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Manual of
Critical Care
Nursing
Nursing Interventions and
Collaborative Management

SEVENTH EDITION

MARIANNE SAUNORUS BAIRD,

MN, RN, ACNS-BC
Corporate Director, Magnet Recognition Program, Magnet Program
Director, Clinical Nurse Specialist, Emory Healthcare, Nursing
Administration, Atlanta, Georgia

2
3
Table of Contents
Cover image

Title page

Copyright

Contributors

Preface

1. General concepts in caring for the critically ill

Acid-base imbalances

Altered mental status

Fluid and electrolyte disturbances

Hemodynamic monitoring

Mechanical ventilation

Nutrition support

Pain

Prolonged immobility

4
 Sedation and neuromuscular blockade

Wound and skin care

Selected references

2. Managing the critical care environment

Bioterrorism

Emerging infections

Emotional and spiritual support of the patient and significant others

Ethical considerations in critical care

Patient safety

Selected references

3. Trauma
Major trauma

Abdominal trauma

Acute cardiac tamponade

Acute spinal cord injury

Burns

Compartment syndrome/ischemic myositis

Drowning

Pelvic fractures

Renal and lower urinary tract trauma

Thoracic trauma

Traumatic brain injury

Selected references

5
4. Respiratory disorders
Respiratory assessment: General

Acute asthma exacerbation

Acute respiratory distress syndrome

Acute pneumonia

Acute respiratory failure

Pneumothorax

Pulmonary embolism

Pulmonary hypertension

Selected references

5. Cardiac and vascular disorders

Cardiovascular assessment: General

Heart failure

Acute coronary syndrome

Acute infective endocarditis

Acute pericarditis

Aortic aneurysm/dissection

Cardiogenic shock

Cardiomyopathy

Dysrhythmias and conduction disturbances

Hypertensive emergencies

Peripheral vascular disease

Valvular heart disease

6
 Selected references

6. Kidney injury
Genitourinary assessment: General

Acute kidney injury

Continuous renal replacement therapies

Selected references

7. Neurologic disorders
General neurologic assessment

Brain death

Cerebral aneurysm and subarachnoid hemorrhage

Care of the patient after intracranial surgery

Meningitis

Neurodegenerative and neuromuscular disorders

Status epilepticus

Stroke: Acute ischemic and hemorrhagic

Selected references

8. Endocrinologic disorders
Endocrine assessment

Acute adrenal insufficiency (adrenal crisis)

Diabetes insipidus

Hyperglycemia

Myxedema coma

7
 Syndrome of inappropriate antidiuretic hormone

Thyrotoxicosis crisis (thyroid storm)

Selected references

9. Gastrointestinal disorders
Gastrointestinal assessment: General

Acute gastrointestinal bleeding

Acute pancreatitis

Enterocutaneous fistula

Hepatic failure

Peritonitis

Selected references

10. Hematologic/immunologic disorders

General hematology assessment

Anaphylactic shock

Profound anemia and hemolytic crisis

Bleeding and thrombotic disorders

Selected references

11. Complex special situations

Abdominal hypertension and abdominal compartment syndrome

Drug overdose

Stimulants

High-risk obstetrics: Hypertension in pregnancy

8
 Oncologic emergencies

Organ transplantation

Sepsis, septic shock, systemic inflammatory response syndrome, and

multiple organ dysfunction syndrome

Selected references

Heart and breath sounds

Glasgow coma scale

Cranial nerves Assessment and dysfunctions

Major deep tendon muscle stretch reflexes

Major superficial cutaneous reflexes

Inotropic and vasoactive medication infusions

Sample relaxation technique

Abbreviations used in this manual

Index

Ibc

9
Copyright

3251 Riverport Lane

St. Louis, Missouri 63043
MANUAL OF CRITICAL CARE NURSING: NURSING
INTERVENTIONS AND COLLABORATIVE MANAGEMENT,
SEVENTH EDITION
ISBN: 978-0-323-18779-4
Copyright © 2016 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in

any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details
on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are

protected under copyright by the Publisher (other than as may be
noted herein).

All rights reserved. No part of this publication may be reproduced

or transmitted in any form or by any means, electronic or

10
mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from
the publisher, except that, until further notice, instructors requiring
their students to purchase Book Title by Author, may reproduce the
contents or parts thereof for instructional purposes, provided each
copy contains a proper copyright notice as follows: Copyright ©
2016 by Elsevier Inc.
Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
Notices
Knowledge and best practice in this field are constantly changing.
As new research and experience broaden our understanding,
changes in research methods, professional practices, or medical
treatment may become necessary. Practitioners and researchers
must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety
of others, including parties for whom they have a professional
responsibility.
With respect to any drug or pharmaceutical products identified,
readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of
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or formula, the method and duration of administration, and
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their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the
authors, contributors, or editors, assume any liability for any injury
and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the
material herein.

