Congestive Heart Failure

CRITICAL CARE NURSING CARE PLANS

Sheree Corner

Contributor: Barbara Sage1 R.N., M.s., C.C.R.N.

-- -- DELMAR THOMSON LEARNING Africa Australia Canada Denmark Japan Mexico New Zealand Philippines Puerto Rico Singapore Spain United Kingdom United States NOTICE TO THE READER

Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection with any of the product information contained herein. Publisher does not assume, and expressly disclaims, any obligation to obtain and include information other than that provided to it by the manufacturer. The reader is expressly warned to consider and adopt all safety precautions that might be indicated by the activities herein and to avoid all potential hazards. By following the instructions contained herein, the reader willingly assumes all risks in connection with such instructions. The Publisher makes no representation or warranties of any kind, including but not limited to, the warranties of fitness for particular purpose or merchantability, nor are any such representations implied with respect to the material set forth herein, and the publisher takes no responsibility with respect to such material. The publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or part, from the readers' use of, or reliance upon, this material.

COPYRIGHT 0 1998 Delmar, a division of Thomson Learning, Inc. The Thomson Learningm is a trademark used herein under license.

Printed in the United States of America 2345678910XXX050403020100

For more information, contact Delmar, 3 Columbia Circle, PO Box 15015, Albany, NY 12212-0515; or find us on the World Wide Web at http://www.delmar.com

International Division List Asia AustraliaINew Zealand: Latin America: Thomson Learning NelsonfI'homson Learning Thomson Learning 60 Albert Street, #15-01 102 Dodds Street Seneca, 53 Albert Complex South Melbourne, Victoria 3205 Colonia Polanco Singapore 189969 Australia 11560 Mexico D.F. Mexico Tel: 65 336 6411 Tel: 61 39 685 4111 Tel: 525-281-2906 Fax: 65 336 7411 Fax: 61 39 685 4199 Fa: 525-281-2656

Japan: UWEuropeMiddle East Canada: Thomson Learning Thomson Learning NelsonlThomson Learning Palaceside Building 5F Berkshire House 1120 Birchmount Road 1-1-1 Hitotsubashi, Chiyoda-ku 168-173 High Holbom Scarborough, Ontario Tokyo 100 0003 Japan London Canada M1 K 5G4 Tel: 813 5218 6544 WClV 7AA United Kingdom Tel: 416-752-9100 Fax: 813 5218 6551 Tel: 44 171 497 1422 Fa: 416-752-8102 Fax: 44 171 497 1426

ALL RIGHTS RESERVED. No part of this work covered by the copyright hereon may be reproduced or used in any form or by any means-graphic, electronic, or mechanical, including photocopying, recording, taping, Web distribution or information storage and retrieval systems-without the written permission of the publisher.

For permission to use material from this text or product contact us by Tel (800) 730-2214; Fax (800) 730-2215; www.thomsonrights.com

Library of Congress Cataloging-in-Publication Data

ISBN: 1-56930-035-6 1

TABLE OF CONTENTS This Page Intentionally Left Blank CARDlOUASCUwl SYSTEM ...... 1 Congestive Heart Failure ...... 3 Myocardial Infaction (MI) ...... 13 Pericarditis ...... 25 Infective Endocarditis (IE) ...... 31 Hypertension ...... 39 Thrombophlebitis ...... 47 Intra-Aortic Balloon Pump (IABP) ...... 53 Pacemakers ...... 59 Cardiac Surgery ...... 67 Aortic Aneurysm ...... 77 RESPlRlYrORY SYSTEM ...... 83 Adult Respiratory Distress Syndrome (ARDS) ...... 85 Chronic Obstructive Pulmonary Disease (C 0 P D) ...... 91 Pulmonary Embolism ...... 99 Pneumonia ...... 105 Pneumothorax ...... 111 Status Asthmaticus ...... 117 Mechanic al Ventilation ...... 121 NEUROLOGICAL SYSTEM ...... 137 C V A ...... 139 Head Injuries ...... 147 Spinal Cord Injuries ...... 159 Guillain-Barre Syndrome ...... 169 Status Epilepticus ...... 175 Meningitis ...... 181 Ventriculostomy/ICP Monitoring ...... 185 Endarterectomy ...... 189 GASTROMTESTINAUHEPATIC SYSTEM ...... 191 Gastrointestinal Bleeding ...... 193 Esophageal Varices ...... 199 Hepatitis ...... 203 Pancreatitis ...... 207 Acute Abdomen/ Abdominal Trauma ...... 211 Liver Failure ...... 217 HEMATOLOGIC SYSTEM ...... 223 Disseminated Intravascular Coagulation (DIC) ...... 225 H E L L P Syndrome ...... 229 Anemia ...... 233 iv

RENWDOCRINE SYSTEMS ...... 237 Acute Renal Failure (ARF) ...... 239 Diabetic Ketoacidosis (D K A) ...... 251 Hyperglycemic Hyperosmolar Nonketotic Coma (H H N K) ...... 261 Syndrome of Inappropriate ADH Secretion (SIADH) ...... 265 Diabetes Insipidus (DI) ...... 269 Pheochromocytoma ...... 273 Thyrotoxicosis (Thyroid Storm) ...... 281 MUSCULOSKELETAL SYSTEM ...... 289 Fractures ...... 291 Amputation ...... 299 Fat Embolism ...... 307 IHTEGUMarrARY SYSTEM ...... 311 Frostbite/Hypothermia ...... 313 Malignant Hyperthermia ...... 319 Burns/Thermal Injuries ...... 323 OTHER ...... 329 Multiple Organ Dysfunction Syndrome (MODS) ...... 331 Acute Poisoning/Drug Overdose ...... 337 Snakebite ...... 343 Transplants ...... 349 Cardiogenic Shock ...... 357 INDEN OF NURSING DIAGNOSES ...... 361

REFERENCES ...... 365 CARDIOVASCULAR SYSTEM 1

Congestive Heart Failure Myocardial Infarction (MI) Pericarditis Infective Endocarditis (IE) Hypertension Thrombophlebitis Intra-Aortic Balloon Pump (IABP) Pacemakers Cardiac Surgery Aortic Aneurysm This Page Intentionally Left Blank CARDIOVASCULAR SYSTEM 3

Right-sided heart failure is usually caused by left- Congestive Heart Failure sided heart failure, but can also be caused by pulmonary emboli, pulmonary hypertension, Heart failure is the inability of the heart to supply blood fl~wto meet physiologic demands, without COPD, and the presence of right ventricular utilizing compensatory changes. There may be infarctions. failure involving one or both sides of the heart, The lungs can accept a certain amount of fluid and over time, causes the development of build-up, but eventually, if no intervention is pulmonary and systemic congestion and complica- taken, the pressure in the lungs increases to the tions. Congestive heart failure, or CHF, is a point whereby the right ventricle cannot eject its common complication after myocardial infarction blood into the lungs. The right ventricle fails and and can be attributed to one-third of the deaths of then the blood in the right atrium cannot drain patients with MIs. Usually following MI, the heart completely, and thus cannot accept the total failure is left-sided since most infarctions involve amount of blood from the vena cavae. Venous damage to the left ventricle. pooling occurs with the impairment of venous blood flow, and eventually organs become Heart failure can also be classified as acute or the congested with venous blood. chronic. In chronic heart failure, the body experiences a gradual development as the heart becomes Treatment of heart failure involves attempts to unable to pump a sufficient amount of blood to improve contractility of the ventricle by use of meet the body’s demands. Chronic heart failure positive inotropic drugs, decrease of afterload by can become acute without any overt cause. the use of nitrates and vasodilators, and in some instances, by use of the IABP, and decrease of pre- Often, the patient will have no early symptoms of left-sided heart failure. Symptoms of decreased load by the use of diuretics, IV nitroglycerin, and cardiac output will develop once the heart fails to fluid/sodium restrictions. pump enough blood into the systemic circulation. The pressure in the left ventricle increases, which in turn causes retrograde increases of pressure in Oxygen: to increase available oxygen supply the left atrium because of the increased difficulty for blood to enter the atrium from the pulmonary Morphine: used to induce vasodilation, decrease veins. Blood backs up in the lung vasculature, and venous return to the heart, reduce pain and anxi- when the pulmonary capillary pressure is exceeded ety, and decrease myocardial oxygen consumption by the oncotic pressure of the proteins in the Cardiac glycosides: digitalis (Digoxin, Lanoxin) plasma fluid (usually > 30 mmHg), the fluid leaks PO or IV to increase the force and strength of into the interstitial spaces. When this fluid moves ventricular contractions and to decrease rate of into the alveoli, shortness of breath, coughing, and contractions in order to increase cardiac output crackles (rales) occur, and the patient progresses into overt pulmonary edema, with the classic sign Diuretics: furosemide (Lasix) PO or IV, chloroth- of coughing up copious amounts of pink frothy iazide (Diuril) PO, bumetanide (Bumex) PO or sputum. IV to promote excess fluid removal, to decrease edema and pulmonary venous pressure by preventing sodium and water reabsorption 4 CRITICAL CARE NURSING CARE PLANS

