dysrhythmias that most often occur within the first 4 hours after
the onset of pain. Premature ventricular contractions may
precede ventricular tachycardia and fibrillation. Life-threatening
ventricular dysrhythmias must be treated immediately.
■ Heart failure (HF) occurs when the heart’s pumping action is
reduced. Left-sided HF occurs initially with subtle signs such
as mild dyspnea, restlessness, agitation, or slight tachycardia.
Acute Coronary Syndrome 9

Other signs indicating the onset of left-sided HF include pul- A

monary congestion on chest x-ray, S3 or S4 heart sounds on
auscultation of the heart, crackles on auscultation of the lungs,
paroxysmal nocturnal dyspnea (PND), and orthopnea. Signs of
right-sided HF include jugular venous distention, hepatic con-
gestion, and lower extremity edema. (See Heart Failure, p. 274.)
■ Cardiogenic shock occurs when inadequate oxygen and nutri-
ents are supplied to the tissues because of severe left ventricular
(LV) failure, papillary muscle rupture, ventricular septal rupture,
LV free wall rupture, or right ventricular infarction. Cardiogenic
shock requires aggressive management, including control of
dysrhythmias, intraaortic balloon pump therapy, and support of
contractility with vasoactive drugs.

Diagnostic Studies
In addition to the patient’s history of pain, risk factors, and health
history, the primary diagnostic studies used to determine whether
a person has UA or an MI include an ECG and serum cardiac
markers. Other diagnostic measures can include coronary angiog-
raphy, exercise stress testing, and echocardiogram.
ECG
■ When a patient first presents with chest pain, ST elevations on
the 12-lead ECG are most likely indicative of a STEMI. The
ECG should be compared with a previous ECG whenever pos-
sible. For a patient with chest pain whose ECG does not show
ST elevation or ST-T wave changes, it is difficult to distinguish
between UA and NSTEMI until serum cardiac biomarkers are
measured.
■ A patient with STEMI tends to have a more extensive MI that
is associated with prolonged and complete coronary occlusion.
A pathologic Q wave develops on the ECG.
■ A patient with UA or NSTEMI usually has transient thrombosis
or incomplete coronary occlusion, and the ECG typically does
not develop pathologic Q waves.
■ Serial ECGs often reveal the evolution and time sequence of
ischemia, injury, infarction, and resolution of the infarction.
■ Even if the initial ECG is normal or nondiagnostic when the
patient presents with chest pain, the ECG pattern may change
within a few hours to reflect the infarction process.
Cardiac Biomarkers
Certain proteins, called serum cardiac biomarkers, are released
into the blood from necrotic heart muscle after an MI.
■ Cardiac-specific troponin has two subtypes: cardiac-specific
troponin T (cTnT) and cardiac-specific troponin I (cTnI). These
markers are highly specific indicators of MI and have greater
10 Acute Coronary Syndrome

sensitivity and specificity for myocardial injury than creatine

kinase (CK)-MB.
■ Myoglobin is released into the circulation within 2 hours after
an MI and peaks in 3 to 15 hours. Although it is one of the first
serum cardiac markers to appear after an MI, it lacks cardiac
specificity.