11
NANDA International, Inc. Nursing Diagnoses: Definitions &
Classifications 2015-2017, Tenth Edition. Edited by T. Heather
Herdman and Shigemi Kamitsuru. 2014 NANDA International, Inc.
Published 2014 by John Wiley & Sons, Ltd. Companion website:
www.wiley.com/go/nursingdiagnoses.

Previous editions copyrighted 2011, 2005, 2001, 1998, 1995, 1991.

International Standard Book Number: 978-0-323-18779-4

Executive Content Strategist: Lee Henderson

Content Development Manager: Jean Fornango
Content Development Specialist: Melissa Rawe
Publishing Services Manager: Julie Eddy
Senior Project Manager: Marquita Parker
Book Designer: Ashley Miner

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

12
Contributors
Patrice C. Al-Saden, BS, RN, CCRC, Senior Clinical Research
Associate, Comprehensive Transplant Center, Feinberg School of
Medicine, Chicago, Illinois

Sonia Astle, RN, MS, CCNS, CCRN, CNRN, Clinical Nurse

Specialist, Critical Care, Inova Fairfax Medical Campus, Falls
Church, Virginia

Carol Ann Batchelder, MSN, RN, CCRN, ACCNS-AG BC,

Clinical Nurse Specialist, Intensive Care Units, Tri-campus,
Northside Hospital System, Atlanta, Georgia

Risa Benoit, DNP, CNS-BC, Advanced Practice Nurse,

Perioperative Services, Sarasota Memorial Healthcare System,
Sarasota, Florida

Cheryl L. Bittel, MSN, APRN, CCNS, NP-C, CCRN, Clinical

Nurse Specialist, Emory Saint Joseph’s Hospital, Atlanta, Georgia

Carolyn Blayney, BSN, RN, Clinical Operation Manager,

Pediatrics, Harborview Medical Center, Seattle, Washington

13
Madalina Boitor, BScN, RN, PhD Student, Ingram School of
Nursing, McGill University, Montreal, Canada

Jemma Brown, MSN-ED, RN, CCRN, CCM-BC, Stroke Program

Coordinator, Emory University Hospital Midtown, Atlanta,
Georgia

Susan B. Cali, MSN, RN, MHA, Infection Control Coordinator,

Emory University Hospital Midtown, Atlanta, Georgia

Mimi Callanan, MSN, RN, Epilepsy Clinical Nurse Specialist,

Stanford Comprehensive Epilepsy Center, Stanford Health Care,
Stanford, California

Gretchen J. Carrougher, MN, RN, Research Nurse Supervisor,

Department of Surgery, Harborview Medical, Center, Seattle,
Washington

Cynthia Rebik Christensen, MSN, CVN, ARNP-BC, Nurse

Practitioner, Family Practice, Certified Vascular Nurse, Mobile
Medical Professionals, Ankeny, Iowa

Janice C. Colwell, MS, RN, CWOCN, FAAN, Advanced Practice

Nurse, University of Chicago Medicine, Chicago, Illinois

Alice E. Davis, PhD, GNP-BC, ACNP-BC, FNP-BC, Associate

Professor, School of Nursing, University of Hawaii at Hilo, Hilo,
Hawaii

Joni L. Dirks, MS RN-BC, CCRN-K, Manager Clinical Educators

& ICU Educator, Providence Health Care, Spokane, Washington

14
Beverly George Gay, MSN, RN, Assistant Professor, Department
of Nurse Anesthesia, School of Allied Health Professions, Virginia
Commonwealth University, Richmond, Virginia

Céline Gélinas, PhD, RN

Associate Professor, Ingram School of Nursing, McGill University
Researcher, Center for Nursing Research and Lady Davis, Institute
for Medical Research, Jewish General Hospital, Montreal, Quebec,
Canada

Patricia R. Gilman, APRN, MSN, ACNS-BC

Adult Health Clinical Nurse Specialist, Cardiac ICU, Emory
University Hospital (2012–2014), Atlanta, Georgia
Robert Wood Johnson Nursing & Health, Policy Collaborative
Fellow, University of New Mexico College of Nursing,
Albuquerque, New Mexico

Vicki S. Good, RN, MSN, CENP, CPSS, System Director

Quality/Safety, CoxHealth, Springfield, Missouri

Phyllis Gordon, MSN, APRN, ACNS-BC

Clinical Nurse Specialist, Vascular Surgery, Division
Clinical Assistant Professor, School of Nursing, University of Texas
Health Science Center, San Antonio, San Antonio, Texas

