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Copyright © 2008 by F. A. Davis.


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A Davis’s Notes Book

Tracey Hopkins, BSN, RN

Ehren Myers, RN

MedSurg

Notes Nurse’s Clinical Pocket Guide MedSurg

Notes Nurse’s Clinical Pocket Guide

2nd Edition



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F. A. Davis Company1915 Arch StreetPhiladelphia, PA 19103

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Copyright © 2008 by F. A. Davis Company

All rights reserved. This book is protected by copyright. No part of it may bereproduced, stored in a retrieval system, or transmitted in any form or by anymeans, electronic, mechanical, photocopying, recording, or otherwise, withoutwritten permission from the publisher.

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Swasey, RN, MN; Deborah Weaver, PhD, RN, MSN; Jessie Williams, BSN, MA;

As new scientific information becomes available through basic and clinicalresearch, recommended treatments and drug therapies undergo changes. Theauthor(s) and publisher have done everything possible to make this bookaccurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errorsor omissions or for consequences from application of the book, and make nowarranty, expressed or implied, in regard to the contents of the book. Any

practice described in this book should be applied by the reader in accordancewith professional standards of care used in regard to the unique circumstancesthat may apply in each situation. The reader is advised always to check productinformation (package inserts) for changes and new information regarding doseand contraindications before administering any drug. Caution is especiallyurged when using new or infrequently ordered drugs.

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Look for our other Davis’s Notes titles

RNotes®: Nurse's Clinical Pocket Guide, 2nd Edition ISBN-10: 0-8036-1335-0 / ISBN-13: 978-0-8036-1335-5

LPN Notes: Nurse's Clinical Pocket Guide, 2nd Edition ISBN-10: 0-8036-1767-4 / ISBN-13: 978-0-8036-1767-4

NCLEX-RN® Notes: Core Review & Exam Prep ISBN-10: 0-8036-1570-1 / ISBN-13: 978-0-8036-1570-0

MedNotes: Nurse's Pharmacology Pocket Guide, 2nd Edition ISBN-10: 0-8036-1531-0 / ISBN-13: 978-0-8036-1531-1

MedSurg Notes: Nurse's Clinical Pocket Guide, 2nd Edition ISBN-10: 0-8036-1868-9 / ISBN-13: 978-0-8036-1868-8

Coding Notes: Medical Insurance Pocket Guide ISBN-10: 0-8036-1536-1 / ISBN-13: 978-0-8036-1536-6

Derm Notes: Dermatology Clinical Pocket Guide ISBN-10: 0-8036-1495-0 / ISBN-13: 978-0-8036-1495-6

ECG Notes: Interpretation and Management Guide ISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8

IV Therapy Notes: Nurse's Clinical Pocket Guide ISBN-10: 0-8036-1288-5 / ISBN-13: 978-0-8036-1288-4

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NutriNotes: Nutrition & Diet Therapy Pocket Guide ISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6

OB Peds Women's Health Notes: Nurse's Clinical Pocket Guide ISBN-10: 0-8036-1466-7 / ISBN-13: 978-0-8036-1466-6

IV Med Notes: IV Administration Pocket Guide ISBN-10: 0-8036-1446-2 / ISBN-13: 978-0-8036-1466-8

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Assess Notes: Nursing Assessment and Diagnostic Reasoning for Clinical Practice ISBN-10: 0-8036-1749-6 / ISBN-13: 978-0-8036-1749-0

For a complete list of Davis’s Notes and other titles for health care providers,visit www.fadavis.com.



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1

Legal Issues in MedSurg Care

Legal issues affect all aspects of nursing care. Urgent care situations, inwhich the patient’s life may be lost or potential quality of life compromised,require even more vigilant attention to nursing standards of care and bestpractices.

The nurse practice law of each state defines the scope of nursingpractice for that state.Advanced practice nurses, such as nurse midwives, nurse anesthetists, andclinical nurse specialists, function under a broader scope of practice.

■ Know your state’s nurse practice law; contact your state board of nursingfor a copy.

■ Know your state’s requirements for licensure, and maintain your nursinglicense as required.

■ Keep informed of local, state, and national nursing issues; get involved asa lobbyist in your state; contact your state representatives regardingissues that affect nursing practice.

■ Know if and how a nursing union could affect your practice.

Nurses have a duty of care of careful and continuous monitoringof the patient’s status.Nurses assess and directly intervene on patients more than any other health-care professionals.

■ Monitor each patient’s vital signs, neurological status, intake and output,status per physician order, nursing care plan, hospital policy andprocedure; increase frequency of vital signs if indicated, and notify thephysician.

■ Evaluate family members’ concerns as soon as possible; the family oftendetects subtle changes in a patient’s status.

Nurses have a duty to communicate the patient’s status to themedical staff, particularly on an immediate/STAT basis when thepatient’s status warrants.The nurse is usually the first team member to detect an urgent care situationand has an obligation to report any changes in patient condition to themedical staff for timely intervention.

■Notify the physician as soon as you detect any change in the patient’scondition that indicates deterioration in status. Document assessment,time of call to physician, and nursing interventions and patient’s response.

■ Use the hospital’s chain of command if the physician fails to respondwithin minutes. Notify the nursing supervisor if the physician does notrespond immediately.

BASICS

(Continued on the following page)



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■ The nurse must maintain accurate nursing notes, flow sheets, medicalKardexes, and nursing care plans that record the patient’s symptoms, timesymptoms were present, time physician was notified, and time physician

arrived. The medical chart should be a factual record of the patient’smedical treatment, responses thereto, vital signs, and all nursinginterventions.

Nurses have a duty to administer medications safely at all times,including urgent care situations.Medication errors are the most common source of nursing negligence.Procedural safeguards should be followed to prevent medication errors. The“five rights” of medication administration are minimum practice standards.

■ Give the right drug in the right dose to the right patient by the right routeat the right time.■ Document the five rights—which medication, to whom, in what dose,

through which route, and at what time.■ Document fully any suspected adverse drug reaction, time and nature

of the reaction, time physician notified, interventions taken, and patient’sresponse.

■ Nurses have a duty to know about all the drugs they administer: drugnames, drug categories, dosage, timing, technique of administration,

expected therapeutic response, duration of drug use, and procedures tominimize the incidence or severity of adverse drug effects.

Nurses have a duty to maintain safe patient care conditions.This is akin to the nurse’s duty to advocate for the patient at all times.

■ Report an unsafe staffing condition to the nursing supervisor as soon asit is apparent. The nurse-patient ratio in intensive care settings should notexceed 1:2; on general floors, 1:6.

■ Working beyond a 12-hour shift can create a substantial decline in

performance.■ Know the nurse practice limitations on nurses under your supervision;

licensed practical nurses and student nurses cannot perform all theactions of the registered nurse.

Nurses have a duty to keep the patient safe from self-harm.The nurse must be vigilant regarding any changes in the patient’s sensorium/ mental status. Any patient can experience a psychiatric crisis from a myriadof causes, including hypoxia, drug reaction, drug withdrawal, ICU psychosis,or underlying organic disease.

■ Assess the patient’s mental status with each nursing intervention; notesubtle changes, and notify the physician.

■ Signs of impending psychiatric crisis include changes in orientation toperson, place, and time; verbal abusiveness; restlessness; increasedanxiety; and agitation.

BASICSCopyright © 2008 by F. A. Davis.


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■ If a patient is at risk of self-harm and/or of harming others, restraints canbe applied.

■ Most states require a written physician order before restraining thepatient, except in an emergency. The physician must be notifiedimmediately of the use of restraints.

■ If restraints are applied, the patient must be monitored closely for changesin medical condition and mental status, for maintenance of adequate circu-lation, and for prevention of positional asphyxiation. Document all assess-ments and frequency of checks (no less frequent than every 15 minutes).

■ Know the hospital’s policy and procedure regarding use of restraints, andfollow them at all times.

Nurses have a duty to carry out physician orders as required bystate law, hospital policy and procedure, and nursing practicestandards.Concurrently, as patient advocate, the nurse must question an order he orshe deems problematic, particularly when an urgent care situation is presentor when one could arise from fulfillment of the order.

■ Contact the physician immediately for any order that is unclear, contraryto standard drug dosage/route/frequency of administration, or that does

not address the acuity of the patient’s medical condition; e.g., an order forvital signs every shift for a postoperative patient recently transferred to ageneral surgical floor.

■ Question an order for a patient’s discharge from the hospital when thepatient’s medical condition is not stable, when delay in treatment resultingfrom discharge could injure the patient, or when the patient is going to apotentially unsafe environment. Document interaction with the physicianand health-care team.