Vasodilators: hydralazine (Apresoline) PO or IV, decreases afterload, decreases preload, improves isosorbide dinitrate (Isordil) SL or PO, prazosin cardiac output and tissue perfusion (Minipress) PO, minoxidil (Loniten) PO, diazoxide (Hyperstat) IV, sodium nitroprusside NURSING CARE PLANS (Nipride) IV, nitroglycerine (Nitrostat, Tridil) PO, SL, IV to relax vascular smooth muscle, decrease Fluid volume excess preload and afterload, decrease oxygen demand, Related to: increased sodium and water retention, decrease systemic vascular resistance, and increase decreased organ perfusion, compromised venous capacitance regulatory mechanisms, decreased cardiac output, Renin-angiotensin system inhibitors: captopril increased ADH production (Capoten) PO used to inhibit angiotensin Defining characteristics: edema, weight gain, converting enzyme to reduce the production of intake greater than output, increased blood pres- angiotensin I1 to enable the decrease in vasocon- sure, increased heart rate, shortness of breath, striction and to reduce afterload dyspnea, orthopnea, crackles (rales), S3 gallop, Inotropic agents: dopamine, dobutamine oliguria, jugular vein distention, pleural effusion, (Dobutrex) IV, amrinone (Inocor) IV used to specific gravity changes, altered electrolyte levels increase myocardial contractility, without increasing the heart rate, to produce peripheral Outcome Criteria vasodilation and decrease preload and afterload Blood pressure will be maintained within normal Electrolytes: mainly potassium to replace that limits and edema will be absent or minimal in all which is lost during diuretic therapy body parts. Laboratory: electrolyte levels to monitor for Fluid volume will be stabilized with balanced imbalances; renal profiles to monitor for kidney intake and output. function problems; digoxin levels to monitor for toxicity; platelet count to monitor for thrombocy- INTERVENTIONS RATIONALES topenia from amrinone Monitor vital signs and hemo- Fluid volume excess will cause dynamic readings if available. increases in blood pressure, and Chest x-ray: shows any enlargement of the heart CVP and pulmonary artery and pulmonary vein, presence of pulmonary pressures, and these changes will be reflected from the ederna or pleural effusion development of pulmonary Electrocardiography: used to monitor for congestion and heart failure. dysrhythmias which may occur as a result of the Auscultate lungs for presence May indicate pulmonary edema heart failure or as a result of digitalis toxicity of crackles (rales), or other from cardiac decornpensation and adventitious breath sounds. pulmonary congestion. Pulmon- Echocardiography: used to study structural abnor- Observe for presence of cough, ary edema symptoms reflect left- malities and blood flow through the heart increased dyspnea, tachypnea, sided hearr failure. Right- orthopnea or paroxysmal noc- sided heart failure may have Intra-aortic balloon pump: decreases the turnal dyspnea. slower onset, but symptoms of workload on the heart, decreases myocardial dyspnea, orthopnea, and cough are more difficult to oxygen demand, increases coronary perfusion, reverse. CARDIOVASCULAR SYSTEM 5

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Observe for jugular vein dis- May indicate impending conges- Place and maintain patient in Diuresis may be enhanced by tention and dependent edema. tive failure and fluid excess. semi-Fowler's position. recumbent position due to Note presence of generalized Peripheral edema begins in increased glomerular filtra- body edema (anasarca). feet and ankles, or other de- tion and decreased production pendent areas and ascends as ofADH. failure progresses. Pitting will usually occur only after 10 or more pounds of excess fluid is retained. Anasarca will Auscultate bowel sounds and ob- CHF progression can impair be seen only with right heart serve for abdominal distention, gastric motility and intestinal failure or bi-ventricular failure. anorexia, nausea, or constipa- function. Small, frequent meals tion. Provide small, easily- may enhance digestion and pre- Investigate abrupt complaints Excessive fluid build-up can digestible meals. vent abdominal discomfort. of dyspnea, air hunger, feeling promote other complications of impending doom or suffocation. such as pulmonary edema or Measure abdominal girth if Progressive right-sided heart pulmonary embolus and inter- warranted. failure can cause fluid to shift vention must be immediate. into the peritoneal space and cause ascites. Determine fluid balance by Renal perfusion is impaired with measuring intake and output, excessive fluid volume, which Palpate abdomen for liver en- Progressive heart failure can and observing for decreases in causes decreased cardiac output largement; note any right lead to venous congestion, ab- output and concentrated urine. leading to sodium and water upper quadrant tenderness or dominal distention, liver engor- retention and oliguria. pain. gement, and pain. Liver function may be impaired and can Weigh daily and notify MD of Abrupt changes in weight usually impede drug metabolism. greater than 2 lblday increase. indicate excess fluid. Assist with dialysis or hemo- Mechanically removing excess filtration as warranted. fluid may be performed to Provide patient with fluid in- Fluids may need to be restricted rapidly reduce circulating take of 2 Llday, unless fluid due to cardiac decompensation. volume in cases refractory to restriction is warranted. Fluids maintain hydration of other medical therapeutics. tissues. Instruction, Information, Administer diuretics as ordered Drugs may be necessary to cor- Demonstration (furosemide, hydralazine, spiro- rect fluid overload depending lactone with hydrochlorothiazide). on emergent nature of problem. Diuretics increase urine flow INTERVENTIONS RATIONALES rate and may inhibit reabsorp- Instruct patient regarding diet- Fluid retention is increased tion of sodium and chloride ary restrictions of sodium. with intake of sodium. in the renal tubules. Instruct patient to observe for Weight gain may be firsr overt Monitor electrolyte for imbal- Hypokalemia can occur with the weight changes and report these sign of fluid excess and should ances. Note increasing lethar- administration of diuretics. to MD. be monitored to prevent compli- gy, hypotension, or musde Signs of potassium and sodium cations. cramping. deficits may occur due to fluid shifts with diuretic Consult with dietitian. May be required to ensure therapy. adequacy of caloric intake with fluid and sodium resrric- tion requirements. 6 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Outcome Criteria Instruct patient in medications Promotes knowledge and compli- Vital signs and hemodynamic parameters will be ance with treatment regimen. prescribed after discharge, with within normal limits for patient, with no dose, effect, side effects, .... contraindications. dysrhythmias noted.

Monitor chest x-rays. Reveal changes in pulmonary Patient will be eupneic with no adventitious status regarding improvement breath sounds or abnormal heart tones. or deterioration.

Discharge or Maintenance Evaluation INTERVENTIONS RATIONALES Determine level of cardiac func- Additional disease states and Patient will have no edema or fluid excess. tion and existing cardiac and complications may place an other conditions. additional workload on an Fluid balance will be maintained and blood already compromised heart. pressure will be within normal limits of baseline. Auscultate apical pulses and Decreased contractility will be Lung fields will be clear, without adventitious monitor heart rate and rhythm. compensated by tachycardia, es- Monitor BP in both arms. pecially concurrently with heart breath sounds, and weight will be stable. failure. Blood volume will be Patient will be able to accurately verbalize lowered if blood pressure is increased resulting in increased understanding of dietary restrictions and med- afterload. Pulse decreases may ications. be noted in association with toxic levels of digoxin, and Decreased cardiac output peripheral pulses may be hard to accurately determine if per- Related to: damaged myocardium, decreased confusion is decreased. Hypo- tractility, dysrhythmias, conduction defects, tension may occur as a result alteration in preload, alteration in afterload, vaso- of ventricular dysfunction and poor perfusion of rhe myocard- constriction, myocardial ischemia, ventricular ium. hypertrophy, accumulation of blood in lungs or in systemic venous system Measure cardiac output and Provides measurement of cardiac cardiac index, and calculate function and calculated mea- Defining characteristics: dependent edema, hernodynamic pressures every 4 surements of preload and after- elevated blood pressure, elevated mean arterial hours and prn. load to facilitate titration of vasoactive drugs and manipula- pressure greater than 120 mmHg, elevated tion of hemodynamic pressures. systemic vascular resistance greater than 1400 dyne-secondslcm5, cardiac output less than 4 Monitor EKG for dysrhythmias Conduction abnormalities may and treat as indicated. occur due to ischemic myocar- L/min or cardiac index less than 2.5 L/min/m2, dium affecting the pumping tachycardia, cold, pale extremities, absent or efficiency of the heart. decreased peripheral pulses, EKG changes, hypotension, S3 or S, gallops, decreased urinary Observe for development of new S3 gallops are usually asso- S3 or S4 gallops. ciated with congestive hearr output, diaphoresis, orthopnea, dyspnea, crackles failure but can be found with (rales), frothy blood-tinged sputum, jugular vein rnitral regurgitation and left distention, edema, chest pain, confusion, restlessness CARDIOVASCULAR SYSTEM 7

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES ventricular overload after MI. Avoid Valsalva-type maneuvers Increasing intra-abdominal pres- S4 gallops can be associated with straining, coughing or sure results in an abrupt de- with myocardial ischemia, ven- moving. crease in cardiac output by tricular rigidity, pulmonary preventing blood from being hypertension, or systemic hy- pumped into the thoracic cavity pertension, which can decrease and thus, less blood being pump- cardiac output. ed into the heart which then decreases the heart rate. When Auscultate for presence of Indicates disturbances of normal the pressure is released, there murmurs andlor rubs. blood flow within the heart re- is a sudden overload of blood lated to incompetent valves, which then increases preload. septal defects, or papillary muscle/chordae tendonae com- Provide small, easy to digest, Large meals increase the work- plications post-MI. Presence meals and restrict caffeine. load on the heart. Caffeine of a rub with an MI is asso- directly stimulates the heart ciated with pericarditis and/ and increases heart rate. or pericardial effusion. Have emergency equipment and Coronary occlusion, lethal dys- Observe lower extremities for Reduced venous return to the medications available at all rhythmias, infarct extensions or edema, distended neck veins, heart can result in low cardiac times. intractable pain may precipitate cold hands and feet, mottling, output; oliguria results from cardiac arrest that requires oliguria. decreased venous return due to life support and resuscitation. fluid retention.

Position in semi-Fowler’s Promotes easier breathing and Information, Instruction, position. prevents pooling of blood in Demonstration the pulmonary vasculature. INTERVENTIONS RATIONALES Administer cardiac glycosides, Used in the treatment of vaso- nitrates, vasodilators, diure- constriction and to reduce heart Instruct on medications, dose, Promotes knowledge and compli- tics, and antihypertensives as rate and contractility, reduces effects, side effects, contra- ance with regimen. Prevents ordered. blood pressure by relaxation of indications, and avoidance of any adverse drug interactions. venous and arterial smooth mus- over-the-counter drugs without cle’ which then in turn increases MD approval. cardiac output and decreases the workload on the heart. Instruct in activity limitations. Promotes compliance. Reduces Demonstrate exercises to be done. decrease in cardiac output by Titrate vasoactive drugs as Maintains blood pressure and lessening the worMoad placed ordered per MD parameters. heart rate at levels to optimize on the heart. cardiac output function. Instruct to report chest pain. May indicate complications of Weigh every day. Weight gain may indicate fluid decreased cardiac output. retention and possible impending congestive failure. Instruct patiendfamily regard- Alleviates fear and promotes Arrange activities so as to Avoids over-fatiguing patient ing placement of pulmonary ar- knowledge. Pulmonary artery not over-tax patient. and decreasing cardiac output tery catheter, and post- catheter necessary for direct further. Balancing rest with procedure care. measurement of cardiac output activity minimizes energy expen- and for obtaining values for diture and myocardial oxygen other hemodynamic measurements. demands by maintaining cardiac output. 8 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Assist with insertion and main- Cardiac pacing may be necessary Monitor respiratory status for Changes in respiratory pattern tainance of pacemaker when during the acute phase of MI or rate, regularity, depth, ease of or patency of airway may result needed. may be necessary as a permanent effort at rest or with exertion, in gas exchange imbalances. measure if the MI severely inspiratory/expiratory ratio. damages the conduction system. Observe for presence of cyanosis Cyanosis results from decreases and mottling; monitor oximetry in oxygenated hemoglobin in the Discharge or Maintenance Evaluation for oxygen saturation; monitor blood and this reduction leads ABGs for ventilation/perfusion to hypoxia. Reading of 90% problems. on pulse oximeter correlates Patient will have no chest pain or shortness of with pO2 of GO. breath. Monitor for mental status chan- Hypoxia affects all body systems Vital signs and hemodynamic parameters will ges, deterioration in level of and mental status changes can be within normal limits for age and disease con- consciousness, restlessness, ir- result from decreased oxygen to dition. ritability, easy fatigueability. brain tissues. Minimal activity will be tolerated without Position in semi- or high- Promotes breathing and lung ex- Fowler's position. pansion to enhance gas distri- fatigue or dyspnea. bution.