Kimberly Graham, MSN, APRN, ACNS-BC, Clinical Nurse

Specialist, General Medical, Emory University Hospital Midtown,
Atlanta, Georgia

Vinay Paul Singh Grewal, B.Sc., Medical Student, Windsor

University School of Medicine, St. Kitts

15
Kiersten Henry, MSN, ACNP-BC, CCNS, CCRN-CMC, Acute
Care Nurse Practitioner, Chief Advanced Practice Provider,
MedStar Montgomery Medical Center, Olney, Maryland

Adina Hirsch, PharmD, BCNSP

Clinical Specialist–Nutrition Support, Critical Care, Saint Joseph’s
Hospital of Atlanta;
Assistant Professor of Pharmacy Practice, School of Pharmacy,
Philadelphia College of Osteopathic Medicine, Atlanta, Georgia

Beth Hundt, MS, APRN, NP-C, ACNS-BC

Clinical Nurse Specialist, Marcus Stroke & Neuroscience Center,
Grady, Health System, Atlanta, GA (2012–2014);
Clinical Nurse Specialist, Neuroscience Center of Excellence,
University, of Virginia Health System, Charlottesville, Virginia
(current)

Susie Hutchins, DNP, RN, Associate Clinical Professor,

Coordinator, Simulation and Standardized Patient Lab for, MEPN,
University of San Diego, Hahn School of Nursing, San Diego,
California

Anne E. Hysong, MSN, APRN, CCNS, Clinical Nurse Specialist,

Critical Care, Gwinnett Medical Center–Duluth, Duluth, Georgia

Jonathan Wesley Kandiah, B.Sc., Medical Student, All Saints

University, St. Vincents and the Grenadines

Roberta Kaplow, PhD, APRN-CCNS, AOCNS, CCRN,

Oncology Clinical Nurse Specialist, Emory University Hospital,
Atlanta, Georgia

16
Alice S. Kerber, MN, APRN, ACNS-BC, AOCN, APNG, Clinical
Nurse Specialist, Oncology, Advanced Practice Nurse in Genetics,
Georgia Center for Oncology Research and, Education (Georgia
CORE), Atlanta, Georgia

Kathleen Kerber, MSN, RN, ACNS-BC, CCRN, Clinical Nurse

Specialist, Medical Intensive Care Unit/Critical Care, Step Down
Unit, MetroHealth Medical Center, Cleveland, Ohio

Barbara McLean, MN, RN, CCNS-BC, NP-BC, CCRN, FCCM,

Critical Care Clinical Specialist, Critical Care Division, Grady
Health Systems, Atlanta, Georgia

James P. McMurtry, MSN, APRN, CNS-BC, CCRN, Clinical

Nurse Specialist, MICU; Pulmonary Critical Care, Emory
University Hospital Midtown, Atlanta, Georgia

Maria Paulsen, BSN, RN, Critical Care Nurse, Coordinator,

Trauma Outreach Education, Program, Harborview Medical
Center, Seattle, Washington

Lisa Reif, MSN, RN, APRN-CCNS, CCRN, Clinical Nurse

Specialist, Neuroscience ICU, Emory University Hospital, Atlanta,
Georgia

Alan Sanders, PhD, Director, Ethics, Trinity Health, Newtown

Square Office, Pennsylvania

Paul E. Schmidt, RPh, BCPS, Clinical Pharmacist, Critical Care,

Northside Forsyth Hospital, Cumming, Georgia

Elizabeth Scruth, PhD, RN, MPH, FCCM, CCNS, CCRN

17
Clinical Practice Consultant, Clinical Effectiveness Team, Kaiser
Permanente Northern California, Regional Quality and Regulatory
Services, Oakland, California
Critical Care Transport RN, Bayshore Ambulance, Foster City,
California

Maureen A. Seckel, MSN, RN, APN, ACNS-BC, CCNS, CCRN,

FCCM, Clinical Nurse Specialist, Medical Pulmonary Critical
Care, Christiana Care Health System, Newark, Delaware

Kara A. Snyder, MS, RN, CCRN, CCNS, Director, Quality

Improvement and Outcomes, Management, Banner University
Medical Center, Tucson, and South Campuses, Tucson, Arizona

Monica Tennant, MSN, APRN, CCNS, Critical Care Clinical

Nurse Specialist, Emory Saint Joseph’s Hospital, Atlanta, Georgia

Daryl Todd, MS, APRN-CNS, CCCC, ACNS-BC, Certified

Cardiovascular Care Coordinator, Clinical Nurse Specialist,
Coordinator Bariatrics and Chest Pain, Centers of Excellence,
Clinical Support for, Hospice and Observation Units, Emory
University Hospital Midtown, Atlanta, Georgia

Sharon Vanairsdale, MS, APRN, ACNS-BC, NP-C, CEN,

Clinical Nurse Specialist, Emergency Department and Serious
Communicable Disease Unit, Emory University Hospital, Atlanta,
Georgia