■ Follow written physician orders; be particularly vigilant in carrying out anorder that changes over time; e.g., tapering of medication or oxygen atspecified time intervals.

Informed consent is the process of informing the patient, notsimply completing the form with the patient’s signature.

■ Informed consent involves providing the patient with adequate medicalinformation so that he or she can make a reasonable decision as totreatment based upon that information. In urgent care situations it can

be impossible to obtain a patient’s informed consent for an immediateintervention.

■ State laws differ regarding the informed consent standards; know yourstate’s informed consent law and the hospital’s policy and procedure forobtaining informed consent.

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■ Exceptions to informed consent include an emergency in which thepatient is incompetent and cannot make an informed choice, there is notsufficient time to obtain an authorized person’s consent, and the patient’s

medical condition is life-threatening.■ If a patient is competent and refuses medical care, even when the

condition is life-threatening, the patient’s choice supersedes the opinionof the health-care provider.

■ Ensure that each patient’s advance directive or living will (patient’sadvance legal permission to the physician to withhold or discontinuetreatment) is complied with and well documented in the medical chartper state law and hospital policy and procedure. Know if the patienthas a do not resuscitate order, and ensure that it is well documented.

Nurses are held to the standard of care of the profession.When nursing care falls below the standard of care, the care could bedeemed to be negligent or deficient if that care (or lack of care) causes thepatient some type of injury. This is the basis of a lawsuit against the health-care professional, called medical malpractice.

■ Each nurse owes every patient the duty of “reasonable care.” This isimplicit in the standard of care defined by what nursing professionalsgenerally recognize on a national level as correct patient care.

■ Nationally recognized nursing textbooks, nursing journals, and nursingtreatises that nurses generally regard as authoritative define the nursingstandards of care.

■ Whether a nurse’s care of a patient met the applicable standards of nursing care in a medical malpractice case is determined by a nursingexpert, a nurse who has the requisite experience and knowledge of theauthoritative resources.

As nursing practice, along with medical technology, continues to become

more sophisticated and complex, the standards of nursing care will likewise increase.

Documentation Guidelines for Urgent Situations

Documentation is critical in urgent situations. It enhances decision makingand helps anyone who reads it understand what happened, how it washandled, and what the outcomes were. It is crucial in any legal analysis of

care. Keep the following in mind as you document:

■ Always document your assessment findings, your interventions, and whattriggered the situation. Did you observe a problem, did the patient call forhelp, or did you find the patient in distress? What were your immediateinterventions?



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■ Document as you go. It establishes a timeline for the incident as well asconveying the interventions and outcomes accurately. Time, date, and signevery individual entry.

■ Always note at what time, by what route, and how much medication youor another member of the team has administered. Always recordresponse to the medication and the time the response(s) occurred or thetime you observed for a response, whether there was a response or not.The same applies to any non-drug intervention.

■ Always note the time you called the physician or nurse practitioner andhis or her response.

■ If you do not get the response from the physician or nurse practitioner

you think is required for the patient’s best interests, call youradministrative superior (nurse manager), and report the problems.Document your call and the supervisor’s response. Do not blame orcomplain about someone; just note that you called the supervisor toreport the patient’s condition.

■ If you fail to document something, write another entry called “Addendum”to the note above, and give the time and date of the first note.

Delegation Guidelines

The National Council of State Boards of Nursing defines delegation as“transferring to a competent individual the authority to perform a selectednursing task in a selected situation. The nurse retains accountability for thedelegation.” Check your state’s nurse practice act for details about whichnursing activities cannot be delegated.

Sample of nursing tasks that cannot be delegated:

■ Initial assessment or assessments of change in patient condition■ Formulating the nursing diagnosis; creating the nursing plan of care■ Administration of medications by direct IV bolus (IV push)■ Administration of blood products■ Programming a PCA pump■ Changing a tracheotomy tube

Before delegating, determine the following:

■ The complexity of the task and the potential for harm posed by the task

(what psychomotor skills are required? what harm can occur if the proce-dure is done incorrectly?)

■ The predictability or unpredictability of the outcome (is this procedurenew to the patient, or has the patient tolerated this procedure wellbefore?)

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■ The problem-solving or critical thinking abilities required (problem-proneactivities such as changing a new colostomy appliance, for example, mayrequire the more in-depth knowledge and problem-solving skills only the

RN can supply)Remember the Five Rights of Delegation:

■ Right Task—is the task within the caregiver’s scope of practice?■ Right Person—does the assigned caregiver have the knowledge and skill

required?■ Right Circumstances—is the setting appropriate; are the right resources

available? what is the current health status of the patient?■ Right Direction—clear description of the activity to be performed, relevant

patient conditions, limits, and expectations.■ Right Supervision—monitoring performance, maintaining your availability

to assist, receiving feedback about the procedure and patient’s tolerance,providing feedback.

Remember: The RN delegates a task but retains responsibility and account-ability. Specialized nursing skills and nursing judgment cannot be delegated.

Critical Thinking GuidelinesIdentifying

■ The first thing the nurse must do is identify that a problem exists. Thetriggering event is something unexpected. It may be as obvious ascrushing chest pain or as subtle as a complaint of thirst. Big red flags areeasy to see; do not ignore tiny red flags.

■ Listen and observe. Know recent trends in the patient’s status; understand

normal and abnormal findings. Recognize differences and similarities.■ Have you noticed or has the patient complained of something

unexpected?■ Follow up with questions any new complaint or unusual finding.■ If you have any doubts, do not ignore them; ask a nurse who is senior

to you, or notify the physician/NP.

Assessing

■ Once a problem is identified, seek information; gather objective,

subjective, historical, and current data.■ Perform a focused physical examination; obtain relevant laboratory and

diagnostic reports; read recent entries in the chart.■ Order problems in importance; determine if the problem is urgent; if not,

determine how important it is.



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Analyzing

■ Analysis involves breaking the whole into parts and discovering the

relationships of the part to the whole. Is the problem hypotension? Thinkabout the factors that influence blood pressure: What is the hemoglobinlevel, urinary output, recent blood loss? Can you assess cardiac output?Is the patient on medications that affect blood pressure?

■ Think about what you have discovered through assessment. Ask if thelaboratory values or tests suggest a cause.

■ Consider if the data fit any of the known complications of the patient’scondition. Do the data suggest something is worsening? Link the datato the patient’s physical status. Do the data “fit”?

■ Ask yourself if you are making the data fit and if you have overlookedanother cause.

■ Ask yourself what other information is needed. Do you need to assessanother body system? Have you asked the patient about all recent relatedevents? Should you check the medication record?

■ Other types of problems may require a different set of information (Whatother supplies are needed? Does the patient require referral to a religiousleader? Does the family need to see a social worker?).

■ While you analyze, double-check that you are not making erroneousassumptions. Ask yourself if the data can be interpreted another way.Ask yourself what other issues or conditions could cause similar signsand symptoms.

Diagnosing

■ The end result of analysis is a conclusion. For nurses who are thinkingcritically about a problem, this conclusion is a nursing diagnosis or adefinition of the problem.

■

State the problem clearly, what the problem is related to, and what datasupport this conclusion. State the desired outcomes as well and in whattime frame you expect them to be achieved.

■ Determine the significance of this problem. Ask yourself again: Is it urgent?Does it have the potential to cause a sudden and rapid deterioration in thepatient’s health status? Is it imperative that you act immediately? Do youneed help?

Planning

■ Consider which intervention(s) will be most effective; predict the conse-quences of the intervention and if it will produce the desired outcome.■ Urgent problems require that you immediately summon a

physician or nurse practitioner.■ Implement the plan; document all problems and interventions.

BASICS




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Evaluating

■ Evaluation is the step that lets you know if the plan is working.■ Assess the status of the problem at appropriate intervals; evaluate if the

interventions are effective.■ Determine if further intervention is required.

Enhance Your Clinical Reasoning Abilities

■ The link between a problem and a positive outcome is sound professional judgment. Pose new questions to yourself every day. Ask yourself why acertain complication occurs or why a medication helps. Find out theanswers. Ask others; consult the literature.

■ Keep current. Read journals and other literature.■ Learn about other specialty areas such as oncologic nursing, wound care,

respiratory or physical therapy.■ Know your real strengths, skills, and weaknesses. Correct weaknesses.■ Be alert in your observations and assessments. Realize that everybody

makes assumptions and that assumptions can be wrong. Ask yourself

what else might be responsible for the signs and symptoms.■ Work in other fields to gain experience. Challenge yourself.■ Ask questions of other experts in medicine, surgery, nursing, and related

fields. All practioners fundamentally are teachers. Learn from them.