Urinary output will be adequate. Administer oxygen via nasal can- Maintains adequate oxygenation Cardiac output will be adequate to ensure ade- nula at 2-3 L/min, or other de- without depression of respira- livery systems. tory drive. CO2 may be retained quate perfusion of all body systems. with higher flow rates when used in patients with COPD. Impaired gas exchange Assist with placement of ETT Mechanical ventilation may be Related to: ventilationlperfusion imbalance caused and placement on mechanical required if respiratory failure from excess fluid in alveoli and reduction of air ventilation. is progressive and adequate oxy- exchange area in lung fields, fluid collection shifts gen levels cannot be maintained into the interstitial space by other delivery systems. Defining characteristics: confusion, restlessness, irritability, hypoxia, hypercapnea, dyspnea, Instruction, Information, orthopnea, abnormal ABGs, abnormal oxygen sat- Demonstration uration INTERVENTIONS RATIONALES Instruct in breathing exercises as Assists to restore function to Outcome Criteria warranted. diaphragm, decreases work of breathing, and improves gas Patient will have adequate oxygenation with respi- exchange. ratory status within limits of normal based on age Assess for nausea and vomiting. May indicate effects of hypoxia and other conditions, and ABGs will be within on gastrointestinal system. normal limits. Avoid activities that promotes Activity increases oxygen con- dyspnea or fatigue. Allow for sumption and demand, and can periods of rest between impair breathing pattern. activities. CARDIOVASCULAR SYSTEM 9

INTERVENTIONS RATIONALES Outcome Criteria Instruct in safety concerns with Promotes safety with oxygen oxygen use. and provides knowledge. Patient will have and maintain skin integrity. INTERVENTIONS RATIONALES Instruct patiendfamily in need Promotes knowledge and for placement on mechanical decreases anxiety and fear of the Monitor mobility status and pa- Immobility is the primary cause ventilation, what to expect, unknown. tient's ability to move self. of skin breakdown. what benefits are to be received, what potential problems may be Inspect all skin surfaces, espe- Skin is at risk because of de- encountered. cially bony prominences, for skin creased tissue perfusion, im- breakdown, altered circulation to mobility, decreased peripheral areas, or presence of edema. perfusion, and possible nutri- Discharge or Maintenance Evaluation tional alterations. Provide skin care to blanched Stimulates blood flow and de- Patient will exhibit no ventilation/perfusion or reddened areas. creases tissue hypoxia. Excess imbalances. dryness or moistness of skin can promote breakdown. Patient will be eupneic with no adventitious breath sounds. Provide eggcrate mattress, al- These items can reduce pressure ternating pressure mattress, on skin and may improve circu- ABGs will be within acceptible ranges for sheepskin, elbow protectors, lation. patient with adequate oxygenation of all tissues. heel protectors, etc. Patient will be able to verbalize/demonstrate the Reposition frequently, at least Improves circulation by reduc- every 2 hours. Assist with ROM tion of time pressure is on any correct use of oxygen. exercises. Maintain body align- one area. Proper body alignment ment. Raise head of bed prevents contractures. Eleva- Risk fir impaired skin intephy no higher than 30 degrees. tions higher than this may pro- Related to: bed rest, decreased tissue perfusion, mote pressure and friction from sliding down, and shearing force edema, immobility, decreased peripheral may result in breakdown of skin. perfusion, shearing forces or pressure, secretions, excretions, altered sensation, skeletal prominence, Avoid subcutaneous or IM injec- Edema and tissue hypoxia tions when possible. impede circulation which can poor skin turgor, altered metabolic rate cause decreased absorption of medication and can predispose Defining characteristics: disruption of skin sur- patient to tissue breakdown and face, pressure areas, reddened areas, blanched development of abscess/ areas, mottling, warmth, firmness to area of skin, infection. irritated tissues, excoriation of skin, maceration of skin, lacerations of skin, pruritis, dermatitis 10 CRITICAL CARE NURSING CARE PLANS

Instruction, Information, Demonstration

INTERVENTIONS RATIONALES Instruct on safety precautions May cause breaks in skin inte- in bed-avoiding bumping against grity. rails, falls, etc.

Instruct on hazards of immobili- Bedrest promotes pressure to ty; avoid lying or sitting in skin and tissues. one position for prolonged time.

Instruct on the use of lotions Prevents skin dryness and chance and oil to apply to skin. of tissue breakdown.

Discharge or Maintenance Evaluation

Patient will have intact skin, free of redness, irritation, rashes, or bruising. Patient will be able to verbally relate measures to reduce chance of tissue injury. Anxiety [See MI] Related to: change in health status, fear of death, threat to body image, threat to role functioning, pain Defining characteristics: restlessness, insomnia, anorexia, increased respirations, increased heart rate, increased blood pressure, difficulty concentrating, dry mouth, poor eye contact, decreased energy, irritability, crying, feelings of helplessness Knowledge deficit [See MI] Related to: lack of understanding, lack of understanding of medical condition, lack of recall Defining characteristics: questions regarding problems, inadequate follow-up on instructions given, misconceptions, lack of improvement of previous regimen, development of preventable complications CARDIOVASCULAR SYSTEM 11

LEFT-SIDED HEART FAILURE

Burden placed on cardiovascular system by any of the following: hypertension, myocardial infarction, valvular heart disease, dysrhythmias, tachy/bradycardia, cardiomyopathy, cardiac tamponade, constrictive pericarditis, aortic stenosis, mitral insufficiency, or anemia 4 Decreased cardiac output + ------+Sympathetic nervous system stimulated Fatigue, weakness Heart rate increases Arteriolar vasoconstriction 4 Myocardial contractility increases Venous tone increases Venous and ventricular filling pressures increase Decreased effective arterial blood volume

Renal com ensatory changes occur Rend bfood flow decreases GFR decreases Cortical blood flow decreases Renin and angiotensin increase Aldosterone increases ADH increases

J, Sodium reabsorption and free water clearance decreases Effective blood volume increases

4 Accumulation of blood in lungs J, LV cannot pump blood from lungs into systemic circulation J LV pressures and LV volume increase 4 LA pressures and volume increase J,

Fluid backs U into pulmonary vasculature = pulmonary congestion Paroxysmafnocturnal dyspnea, orthopnea 4 Pulmonary hypertension, PA diastolic and PCWP pressure increases 6 Fluid leaks into interstitial and alveoli 4 Pulmonary edema Cou h Frotl& blood-tinged sputum Rales (crackles) 4 Decreased oxygen in blood Impaired as exchange and hypoxia Tackypnea Restlessness Cyanosis Pulmonary effusion Confusion Pulsus alternans 12 CRITICAL CARE NURSING CARE PLANS

RIGHT-SIDED HEART FAILURE

Burden placed on the cardiovascular system by any of the following: left-sided heart failure, pulmonary hypertension, COPD, cor pulmonale, pulmonary embolus, anemia, thyrotoxicosis, pulmonary stenosis, or mitral stenosis. 4 Accumulation of blood in systemic venous system Lung pressure increases Pressure in pulmonary vasculature increases 4 Increased right atrial and ventricular pressures Increased peripheral venous pressure

J, Right heart cannot pump blood into pulmonary system Right-sided heart failure Bounding pulses Dysrhythmias Sjor S4 gallop 4 Venous return decreases Organs become congested with blood Peripheral dependent edema occurs

J, Congestion of portal circulation Hepatomegaly, hepatojugular reflux JVD, weight gain Anorexia Ascites, abdominal pain, anorexia, nausea Fatigue, cyanosis 4 Advanced heart failure 4 Air hunger, gasping Tachycardia Crackles, frothy blood-tinged sputum Skin cool and moist Cyanotic lips, nailbeds Confusion, stupor Enlarged RA and RV Tricuspid murmur CARDIOVASCULAR SYSTEM 13

tricular filling pressures and often has severe tri- MYoeardial Infaretion (MD cuspid regurgitation. Transmural infarcts involve Myocardial infarction (MI) is a critical emergency the entire thickness of the myocardium and are that requires timely management to save heart characterized by Q waves on the muscle and limit damage that may evolve over electrocardiogram. Nontransmural infarcts are several hours. Blood flow is abruptly decreased or characterized by S-T segment and T wave stopped through the coronary arteries and results changes. Subendocardial infarcts usually involve in ischemia and necrosis to the myocardium if not the inner portion of the myocardium where wall treated. Many people die prior to receiving med- tension is highest and the blood flow is most vul- ical care due to the denial that anything may be nerable to circulatory problems. Occlusion of the wrong and postponement of seeking medical care. right coronary artery will result in an inferior Cardiac dysrhythmias, mainly ventricular fibrilla- infarction that may also include posterior portions tion, is usually the cause of death in these of the heart. Occlusion of the left main artery, individuals. An MI is diagnosed based on type of known as “the widow maker,” usually results in chest pain, electrocardiographic changes, and death due to the extensive damage. Occlusion of increase of cardiac enzymes, such as CK, SGOT, the left anterior descending artery results in an and LDH. Precordial pain is similar to but usually anterior infarction and may include some inferior more intense and prolonged than anginal pain, parts of the heart, and occlusion of the circumflex and in the instance of MI, the chest pain is usu- artery results in a lateral infarction. ally constant and not relieved with nitroglycerin Precipitating factors that preclude MIs include or rest. heredity, age, gender, presence of hypertension, Atherosclerosis of the arteries is usually the most presence of diabetes mellitus, cigarette smoking, common finding in patients. Atherosclerosis and hyperlipidemia, obesity, sedentary lifestyles, and arteriosclerosis are used interchangeably when dis- stress. cussing the fatty plaques that adhere to the inner The main goals in treating myocardial infarction layer of the arteries. The continuous build-up of are to increase blood flow to the coronary arteries these plaques, as well as the potential for hemor- and thus decrease infarction size, increase oxygen rhage at the intimal layer may result in alterations supply and decrease oxygen demand to prevent of the blood flow through the coronary arteries myocardial death or injury, and control or correct and abnormalities in platelet aggregation may con- dys r hyt hm ias . tribute to changes in coronary perfusion. Infarction may occur without coronary artery dis- MEDICAL CARE ease or occlusion, and if the patient has developed an adequate collateral circulation, coronary occlu- Oxygen: to increase available oxygen supply sion may occur without infarction. Analgesics: morphine is the drug of choice, given MI is usually a disease involving the left ventricle in incremental doses IV every 5 minutes as but the damage may extend to other areas, such as needed; IM injections are avoided because they the atria or right ventricle. A right ventricular can raise the enzyme levels and do not act as myocardial infarction usually has high right ven- quickly 14 CRITICAL CARE NURSING CARE PLANS