Colleen Walsh-Irwin, DNP, RN, ANP, CCRN

Cardiology Nurse Practitioner, Northport VAMC, Northport, New
York;
Cardiovascular Clinical Nurse Advisor, Department of Veterans
Affairs, Washington, DC;

18
Clinical Assistant Professor, Stony Brook University, Stony Brook,
New York

Joyce Warner, MN, RN, CCRN, Nurse Clinician, Surgical

Intensive Care Unit, Emory Healthcare, Atlanta, Georgia

Karen E. Zorn, MSN, RN, ONC, Enterprise Solution Architect,

Acute Care Integration, Emory Healthcare, Atlanta, Georgia

Reviewers
Bimbola Fola Akintade, PhD, ACNP-BC, MBA, MHA, Co-
Specialty Director and Assistant Professor, Adult Gerontological
Acute Care Nurse, Practitioner/Clinical Nurse Specialist, Program,
University of Maryland Baltimore, School of Nursing, Baltimore,
Maryland

David Allen, MSN, RN, CCRN, CCNS-BC, Deputy Chief,

Center for Nursing Science and, Clinical Inquiry, Brooke Army
Medical Center, Fort Sam Houston, TX 78109

Penelope S. Benedik, PhD, CRNA, RRT, Associate Professor of

Clinical Nursing, University of Texas Health Science Center at,
Houston, Houston, TX

Marcia Bixby, RN, MS, CCRN, APRN-BC, Critical Care Clinical

Nurse Specialist, Consultant, Randolph, Massachusetts

Marylee Bressie, DNP, RN, CCRN, CCNS, CEN, Assistant

Professor, University of Arkansas Fort Smith and, Capella
University, Ft Smith, Arkansas and Minneapolis, Minnesota

19
Diane Dressler, MSN, RN, CCRN, Clinical Assistant Professor,
Marquette University College of Nursing, Milwaukee, WI

Jennifer L. Embree, DNP, RN, NE-BC, CCNS, Clinical Assistant

Professor and Consultant, Indiana University School of Nursing -
Indiana, University Purdue University Indianapolis, Indianapolis,
Indiana

Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CPEN,

CCRN, CTRN, SANE-A, AFN-BC, EMT-P, FAEN, Clinical
Nurse Educator, Lankenau Medical Center, Wynnewood, PA

David Goede, DNP, ACNP-BC, Assistant Professor of Nursing,

Hospitalist, Nurse Practitioner, University of Rochester School of
Nursing, Rochester New York

Vinay Paul Singh Grewal, B.Sc., Medical Student, Windsor

University School of Medicine, Basseterre, Saint Kitts & Nevis

Elizabeth A. Henneman, PhD, RN, CCNS, FAAN, Associate

Professor of Nursing, University of Massachusetts Amherst,
Amherst, Massachusetts

Jennifer M. Joiner, MSN, RN, AGPCNP-BC, CCRN-CSC,

Clinical Nurse Educator, CTICU, and CCU Robert Wood Johnson
University Hospital, New Brunswick, NJ

Irena L. Kenneley, PhD, APHRN-BC, CIC, Assistant

Professor/Faculty Development Coordinator, Case Western Reserve
University, Cleveland, Ohio

20
Julene B. Kruithof, MSN, RN, CCRN, Nurse Educator, Spectrum
Health, Grand Rapids, Michigan

Elaine Larson, PhD, RN, FAAN, Anna C. Maxwell Professor of

Nursing, Research, School of Nursing and Professor, of
Epidemiology, Mailman School of Public, Health, Columbia
University, Columbia University, NY, NY

Rosemary K. Lee, DNP, ARNP-BC, CCNS, CCRN, Clinical

Nurse Specialist, Homestead Hospital, Homestead, FL

Justin Milici, MSN, RN, CEN, CPEN, CFRN, CCRN, TNS, RN

III Emergency Department, Parkland Health and Hospital System,
Dallas, Texas

Fadi B. Nahab, MD
Associate Professor, Department of Necrology and Pediatrics,
Emory University
Medical Director, Stroke Program, Emory University Hospitals,
Atlanta, Georgia

Michaelynn Paul, MS, RN, CCRN, Assistant Professor, Walla

Walla University, College Place, Washington

Julia Retelski, MSN, RN, CNRN, CCRN, CCNS, Clinical Nurse

Specialist Neurosurgical Intensive Care Unit, Carolinas Health Care
System, Charlotte, NC

Johnnie Robbins, MSN, RN, CCRN, CCNS, Critical Care

Clinical Nurse Specialist, US Army Institute of Surgical Research,
Fort Sam Houston, Texas

21
Tara L. Sacco, MS, RN, CCRN, ACNS-BC, ACCNS-AG, Visiting
Assistant Professor, St. John Fisher College Wegmans School of,
Nursing, Rochester, New York