Interprofessional Care
It is extremely important that a patient with ACS is rapidly diag-
nosed and treated to preserve cardiac muscle. Initial management
of the patient with chest pain most often occurs in the emergency
department (ED). Emergency care of the patient with chest pain is
presented in Table 33-12, Lewis et al, Medical-Surgical Nursing,
ed 10, p. 723.
■ Establish an IV line and give sublingual nitroglycerin and
chewable aspirin if not already given. IV morphine sulfate is
given for pain unrelieved by nitroglycerin.
■ Obtain a 12-lead ECG and start continuous ECG monitoring.
Position patient in an upright position unless contraindicated,
and initiate O2 by nasal cannula to keep O2 saturation above
93%.
■ The patient usually receives ongoing care in a critical care or
telemetry unit where continuous ECG monitoring is available
and dysrhythmias can be treated.
■ Monitor vital signs, including pulse oximetry, frequently during
the first few hours after admission and closely thereafter. Main-
tain bed rest and limit activity for 12 to 24 hours, with a gradual
increase in activity unless contraindicated.
■ For a patient with UA or NSTEMI, aspirin and heparin (unfrac-
tionated heparin [UH] or low-molecular-weight heparin
[LMWH]) are recommended. Dual antiplatelet therapy (e.g.,
with aspirin and clopidogrel) and heparin are recommended for
NSTEMI. Cardiac catheterization with possible PCI is consid-
ered as treatment for both UA and NSTEMI once the patient is
stabilized and angina is controlled, or if angina returns or
increases in severity.
■ For a patient with STEMI, reperfusion therapy is initiated.
Reperfusion therapy can include emergent PCI (preferred) or
thrombolytic therapy for STEMI. Thrombolytic therapy (e.g.,
reteplase [Retavase]) is given as soon as possible, ideally within
the first hour after the onset of symptoms. The goal is to save
as much heart muscle as possible. Contraindications and com-
plications with thrombolytic therapy are described in Lewis
et al, Medical-Surgical Nursing, ed 10, pp. 723 to 724. Dual
antiplatelet therapy and heparin are also used.
Acute Coronary Syndrome 11

Coronary artery bypass graft (CABG) surgery consists of the A

placement of conduits to transport blood between the aorta, or other
major arteries, and the myocardium distal to the obstructed coro-
nary artery (or arteries). It requires a sternotomy (opening of the
chest cavity) and the use of cardiopulmonary bypass (CPB). It is
a palliative treatment for CAD and not a cure. Newer techniques
include minimally invasive direct coronary artery bypass, off-
pump coronary artery bypass, totally endoscopic coronary artery
bypass (TECAB), and transmyocardial laser revascularization.
These surgical procedures and related nursing care are further
discussed in Lewis et al, Medical-Surgical Nursing, ed 10, pp. 726
to 733.
Drug therapy includes IV nitroglycerin, aspirin, β-adrenergic
blockers, and anticoagulation. Systemic anticoagulation may be
achieved with LMWH given subcutaneously or IV UH. If PCI
is anticipated, glycoprotein IIb/IIIa inhibitors may be used.
Angiotensin-converting enzyme (ACE) inhibitors are added for
some patients after an MI. Calcium channel blockers may be used
if the patient is already taking adequate doses of β-blockers or does
not tolerate these blockers.

Nursing Management
Goals
The patient with an MI will experience relief of pain, preservation
of myocardium, immediate and appropriate treatment, effective
coping with illness-associated anxiety, participation in a rehabilita-
tion plan, and reduction of risk factors. See eNursing Care Plan
33-1 for the patient with ACS on the website.
Nursing Diagnoses
■ Acute pain
■ Decreased cardiac output
■ Anxiety
■ Activity intolerance
■ Ineffective health management
Nursing Interventions
Priorities for nursing interventions in the initial phase include
pain assessment and relief, physiologic monitoring, promotion
of rest and comfort, alleviation of stress and anxiety, and under-
standing of the patient’s emotional and behavioral reactions.
Proper management of these priorities decreases the O2 needs of
a compromised myocardium. In addition, you should institute
measures to avoid the hazards of immobility while encouraging
rest.
■ Provide nitroglycerin, morphine, and supplemental O2 as
needed to eliminate or reduce chest pain.
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 mas por ser la que miré
de las más lindas que ví.

Amor, das á tantos muerte,

que pues matar es tu bien,
algún día espero verte,
que á ti mismo has de
ofenderte,
porque no tendrás á quién.
¡Oh qué bien parescerás
herido de tus dolores!
cautivo tuyo serás,
que á ti mismo tomarás,
si has de tomar amores.

Entonces dolor doblado

podrás dar á las personas,
y quedarás excusado
de haberme á mí
maltratado,
pues á ti no te perdonas.
Y si quiero reprehenderte,
dirás, volviendo por ti,
razón forzarte y moverte,
que á ti mismo dando
muerte,
vida no dejes á mi.