Thrombolytic agents: Streptokinase, Urokinase, Laboratory: leukocyte count, sed rate and blood or Tissue Plasminogen Activator (tPa) given either glucose may be elevated; creatinine phosphokinase intracoronary or intravenously to activate the (CK, CPK) will normally increase within 4-6 body’s own fibrinolytic system to dissolve the clot hours, peak between 12-24 hours, and last 2-3 and resume coronary blood perfusion days but should not be used as sole indicator due to possibility of elevation with other problems Cardiac glycosides: digitalis to increase force and such as surgery or trauma; lactate dehydrogenase strength of ventricular contractions and to (LDH) will normally increase within 8-12 hours, decrease the conduction and rate of contractions peak between 2-4 days, and last 10-14 days but in order to increase cardiac output; usually not should not be used as sole indicator due to possi- used in the acute phase bility of elevation with other problems such as Diuretics: furosemide (Lasix) to promote excess liver failure; serum glutamic oxaloacetic transami- fluid removal, to decrease edema and pulmonary nase (SGOT) is occasionally used as an infarct venous pressure by preventing sodium and water indicator; isoenzymes of CPK are very specific reabsorption with CPK-MB most specific for MI, and levels will not rise with transient chest pain or in surgi- Vasodilators: hydralazine (Apresoline), nifedipine cal procedures; a definitive level for CPK-MB is (Procardia, Adalat), nitroglycerin (Nitropaste, greater than or equal to 4% of the total CDK; Nitrodur, Nitrostat, Tridil, Nitroglycerine), LDH isoenzymes, specifically LDHl is more spe- prazosin (Minipres), captopril (Capoten)-used to cific for MI; if the total LDH is elevated and relax venous and/or arterial smooth muscle to LDHl is most predominant, MI is confirmed; decrease preload, decrease afterload, and decrease both CPK-MB and LDHl will return to normal oxygen demand 72-96 hours after elevation Beta-adrenergic blockers: used to decrease blood Chest x-ray: shows any enlargement of the heart pressure, decrease elevated plasma renins, and with and pulmonary vein, presence of pulmonary non-selective blockers, may do so without related edema or pleural effusion reflex tachycardias; used to treat ventricular dysrhythmias and for the prophylaxis of angina Electrocardiography: shows indicative changes associated with sites of acute infarcts using Q Aspirin: used to decrease platelet aggregation and waves, S-T segment elevation, and T wave inver- helps with vasodilation of peripheral vessels sion. Also reveals changes with atrial and Thrombolytics: used in the treatment of acute ventricular enlargement, rhythm and conduction MI; acts by activating mechanisms for conversion abnormalities, ischemia, electrolyte abnormalities, of plasminogen to plasmin which is able to drug toxicity, and presence of dysrhythmias dissolve the clot; commonly used are Echocardiography: used to study structural abnor- streptokinase, urokinase, alteplase, or anistreplase malities and blood flow through the heart; Heparin: used with thrombolytic protocols, and M-mode echocardiography measures structures in the treatment of MI; prevents conversion of fib- with a single ultrasonic beam that provides a rinogen to fibrin and prothrombin to thrombin by narrow view of the heart; two-dimensional (2D) its action on antithrombin I11 echocardiography shows a two-dimensional and CARDIOVASCULAR SYSTEM 15 wider look at the heart that is more useful in diag- Ventricular assist device (VAD): used on either or nosing right ventricular infarcts; documents both ventricles to provide total support to the increased right ventricular size, performance and heart and circulation in order to allow recovery to segmental wall motion abnormalities, and blood the heart; usually indicated in patients who are flow through the heart awaiting cardiac transplantation or in those patients with cardiogenic shock and ventricular Nuclear cardiologic testing: MUGA (multiple failure; may be used in conjunction with IABP gated acquisition study) provides information that approximates ejection fractions and the analysis of Pacemakers: either temporary or permanent, used the ventricular wall motion; 99mTc (Technetium- in anticipation of lethal dysrhythmias andlor con- 99 pyrophosphate scan) shows infarcted areas as duction problems increased levels of radioactivity, or “hot spots’’ that Surgery: coronary artery bypass grafting to appear 12-36 hours after infarct and remain for 4- reroute the coronary blood flow around the dis- 7 days; PET (positron emission tomography) eased vessel to allows measurement of myocardial blood flow, enable coronary perfusion fatty acid and glucose metabolism, and blood volume; thallium scans can determine size and NURSING CARE PLANS location of damage as a “cold spot” Alteration in comfort

Magnetic resonance imaging (MRI): provides a Related to: chest pain due to decreased blood three-dimensional view that can detect changes in flow to myocardium, myocardial ischemia or tissues before structural damage is done and is safe infarct, post-procedure discomfort, chest wall pain for pregnant women and children post-surgery, pericarditis Cardiac catheterization: used to assess pathophys- Defining characteristics: chest pain with or with- iology of the patient‘s cardiovascular disorder, to out radiation, facial grimacing, clutching of hands provide left ventricular function information, to or chest, restlessness, diaphoresis, changes in pulse allow for measurement of heart pressures and car- and blood pressure, dyspnea, dizziness diac output, to evaluate stenotic lesions, and to measure blood gas content Outcome Criteria Intra-aortic balloon pump (IABP):decreases the workload on the heart, decreases myocardial Chest pain will be relieved or controlled to oxygen demand, increases coronary perfusion, patient’s satisfaction. decreases afterload, decreases preload, and helps to INTERVENTIONS RATIONALES limit infarct size if quickly initiated, improves car- Evaluate chest pain as to type, Variations may occur with diac output and tissue perfusion; used in location, severity, relief, change patients regarding speci- cardiogenic shock, for support post cardiac with activity or rest, other symp- fic complaints and beha- surgery, intractable chest pain, and in cardiac toms concurrenrly noted, such as vior. Most MI patients pallor, diaphoresis, radiation of look acutely ill and can catheterizations or other cardiovascular procedures pain, nausea, vomiting, shortness only focus on their pain. of high-risk patients of breath, and vital sign changes. Respirations may be increased as a result of anxiety and pain. Heart rate 16 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES may increase due to in- Administer calcium-channel bloc- These drugs can increase creased catecholamines, kers as ordered (such as verapa- coronary blood flow and stress, and pain, which can mil, diltiazem, or nifedipine). collateral circulation, also increase blood pres- reduce preload and myocar- sure. dial oxygen demands, which can decrease pain due to ischemia.

Obtain description of intensity Pain is a subjective ex- Maintain bedrest during pain, with Reduces oxygen consumption, using 0-10 scale, with 0 being perience and personal to position of comfort; nurse to stay and demand; alleviates fear no pain and 10 being the worst that patient. Intensity with patient during pain. and provides caring atmos- pain experienced. scales are useful to gauge phere. improvement or deterioration as perceived by the Maintain relaxing environment to Reduces competing stimuli patient. promote calmness. and reduces anxiety.

Obtain history (when possible) This provides information of previous cardiac pain and that may help to differen- Information, Instruction, familial history of cardiac tiate current pain from Demonstration problems. previous problems, as well as identify new problems and complications. INTERVENTIONS RATIONALES Instruct to notify nurse imme- Delay in notification can Administer oxygen by nasal cannula Supplemental oxygen can in- diately of any chest pain. delay pain relief and may or mask as indicated. crease the available oxygen require increased amounts and can relieve pain asso- of medication in order to ciated with myocardial is- finally achieve relief. chemia. Pain can cause further damage to an already- Administer analgesic as ordered, Morphine is the drug of injured myocardium, and such as morphine sulfate, meperi- choice to control MI pain, may signal extension of dine (Demerol), or Dilaudid IV. but other analgesics may MI, spasm, or other com- be used to reduce pain plication. and reduce the workload on the heart. IM injec- Instruct in relaxation tech- Helps to decrease pain and tions should be avoided niques, deep breathing, guided anxiety and provides dis- because they can alter imagery, visualization, etc. traction from pain. cardiac enzymes and are not absorbed well in tissue that is non- or Instruct in nitroglycerin SL ad- Knowledge facilitates co- under-perfused. ministration after hospitalization; operation and compliance 1 q5 minutes up to 3 times, and if with medical regimen. Pain Administer beta-blockers as or- These drug block sym- pain is unrelieved, patient should unrelieved with NTG may be dered (such as atenolol, pindolol, pathetic stimulation, re- seek emergency medical care. indicative of MI. and propranolol). duce heart rate and systolic blood pressure, and Instruct in activity alterations Decreases myocardial oxygen thus lowers the myocardid and limitations. demand and workload on the oxygen demand. Beta- heart. blockers should not be given in severely impaired Instruct in medication effects, Promores knowledge and com- contractility states due to side effects, contraindications, pliance with therapeutic the negative inotropic and symptoms to report. regimen. Alleviates fear properties. of unknown. CARDIOVASCULAR SYSTEM 17

Discharge or Maintenance INTERVENTIONS RATIONALES Evaluation Monitor vital signs. Provides information about the Obtain hemodynamic values, hernodynamics of the patient Patient will report pain being absent or noting deviations from base- and facilitates early intervention controlled with medication administration. line values. for problems.