Diane Vail Skojec, MS, DNP, CRNP, Nurse Practitioner,

Department of Surgery, The Johns Hopkins Hospital, Baltimore,
Maryland

Scott C. Thigpen, DNP, RN, CCRN, CEN, Dean and Professor of

Nursing, South Georgia State College, Douglas, Georgia

Judith A. Young, DNP, RN, CCRN, Clinical Assistant Professor,

Indiana University School of Nursing, Indianapolis, Indiana

22
Preface
Manual of Critical Care Nursing is a clinical reference for both
practicing nurses and students in critical care, progressive care, and
complex medical-surgical units. It is the most comprehensive of the
critical care handbooks available, yet is a concise and easy reference
with an abbreviated outline format and a portable, trim size. This
handbook provides quick information for more than 75 clinical
phenomena seen in critical care and other high acuity care
environments, which promotes evidence-based practice in planning
goal-driven care.

Who will benefit from this book?

Nurses from novice to expert will have access to key information
used to perform appropriate assessments, plan and implement care,
and evaluate the outcomes of interventions provided to critically ill
and acutely ill patients. The textual information and numerous
tables will serve as a focused review for the practicing nurse and
advanced practice providers. Academicians may find the book
helpful in teaching students to apply didactic classroom
information to clinical practice. Students will have an excellent tool
for assessing the patient systematically, and setting priorities for
nursing interventions.

Why is this book important?

The book provides information concisely, with emphasis on
evidence-based practice and outcomes achievement. Goal-directed
care is vital to patient safety, and promoting interdisciplinary

23
collaboration. Both a collaborative plan of care, and specific nursing
care plans are presented. Given the increasing acuity of
hospitalized patients, problems previously managed in critical care
such as using arterial blood gas interpretation to correct acid-base
imbalances, medically managing dysrhythmias with medication
infusions, or controlling blood pressure with vasoactive drugs can
be part of daily care of patients in progressive care units, telemetry,
stepdown units, and high-acuity medical-surgical units.
Accordingly, the care plans presented are applicable across the
spectrum of high-acuity care, from complex medical-surgical to
critical care. The book addresses the highly technical life-support
equipment as part of the care options for each condition, and in
detail for those who are actively using the technology in separate,
detailed sections.

Benefits of using this book

The primary goal of this reference is to present the information
necessary to provide patient- and family-centered care in a
technologically advanced environment in a concise, easy-to-use
format. The whole patient is addressed with care recommendations
for physical, emotional, mental, and spiritual distress involved in
illness. The prevention of potentially life-threatening complications
is crucial to patient safety and addressed through collaborative,
evidence-based care planning. The intent is to offer a thorough
selection of prioritized actions that can be chosen as needed in
planning individualized care.

How to use this book

Manual of Critical Care Nursing is organized for easy access and
logical presentation. Information regarding general concepts of
patient care, including those unique to the critical care
environment, is presented in the first two chapters, General
Concepts in Caring for the Critically Ill and Managing the Critical
Care Environment. Following is a chapter on Trauma and related
disorders. Chapters 4 through 10 cover disorders classified by body
systems, and Chapter 11 addresses Complex Special Situations,
such as high-risk obstetrics and organ transplantation.

24
 Each body system–specific chapter includes a general physical
assessment, and several chapters include generic plans of care
applicable to patients with all disease processes affecting that body
system. Each disorder includes a brief review of pathophysiology,
physical assessment, diagnostic testing, collaborative management,
NANDA-approved nursing diagnoses and nursing interventions,
patient/significant other teaching, desired outcomes, and disease-
specific discharge planning considerations. Gerontologic icons
highlight material relevant to the care of older adults, bariatric icons
have been added for care specific to people of size, and safety alerts
highlight key information needed to prevent complications. Desired
nursing care outcomes and interventions are based on the
University of Iowa’s Nursing Intervention Classification (NIC) and
Nursing Outcomes Classification (NOC) systems and are
highlighted throughout the text. Nursing interventions are linked to
nursing diagnoses, and suggested outcomes include specific
measurement criteria for physical parameters and time frames for
attainment of expected outcomes. The suggested time frames for
outcomes achievement are guidelines. Each patient’s response to
the illness and interventions is unique.
For clarity and consistency throughout the book, normal values
are given for hemodynamic monitoring and other measurements.
All values should be individualized to each patient’s baseline
health status.

New to this edition

The seventh edition has been revised to further emphasize
evidence-based practices and patient safety and mirrors a practicing
nurse’s approach to patient care. Changes include:

• Enhanced patient safety information, including new patient safety

alerts.