El cantar de Tauriso paresció muy

bien á todos, y en particular á
Ismenia. Que aunque la canción,
por hablar de mal casadas, era de
Diana, la glossa della, por tener
quejas del Amor, era común á
cuantos dél estaban
atormentados. Y por esso
Ismenia, como aquélla que daba
alguna culpa á Cupido de su
pena, no sólo le contentaron las
quejas que dél hizo Tauriso; mas
ella, al mesmo propósito, al son
de la lira, dijo este soneto, que le
solía cantar Montano en el tiempo
que por ella penaba:

Soneto.
Sin que ninguna cosa te
levante,
Amor, que de perderme has
sido parte,
haré que tu crueldad en
toda parte
se suene de Poniente hasta
Levante.
Aunque más sople el Abrego ó
Levante,
mi nave de aquel golfo no
se parte,
do tu poder furioso le abre y
parte,
sin que en ella un suspiro se
levante.
Si vuelvo el rostro estando en
el tormento,
tu furia allí enflaquesce mi
deseo,
y tu fuerza mis fuerzas
cansa y corta;
Jamás al puerto iré, ni lo
deseo,
y ha tanto que esta pena me
atormenta,
 que un mal tan largo hará mi
vida corta.

No tardó mucho Marcelio á

respondelle con otro soneto
hecho al mismo propósito y de la
misma suerte, salvo que las
quejas que daba no eran sólo del
Amor, pero de la Fortuna y de sí
mismo.

Soneto.
Voy tras la muerte sorda
passo á passo,
siguiéndola por campo, valle
y sierra,
y al bien ansi el camino se
me cierra,
que no hay por donde guíe
un sólo passo.
Pensando el mal que de
contino passo,
una navaja aguda, y cruda
sierra
de modo el corazón me
parte y sierra,
que de la vida dudo en este
passo.
La Diosa, cuyo ser contino
rueda,
y Amor que ora consuela,
ora fatiga,
son contra mí, y aun yo
mismo me daño.
Fortuna en no mudar su varia
 rueda,
y Amor y yo, cresciendo mi
fatiga,
sin darme tiempo á lamentar
mi daño.