Principles of Pain Management

■ Differentiate between acute and chronic pain. Patients in chronic pain maynot exhibit signs of being in pain.

■ Do not assume that the patient’s pain is exaggerated because he or sheasks for pain medicine frequently. Look for ways to better manage pain.

■ Assess each patient’s pain, and create an individualized treatment plan■ Reassure patients in pain or who expect to have pain that pain can be

relieved.■ Assess any changes in pain pattern to ensure that new causes are not

overlooked.

■ Try the least invasive route first in patients with cancer or chronic pain.Keep dosage schedules simple.

■ Monitor side effects. Use prevention strategies, especially for constipationwhen opiods are used.



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■ Be careful switching from oral to IV, IM, IT, or other route. Dosageschange, and different drugs may not provide as much pain relief. Use anequianalgesic dosing table for guidance.

■ Teach or arrange for instruction in biofeedback, relaxation exercises, andhypnosis.

■ All can reduce pain and stress and give a greater sense of control.■ Do not avoid opioids because of fear the patient will become addicted.■ Encourage patients to request pain medication before pain becomes

severe.■ Suggest administering medication on an around-the-clock schedule to

maintain therapeutic blood levels.■

Suggest time-released pain medications to avoid peaks and valleys inpain control.■ Consult with a pain management clinical specialist, if available.■ Include family in pain control plan.

Pain Management

Numeric Scale

0 1 2 3 4 5 6 7 8 9 10

No Mild Moderate Severe Very severe Worstpain pain pain pain pain possible

pain

Visual Analog Scale

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

BASICS

0 2 4 6 8

NO HURT HURTS

LITTLE BIT

HURTS

LITTLE MORE

HURTS

EVEN MORE

HURTS

WHOLE LOT

HURTS

WORST

10

Text/image rights not available.



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Using Pain Scales

■ Most patients can use the numerical scale.

■ Say: “On a scale of zero to ten, with zero meaning no pain and tenmeaning the worst pain possible, tell me what level of pain you arefeeling now.”

■ Ask how distressing the pain is, using a scale of 0–10.■ Some patients report a moderate to high numerical score (5 or above)

but are not distressed and do not want medication.■ Some patients report a lower numerical value but are very distressed

by the pain and may need medication or other intervention.■ Always ask the patient directly if he or she would like medication.■ Contact a pain care nurse, if available.■ For patients who cannot use the numerical scale, use the Wong-Baker

FACES Pain Rating Scale. Tailor questions accordingly.

Mnemonics for Thorough Pain Assessment (PQRST and COLDERRA)Perform pain assessment quickly but thoroughly prior to medicating. Alwaysfind out if the pain is new and different; if it is consistent with the patient’sdiagnosis, procedure, or surgery; or if it is typical and expected. New onsetpain, or pain that is unusual for the diagnosis, procedure, or surgery, needs

to be evaluated by the physician or nurse practitioner as soon as possible.Chest pain requires immediate assessment (see Chest Pain in CV tab).

PQRST

P (provokes/point)............What provokes the pain (exertion, spontaneousonset, stress, postprandial, etc.)Point to where the pain is.

Q (quality) .........................Is it dull, achy, sharp, stabbing, pressing, deep,surface, etc.? Is it similar to pain you have hadbefore?

R (radiation/relief) ............Does it travel anywhere (to the jaw, back, arms,etc.)? What makes it better (position, being still)?What makes it worse (deep inspiration,movement)?

S (severity/s/s) ..................Explain the 10/10 pain scale and have patient rate

pain. Are there any signs or symptoms associatedwith this pain (n/v, dizziness, diaphoresis, pallor,SOB, dyspnea, abnormal vital signs, etc.)?

T (time/onset) ...................When did it start? Is it constant or intermittent?How long does it last? Sudden or gradual onset?Does it start after you have eaten? Frequency?



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COLDERRA

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

Nursing Interventions for Pain Management

Provide comfort ..................................................positioning, rest and relaxationValidate patient’s response to pain .....................................offering reassuranceRelieve anxiety and fears ....................................setting aside time with patientTeach relaxation techniques......................rhythmic breathing, guided imageryProvide cutaneous stimulation ........................massage, heat and cold therapy

Decrease irritating stimulation ....................................bright lights, noise, temp

Comparison of Routes of Analgesic Administration

Route Advantages Disadvantages

Oral

IM

Subcutaneous

BASICS

Easiest, least invasive;consider oral firstwhile taking intoaccount patient status

Quicker onset of actionthan oral route

No need for IV access;changing sites usuallyeasy; 80% of drugavailable

Metabolized in the liver beforereaching bloodstream—lessdrug available (40% to 60%)than with other routes; takeslonger to act. Cannot be usedif patient has difficulty takingoral medications.

Painful, potential nerve injury;difficulty finding sites inundernourished patients

Only small volumes of fluid canbe injected each hour. Mustuse concentrated medica-tions, which increases risk fordrug error.




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BASICS

Comparison of Routes of Analgesic Administration (continued)

Route Advantages Disadvantages

IV PCA

IT Epidural

Transdermal

Sublingual

Cultural Sensitivity

It is not possible for nurses to know intimately all other cultures differentfrom his or her own. It is possible, however, to acknowledge that significantcultural variations exist and to adopt an attitude of sensitivity that includes

a desire to learn about and respect the culture of the patients for whom youcare.

Potential for Stereotyping

Books that list cultural characteristics of various groups have some value butcan lead to stereotyping. Too often people make assumptions based on the

Immediate effect; can havea continuous rate and abolus

Much lower doses, fewerside effects

Easy to use. Slow buildupof drug, fewer sideeffects.

Usually used for patientswith cancer pain.

Better absorption, quickeronset than oral route.Good for patients whocannot tolerate POmedications

IV sites are portal forinfection.

May not be appropriatefor confused patient.NOTE: Never admin-ister a dose for thepatient—can lead torespiratory depres-

sion and death.Inform family also.

Potential for infection orother complication

Not suitable for acutepain. Drug remainsactive for 14–25 hours

after removal, whichpresents problems if patient overdosed.

Used primarily forbreak-through painfor cancer patients.



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color of someone’s skin or other overt characteristics. The challenge fornurses is to learn whether a person considers himself or herself to be amember of a group and to recognize that significant variation exists withingroups.

Cultural AssessmentCultural assessment covers many factors, too numerous for this book. Keepin mind that cultural variation is frequently expressed within domainsapplicable to any culture. Maintain a respectful and open attitude as youlearn about each patient. Common domains of importance related to healthcare include:

■ Communication styles—eye contact, personal space, tone of voice, andmore. Observe each patient, and follow his or her lead. If you are not sure,ask politely and respectfully.

■ Religion—you may ask how important religion is to the patient in daily lifeand if he or she consults with another member of that religion in health-care matters.

■ Language—it is very important to use competent interpreters whenobtaining and receiving health information. Do not automatically usea family member. Sensitive information may be embarrassing for thetwo people to discuss. Try to get someone of about the same age andgender as the patient. Always ask if the patient is willing to use theinterpreter. In an emergency, communicate through the oldest familymember present.

■ Family relationships—families may have a hierarchy that includes aspokesperson, so to speak. Show respect for that person’s role. As always,do not reveal confidential information about a person’s health without theexpress consent of the patient.

■ Food preferences—providing the patient’s preferred food can beinstrumental in rate of recovery. Ask about any natural remedies thepatient has or is using.

■ Health beliefs—What causes illness, how care is provided, how the patienthandles being ill or in pain are powerful cultural beliefs. Ask the patient orfamily members about these issues and integrate the information intoyour plan of care.

■ Birth and death rituals—End-of-life beliefs can vary significantly withinany culture. Suggest meeting with the family if the patient approves of

you sharing or receiving information about personal preferences. Discussissues such as organ donation, autopsy if applicable to the case, specialcare of the body, and what the family will want to do in the immediatetime after death.

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Spiritual Care

Providing spiritual care means different things to different people. Somenurses may be too intimidated to address this issue. Many do not feelcompetent to do so or that it is none of their business. You can always askthe patient how he or she feels spiritually. The answer will be very revealingin terms of willingness to discuss the topic. Follow the patient’s lead, andnever impose your own beliefs. Often, the best spiritual intervention is toask open-ended questions and then listen.