Medication will be administered prior to pain Monitor EKG for disturbances Decreased cardiac perfusion may becoming severe. in conduction and for dysrhy- instigate conduction abnormali- thmias and treat as indicated. ties. Ventricular fibrillation Patient will be able to recall effects, side effects, is the most common dysrhythmia following MI. Reperfusion and contraindications of medications accurately. dysrhythmias may occur after the administration of thrombolytic Activity will be modified in such a way as to therapy. prevent onset of chest pain. Administer oxygen by nasal Provides oxygen necessary for Altered tissue pe+ion: cardiopulmonary, cannula as ordered, with rate tissues and organ perfusion. cerebral, peripheral dependent on disease process and condition. Related to: tissue ischemia, reduction or interruption of blood flow, vasoconstriction, hypovolemia, Auscultate lungs for crackles May indicate fluid overload (rales), rhonchi, or wheezes. that will further decrease tis- shunting, depressed ventricular function, sue perfusion. dysrhythmias, conduction defects Auscultate heart sounds for May indicate impending or pre- Defining characteristics: abnormal hemodynamic S3 or S4 gallop, new murmurs, sent heart failure. readings, dysrhythmias, decreased peripheral presence of jugular vein dis- pulses, cyanosis, decreased blood pressure, short- tention, or hepatojugular re- ness of breath, dyspnea, cold and clammy skin, flex. decreased mental alertness, changes in mental Monitor oxygen status with ABGs, Provides information about the status, oliguria, anuria, sluggish capillary refill, Sv02 monitoring, or with pulse oxygenation status of the pa- abnormal electrolyte and digoxin levels, hypoxia, oximetry. tient. Continuous monitoring of saturation levels provide an in- ABG changes, chest pain, ventilation perfusion stant analysis of how activity imbalances, changes in peripheral resistance, affects oxygenation and per- impaired oxygenation of myocardium, EKG fusion for the patient. changes (S-T segment, T wave, U wave), LV Monitor for changes in respi- Decreased cardiac perfusion may enlargement, palpitations ratory status, increased work result in pump failure and pre- of breathing, dyspnea, etc. cipitate respiratory distress and failure. Outcome Criteria Determine the presence and May indicate decreased perfusion Blood flow and perfusion to vital organs will be character of peripheral pulses, resulting from impaired coronary preserved and circulatory function will be maxi- capillary refill time, skin blood flow. color and temperature. mized. Patient will be free of dysrhythmias. Hemodynamic parameters will be within normal limits. 18 CRITICAL CARE NURSING CARE PLANS

Information, Instruction, INTERVENTIONS RATIONALES Demonstration Discourage any non-essential Ambulation, exercise, transfers, activity. and Valsalva-type maneuvers INTERVENTIONS RATIONALES can increase blood pressure and decrease tissue perfusion. Instruct on medications, dosage, Promotes compliance with effects, side effects, and con- regimen and knowledge base. Assist patient with planned, Allows for balance between rest traindications. graduated levels of activity. and activity to decrease myocardial workload and oxygen Instruct to refrain from smok- Smoking causes vasoconstriction demand. Gradual increases help ing. with can decrease perfusion. to increase patient tolerance to activity without pain. Instruct in dietary require- Reduction of high-cholesterol ments, menu planning, sodium and sodium foods will help to Titrate vasoactive drugs as Maintain blood pressure and restrictions, foods to avoid. control atherosclerosis, hyper- ordered. heart rate at parameters set by lipidemia, fluid retention, and MD for optimal perfusion with the effects on coronary blood minimal workload on heart. flow.

Administer thrombolytic drugs Drugs Iyse the clot that may be as ordered. occluding the coronary artery Discharge or Maintenance Evaluation and promote restoration of oxygen and blood flow to increase Lung fields will be clear and free of adventitious perfusion. breath sounds. Auscultate for bowel sounds and Decreased perfusion to mesen- monitor for complaints of nau- tery may result in loss or change Extremities will be warm and pink, with easily sea, vomiting, anorexia, abdo- in peristalsis, resulting in GI palpable pulses. minal distention, abdominal pain, use of analgesics, and change or constipation. in surroundings may contribute Vital signs and hemodynamic parameters will to changes in GI status. be within normal limits for patient. Oxygenation will be optimal as evidenced by Monitor urine output for ade- Decreased perfusion to renal pulse oximetry greater than 90%, SvOz greater quate amounts, character of arteries may result in oliguria. urine, presence of sediment, Dehydration secondary to than 75%, or normal ABGs. and specific gravity. nausea and vomiting may affect Patient will be free of chest pain and shortness renal perfusion. of breath. Monitor labwork such as renal May indicate organ dysfunction or liver profiles. and decreased perfusion. Patient will be able to verbalize information accurately regarding medications, diet and activity limitations. Decreased cardiac output

Related to: damaged myocardium, decreased contractility, dysrhythmias, conduction defects, alteration in preload, alteration in afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy CARDIOVASCULAR SYSTEM 19

Defining characteristics: elevated blood pressure, INTERVENTIONS RATIONALES elevated mean arterial pressure greater than 120 mmHg, elevated systemic vascular resistance Monitor for development of new Sg gallops are usually asso- Sg or S4 gallops. ciated with congestive heart greater than 1400 dyne-seconds/cm5, cardiac failure but can be found with output less than 4 L/min or cardiac index less mitral regurgitation and left than 2.7 L/min/m2, tachycardia, cold, pale ventricular overload after MI. S4 gallops can be associated extremities, absent or decreased peripheral pulses, with myocardial ischemia, ven- EKG changes, hypotension, S3 or S4 gallops, tricular rigidity, pulmonary decreased urinary output, diaphoresis, orthopnea, hypertension, or systemic hy- dyspnea, crackles (rales), jugular vein distention, pertension, which can decrease cardiac output. edema, chest pain Auscultate for presence of Indicates disturbances of normal murmurs andlor rubs. blood flow within the heart re- Outcome Criteria lated to incompetent valves, sepia1 defects, or papillary Vital signs and hemodynamic parameters will be muscle/chordae tendonae rup- within normal limits for patient, with no ture post-MI. Presence of a dysrhythmias noted. rub with an MI may be associated with pericarditis and/ INTERVENTIONS RATIONALES or pericardial effusions.

Auscultate apical pulses and Decreased contractility will be Observe lower extremities for Reduced venous return to the monitor heart rate and rhythm. compensated by tachycardia, es- edema, distended neck veins, heart can resulr in low cardiac Monitor BP in both arms. pecially concurrently with heart cold hands and feet, mottling, output; oliguria results from failure. Blood volume will be oliguria. Notify MD if urine decreased venous return due to lowered if blood pressure is output is < 30 cclhr. fluid retention. increased resulting in increased afterload. Pulse decreases may be noted in association with Position in semi-Fowler's Promotes easier breathing by toxic levels of digoxin. Hypo- position. allowing for chest expansion tension may occur as a result and prevents pooling of blood in of ventricular dysfunction and the pulmonary vasculature. poor perfusion of the myocardium. Administer cardiac glycosides, Used in the treatment of vaso- nitrates, vasodilators, diure- constriction and 10 reduce heart Monitor EKG for dysrhythmias. Conduction abnormalities may tics, and antihypertensives as rate and contractility, reduces and treat as indicated. occur due to ischemic myocar- ordered. blood pressure by relaxation of dium affecting the pumping venous and arterial smooth mus- efficiency of the heart. cle which then in turn increases cardiac output and decreases the Determine level of cardiac func- Additional disease states and workload on the heart. tion and existing cardiac and complications may place an other conditions. additional workload on an Titrate vasoactive drugs as Maintains blood pressure and already compromised heart. ordered per MD parameters. heart rate at levels to optimize cardiac output function. Measure CO and perform other Provides direct measurement hemodynamic calculations. of cardiac output function, Weigh every day. Weight gain may indicate fluid and calculated measurement retention and possible impend- of preload and afterload. ing congestive failure. 20 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS MTIONALES Arrange activities so as to Avoids fatiguing patient diac output by lessening not overwhelm patient. and decreasing cardiac output the workload placed on the further. Balancing rest with heart. activity minimizes energy expenditure and myocardial oxygen Instruct to report chest pain May indicate complications of demands by maintaining ade- immediately, decreased cardiac output. quate cardiac output. Instruct patientlfamily regard- Alleviates fear and promotes Avoid Valsalva-type maneuvers Increasing intra-abdominal pres- ing placement of pulmonary ar- knowledge. Pulmonary artery with straining, coughing or sure results in an abrupt de- tery catheter, and post- catheter necessary for direct moving. crease in cardiac output by procedure care. measurement of cardiac output preventing blood from being and for obtaining values for pumped into the thoracic cavity other hemodynamic measure- and thus, less blood being ments. pumped into the heart which then decreases the heart rate. Assist with insertion and main- Cardiac pacing may be necessary When the pressure is released, tenance of pacemaker when need- during the acute phase of MI or there is a sudden overload of ed. may be necessary as a permanent blood which then increases pre- measure if the MI severely load and the workload on the damages the conduction system. heart.

Provide small, easy to digest, Large meals increase the work- Discharge or Maintenance Evaluation meals and restrict caffeine. load on the heart by diverting blood flow to that area. Caf- feine directly stimulates the 0 Patient will have no chest pain or shortness of heart and increases heart rate. breath.

Have emergency equipment and Coronary occlusion, lethal dys- Vital signs and hemodynamic parameters will be medications availabIe at all rhythmias, infarction extensions within normal limits for age and disease condi- times. or intractable pain may preci- tion. pitate cardiac arrest that requires life support and resus- Minimal activity will be tolerated without citation. fatigue or dyspnea. Urinary output will be adequate. Information, Instruction, Demonstration Cardiac output will be adequate to ensure adequate perfusion of all body systems. INTERVENTIONS RATIONALES for volume excess Instruct on medications, dose, Promotes knowledge and Risk fluid effects, side effects, contra- compliance with regimen. Related to: increased sodium and water retention, indications, and avoidance of Prevents any adverse drug inter- over-the-counter drugs without actions. decreased organ perfusion MD approval. Defining characteristics: edema, weight gain, Instruct in activity limitations. Promotes compliance. Reduces intake greater than output, increased blood pres- Demonstrate exercises to be done. potential for decrease in car- sure, increased heart rate, shortness of breath, CARDIOVASCULAR SYSTEM 21