El deseo que tenía Diana de ir á

la casa de Felicia no le sufría
detenerse allí más, ni esperar
otros cantares, sino que
acabando Marcelio su canción se
levantó. Lo mismo hicieron
Ismenia, Clenarda y Marcelio,
conosciendo ser aquella la
voluntad de Diana, aunque sabían
que la casa de Felicia estaba muy
cerca, y había sobrado tiempo
para llegar á ella antes de la
noche. Despedidos de Tauriso y
Berardo, salieron de la fuente
bella por la misma parte por
donde habían entrado, y
caminando por el bosque su
passo á passo, gozando de las
gentilezas y deleites que en él
había, á cabo de rato salieron dél,
y comenzaron á andar por un
ancho y espacioso llano, alegre
para la vista. Pensaron entonces
con qué darían regocijo á sus
ánimos, en tanto que duraba
aquel camino, y cada uno dijo
sobre ello su parescer. Pero
Marcelio, como estaba siempre
con la imagen de su Alcida en el
pensamiento, de ninguna cosa
más holgaba que de mirar los
gestos y escuchar las palabras de
Polydoro y Clenarda. Y ansí por
gozar á su placer deste contento,
dijo: No creo yo, pastoras, que
todos vuestros regocijos igualen
con el que podéis haber si
Clenarda os cuenta alguna cosa
de las que en los campos y
riberas de Guadalaviar ha visto.
Yo passé por allí andando en mi
peregrinación, pero no pude á mi
voluntad gozar de aquellos
deleites, por no tenerle yo en mi
corazón. Pero, pues para llegar á
donde imos tenemos de tiempo
largas dos horas, y el camino es
de media, podremos ir á espacio,
y ella nos dirá algo de lo mucho
que de aquella ameníssima tierra
se puede contar. Diana y Ismenia
á esto mostraron alegres gestos,
señalando tener contento de oirlo,
y aunque Diana moría por llegar
temprano al templo, por no
mostrar en ello sobrada passión
hubo de acomodarse á la
voluntad de todos. Clenarda
entonces, rogada por Marcelio,
prosiguiendo su camino, desta
manera comenzó á hablar:
Aunque decir yo con mal orden y
rústicas palabras las extrañezas y
beldades de la Valentina tierra
será agraviar sus merescimientos
y ofender vuestros oídos, quiero
deciros algo della, por no
perjudicar á vuestras voluntades.
No contaré particularmente la
fertilidad del abundoso suelo, la
amenidad de la siempre florida
campaña, la belleza de los más
encumbrados montes, los
sombríos de las verdes silvas, la
suavidad de las claras fuentes, la
melodía de las cantadoras aves,
la frescura de los suaves vientos,
la riqueza de los provechosos
ganados, la hermosura de los
poblados lugares, la blandura de
las amigables gentes, la
extrañeza de los sumptuosos
templos, ni otras muchas cosas
con que es aquella tierra
celebrada, pues para ello es
menester más largo tiempo y más
esforzado aliento. Pero porque de
la cosa más importante de aquella
tierra seáis informados, os
contaré lo que al famoso Turia,
río principal en aquellos campos
le oí cantar. Venimos un día
Polydoro y yo á su ribera para
preguntar á los pastores della el
camino del templo de Diana y
casa de Felicia, porque ellos son
los que en aquella tierra le saben,
y llegando á una cabaña de
vaqueros, los hallamos que
deleitosamente cantaban.
Preguntámosles lo que
deseábamos saber, y ellos con
mucho amor nos informaron
largamente de todo, y después
nos dijeron que, pues á tan buena
sazón habíamos llegado, no
dejássemos de gozar de un
suavíssimo canto que el famoso
Turia había de hacer no muy
lejos de allí antes de media hora.
Contentos fuimos de ser
presentes á tan deleitoso regocijo,
y nos aguardamos para ir con
ellos. Passado un rato en su
compañía, partimos caminando
riberas del río arriba, hasta que
llegamos á una espaciosa
campaña, donde vimos un grande
ajuntamiento de Nymphas,
pastores y pastoras, que todos
aguardaban que el famoso Turia
comenzasse su canto. No mucho
después vimos al viejo Turia salir
de una profundíssima cueva, en
su mano una urna, ó vaso muy
grande y bien labrado, su cabeza
coronada con hojas de roble de
laurel, los brazos vellosos, la
barba limosa y encanescida. Y
sentándose en el suelo, reclinado
sobre la urna, y derramando della
abundancia de claríssimas aguas,
levantando la ronca y congojada
voz, cantó desta manera:

Canto de Turia.
Regad el venturoso y fértil
suelo,
corrientes aguas, puras y
abundosas,
 dad á las hierbas y árboles
consuelo,
y frescas sostened flores y
rosas;
y ansí con el favor del alto
cielo
tendré yo mis riberas tan
hermosas,
que grande envidia habrán
de mi corona
el Pado, el Mincio, el
Rhódano y Garona.

Mientras andáis el curso

apressurando,
torciendo acá y allá vuestro
camino,
el Valentino suelo
hermoseando
con el licor sabroso y
cristalino,
mi flaco aliento y débil
esforzando,
quiero con el espíritu
adevino
cantar la alegre y próspera
ventura
que el cielo á vuestros
campos assegura.

Oidme, claras Nimphas y

pastores,
que sois hasta la Arcadia
celebrados:
no cantaré las coloradas
flores,
la deleitosa fuente y verdes
prados,
bosques sombríos, dulces
ruiseñores,
valles amenos, montes
encumbrados,
mas los varones célebres y
extraños
que aquí serán después de
largos años.

De aquí los dos pastores estoy

viendo
Calixto y Alexandre, cuya
fama,
la de los grandes Césares
venciendo,
desde el Atlante al Mauro se
derrama:
á cuya vida el cielo
respondiendo,
con una suerte altíssima los
llama,
para guardar del báratro
profundo
cuanto ganado pasce en
todo el mundo.

De cuya ilustre cepa veo

nascido
aquél varón de pecho
adamantino,
por valerosas armas
conoscido,
Cesar romano y Duque
valentino,
valiente corazón, nunca
vencido,
 al cual le aguarda un hado
tan malino,
que aquél raro valor y ánimo
fuerte
tendrá fin con sangrienta y
cruda muerte.