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Focused Assessment of the CV System

■ A focused assessment of CV status includes:■ The core cardiovascular system—the heart, its rate and rhythm, the

carotid arteries, blood pressure, and other hemodynamic measures.■ The peripheral vascular system—the extremities, particularly the

lower extremities.■ The lungs—adventitious sounds, cough, and oxygenation status.■ Mental status—level of alertness, restlessness, confusion, irritability,

or stupor.■ Vital signs:■ Blood pressure, heart rate, respiratory rate, O2 saturation.

■ Mental status, head and neck:■ Look for restlessness, ↓ LOC, circumoral cyanosis, color of conjunctiva,

jugular venous distention.■ Inspect the anterior chest:■ Look for visible pulsations of the chest wall.

■ Palpate the anterior chest:■ Locate apical beat, which is the point of maximum impulse (PMI).■

Assess for heaves—a very forceful PMI.■ Assess for thrills—a palpable murmur; feels like a cat purring.■ Auscultate the heart and lungs:■ Obtain rate and rhythm; assess for rhythm abnormalities.■ Listen for normal heart sounds and possible murmurs.■ Use the diaphragm of stethoscope first, then the bell.■ Listen for carotid abdominal and femoral bruits.

■ Assess extremities: Check for:■ Cyanosis, temperature, color, and amount of moisture.

■ Capillary refill time in hands and feet.■ Changes in foot color, ulcers, varicose veins.■ Edema of lower extremities (check sacrum if client is bedridden).■ Presence and equality of pedal pulses. If pulses are not palpable,

use a Doppler sonogram.■ Assess current symptoms:■ RED FLAG symptoms require immediate attention and intervention.

Shortness of breath.Chest pain, possibly with neck, jaw, or left arm pain.

Syncope possibly with palpitations and shortness of breath.Palpitations possibly with chest pain and dizziness.Cyanosis of lips, fingers, or nailbeds.Pain, coolness, pallor, or pulse changes in extremities.Sweating, nausea, vomiting, fatigue (especially in women).

CARDIAC



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CARDIAC

Pulse Strength

Absent 0

Weak 1

Normal 2

Full 3

Bounding 4

Coronary artery disease, angina, MI, heart failure,cardiomyopathy, valve disease, left ventricularhypertrophy, pericarditis, dysrhythmias

COPD, asthma, pneumothorax, pulmonary embolus(PE), pulmonary edema

COPD with comorbid cardiac disorder, deconditioning,chronic pulmonary emboli, trauma

Metabolic acidosis, pain, neuromuscular disorders,upper airway disorders, anxiety, panic,hyperventilation

Assessment Guides

Circulation Scale Pulse Scale

Capillary Refill

Normal 3 sec

Delayed 3 sec

Edema Scale

Press thumb carefully into edematous area, usually on the shin(pretibial edema) or dorsum of foot (pedal edema):

0–1/4 inch; disappears in 5 sec 1

1/4–1/2 inch; disappears in 10–15 sec 2

1/2–1 inch; disappears in 1–2 min 3

1 inch; disappears 2 min 4

Possible Causes of Shortness of Breath

Source Potential Causes

Cardiac

Pulmonary

Combined car-diopulmonary

Other



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Arterial Hematoma

CLINICAL PICTUREThe patient may have:

■ Pressure dressing to radial/brachial/femoral artery insertion site that issaturated with blood.

■ Cannulated artery that has been inadvertently decannulated and ishemorrhaging.

■ Hematoma, possibly pulsatile, around arterial puncture site.

IMMEDIATE INTERVENTIONS

■ Notify physician or NP.■ Place patient in a supine position with affected limb extended.

■ Don sterile gloves and, using folded sterile gauze dressings, applyfirm pressure 2 cm above puncture site, using the first three fingersof one hand.

■ Continue to apply pressure for 10 minutes or more, until bleeding hasbeen controlled.

CARDIAC

Cardiac auscultation sites.



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■ Once bleeding is controlled, apply sterile gauze dressing overlayed witha pressure dressing (Elastoplast). Depending on institution protocol, usea sandbag or other pressure device over the pressure dressing for added

pressure.■ Document patient’s status, phone call to physician or NP, and physician or

NP response.

FOCUSED ASSESSMENT

■ Monitor distal pulses, skin color, temperature, and sensation of affectedlimb.

■ Assess VS, noting decrease in BP or increase in HR.■ Assess LOC and patient’s ability to maintain extremity in immobile,

neutral position.■ Assess for pain.

STABILIZING AND MONITORING

■ Instruct patient to maintain supine position a minimum of 6 hours.■ Frequently assess site for rebleeding.■ Monitor circulation, mobility, and sensation in affected extremity.■ Frequently monitor VS for changes in BP and HR.

■ Reassess for pain.■ Assess for history of preexisting conditions such as clotting abnormalities

or blood dyscrasias or for recent/current administration of antiplatelet oranticoagulant medications.

■ Chart patient status, and convey to physician or NP.

BE PREPARED TO

■ Assist physician or NP with cannulation of an alternate arterial site.■ Obtain IV access for the administration of blood, clotting factors, or

anticoagulant reversal agents such as protamine sulfate.

POSSIBLE ETIOLOGIES

■ Hemophilia, von Willebrand’s disease, thrombocytopenia, DIC, vasculartrauma or iatrogenic arterial injury, anticoagulant therapy, antiplatelettherapy, thrombolytic therapy.

Arterial OcclusionCLINICAL PICTUREThe patient may have:

■ Numbness, tingling, severe burning pain, or coolness in affected extremity.■ Loss of sensation in the extremity.

CARDIACCopyright © 2008 by F. A. Davis.


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


■ Check all arterial pulses in the affected extremity. Compare with those incontralateral extremity.

■ Assess any sites of arterial puncture (e.g., arteriogram puncture site orA-line insertion site) for swelling or hematoma.

■ Assess mobility of affected extremity; compare with that of contralateralextremity.

■ Assess VS.■ Notify physician or NP.■ Document patient’s status, phone call to physician or NP, and physician

or NP response.

FOCUSED ASSESSMENT

■ Assess for p allor, p ain, p aresthesias, p aralysis, and p ulselessness (5 P s)by assessing circulation (skin color, capillary refill, pulses), movement

(flexion, extension, rotation), and sensation (response to pinprick or lighttouch; pain level) of affected extremity.

■ Assess pulses with Doppler amplification.■ Assess bandages or cast proximal to diminished pulses.


■ Continue to monitor condition of extremity.■ Keep extremity at heart level to promote arterial flow without diminishing

venous return.■ Remove or do not use ice on the extremity.■ Control and manage pain.

BE PREPARED TO

■ Remove any external fixtures (casts) on the extremity, or assist thephysician or NP with fasciotomy for immediate relief of pressure.

■ Prepare the patient for surgery.■ Initiate large-bore IV access.

POSSIBLE ETIOLOGIES

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

CARDIAC



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Bradycardia


■ HR 60 bpm.■ Nausea and vomiting, dizziness or lightheadedness.■ Signs of unstable bradycardia:■ Altered LOC.■ Chest pain, shortness of breath (SOB).■ Hypotension, pulmonary congestion, and/or cyanosis.

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

or NP response.

FOCUSED ASSESSMENT

■ Assess LOC and orientation.■ Assess BP and HR.■ Assess respirations for rate and effort; assess SaO2 if readily available.■ Assess skin for color, moistness, and temperature. Assess for associated

symptoms (chest pain, SOB, hypotension).■ If patient on telemetry or cardiac monitor, assess ECG.


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

BE PREPARED TO

■Administer oral or IV medications as ordered.

■ Obtain or order laboratory tests.■ Titrate O2 to SaO2 90%.■ Obtain IV access if none available.■ Assist with external pacing.■ Transfer patient to ICU or telemetry unit.



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POSSIBLE ETIOLOGIES

■ Medication toxicity, vasovagal response, hyperkalemia, hypothermia,

hypothyroidism, sepsis, severe infection, hypoglycemia, hypothermia,excellent physical condition (athletes), myocardial infarction, shock.

Chest Pain

CLINICAL PICTUREThe patient may have (see table below on Possible Causes of Chest Pain):

■ Substernal or epigastric sensations of fullness, pressure, or tightness; painmay radiate to left neck, jaw, back, and/or arm.

■ Cool, pale, and/or diaphoretic skin.■ Nausea, vomiting.■ SOB, tachypnea.■ Dizziness, fatigue, fainting.■ Marked anxiety, expression of “impending doom.”