dyspnea, orthopnea, crackles (rales), oliguria, jugu- INTERVENTIONS RATIONALES lar vein distention, pleural effusion, specific Instruct patient in medications gravity changes, altered electrolyte levels Promotes knowledge and prescribed after discharge, with compliance with treatment dose, effect, side effects, con- regimen. Outcome Criteria traindications. Discharge or Maintenance Evaluation Blood pressure will be maintained within normal limits and edema will be absent or minimal in all Patient will have no edema or fluid excess. body parts. . Fluid balance will be maintained and blood INTERVENTIONS RATIONALES pressure will be within normal limits of Auscultate lungs for presence May indicate pulmonary edema baseline. of crackles (rales). from cardiac decompensation. . Lung fields will be clear, without adventitious Observe for jugular vein dis- May indicate impending conges- breath sounds, and weight will be stable. tention and dependent edema. tive failure and fluid excess. Patient will be able to verbalize understanding Renal perfusion is impaired with Determine fluid balance by of dietary restrictions and medications. measuring intake and output, decreased cardiac output, which and observing for decreases in leads to sodium and water reten- Anxiety output and concentrated urine. tion and oliguria. Related to: change in health status, fear of death, Weigh daily and notify MD of Abrupt changes in weight usually greater than 2 Ib/day increase. indicate excess fluid. threat to body image, threat to role functioning, pain Provide patient with fluid in- Fluids provide hydration of tis- take of 2 L/day, unless fluid sues. Fluids may need to be Defining characteristics: restlessness, insomnia, restricrion is warranted. restricted due to cardiac decom- anorexia, increased respirations, increased heart pensation. rate, increased blood pressure, difficulty concentrating, dry mouth, poor eye contact, decreased Administer diuretics as ordered Drugs may be necessary to cor- energy, irritability, crying, feelings of helplessness (furosemide, hydralazine, spiro- rect fluid overload depending lactone, hydrochlorothiazide). on emergent nature of problem. Outcome Criteria Monitor electrolyte for imbal- Hypokalemia can occur with the ances. administration of diuretics. Patient will be able to use coping mechanisms effectively, will appear less anxious, and be able to Instruction, Information, verbalize feelings. Demonstration INTERvENTf ONS RATIONALES Identify patient’s perception Patient may be afraid of dying INTERVENTIONS RATIONALES of illness or situation. En- and be anxious about his imme- Instruct patient regarding diet- Fluid retention is increased courage expressions of anger, diate problem as related to his ary restrictions of sodium. with intake of sodium. grief, sadness, fear, and loss. lifestyle and the problems that have been left unattended. Instruct patient to observe for Weight gain may be first overt weight changes and report these sign of fluid excess and should Explain all procedures to pa- Knowledge reduces fear of the to MD. be monitored to prevent compli- tient in concise and reassur- unknown. Establishes feelings cations. ing manner. Repeat information of trust and concern. Informa- 22 CRITICAL CAFE NURSING CARE PLANS

INTERVENTIONS RATIONALES Information, Instruction, Demonstration as needed based on patient’s tion may need to be repeated or ability to comprehend. reintbrced due to competing stimuli. INTERVENTIONS RATIONALES Instruct patient and family Accurate information reduces as to all procedures, tests, anxiety, facilitates the rela- Encourage the patient to dis- Assists the patient in verba- medications, and care in a tionship between patient and cuss his fears and feelings. lizing concerns and provides the factual consistent manner. nurse, and allows the patienr Provide an atmosphere of accep- opportunity to deal with matters Reinforce as needed. and family to deal with the tance without judgment. Accept of import to the patient. Ac- problem in a realistic manner. his use of denial, but do not cepting the patient’s feelings Repetition, when needed, helps reinforce false beliefs. Avoid may decrease his anxiety which in the retention of information confrontations and upsets. can facilitate a therapeutic when the attention span is di- environment for instruction. minished. Denial can be useful to decrease anxiety but can postpone dealing Instruct patient in relaxa- Reduces anxiety and stress. with the reality of the problem. tion techniques. Provide for Confrontations can lead to anger diversionary activities. and exacerbate the use of denial and decrease cooperation. Instruct about post-discharge Reduces anxiety and promores care, activities, limitations, increased independence and self- Provide opportunities for the Familiar people can decrease symptoms to report, problems confidence; decreases fear of family to visit and assist with anxiety of the patient, as that might be encountered, and abandonment that can occur care if possible. Orient to well as provide a more con- goals. with discharge from hospital; routines. ducive atmosphere for learn- assists patient and family to ing and recovery. Predicta- identi+ realisric goals and bility can decrease anxiety. decreases the chances of discour- Supportive family members agemenr with limitations during can comfort the patient and recuperation. relieve worries.

Provide private time for pa- Allows time for expression Discharge or Maintenance Evaluation tient and family member(s) of concerns and feelings, and ro verbalize feelings. relieves tension by establishing a more normal routine. Patient is able to recognize feelings and identify mechanisms to cope and identify causes. Provide opportunities for pa- Allows the patient to have some tient to control his environ- control over his situation and Patient has significant reduction in fear and ment and activities as much as facilitates compliance with care anxiety and appears less tense, with normal vital feasible based on condition. of which patient is not in con- signs. trol. Patiendfamily can appropriately utilize Provide opportunity for patient Facilitates coping mechanism to rest withour interruption as by conserving energy, and by problem-solving skills. much possible. providing required rest. as Patient can verbalize concerns easily and has Adminisrer antianxiety drugs as Promotes rest and reduces anxi- increased energy. ordered (diazepam, flurazepam, ety. lorazepam). Patient can make appropriate decisions based on factual information regarding his condition and is able to discuss future plans. CARDIOVASCULAR SYSTEM 23

Knowledge Wcit INTERVENTIONS RATIONALES Related to: lack of understanding, lack of under- Instruct in dietary needs and Patient may need to increase restrictions, such as limiting dietary potassium if placed on standing of medical condition, lack of recall caffeine and sodium or in- diuretics; caffeine should be Defining characteristics: verbalized questions creasing potassium, etc. limited due to the direct stimu- lant effect on the heart; so- regarding problems, inadequate follow-up on dium should be limited due to instructions given, misconceptions, lack of the potential for fluid reten- improvement of previous regimen, development tion. of preventable complications Provide printed materials when Provides references for patient possible for patientlfamily to and family to refer to once dis- review. charged, and can enhance the Outcome Criteria understanding of verbally- given instructions. Patient will be able to verbalize and demonstrate understanding of information given regarding Demonstrate and instruct on Self-monitoring promotes self- condition, medications, and treatment regimen. technique for checking pulse independence and can provide rate and regularity Instruct timely intervention for abnor- in situations where immediate malities or complications. Information, Instruction, action must be taken. Heart rates that exceed set parameters may require furrher Demonstration medial alteration in medications or regimen. INTERVENTIONS RATIONALES Determine patient’s baseline of Provides information regarding Have patient demonstrate all Provides information that knowledge regarding disease pro- patient$ understanding of skills that will be necessary patient has gained a full cess, normal physiology, and condition as well as a baseline for post-discharge. understanding of instruction function of the heart. from which to base teaching. and is able to demonstrate correct information.

Monitor patient’s readiness to Promotes optimal learning en- Instructldemonstrate exercises Exercise programs are help- learn and determine best methods vironment when patient shows to be performed, avoiding over- ful in improving cardiac to use for teaching. Attempt willingness to learn. Family taxing activities, signs/ function. to incorporate family members members may assist with help- symptoms that may require the in learning process. Rein- ing the patient to make in- cessation of any activity, structlreinforce information as formed choices regarding his and to report symptoms that needed. treatment. Anxiety or latge may require medical attention. volumes of instruction may impede comprehension and limit learning. Discharge or Maintenance Evaluation

Provide time for individual in- Promotes relationship between Patient will be able to verbalize understanding teraction with patient. patient and nurse, and estab- condition, treatment regimen, and blishes trus:. of signs/symptoms to report. Instruct patient on procedures Provides knowledge and pro- that may be performed. motes the ability to make Patient will be able to correctly perform all informed choices. tasks prior to discharge.

Instruct patient on medications, Provides information to :he Patient will be able to verbalize understanding dose, effects, side effects, con- patient to manage medication of cardiac disease, risk factors, dietary traindications, and signs/ regimen and ensure compliance. restrictions, and lifestyle adaptations. symptoms to report to MD. 24 CRITICAL CARE NURSING CARE PLANS

MYOCARDZAL INFARCTION (MI)

Endothelial cells in intimal layer Vasoconstriction occurs of artery are injured s J, Permeability to lipoproteins increase 4 Platelets and fibrin aggregate at injury site Platelet-fibrin thrombus form J, Macrophages aggregate Coronary artery spasm occurs 4 s Lipoproteins enter smooth muscle cells of intima and create a fatty plaque s Plaque ruptures and fatty thrombus or clot forms ...... c J, Progressive narrowing of vessel occurs s Partial or complete obstruction of coronary artery(s) occur J, Blood flow decreases Oxygen supply decreases s Coronary insufficiency s Coronary ischemia J, Myocardial necrosis = Myocardial infarction

COMPLICATIONS RESULTING FROM MI THAT MAY LEAD TO DEATH IF NOT TREATED: Congestive heart failure Dysrhythmias Conduction problems Cardiogenic shock Systemic embolus Pulmonary embolus Papillary muscle rupture Dressler’s syndrome Ventricular rupture Ventricular septal defects CARDIOVASCULAR SYSTEM 25

The main symptoms of pericarditis include sharp, Per Scar dit is retrosternal and/or left precordial pain that worsens while in a supine position, and a pericardial Pericarditis is an inflammation of the pericardium friction rub best auscultated at the lower left ster- that can occur due to a variety of circumstances. nal border. The pain may be exacerbated by The inflammation is usually a manifestation of coughing, swallowing, breathing, or twisting. another disease process, but may be drug induced, Other symptoms may be seen depending on the from agents such as procainamide, hydralazine, severity of the pericarditis and the rapidity in phenytoin, penicillin, phenylbutazone, minoxidil, which the fluid accumulates. Volumes of 100 cc or daunorubicin. Other causes for pericarditis that accumulates quickly may produce a more include idiopathic causes, viral, bacterial, fungal, life-threatening complication, cardiac tamponade, protozoal, uremia, MI, tuberculosis, neoplasms, than a larger accumulation of fluid that is gener- trauma, surgical procedures, autoimmune disor- ated over a long period of time. ders (lupus, rheumatoid arthritis, scleroderma), inflammatory disorders (amyloidosis), dissecting MEDICAL CARE aortic aneurysms, or radiation treatments to the Oxygen: to increase available oxygen supply thorax. Analgesics: morphine or meperidine used to alle- Pericarditis may be classified as acute or chronic, viate pain as well as constrictive or restrictive. Constrictive pericarditis occurs when fibrin material is Steroids: large doses of corticosteroids, such as deposited on the pericardium and adhesions form prednisone, are given to reduce inflammation and between the epicardium and pericardium. control the symptoms of pericarditis Restrictive pericarditis results when effusion into NSAIDs: aspirin or indomethacin are used to the pericardial sac occurs. Both types cause inter- reduce fever and inflammation ference with the heart’s ability to fill properly, which causes increases in systemic and pulmonary IV fluids: given to help restore left ventricular fill- venous pressures. Eventually systemic blood pres- ing volume and to offset any compressive effects sure and cardiac output decrease. of intrapericardial pressure increases The visceral pericardium is a serous membrane Inotropic drugs: isoproterenol or dobutamine IV that is separated from a fibrous sac, or parietal given for their positive inotropic effects as well as pericardium, by a small (less than 50 cc) amount peripheral vasodilating properties of fluid. If the fluid increases to the point where Laboratory: white blood cell count may be the heart function is compromised, pleural effu- elevated, sed rate may be elevated from non-spe- sion occurs and cardiac tamponade becomes a cific inflammatory response; CKMB may be critical concern. The pericardium is important mildly elevated; blood cultures done to identify because it holds the heart in a fixed position to organism responsible for infective process and to minimize friction between it and other structures. ascertain appropriate drug for eradication; renal Other functions include prevention of exercise- or profile done to evaluate for uremic pericarditis hypervolemic-induced dilatation of the cardiac and worsening renal status chambers and assistance with atrial filling during systole. 26 CRITICAL CARE NURSING CARE PLANS