• Updated evidence-based guidelines, including evolving strategies

for management of heart and respiratory failure, and advances in
technology associated with mechanical ventilation, cardiac
mechanical assist devices, and hemodynamic monitoring.

25
• Information to help assess and plan care for bariatric patients.

• Enhanced medical and nursing management information for

correction of acid-base imbalances, management acute asthma,
brain injury, burns, sepsis, organ transplantation, obstetric
emergencies, cardiogenic shock, heart and respiratory failure,
and the management of altered mental status including delirium.

• Appropriate resuscitation interventions within the section on

Dysrhythmias and Conduction Disturbances.

I hope that critical care and high-acuity acute care providers,

students, and academicians will find that the new edition of Manual
of Critical Care Nursing provides a wealth of updated, concisely
comprehensive, easy-to-access knowledge applicable to clinical
practice as well as the classroom.

Acknowledgments
I want to thank many individuals who supported the development
of this manuscript. In particular, I am grateful for the time and
efforts of the Elsevier Science staff, including Melissa Rawe,
Content Development Specialist, and Marquita Parker, Senior
Project Manager, Book Production. I appreciate the guidance of Lee
Henderson, Executive Content Strategist. I thank all the
contributors for their work, as well as all the reviewers whose
comments helped guide our revisions. All are recognized as shining
stars in their own right. Both perseverance and patience are the
fundamental characteristics inherent in all participants.
Marianne Saunorus Baird
I acknowledge the support of my daughter Rachel, my best
cheerleader, and my husband Thom for his patience. I also cannot
thank the authors enough for your attention to detail; particularly
all the new authors who “filled the gaps” from Emory Healthcare,
Atlanta, Georgia. I would also like to acknowledge Savannah Davis,
who helped the team begin our process with Elsevier Science.
MSB

26
CHAPTER 1

General concepts in
caring for the
critically ill
Acid-base imbalances
Cells must transport ions, metabolites, and gases to function
appropriately in their respective roles in the body. For this to occur,
the chemical environment of the bloodstream must be electrically
stable. The stability of the environment is measured by the arterial
pH and must be chemically neutral (pH 7.40) for all systems to
function properly. The arterial blood gas (ABG) is the most
commonly used analysis to measure acid-base balance and to assess
the efficacy of oxygenation. Respiratory (CO2) and metabolic acids
(H+) are generated as cells work and must be buffered or eliminated
to maintain a neutral chemical environment. When the chemical
environment is no longer neutral, the patient has an acid-base
imbalance. Ineffective metabolism (tissue level), renal dysfunction,
and/or problems with ventilation (breathing gasses effectively) are
often the cause of acid-base imbalance.
There are two main types of acid-base imbalance: acidosis and
alkalosis. The kidneys and lungs work in tandem to maintain
chemical neutrality, but it is actually cellular function that produces
acid. When either the kidneys or lungs are overfunctioning or
underfunctioning, the other system is designed to have the opposite
response to compensate and bring the pH back to a normal range.

27
When the kidneys fail to regulate metabolic acids (H+), the lungs
must compensate. When the lungs fail to regulate respiratory acid
(CO2), the kidneys must compensate. Additional buffering
mechanisms are also available to help regulate the accumulation of
acids. Control of alkaline states, resulting from accumulation of
bases or loss of acids, is maintained in a similar manner between
the lungs and kidneys.

Pathophysiology of acid-base regulation

Arterial pH is an indirect measurement of CO2 and H+
concentration, which reflects the overall level of acid and
effectiveness of maintaining the balance. The normal acid-base ratio
is 1:20—1 part acid (the H+ and CO2 component of H2CO3) to 20
parts base (HCO3−). If the ratio is altered through an increase or a
decrease in either acid H+, or CO2, or the base, HCO3−, the pH
changes. Chemically, the CO2 does not contain H+, but when
dissolved in water (plasma), CO2 + H2O yields H2CO3 (carbonic
acid). CO2, when combined with H2O, becomes the largest
contributor of H+ (acids), which must be eliminated or buffered to
maintain normal pH. Too many H+ ions in the plasma create
acidemia (pH less than 7.35), whereas too few H+ ions create
alkalemia (pH greater than 7.45).
Maintaining the 1:20 ratio (“the balance”) depends on the ability
of the lungs and kidneys to help normalize concentrations of
carbonic acid (H2CO3), a product of hydrogen ion (H+) plus
bicarbonate buffer (HCO3−). Both the kidneys and lungs are
designed to eliminate carbonic acid effectively, and therefore
without the presence of lung or kidney disease, the pH should
always be in the normal range. A pH change is a symptom that
there is a significant problem with one or both of the systems.

• Acidosis: Extra acids are present or base is lost, with a pH less

than 7.35.

1. Cellular acidosis: When cells are hypoxic or

28
 processing proteins to yield glucose, there is an
increase in lactic acid or ketoacid.