■ Elevate head of bed (HOB) to facilitate breathing.■ Administer high-flow O2 by nonrebreather mask (10–15 L/min) or by nasal

cannula (4–6 L/min).■ Assess VS, character and quality of pain (PQRST), skin color.■ Check for standing orders of nitrogylcerine (NTG) sublingual 0.4 mg q

5 min 3 doses maximum (hold for BP 90 mm Hg) and one 325 mgnonenteric-coated aspirin. Administer STAT.

■ Check for IV access. Prepare to initiate saline lock IV access.■ Notify physician or NP.■ Document patient’s status, phone call to physician or NP, and physician

or NP response.

FOCUSED ASSESSMENT

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

■ Auscultate lung fields.


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

CARDIAC



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■ Assess response to medications.■ Identify underlying rhythm.■ Obtain cardiac enzymes/troponin levels.


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

POSSIBLE ETIOLOGIES■ Angina, anxiety, MI, pulmonary embolism, pulmonary edema, chest

trauma, endocarditis, pericarditis, indigestion, gastroesophageal refluxdisorder, pleurisy, bronchitis.



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Possible Causes of Chest Pain

Provocation Quality LocEtiology and Onset and Relief Rad

MI

Angina

Pneumonia

PE

2 3

No provocation;

large, heavy meal;extreme exertion,stress, or fright.

Sudden onset.

Provoked by exertion.Sudden onset.

No provocation orcoughing.

Gradual or suddenonset.

No provocation.Sudden.

Pressure,

squeezing.No relief.

Pressure,tightness.

Rest or sl NTG

provides relief

Ache with sharp,stabbing pain.

No relief.

Dull, aching butmay also havesharp pain.

No relief.

Subst

anteepigto learm

Same

Anterisho

Variab

C o p y r i g h t ©

2 0 0 8 b y F .

A .

D a v i s .


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C A R D I A C

Possible Causes of Chest Pain (continue

Provocation Quality LocaEtiology and Onset and Relief Radi

Pericarditis

Epigastricdisorders

Musculoskeletaldisorders

No provocation;

deep breathing,coughing.

Gradual or suddenonset.

Gradual or sudden.

Gradual or sudden.

Sharp.

Sharp, burningwhen patientin upright

position,antacidsprovide relief.

Dull ache;possible sharppain.

Rest and mild

analgesics orNSAIDsprovide relief.

Subste

ante

Chest,RUQ

Arm, snecksternabdo

C o p y r i g h t ©

2 0 0 8 b y F .

A .

D a v i s .


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Heart Failure


■ Fatigue, weakness, anxiety.■ SOB, orthopnea, dyspnea, adventitious breath sounds (rales or crackles),

cyanosis.■ Change in mental status anxiety, restlessness, confusion.■ Edema, jugular vein distention, increased CVP, positive fluid balance.

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

FOCUSED ASSESSMENT

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

STABILIZING AND MONITORING■ Restrict fluids, and administer diuretics as ordered.■ Closely monitor I&O.

■ Assess for improvement of LOC and oxygenation status.

BE PREPARED TO■ Titrate O2 to keep SaO2 90%.■ Obtain IV access.■ Set up cardiac monitoring.■ Administer oral or IV diuretics, NTG, morphine, and electrolytes as

ordered.■ Order a chest x-ray and ECG.■ Order or obtain laboratory tests (BUN, creatinine, CBC, electrolytes).■ Transfer patient to ICU or telemetry unit.

POSSIBLE ETIOLOGIES■ Atrial fibrillation, marked bradycardia, systemic infection, septic shock,

pulmonary embolism; physical, environmental, and emotional excesses;

CARDIAC



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stress; cardiac infection and inflammation; excessive intake of waterand/or sodium administration of cardiac depressants or drugs causesalt retention; cardiomyopathy, hypertension, severe aortic stenosis,

ischemic myocardial disease, coronary artery disease, acute mitralor aortic regurgitation, infective endocarditis with acute valve incom-petence, MI, anemia, hyperthyroidism, pregnancy, glomerulonephritis,cor pulmonale, polycythemia vera, carcinoid syndrome, obesity.

Hemorrhage/Wound Hemorrhage


■ Saturated postoperative dressings.■ Excessive amounts of blood in wound drainage system.■ Peri-incisional swelling and hematoma.■ Subtle changes in LOC, anxiety, irritability, restlessness, decreased

alertness (early CNS signs of blood loss).■ Confusion, combativeness, lethargy, coma (later CNS signs).■ Increased HR to severe tachycardia.

■ Delayed capillary refill (3 sec), diminished peripheral pulses (l2),cool extremities and pale, mottled, or cyanotic skin.

■ Slightly elevated RR to severe tachypnea.■ Hypotension.■ Narrowing of pulse pressure.■ Thirst.■ Bruising around umbilicus or retroperitoneally in flank areas (internal

bleeding).

IMMEDIATE INTERVENTIONS■ Get help, and notify surgeon.■ Discontinue thrombolytics or anticoagulants.■ Control external bleeding with direct pressure.■ Do not remove saturated dressings, as this may also remove any clot

formation.■ Instead, reinforce with additional dressing and pressure.■ Administer supplemental O2; maintain patent airway.

■ If IV not in place, obtain large gauge (#18) IV access, and have IVF readyto hang.■ Monitor VS frequently.■ Document patient’s status, phone call to physician or NP, and physician

or NP response.



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FOCUSED ASSESSMENT■ Assess LOC, orientation, and VS (HR, RR, BP).■ Assess for orthostatic hypotension if possible.■ Assess SaO2 via pulse oximetry if available (Note: may be unreliable due

to decreased peripheral perfusion).■ Assess skin for color, temperature, moistness, turgor, capillary refill.

STABILIZING AND MONITORING■ Monitor VS and oxygenation status.■ If patient previously typed and cross-matched, call blood bank to see if

any blood available.■ Monitor output from Hemovac, JP drains, NGT, and urinary catheter.■ Check laboratory values.■ Provide emotional support to patient/family.■ Chart patient status, and convey to physician or NP.

BE PREPARED TO■ Assist with insertion of a central line.■ Obtain laboratory tests STAT (Hgb/Hct, ABGs, electrolytes, blood type and

crossmatch).■

Prepare the patient for surgery.■ Administer colloidal infusions.■ Insert Foley catheter.■ Administer blood.■ Mechanically ventilate.

POSSIBLE ETIOLOGIES■ External bleeding: wounds (postsurgical and traumatic); internal bleeding:

blunt trauma, cancer, ruptured aneurysm, postsurgical, GI perforation,

thrombolytic therapy.

Hypertensive Urgency/Emergency

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


■ Fatigue, headache, restlessness, confusion, visual disturbances, seizure.■ Dyspnea, tachycardia, bradycardia, pedal edema, chest pain.■ Lightheadedness, dizziness.■ Nausea, vomiting.

CARDIAC



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IMMEDIATE INTERVENTIONS■ Assess BP in both arms.■ Elevate HOB to 30–45.

■ Administer supplemental O2.■ Notify physician or NP.■ Document patient’s status, phone call to physician or NP, and physician

or NP response.

FOCUSED ASSESSMENT■ Assess LOC and orientation.■ Assess respiratory status.■ Assess for neurological deficits (hemiparesis, slurred speech).

■ Assess baseline VS (temperature, HR, RR, BP).■ Assess SaO2 via pulse oximetry, if available.■ Assess for associated symptoms: visual disturbances, chest pain,

peripheral edema, hematuria.

STABILIZING AND MONITORING■ Maintain continuous monitoring of BP and HR.■ Assess for changes in cardiac rhythm if patient is on a monitor.■ Monitor I&O.


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

POSSIBLE ETIOLOGIES■ Atherosclerosis, primary hypertension, stress, anxiety, anger, medication,

stroke, toxemia of pregnancy, diabetes, cardiac or renal disease, drugs(amphetamine, cocaine, corticosteroids, oral contraceptives).

Hypotension


■ A systolic BP of 90 mm Hg or systolic BP 40 mm Hg less than baseline.■ Altered LOC or orientation.■ Cool, pale, ashen, cyanotic, diaphoretic skin.



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

IMMEDIATE INTERVENTIONS■ Place patient in a supine position with legs elevated above heart level to

increase circulation to vital organs. Note: This position is contraindicatedif the airway is compromised; to maintain airway patency, place patientin supine or low Fowler’s position (HOB slightly elevated).

■ If respiratory effort inadequate (RR 8, cyanosis, SaO2 90%), administerhigh-flow O2 via mask (10–15 L/min), or manually assist ventilations withan Ambu bag (mask-valve device).