Electrocardiography: used to monitor for S-T ele- imbalances, changes in peripheral resistance, vation, T wave changes associated with impaired oxygenation of myocardium, EKG pericarditis, and to monitor for dysrhythmias changes (S-T segment, T wave, U wave), LV Echocardiography: used to establish presence of enlargement, palpitations, abnormal renal function pericardial fluid and an estimate of volume, any studies vegetation on valves, and to observe for right atrium and right ventricular dilatation Outcome Criteria

Chest x-ray: used to show cardiomegaly and to Blood flow and perfusion to vital organs will be assess lung fields preserved and circulatory function will be Pericardiocentesis: used to relieve fluid build-up maximized. and pressure in emergency situations where the Patient will be free of dysrhythmias. patient is deteriorating or is in shock Hemodynamic parameters will be within normal Surgery: open surgical drainage is usually the limits. treatment of choice for cardiac tamponade INTERVENTIONS RATIONALES Obtain vital signs. Provides information about the NURSING CARE PLANS Obtain hemodynamic values, hemodynamics of the patient. Alterution in comfort noting deviations from base- [See MI] line values. Determine the presence and May indicate decreased perfusion Related to: chest pain due to pericardial inflam- character of peripheral pulses, resulting from impaired coronary mation capillary refill time, skin blood flow. color and temperature. Defining characteristics: chest pain with or without radiation, facial grimacing, clutching of hands Discourage any non-essential Ambulation, exercise, transfers, or chest, restlessness, diaphoresis, changes in pulse activity. and Valsalva-type maneuvers can increase blood pressure and de- and blood pressure, dyspnea crease tissue perfusion.

Altered tissue perfision: curdiopulmonury, Monitor EKG for disturbances Decreased cardiac perfusion may renal, peripherul, cerebrul in conduction and for dysrhy- instigate conduction abnormali- thrnias and treat as indicated. ties. Dysrhythmias may occur Related to: tissue ischemia, reduction or interrup- due to compromised function of tion of blood flow, vasoconstriction, hypovolemia, ventricles due to pressure exer- shunting, depressed ventricular function, ted on them by excess fluid. dysrhythmias, conduction defects Titrate vasoactive drugs as Maintain blood pressure and Defining characteristics: abnormal hemodynamic ordered. heart rate at parameters set by MD for optimal perfusion with readings, dysrhythmias, decreased peripheral minimal workload on heart. pulses, cyanosis, decreased blood pressure, shortness of breath, dyspnea, cold and clammy skin, Administer oxygen by nasal Provides oxygen necessary for cannula as ordered, with rate tissues and organ perfusion. decreased mental alertness and changes in mental dependent on disease process status, oliguria, anuria, sluggish capillary refill, and condition. abnormal electrolyte and digoxin levels, hypoxia, ABG changes, chest pain, ventilation perfusion CARDIOVASCULAR SYSTEM 27

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Auscultate lungs for crackles Suggestive of fluid overload Lung fields will be clear and free of adventitious (rales), rhonchi, or wheezes. that will further decrease tissue perfusion. breath sounds. Extremities will be warm, pink, with easily pal- Auscultate heart sounds for Suggestive of impending or Sg or S4 gallop, new murmurs, present heart failure. pable pulses of equal character. presence of jugular vein distention, or hepatojugular re- Vital signs and hemodynamic parameters will flex. be within normal limits for patient.

Monitor oxygen status with ABGs, Provides information about the Oxygenation will be optimal as evidenced by SvO, monitoring, or with pulse oxygenation status of the pa- pulse oximetry greater than 90%, Sv02 greater oximetry. tient. Continuous monitoring of than or normal saturation levels provide an in- 75%, ABGs. stant analysis of how activity Patient will be free of chest pain and shortness can affect oxygenation and perfusion. of breath. Patient will be able to verbalize information cor- Assist patient with planned, Allows for balance between rest graduated levels of activity. and activity to decrease myocar- rectly regarding medications, diet and activity dial workload and oxygen limitations. demand. Gradual increases help to increase patient tolerance to Decreased cardiac output activity without pain occurring. [See MI] Related to: fluid in pericardial sac from pericardial Information, Instruction, effusion, potential for cardiac tamponade because Demonstration of effusion, damaged myocardium, decreased contractility, dysrhythmias, conduction defects, INTERVENTIONS RATIONALES alteration in preload, alteration in afterload, vaso- Instruct on medications, dosage, Promotes compliance with regi- constriction, myocardial ischemia, ventricular effects, side effects, and con- men and knowledge base. traindications. hypertrophy Defining characteristics: decreased blood pressure, Instruct to refrain from smok- Smoking causes vasoconstriction tachycardia, pulsus paradoxus greater than 10 ing. with can decrease perfusion. mmHg, distended neck veins, increased central venous pressure, dysrhythmias, decreased QRS Instruct in dietary require- Reduction of high-cholesterol ments, menu planning, sodium and sodium foods will help to voltage or electrical alternans, diminished heart restrictions, foods to avoid. control atherosclerosis, hyper- sounds, dyspnea, friction rub, cardiac output less lipidemia, fluid retention, and than 4 L/min, cardiac index less than 2.5 the effects on coronary blood flow. L/min/m’ Anxiety [See MI] Related to: change in health status, fear of death, threat to body image, threat to role functioning, pain 28 CRITICAL CARE NURSING CARE PLANS

Defining characteristics: restlessness, insomnia, anorexia, increased respirations, increased heart rate, increased blood pressure, difficulty concentrating, dry mouth, poor eye contact, decreased energy, irritability, crying, feelings of helplessness Knowledge &+&it [See MI] Related to: lack of understanding, lack of understanding of medical condition, lack of recall Defining characteristics: questions regarding problems, inadequate follow-up on instructions given, misconceptions, lack of improvement of previous regimen, development of preventable complications CARDIOVASCULAR SYSTEM 29

PERICARDITIS

Inflammation c Infiltration of neutrophils c Increased pericardial vascularity 4 Increased deposits of fibrin c Fibrinous adhesions form between pericardium and epicarium e Fluid accumulates in pericardial sac c Pericardial effusion c Heart function restricted J, Cardiac output decreased c Pressures in heart equalize c Cardiogenic shock occurs c Death This Page Intentionally Left Blank CARDIOVASCULAR SYSTEM 31

(NBTE). After this stage, the heart is then set up for vegetation to colonize from bacteria from other areas of the body during transient episodes of bac- Bacterial endocarditis is now referred to as infec- teremia. As these organisms grow, more platelets tive endocarditis due to the presence of other and fibrin adhere and eventually valves are organisms besides bacteria being the causative destroyed, vegetation breaks off and embolizes to agent. It is an infection of the cardiac valves and other areas of the body, and a systemic immune inner lining of the heart that is characterized as a response occurs. systemic illness. Endocarditis may be misdiagnosed Patients who are at risk for endocarditis include as other infections in the early stages if signs and those with rheumatic heart disease, open-heart symptoms of cardiac involvement are not present, surgery, congenital heart defects, prosthetic valve Common complaints range from fever with tem- replacements, dental procedures, gynecological perature less than 102 degrees, chills, arthralgia, surgery or procedures, genitourinary surgery or lethargy, and anorexia. Acute endocarditis may procedures, invasive tests or lines, infected periph- result in death within a matter of hours if not eral or central venous lines, IUDs, AV shunts or treated. Antimicrobial therapy can decrease mor- fistulas, skin abnormalities in preexisting cardiac tality to 15%, but heart failure secondary to disease, immunosuppressive therapy, and IV drug valvular scarring and damage can occur after the use. infection is resolved. Patients who have had prosthetic valves placed and Almost any organism can cause endocarditis but who develop endocarditis are divided into early the most common ones noted have been (occurring less than two months postoperatively) Streptococcus viridans, Staphylococcus aureus, and late (occurring greater than two months post- Enterococci, Staphylococcus epidermidis, operatively) classes, and develop chills, fever, Streptococcus pneumoniae, Pseudornonas aerugi- leukocytosis, and/or a new murmur. Mortality is nosa, Candida albicans, and Aspergillus fumigatus. higher in early prosthetic valve endocarditis and is Endocarditis may be subdivided into the acute and a serious problem. subacute classes, depending on the virulence of the organism involved and the length of duration. MEDICAL CARE Acute infective endocarditis (AIE) has less than Antibiotics: penicillin is the treatment of choice for one month duration whereas subacute infective Streptococcus viridans, with cephalothin or endocarditis (SIE) is usually greater than one vancomycin being alternate choices; penicillin plus month in duration, SIE usually involves congeni- gentamicin is the treatment of choice for tally-deformed or damaged heart valves, and AIE Steptococcus faecalis; synthetic penicillins, such as usually involves normal heart valves. Trauma in oxacillin or nafcillin, cephalothin and/or gentam- many forms can occur to the epithelia1 layer of the icin are used in Staphylococcus epidermidis valves/endocardium causing injury and deposits of platelets and fibrin to adhere to this surface. This Laboratory: a series of blood cultures is done to is known as nonbacterial thrombotic endocarditis isolate the causative organism and sensitivity to antimicrobial agents; CBC is used to assess for anemia that may occur in up to 70% of patients, 32 CRITICAL CARE NURSING CARE PLANS

to monitor leukocyte levels, and to assess platelet areas, hematuria, oliguria, anuria, chest pain, short- counts; sedimentation rates may increase; immune ness of breath, dyspnea, confusion, weakness, titers show antigen-antibody response convulsions, coma, hemiplegia, aphasia, hemiparesis, cardiac tamponade, pericardial friction rub, Electrocardiography: shows alterations in conduc- murmur, dysrhythmias, conduction defects, cold tion, dysrhythmias, ischemia clammy skin, cyanosis, mental status changes, Echocardiography: used to establish diagnosis, to hypotension, tachycardia, decreased urinary output, determine underlying cardiac disease, to estimate increased BUN myocardial contractility, and demonstrate early mitral valve closure and aortic insufficiency Outcome Criteria