La mesma ha de acabar en un
momento
al Hugo, resplandor de los
Moncadas,
dejando ya con fuerte
atrevimiento
las mauritanas gentes
subjectadas:
ha de morir por Carlos
muy contento,
después de haber vencido
mil jornadas,
y pelear con poderosa mano
con el francés y bárbaro
africano.

Mas no miréis la gente

embravescida
con el furor del iracundo
Marte:
mirad la luz que aquí veréis
nascida,
luz de saber, prudencia,
genio y arte;
tanto en el mundo todo
esclarescida,
que ilustrará la más oscura
parte:
Vives, qué vivirá, mientras
al suelo
 lumbre ha de dar el gran
señor de Delo.

Cuyo saber altíssímo

heredando
el Honorato Juan, subirá
tanto,
que á un alto rey las letras
enseñando,
dará á las sacras Musas
grande espanto;
parésceme que ya le está
adornando
el obispal cayado y sacro
manto:
ojalá un mayoral tan
excelente
sus greyes en mis campos
apasciente.

Cuasi en el mesmo tiempo ha

de mostrarse
Núñez, que en la doctrina
en tiernos años
al grande Stagyrita ha de
igualarse,
y ha de ser luz de patrios y
de extraños:
no sentiréis Demósthenes
loarse
orando él. ¡Más, ay, ciegos
engaños!
¡ay, patria ingrata, á causa
tuya siento
que orillas de Ebro ha de
mudar su assiento!
¿Quién os dirá la excelsa
melodía,
con que las dulces voces
levantando,
resonarán por la ribera mía
poëtas mil? Ya estoy de
aquí mirando
que Apolo sus favores les
envía,
porque con alto espíritu
cantando,
hagan que el nombre de
este fértil suelo
del uno al otro polo extienda
el vuelo.

Ya veo al gran varón que

celebrado
será con clara fama en toda
parte,
que en verso al rojo Apolo
está igualado
y en armas está al par del
fiero Marte:
Ausías March, que á tí,
florido Prado,
Amor, Virtud y Muerte ha de
cantarte,
llevando por honrosa y justa
empresa
dar fama á la honestíssima
Teresa.

Bien mostrará ser hijo del

famoso
y grande Pedro March,
que en paz y en guerra,
 docto en el verso, en armas
poderoso,
dilatará la fama de su tierra;
cuyo linaje ilustre y
valeroso,
donde valor claríssimo se
encierra,
dará un Jáime y Arnau,
grandes poëtas,
á quien son favorables los
planetas.

Jorge del Rey con verso

aventajado
ha de dar honra á toda mi
ribera,
y siendo por mis Nimphas
coronado
resonará su nombre por do
quiera;
el revolver del cielo
apressurado
propicio le será de tal
manera,
que Italia de su verso terná
espanto
y ha de morir de envidia de
su canto.

Ya veo, Franci Oliver, que el

cielo hieres
con voz que hasta las nubes
te levanta,
y á ti también, claríssimo
Figueres,
en cuyo verso habrá lindeza
tanta;
 y á tí, Martín García, que
no mueres,
por más que tu hilo Lachesis
quebranta;
Innocent de Cubells,
también te veo
que en versos satisfaces mi
deseo.

Aquí tendréis un gran varón,

pastores,
que con virtud de hierbas
escondidas
presto remediará vuestros
dolores
y enmendará con versos
vuestras vidas:
pues, Nimphas, esparcid
hierbas y flores
al grande Jaime Roig
agradescidas,
coronad con laurel, serpillo y
apio
el gran siervo de Apolo y de
Esculapio.

Y al gran Narcis Viñoles,

que pregona
su gran valor con levantada
rima,
tejed de verde lauro una
corona,
haciendo al mundo pública
su estima;
tejed otra á la altíssima
persona,
 que el verso subirá á la
excelsa cima,
y ha de igualar al amador de
Laura,
Crespi celebradíssimo
Valldaura.

Parésceme que veo un

excelente
Conde, que el claro nombre
de su Oliva
hará que entre la extraña y
patria gente,
mientras que mundo habrá,
florezca y viva;
su hermoso verso irá
resplandesciente
con la perfecta lumbre, que
deriva
del encendido ardor de sus
Centellas,
que en luz competirán con
las estrellas.