■ Control bleeding, if any, with direct pressure.■ Check for patent IV access. Note: IVF is not routinely administered until

reason for hypotension is determined. Hypotension could be due tocardiac compromise, in which case fluids might be contraindicated.

■ Notify physician or NP.■ Document patient’s status, phone call to physician or NP, and physician or

NP response.

FOCUSED ASSESSMENT■ Assess LOC, orientation, baseline VS (temperature, HR, RR, BP), and pulse

quality and rhythm.■ Assess respiratory effort and airway patency.■ Assess skin for color, temperature, moistness, turgor, and capillary refill.■ Assess for associated symptoms (chest pain, dyspnea, nausea).■ Assess I&O; ask patient about recent history of vomiting, diarrhea, or

urinary symptoms (burning, frequency, flank pain, hematuria).

■ Assess MAR for medications that can affect blood pressure.

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

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

CARDIAC



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POSSIBLE ETIOLOGIES■ Medication; dehydration; hemorrhage; vasovagal response to anxiety;

sepsis; shock; GI bleed or other internal bleeding; aneurysm; congestive

heart failure; cardiac dyrsrhythmias; myxedema; adrenal crisis;hypoglycemia; completed stroke.

Palpitations

CLINICAL PICTUREThe patient may have or be:

■ Sensation of fluttering in chest, heart racing, or dizziness.■ Tachycardia, bradycardia, irregular rate.■ Cold and clammy skin, hypotensive (drop in BP 20 mm Hg from

baseline).■ SOB, dyspnea, nausea.

IMMEDIATE INTERVENTIONS■ Place patient supine in bed. Apply O2 if available at bedside.■ Stay with patient, and provide reassurance.■

Take BP, and assess apical HR and rhythm. Compare apical rate to radialrate as one measure of perfusion.■ Check for patent IV access.■ Quickly assess perfusion by assessing mental status, peripheral pulses.■ Observe cardiac monitor if patient is being monitored. Obtain rhythm strip

to document event.■ Notify physician or NP.■ Document patient’s status, phone call to physician or NP, and physician

or NP response.

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

if appropriate.

■ Document assessment thoroughly.

STABILIZING AND MONITORING■ Continue to monitor rhythm; obtain and analyze rhythm strip every

4 hours and when rate or rhythm changes.■ Continue to monitor VS and O2 saturation.



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■ Keep IV line patent, and infuse IVF.■ Review laboratory data such as Hgb/Hct; BUN and creatinine; electrolytes,

other chemistries, blood glucose, liver and cardiac enzymes.■ Check MAR for possible drug side effect or interactions.■ Chart patient status, and convey to physician or NP.

BE PREPARED TO■ Obtain a 12- or 15-lead ECG■ Administer antiarrhythmic medication (e.g.: procainamide, quinidine,

amiodarone).■ Obtain IV access, administer ordered IVF and medications.

■ Transfer patient to a unit with cardiac monitoring.■ Assist with placement of temporary transvenous or external pacemaker

or cardioversion.

POSSIBLE ETIOLOGIES■ Premature atrial or ventricular contractions (PACs or PVCs) or other

cardiac dyrsrhythmia, mitral valve prolapse; stress, anxiety; medications;hyperthyroidism; dehydration; hemorrhage; heart failure; adrenal crisis;hypoglycemia.

Possible Causes of Palpitations

Source Conditions

Cardiac

Drugs

Vascular

Other

CARDIAC

Sinus tachycardia or bradycardia.PAC, PVC, PJC, SVT, VT.Bradycardia/tachycardia syndrome (sick sinus syndrome).

Atrial fibrillation or flutter.Wolff-Parkinson-White syndrome.Heart failure, cardiomyopathy, pericarditis.Congenital heart disease.Pacemaker malfunction.

Theophylline, digoxin, phenothiazine.Vasodilators, antiarrhythmics.Beta2 agonists (e.g., albuterol, terbutaline, salmeterol).

Cocaine, alcohol, tobacco, caffeine.

Vasovagal or postural hypotension.Transient ischemic attack, stroke.

Hyperventilation, hypoxia, fever, hypoglycemia, thyrotoxicosis,anemia.



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Syncope


■ Lightheadedness, feeling faint.■ Palpitations.■ Tachypnea, hyperventilation.■ Nausea, vomiting.■ Cool, pale, diaphoretic skin.

IMMEDIATE INTERVENTIONS■ Assist patient to chair or bed, or floor (if necessary).■ Administer supplemental O2 via nasal cannula.■ Assess rate, ease of breathing.■ Assess BP.■ Assess HR, rhythm, and quality.■ If patient is hypotensive, keep supine, and elevate lower legs above heart

level, using pillows.■ Notify physician or NP.■ Document patient’s status, phone call to physician or NP, and physician

or NP response.

FOCUSED ASSESSMENT■ Assess patency of airway and patient’s breathing.■ Assess LOC and mental status; determine if patient had a sensation

of spinning or movement.■ Assess for associated neurological signs (slurred speech, numbness,

weakness).

■ Assess skin for color, temperature, turgor, and moistness.■ Ask if patient feels nauseated or is experiencing chest pain.■ Check recent chemistry and hematology laboratory results.■ Check if new medications have been administered.■ Review I&O records from preceding days.

STABILIZING AND MONITORING■ Assess orthostatic VS: take HR and BP in supine, sitting, and standing

positions, each 2 min apart. Note if pulse increases by 20 or more bpm

and the systolic BP drops by 20 mm Hg or more, which suggestshypovolemia or dehydration.

■ Assess mucous membranes and skin turgor for signs of dehydration.■ Continue to assess VS as frequently as indicated.■ Review history and all current medications.



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

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

POSSIBLE ETIOLOGIES

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

Possible Causes of Syncope

Source Conditions

Cardiac

Neurological

Vascular

Other

Tachycardia


■ HR 100–150 bpm (sinus tachycardia—may be asymptomatic);HR 150 bpm (supraventricular tachycardia).

■ Palpitations, dizziness or lightheadedness.■ Chest discomfort, SOB.■ Anxiety, restlessness.

CARDIAC

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

Seizure, head trauma.

Vasovagal or postural hypotension.

Transient ischemic attack, stroke.

Hyperventilation, hypoxia.



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■ Signs of unstable tachycardia:■ Altered LOC.■ Chest pain.

■ Hypotension.■ Pulmonary congestion and/or cyanosis.

IMMEDIATE INTERVENTIONS■ Have patient sit or lie in bed.■ Assess blood pressure and respirations.■ Administer supplemental O2.■ Reduce or eliminate environmental stressors.■

Notify physician or NP.■ Document patient’s status, phone call to physician or NP, andphysician or NP response.

FOCUSED ASSESSMENT■ Assess LOC, orientation, and VS (temperature, HR, RR, BP).■ Assess SaO2 via pulse oximetry, if available.■ Assess heart rhythm.■ Assess skin for color, turgor, moistness, and temperature.

■ Assess for associated symptoms (body pain, chest pain, SOB,hypotension, fever, dehydration).

■ If patient on telemetry or cardiac monitor, assess rhythm strip.

STABILIZING AND MONITORING■ Assess HR, BP, and SaO2.■ Assess 12-lead ECG (see ECG in Tools tab).■ Assess recent history of emotional upset, medication use, infectious

disease, diarrhea, vomiting, blood loss from menses, GI pain or nausea,melanotic stool.

■ Assess MAR for medications with potential to cause tachycardia.■ Assess blood glucose level.■ Assess recent I&O.■ Chart patient status, and convey to physician or NP.

BE PREPARED TO■

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



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

POSSIBLE ETIOLOGIES■ Hypoxia, exercise, caffeine, fever, medications, pain, anxiety, stress, atrial

fibrillation, infection, hypoglycemia, hemorrhage, hypovolemia,dehydration, electrolyte imbalance.

A & P Snapshot

Cardiac structure and blood flow.

CARDIAC

Brachiocephalic artery

Superior vena cava

Left common carotid arteryLeft subclavian artery

Aortic arch

Right pulmonary

artery

Right pulmonary veins

Right atrium

Inferior vena cava

Tricuspidvalve

Pulmonarysemilunar valve

Left pulmonary artery

Left atrium

Left pulmonary

veins

Mitral valve

Left ventricle

Aortic

semilunar

valveInterventricular

septum

ApexChordaetendinea Right

ventriclePapillarymuscles



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Occipital

Internal carotid

Vertebral

Brachiocephalic

Aortic arch

Maxillary

FacialExternal carotidCommon carotid

Subclavian

Axillary

Pulmonary

Celiac

Left gastric

HepaticSplenic

Superiormesenteric

Abdominal aorta

Rightcommon iliac

Internal iliac

External iliac

Femoral

Popliteal

Anterior tibial

Posterior tibial

Intercostal

Brachial

Renal

Gonadal Inferiormesenteric

Radial

Ulnar

Deep

palmar arch

Superficialpalmar arch

Deep femoral

Arterial circulation.