2. Respiratory acidosis: If lung function is

inadequate, such as in chronic obstructive
pulmonary disease (COPD), the failure to
effectively ventilate results in the inability to
excrete CO2, and that failure causes carbonic acid
to increase (more acid) and pH to decrease.

3. Renal acidosis: When the kidney function is

inadequate, the ability to break down carbonic
acid into H+ and HCO3− is impaired. When this
failure occurs, carbonic acid increases (more acid)
and pH decreases.
• Buffering of acid or compensation for acidosis occurs in three
primary ways:

1. Plasma and cellular buffering: Using bicarbonate,

proteins, intracellular electrolytes, and chloride to
buffer H+, the most common is the marriage of H+
and HCO3−, which yields carbonic acid (H2CO3).

2. Hyperventilation (lungs): The presence of

increased carbonic acid stimulates a
hyperventilation response. This allows for
exhaling (“blow off”) more of the CO2 component
of carbonic acid. This compensatory response for
metabolic acidosis occurs within minutes and
should bring the pH to a normal range.

29
 3. Acid excretion (kidneys): A functional kidney
will use increased carbonic acid by breaking
H2CO3 into bicarbonate and H+, excreting H+ and
retaining bicarbonate. This should compensate
for the increased respiratory acidosis but is very
slow, taking 4 to 48 hours for compensation to
occur.
• Alkalosis: Extra base is present or there is loss of acid, with a pH
greater than 7.45.

1. Respiratory alkalosis: When hyperventilation is

the primary problem, there is a very rapid
removal of CO2, causing carbonic acid to decrease
(less acid) and pH to increase.

2. Renal alkalosis: If kidney function is

overstimulated (e.g., with aggressive diuresis),
there may be excessive loss of hydrogen ions
(H+), causing carbonic acid to decrease (less acid)
and pH to increase.

3. Other contributors: Gastric and intestinal removal

of acids may occur when patients have diarrhea,
vomiting, or when excessive gastric drainage
influences the acid-base balance.

• Compensation for alkalosis occurs in two ways:

1. Hypoventilation: The respiratory system

responds by slowing ventilation and retaining
CO2 (acid) to help compensate for metabolic

30
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Title: Hopeaviulu
Runoja

Author: Elina Vaara

Release date: January 18, 2024 [eBook #72749]

Language: Finnish

Original publication: Porvoo: WSOY, 1928

Credits: Tuula Temonen

*** START OF THE PROJECT GUTENBERG EBOOK

HOPEAVIULU ***
HOPEAVIULU

Runoja

Kirj.

ELINA VAARA

Porvoossa, Werner Söderström Osakeyhtiö, 1928.

SISÄLLYS:

KEVÄTYÖN LAULU

Kevätyön laulu
Gondoolilaulu
Niinkuin ruohon ja reseedan tuoksu
Laulu ulapalta
Läheisyys
Armahtava yö
Mysterium
Meri lepää

PILVIKUVAT

Nuoruus
Tulivuoren laulu
Hautauspäivä
Unessa
Kätketty rakkaus
Yöllinen ajo
Pilvikuvat
Kauhun maa
Aamutaivas
Tuskallinen rakkaus

KUUNVALOSSA

Hopeaviulu
Peilikammio
Äänetön maa
Haavaisin siivin
Kevätlegenda
Kummallinen satu
Kuunvalossa
Sininen hämärä
Alakuloinen oodi
Sokko

AAMU

Omenapuun alla
Ikkunat auki on aamun tuuleen
Helluntaivirsi
Ilta
Uskollisuus
Lapsi
Aamu
Lipas
Lapsen uni
Rukoilevat silmät
KEVÄTYÖN LAULU
KEVÄTYÖN LAULU

Kädet ihanan viileät, aavistettavat koko rannan raukeaksi on

hyväilleet. Maan ruoho rukoilee, puut himmeät huokaa: —
Levon autuus, rauha suloinen meille suokaa! Me olemme
ikävästä sairahat ja hyvin, hyvin väsyneet.

Oi suokaa meidän itsemme unhoittaa ja sulaa meren,

pilvien harmauteen kuin huulet huuliin yhtyvät suudellessa,
povi poveen vaipuu suuressa rakkaudessa! — Ken murtaa
rajat, jotka ahdistaa? Koko maailma kuolee kaipaukseen.
GONDOOLILAULU

Kuu kaita lailla gondoolin

ui illan tummaan sinehen.
Kaikk' avaruuden aallot hengittävät.
Ja tähdet pienet, kirkkahat
kuin suomut kultakalojen
yön verkon silmukoissa kimmeltävät.