Nimphas, haced del resto,

cuando el cielo
con Juan Fernández os
hará dichosas,
lugar no quede en todo
aqueste suelo,
do no sembréis los lirios y
las rosas;
y tú, ligera Fama, alarga el
vuelo,
emplea aquí tus fuerzas
poderosas,
y dale aquel renombre
soberano
que diste al celebrado
Mantuano.

Mirando estoy aquel poëta

raro
Jaime Gazull, que en rima
valentina
muestra el valor del vivo
ingenio y claro
que á las más altas nubes
se avecina;
y el Fenollar que á Tityro
acomparo,
mi consagrado espíritu
adevina,
que resonando aquí su
dulce verso
se escuchará par todo el
universo.

Con abundosos cantos del

Pineda
resonarán también estas
riberas,
con cuyos versos Pan
vencido queda,
y amansan su rigor las
tigres fieras;
hará que su famoso nombre
pueda
subir á las altíssimas
espheras:
por éste mayor honra haber
espero,
que la soberbia Smyrna por
Homero.
La suavidad, la gracia y el
assiento
mirad con que el gravíssimo
Vicente
Ferrandis mostrará el
supremo aliento,
siendo en sus claros
tiempos excelente:
pondrá freno á su furia el
bravo viento,
y detendrán mis aguas su
corriente
oyendo al son armónico y
suave
de su gracioso verso,
excelso y grave.

El cielo y la razón no han

consentido,
que hable con mi estilo
humilde y llano
del escuadrón intacto y
elegido
para tener oficio
sobrehumano,
Fernan, Sans, Valdellos
y el escogido
Cordero, y Blasco ingenio
soberano,
Gacet, lumbres más claras
que la Aurora,
de quien mi canto calla por
agora.

Cuando en el grande Borja,

de Montesa
 Maestre tan magnánimo
imagino,
que en versos y en
cualquier excelsa empresa
ha de mostrar valor alto y
divino,
parésceme que más importa
y pesa
mi buena suerte y próspero
destino,
que cuanta fama el Tíber ha
tenido,
por ser allí el gran Rómulo
nascido.

A ti del mismo padre y mismo

nombre
y misma sangre altíssima
engendrado,
claríssimo Don Juan, cuyo
renombre
será en Parnasso y Pindo
celebrado,
pues ánimo no habrá que no
se assombre
de ver tu verso al cielo
levantado;
las Musas de su mano en
Helicona
te están aparejando la
corona.

Con sus héroes el gran pueblo

Romano
no estuvo tan soberbio y
poderoso,
cuanto ha de estar mi fértil
suelo ufano,
cuando el magno Aguilón
me hará dichoso,
que en guerra y paz consejo
soberano,
verso subtil, y esfuerzo
valeroso,
le han de encumbrar en el
supremo estado
donde Maron ni Fabio no
han llegado.

Al Seraphin centellas voy

mirando,
que el canto altivo y militar
destreza
á la región etérea
sublimando,
al verso añadirá la fortaleza,
y en un extremo tal se irá
mostrando
su habilidad, su esfuerzo y
su nobleza,
que ya comienza en mí el
dulce contento
de su valor y gran
merescimiento.

A Don Luis Millán recelo y

temo
que no podré alabar como
deseo,
que en música estará en tan
alto extremo,
que el mundo le dirá
segundo Orpheo;
tendrá estado famoso, y tan
supremo,
en las heroicas rimas, que
no creo
que han de poder
nombrársele delante
Cino Pistoya y Guido
Cavalcante.

A tí, que alcanzarás tan larga

parte
del agua poderosa de
Pegaso,
á quien de poesía el
estandarte
darán las moradoras de
Parnasso,
noble Falcón, no quiero
aquí alabarte,
porque de ti la fama hará tal
caso,
que ha de tener particular
cuidado
que desde el Indo al Mauro
estés nombrado.

Semper loando el ínclito

imperante
Carlos, gran rey, tan grave
canto mueve,
que aunque la fama al cielo
le levante,
será poco á lo mucho que le
debe;
veréis que ha de passar tan
adelante
con el favor de las
hermanas nueve,