CARDIAC



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Focused Respiratory System Assessment

■ A focused assessment of respiratory status includes:■ Ease of breathing and respiratory rate■ Lung sounds■ Use of O2 and oxygenation■ ABGs■ Ventilator assessment, if applicable■ Mental status level of alertness, restlessness, confusion, irritability,

or stupor

■

Ease of breathing and respiratory rate:■ Ask the patient how his breathing is; use his subjective terminologywhen documenting. Ask if SOB is triggered by activity and if restrelieves the feeling. Ask about energy levels and if the patient can eatand talk comfortably.

■ Assess rate—normal rate is 12–20; however, most adults have arespiratory rate in the lower end of the range. Rates 20respirations/min should be investigated. A rate 26 is cause for alarm,unless it’s the patient’s baseline.

■ Assess use of accessory muscles or nasal flaring, both of which indicaterespiratory distress.

■ Lung sounds:■ Listen to lung sounds in all fields. Ask the patient to breathe deeply with

his mouth open.■ Note adventitious sounds, areas where air movement is not heard,

or areas where breath sounds are diminished.

■ Use of O2 and oxygenation:

■ Note the amount of O2 ordered and the method of delivery (e.g., 3L/min via nasal cannula).■ Note if the patient is wearing the O2 all the time and if the device is

correctly applied.■ Check pulse oximetry to assess percentage of oxygen saturation (SaO2):

97% to 99% is normal, although 93% to 97% may be normal for somepatients. Always look at the whole picture, not just a single reading.Also, pulse oximetry can be inaccurate in the presence of peripheralvascular disease. Reading of 90% or less indicates possible need for

ventilation support. Compare trends in O2 saturation to determine if oxygen therapy is effective.

■ Analyze ABG results:■ ABG allows for assessment of acid-base balance, ventilation, and

oxygenation. It also tells how well the lungs and kidneys arecompensating or responding to treatments.

RESP



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■ pH, PaCO2, and HCO3 tell about acid-base balance.■ PaO2 and SaO2 indicate oxygenation status.■ Normal values (memorize):

pH: 7.35–7.45PaO2: 80–100 mm Hg

PaCO2: 35–45 mm Hg

O2 saturation: 95%–100%

HCO3: 21–28 mEq/L

Base excess: 2 to 2 mEq/L

See detailed explanation of how to interpret ABGs on page 51 in

this tab.

Aspiration


■ Sudden onset of coughing and shortness of breath (SOB) associated with

eating, drinking, or regurgitation.■ Tachypnea, dyspnea, cyanosis, decreased breath sounds.■ Tachycardia, bradycardia.■ Crackles and rhonchi (usually on the right, but may be on the left or

bilaterally).■ Altered mental status.■ Fever.■ Chest pain (pleuritic).

IMMEDIATE INTERVENTIONS■ Elevate head of bed (HOB) to upright position; help patient to expectorate.■ Provide supplemental oxygen.■ Suction oropharynx.■ Encourage coughing.■ If there is evidence of foreign body obstruction see Choking in the

Emergency tab.■ Notify physician or NP.■ Document patient status, phone call to physician or NP, and physician

or NP response.

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

RESPCopyright © 2008 by F. A. Davis.


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■ Assess effectiveness of measures taken to clear airway.■ Assess oxygenation status: level of consciousness (LOC), SaO2, presence

of circumoral and nailbed cyanosis.■ Assess HR, BP, respirations (rate, rhythm, and effort), and work of

breathing.■ Auscultate lung fields.

STABILIZING AND MONITORING■ Continue to monitor airway and respiratory function.■ Consider a speech pathology consultation to assess patient’s level of

airway control and/or gag reflexes.

■ Monitor patient during oral intake, and assess patient for evidence of dysphagia.

BE PREPARED TO■ Set up and assist with intubation, cricothyrotomy, tracheotomy, or

bronchoscopy, if indicated.■ Call a code.

POSSIBLE ETIOLOGIES■ Emesis; disorders that affect normal swallowing and gag reflex (depres-

sion of the laryngeal reflexes, stroke); disorders of the esophagus(esophageal stricture, gastroesophageal reflux); use of sedative drugs;anesthesia; coma; excessive alcohol consumption; tracheitis; epiglottitis;foreign body aspiration.

Chest Tube Dislodgement


■ Signs of respiratory distress: rapid, shallow, or increased work of breathing; cyanosis; decreased LOC; and SaO2, restlessness, or anxiety.

■ Partially or completely dislodged chest tube.■ Visible chest tube drain pores.■ Whistling sound as air enters or exits wound site or chest tube.

IMMEDIATE INTERVENTIONS■ Immediately cover chest tube insertion site with sterile petroleum gauze

(occlusive dressing) covered with several 4 4 pads.■ Maintain constant pressure, but do not tape dressing in order to allow air

to escape from chest cavity.

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■ Administer supplemental O2.■ Notify physician or NP and respiratory therapist STAT.■ Document patient status, phone call to physician or NP, and physician or

NP response.

FOCUSED ASSESSMENT■ Assess respirations and quality of oxygenation including LOC, SaO2, skin

color, and work of breathing.■ Auscultate lung fields, and compare ventilation left to right.■ Assess vital signs (VS) and pain level.

STABILIZING AND MONITORING■ Assure chest x-ray (CXR) is obtained after reinsertion.■ Continue to evaluate lung sounds and quality of oxygenation.■ Make sure all chest tube connections are secure and that tubing is not

tangled or encumbered.■ Maintain drainage system in upright position below heart.■ Place emergency equipment in patient’s room (sterile NS, 4 4 pads,

petroleum gauze, tape and nontoothed padded clamps).■ Assess drainage system for proper functioning.

■ Assure that extra drainage collection system is readily available on theunit.

■ Assist patient with movement and repositioning.

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

POSSIBLE ETIOLOGIES■ Excessive torque or tension on chest tube due to multiple possible causes

(chest tubes not hanging freely during movement, improper transfertechnique, patient confused).

Dyspnea/SOB


■ Mild sensation of discomfort to feeling of suffocation.■ Difficulty breathing; inability to take a deep breath.■ Cyanotic, ashen or pale, and diaphoretic.



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

IMMEDIATE INTERVENTIONS■ Place patient in a position that facilitates breathing.■ Administer supplemental O2 if no history of COPD.■ Assess VS.■ Auscultate lung fields for adventitious sounds and quality of air

movement.■ Place on pulse oximetry and cardiac monitor if readily available; assess

O2 saturation and cardiac rhythm.■ If patient is hyperventilating, encourage slower, deeper breathing or, if

indicated, have the patient perform pursed-lipped breathing.■ Notify physician or NP and respiratory therapy.■ Stay with patient; maintain calm, reassuring demeanor.■ Document patient’s status, phone call to physician or NP, and physician or

NP response.

FOCUSED ASSESSMENT■ Assess VS and respiratory status.■ Assess for chest pain, nausea, leg vein tenderness, other cardiovascular

symptoms.■ Assess for underlying respiratory conditions.■ Assess oxygenation status by evaluating for changes in mental status,

noting evidence of chest pain or tightness, measuring SaO2, andevaluating cardiac rhythm.

■ Ask patient about previous episodes of SOB, what provoked it, if onset

was sudden or gradual, if SOB is made worse by lying flat. Assess cough.■ Assess work of breathing as evidenced by flared nostrils, retraction of subclavicular and intercostal spaces, use of accessory muscles, andorthopnea.

■ Note tracheal alignment, symmetry of chest expansion, bulginginterspaces, and presence of JVD.

■ Assess skin for color, circumoral and nailbed cyanosis, and moistness.■ Auscultate lung fields, noting diminished breath sounds, crackles,

wheezing, friction rubs or stridor.

■ Assess medication administration record for possiblemedication/anaphylactic reactions.

STABILIZING AND MONITORING■ Continue to monitor respiratory status as detailed in Assessment, and

support effort to breathe.

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■ Continue to assess patient for contributing factors and underlying cause.■ Administer medications as ordered.■ Chart patient status, and convey to physician or NP.