Sa, joka juoman tulisen

mun kanssain unelmissa joit,
oi nouse ilon, huimauksen laivaan!
Mun suuni hehkuu suudelmin —
kuin kukat poimia ne voit
ja heittää sinisyvyyksihin taivaan.
NIINKUIN RUOHON JA RESEEDAN
TUOKSU —

Niinkuin ruohon ja reseedan tuoksu on sinun rakkautesi.

Kirkas naurunhelinä kiirii jälkiä askeltesi.

Ah, sinä olet hurmaava hulluus, ilo ja itse kevät! Kun sinä
suutelet surullista neitoa, jumalat hymyilevät.
LAULU ULAPALTA

Meren hopeakalvossa värisee tuhat tähteä kimmeltävää. Mun

korvani laulua kuuntelee, joka aavalta heläjää.

Se laulu on kaunis ja kummallinen — minä värisen

kokonaan. Joku lienee joskus laulanut sen sydän tuskaa
tulvillaan.
LÄHEISYYS

On varjoni sun rinnallas, vaikk' itse loittonen. Kun olet sairas,

hiuksias ma hiljaa hyväilen.

Kun suljet silmäluomesi, niin luokses kumarrun. Vaikk' olen

poissa, sieluni kuin huntu kietoo sun.
ARMAHTAVA YÖ

Yön viitan mustiin silkkipoimuihin nyt murheellisen pääni

verhoisin, kun meri täynnä tummaa unta päilyy ja lasinhauraat
tähtilyhdyt häilyy.

Yön syvä, lainehtiva pimeys

ja outo, ihmeellinen kimmellys
mun aran haavani voi yksin pestä.
Oon sairas murhatusta hellyydestä.

Yö peittää kuolemankin varjoillaan ja hautaa kaikki aaltoin

keinuntaan, kun meri täynnä tummaa unta päilyy ja
lasinhauraat tähtilyhdyt häilyy.
MYSTERIUM

Kuin viini tuoksuu ruusut kirkkoinaan. On niiden ihanuus kuin

kuuma helle. Ja alttartaulun Neitsyt armossaan pois astunut
on kultapuitteistaan nyt käyden kukkaselta kukkaselle.

Ah, kaikki kauniit synnit vainajain

on ruusun muodon saaneet suloisimman.
Ne kärsittyään kiirastulen lain
nyt hehkuu pyhää hartautta vain
Madonnan hymyn lailla ihanimman.

Hän mitä hellin käsin hyväilee ja siunaa, viilein vihkivesin

kastaa. Oi kuule, kuinka urut hymisee ja kuorolaulu kirkas
helmeilee! Puut vanhat himmein huokauksin vastaa.
MERI LEPÄÄ

Nyt meri lepää ulapoin

niin laakein, oudon tyvenin.
Pois hiljaa vaimennut on tuulen tohu.
Mut myrskyn henget ailakoivat
alla pinnan kristallin,
soi syntyvien hyökyaaltoin kohu.

Ja venheen, joka uskaltaa

sen vilpilliseen sylihin,
kuin kalan ahmaista voi aaltoin nielu.
Siell' levämetsät huojuu
kukin kummallisen loistavin,
ja nyyhkyttää ja nauraa meren sielu.
PILVIKUVAT
NUORUUS

Illoin nuoruudesta iloitsen — yöllä kauhunkuvat saartaa mun:

kiedottuna sisään liinojen suljettu oon mustaan kirstuhun.

Raskaan houreen läpi vielä nään, kuinka hehkuu lyhdyt

räikeät, kuulen, kuinka soittoon kimeään nauru, tanssinkohu
yhtyvät.

Tähän kirstuun kuolee sieluni, ruumis tuhon inhoittavan

saa: ruususeppel pääni ympäri toukkain uhrijuhlaa ilmoittaa.
———

Kylmä tuskanhiki otsallain herään huohottaen pimeyteen.

Luojan kiitos, näinkin unta vain —!

Olen valmis leikkiin huomiseen.

TULIVUOREN LAULU

Savuava tulivuori olin, sairaiden liekkien hauta ma olin,

täynnä ääriä myöten mustaa, hivuttavaa hehkua.

Silloin uumenistani loimahti kirkas, humiseva tuli, syöksähti

ilmoihin myrsky: syvyydet aukaisi, vapahti minut.
HAUTAUSPÄIVÄ

Kysyt, miksi verhoudun punaiseen silkkiin tänä mustana

hautauspäivänä. Sieluni ei ymmärrä sinun kuolemaasi. Elämä
ja kuolema ovat minulle yhtä. Rakkaus versoo kuin tulinen
vilja sydämeni vainiolla.

Ystävä, olkaamme julmia kumpikin: muuten ei ole elämää.

Ystävä, olkaamme julmia kumpikin — tänään minä,
huomenna sinä. Kenties jo huomenna sinulla on aseet
murskataksesi minut.