BE PREPARED TO■ Obtain IV access.■ Change or set up an O2 delivery system.■ Assist with diagnostic testing.■ Obtain ABGs.■ Place a nasal or oral airway.■ Suction the oropharynx/trachea.■

Administer medication.■ Assist with intubation or chest tube placement.■ Transfer to ICU.

POSSIBLE ETIOLOGIES■ Allergic reaction, airway obstruction, anxiety/panic attack, aspiration,

asthma, cardiac dysrhythmias or tamponade, emphysema, heart failure,cardiac ischemia, pleural effusion/pleuritis, pneumonia, pneumothorax,pulmonary edema, pulmonary embolism.

Possible Causes of Shortness of Breath

Source Potential Causes

Cardiac

Pulmonary

Combinedcardiopul-monary

Other

RESP

Coronary artery disease, angina, MI, heart failure,cardiomyopathy, valve disease, left ventricularhypertrophy, pericarditis, dysrhythmias

COPD, asthma, pneumothorax, pulmonary embolus(PE), pulmonary edema

COPD with comorbid cardiac disorder, deconditioning,chronic pulmonary emboli, trauma

Metabolic acidosis, pain, neuromuscular disorders,upper airway disorders, anxiety, panic,hyperventilation



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Hypoventilation/Ineffective Breathing Pattern


■ Dyspnea at rest or on exertion.■ Hypoxic and appear cyanotic, ashen, or pale.■ Lethargic, stuporous, obtunded, or unconscious.■ Rapid and shallow breathing pattern, periods of apnea as in Cheyne-

Stokes (neurological), or notably slow (narcotic) breathing.■ Signs of right-sided heart failure (JVD, peripheral edema, and

hepatomegaly).IMMEDIATE INTERVENTIONS■ Attempt to arouse patient with physical stimulation to enhance breathing.■ Assess airway for obstruction.■ Perform orotracheal suctioning to clear secretions.■ Administer supplemental O2.■ Manually ventilate patient with a BVM device if RR 8 or O2 saturation90%.

■ Get help, notify RT, and call physician or NP.■ Document patient status, phone call to physician or NP, and physician

or NP response.

FOCUSED ASSESSMENT■ Assess LOC and orientation.■ Assess VS, noting RR, depth, and quality.■ Assess skin color and moistness.■ Auscultate lung fields for adventitious sounds and equality of breath

sounds.

STABILIZING AND MONITORING■ Insert oral or nasal airway, if necessary.■ Administer bronchodilators.■ For narcotic/opioid OD, administer Narcan 0.4 mg IV.■ For IM benzodiazepine OD, administer Romazicon 0.2 mg IV.■ Continue to monitor breathing and oxygenation closely.■ Chart patient status, and convey to physician or NP.

BE PREPARED TO■ Assist with setup and application of various O2 delivery systems (mask,CPAP, BiPAP, intubation/ventilator).

■ Obtain IV access.■ Obtain CXR, ABGs, other laboratory tests.■ Administer medication as ordered.■ Transfer to ICU.

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POSSIBLE ETIOLOGIES■ COPD, emphysema, chronic bronchitis, neuromuscular disorders,

amyotrophic lateral sclerosis, muscular dystrophy, diaphragm paralysis,

Guillain-Barré syndrome, myasthenia gravis, chest wall deformities,kyphoscoliosis, fibrothorax, thoracoplasty, central respiratory drivedepression, drugs: narcotics, benzodiazepines, barbiturates; neurologicaldisorders: encephalitis, brainstem disease, trauma; primary alveolarhypoventilation, obesity hypoventilation syndrome.

Pulmonary Embolism


■ Dyspnea, pleuritic chest pain, tachycardia.■ Anxiety, diaphoresis.■ Syncope, hypotension.■ Wheezing.■ Lower extremity edema.■ Signs and symptoms of thrombophlebitis.

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

or NP response.

FOCUSED ASSESSMENT■ Auscultate lung fields for adventitious sounds and quality of air

movement.■ Assess O2 saturation, cardiac rhythm, VS.■ Assess for chest pain, leg vein tenderness.■ Assess for history of recent surgery, immobilization, recent DVT,

malignancy.

STABILIZING AND MONITORING■ Continue to assess VS, LOC, respiratory status.■ Initiate anticoagulant therapy (heparin) as ordered. Have second

practitioner independently calculate dilutions and infusion pumpprogramming.




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BE PREPARED TO■ Obtain IV access.■ Change or set up an O2 delivery system.■ Administer medications or fluids to maintain blood pressure.■ Assist with obtaining diagnostic studies (CXR, V/Q scan, spiral CT scan,

pulmonary angiogram).■ Obtain ABGs.■ Obtain serial PTTs, and titrate heparin infusion.■ Transfer to ICU for high acuity care or thrombolytic therapy.

POSSIBLE ETIOLOGIES■ Embolization of thrombi from deep veins of the femur, pelvis, and lower

extremities from multiple causes including venous stasis, hypercoagulablestates, surgery and trauma, oral contraceptive and estrogen replacementtherapy, pregnancy, malignancy.

Respiratory Distress/Failure

CLINICAL PICTURE

The patient may have:■ Dyspnea, excessive work of breathing.■ Cyanosis of skin and mucous membranes.■ Anxiety, confusion, restlessness, or somnolence.■ Tachycardia and dysrhythmias (due to hypoxemia and acidosis).■ Decreased O2 saturation (SaO2 90% is considered abnormal, and

levels below this can represent unstable respiratory status that re-quires immediate intervention; however, evaluate in context of patient

baseline—some patients with COPD may never have SaO2 greater than88% but are stable.■ Abnormal ABG results: Hypoxemic respiratory failure , characterized by

a PaO2 60 mm Hg and a normal or low PaCO2, is most common andis caused by any acute disease of the lung (pulmonary edema, pneumo-nia). Hypercapnic respiratory failure , characterized by a PaCO2 50 mm Hg,is associated with drug overdose, neuromuscular disease, chest wallabnormalities, and severe airway disorders such as asthma oremphysema.

■ Seizures (may occur with severe hypoxemia).

IMMEDIATE INTERVENTIONS■ Notify physician or NP and respiratory therapist of decline in respiratory

function.■ Elevate HOB; position patient to facilitate breathing.

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■ Assess if the airway is patent and if patient is alert enough to managesecretions and to protect airway.

■ Insert nasal or oral airway, and suction if patient unable to clear

secretions.■ Apply supplemental oxygen via nasal prongs or face mask to correct

hypoxemia and keep oxygen saturation above 90%. (Use O2 cautiouslyin patients with severe COPD and chronic CO2 retention.)

■ Document patient’s status, phone call to physician or NP, and physicianor NP response.

FOCUSED ASSESSMENT■ Assess oxygenation, lung sounds, respiratory rate, and work of breathing;

assess for circumoral or nailbed cyanosis.■ Assess VS, LOC, orientation.■ Assess for underlying cause of respiratory distress.

STABILIZING AND MONITORING■ Assess cardiac monitor, BP, pulse oximetry, and ABG results.■ Continue to assess temperature, LOC, orientation.■ Administer medications to treat underlying cause.

■ If hypoxemia is severe, intubation and mechanical ventilation to increasePaO2, lower PaCO2, and rest respiratory muscles may be required.■ Assist with diagnostic and laboratory studies (portable CXR, ABGs, ECG,

other diagnostic tests, sputum culture, bronchoscopy).■ Insert IV access.

BE PREPARED TO■ Call a code.■ Assist with intubation.

■ Transfer to ICU.

POSSIBLE ETIOLOGIES■ Hypoxemic respiratory failure: chronic bronchitis and emphysema (COPD),

pneumonia, pulmonary edema, pulmonary fibrosis, asthma, pneumoth-orax, pulmonary embolism, pulmonary arterial hypertension, pneumo-coniosis, granulomatous lung diseases, bronchiectasis, adult respiratorydistress syndrome, fat embolism syndrome.

■

Hypercapnic respiratory failure: COPD, severe asthma, drug overdose,poisonings, myasthenia gravis, polyneuropathy, poliomyelitis, primarymuscle disorders, head and cervical cord injury, primary alveolarhypoventilation, obesity hypoventilation syndrome, pulmonary edema,adult respiratory distress syndrome, myxedema.



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Ventilators/Mechanical Ventilation

Indications ■ Airway obstruction.■ Inadequate oxygenation—O2 saturation (90% on hi-flow oxygen via

nonrebreather mask).■ Inadequate ventilation—hypoventilation (high pCO2, pH acidosis).■ Increased work of breathing, ineffective breathi

davis med notes2

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