Nuclear cardiologic testing: Technetium-99 scans Patient will achieve and maintain adequate tissue to and gallium-67 imaging used evaluate the perfusion to all body systems. extent of the infective process and to evaluate potential as a surgical candidate INTERVENTIONS RATIONALES Determine mental status and Symptoms may indicate emboliza- Surgery: valve replacement is necessary if patient level of consciousness. Observe tion to cerebrum which may re- develops intractable congestive heart failure with for hemiparesis, paralysis, apha- quire emergency treatment. hemodynamic compromise, persistent bacteremia sia, convulsions, visual field de- despite antimicrobial treatment, prosthetic valve fects, or coma, and notify MD. endocarditis, major systemic emboli, gram negative Monitor EKG for conduction ab- Due to the close proximity of or fungal infection; drainage of abscesses or normalities, especially prolonged aortic valve cusps to the con- empyema; repair of peripheral or cerebral mycotic PR interval, new left bundle duction system, bacterial in- branch block, new right bundle vasion and proliferation may aneurysms branch block with or without left extend the infection process Prophylaxis: prophylactic antibiotic therapy must anterior hemiblo&. Treat as in- into the myocardium and cause dicated per protocol. dysrhythmias. Extension of be prescribed prior to dental procedures, urethral the infection from the mitral or gynecological procedures, or surgery valve to the Bundle of His and AV node may result in junctional tachycardia, Mobitz I, second NURSING CARE PLANS degree or third degree AV blocks. Risk for altered tissue pe@ion: cardiopulmonary, cerebral, renal, gastrointestinal, Observe for sudden shortness of Arterial emboli may affect the and peripheral breath, tachypnea, pleurisy-type heart and other vital organs. pain, pallor or cyanosis. Venous congestion may result Related to: valvular vegetation emboli, platelet- in thrombus formation in deep fibrin emboli, and immunologic responses causing veins and cause embolization to lungs, or embolization of allergic vasculitis; embolu vegetation thrombi may result in pulmonary embolus. Defining characteristics: petechiae, arthritis, arthralgia, myalgias, decreased peripheral pulses, Evaluate chest pain, tachycar- Arterial emboli may affect the Janeway’s lesions, Roth‘s spots, Osler’s nodes, lower dia, decreased blood pressure. heart and cause myocardial infarction. New murmurs may back pain, splinter hemorrhages to subungual Auscultate heart sounds for new CARDIOVASCULAR SYSTEM 33

INTERVENTIONS RATIONALES or changed murmurs, pericardial occur as a result of valve scarring INTERVENTIONS RATIONALES friction rubs, or abnormal lung and distortion, valve aneurysm, sounds (crackles, rales). septal rupture, papillary muscle 1-10 mm in diameter, red with rupture, or myocardial abscess white centers, overtly rupture. Rupture into the pericar- tender, and are usually a late dial sac can cause cardiac tarn- sign of endocarditis, ponade, in which heart tones will typically found in subacute endo- be muffled. Pericardial friction carditis infections. Jane- rubs may indicate pericarditis. way’s lesions are non-tender Abnormal lung sounds may reddened or pink macular lesions, indicate impending congestive 1-5 mm in diameter, and usually heart failure. change to tan and fade within 2 weeks. These are usually an Observe extremities for swelling, Bedrest promotes venous stasis early sign of endocarditis. erythema, tenderness, pain, pos- which can increase the risk of itive Homans’ sign, positive thromboembolus formation. Ac- Evaluate complaints of arthri- Occur in endocarditis due to Pratt’s sign. Observe for de- tual vegetation emboli can mi- tis, arthralgia, and severe lower localized immune responses creased peripheral pulses, pal- grate and occlude peripheral back pain. Medicate as needed. or in decreased perfusion. lor, coldness, cyanosis. arteries, leading to tissue ischemia and necrosis. Monitor blood culture and sen- Usually 3-6 blood cultures are Monitor for complaints of ab- May indicate embolization to sitivity reports. done in a series ro assess for dominal pain to lek upper abdo- spleen. Vegetative emboli may sustained bacteremia because men with radiation ro left occlude mesenteric artery and bacteria are continually re- shoulder, abdominal rigidity, cause bowel infarction. Spleno- leased into the system in endo- tenderness, nausea, or vomiting. megaly may be caused by anti- carditis. The series prevents gen stimulation and allergic the possibility of false read- vasculitis. ings. Cultures determine the specific organism responsible Observe urine for hematuria, Allergic vasculitis from endo- for the bacteremia, and sensi- oliguria, anuria, complaints of carditis can result in focal, tivity results enable the choice flank or back pain. acute, or chronic glomerulo- of antimicrobials to be suited nephritis and progress to renal to the specific infection. insufficiency, renal failure, and uremia. Administer antimicrobials Antibiotics should not be start- as ordered. ed until culture series is com- Observe for petechiae on mucous Petechiae is one of the classic pleted in subacute IE, but with membranes, conjunctiva, neck, symptoms of endocarditis as a acute IE, empiric antibiotics are wrists, and ankles. Observe for result of allergic vasculitis. given until cultures are available. splinter hemorrhages in subungu- Petechiae are usually 1-2 mm in In some instances, early negative results may indicate only that the al areas, Osler’s nodes to distal diameter, flat, red with white fingers and toes, sides of fin- or gray centers, non-tender, and culture could not be grown due to gers, palms or thighs, and for groups fade within a few days. low levels of bacteria or an Janeway’s lesions to the palms, Petechiae may be noted in other unusual organism being present. soles of feet, arms and legs. diagnoses and they should be Obtaining cultures after anribi- ruled our. Hemorrhages to the otics have been started do not give subungual areas may be seen in accurate information. early infective endocarditis but may be seen in trauma, with hemo- or peritoneal dialysis, or in mitral stenosis. Osler‘s nodes are nodules that range from 34 CRITICAL CARE NURSING CARE PLANS

Instruction, Information, Hyperthermia Demonstration

- ~ ~~~ ~ Related to: bacteremia, allergic vasculitis, arterial INTERVENTIONS RATIONALES occlusion/infarction, abscess Instruct patient in signs/ Promotes knowledge and cornpli- Defining characteristics: body temperature greater symptoms to report to MD. ance with regimen. than normal range, flushed warm skin, chills, increased heart rate, increased respiratory rate Discharge or Maintenance Evaluation Outcome Criteria Patient will have adequate tissue perfusion to all body systems. Patient will maintain body temperature within Patient will be mentally lucid, with no confusion normal limits and be free of infection. or neurological deficits. INTERVENTIONS RATIONALES Patient will have adequate urinary output with Monitor temperature every 2-4 Endocarditis usually results hours and prn. Observe for in temperatures less than 102 no hematuria, and renal function studies will be chills and diaphoresis. degrees; temperatures grearer within normal limits. than this indicate an acute infective process. Chills Patient will be able to recall accurately the infor- frequently precede a tempera- mation instructed. ture spike.

Decreased cardiac output Monitor environment tempera- Room temperature may be al- [See MI] ture and limit or add blankets tered to assist with main- as warranted. Change linens as tenance of normal body tem- Related to: complications with infected heart needed. perature. valves, potential for cardiac tamponade because of Monitor I&O; provide adequate Diaphoresis and increased meta- effusion, damaged myocardium, decreased contrac- fluids. bolic rate from temperature tility, dysrhythmias, conduction defects, alteration elevations increase fluid loss in preload, alteration in afterload, vasoconstriction, and may cause dehydration. myocardial ischemia, ventricular hypertrophy Give tepid sponge baths prn. May assist in lowering tempera- Defining characteristics: decreased blood pressure, ture by means of evaporation. Using cooler water or alcohol tachycardia, pulsus paradoxus greater than 10 may cause chilling and thus mmHg, distended neck veins, increased central increase body temperature. venous pressure, dysrhythmias, decreased QRS Place on cooling blanket as voltage or electrical alternans, diminished heart Cooling blankets are usually warranted. only used for severe fever sounds, dyspnea, friction rub, cardiac output less greater than 104 degrees when than 5 L/min, cardiac index less than 2.5 risk of brain damage or seizures L/min/m2, change in mental status, change or new is imminent. cardiac murmur, arterial emboli, decreased urine Administer antipyretic medi- Reduces fever by action on the output, cyanosis, cold clammy skin cations as warranted. hypothalamus. Low grade ternp- eratures may be beneficial to the body’s immune system and ability to retard the growth of organisms. CARDIOVASCULAR SYSTEM 35

Information, Instruction, Outcome Criteria Demonstration Patient will be free of infection, afebrile, with no INTEKVENTIONS RATIONALES over symptoms of infection or infective process Instruct on procedures for de- Provides knowledge and reduces noted. creasing temperature. kar and enhances compliance. INTERVENTIONS RATIONALES Instruct to take temperature Temperature elevations indicate Monitor temperature trends. Decreases in body temperature frequently and to notify MD for infection and prompt notifica- below 9G degrees may indicate elevations immediately. tion will allow for prompt advanced shod states and 1s treatment. a critical indicator of decreased tissue perfusion and Instruct on medications, effects, Promotes knowledge and compli- lack of the body’s ability side effects, contraindications, ance. to muster enough defense to symptoms to report. raise the temperature. Tem- peratures greater than 10 1 degrees are due to the effect Discharge or Maintenance Evaluation of endotoxins on the hypo- thdamus and of pyrogen- Patient will be normothermic with no overt released endorphins. signs/symptoms of infection. Monitor for signs/symptoms of May indicate ineffective anti- Risk for infiction deterioration of patient and biotic therapy or abundance of failure to improve within a resistant organisms. Related to: inhibition of antibodies due to timely manner. immunological system action, inflammatory Observe mouth for patches of Thrush or yeast infections may processes due to vegetation growth, predisposition white plaque and perineal occur as a secondary infection to bacteremia, septic emboli, myocardial abscess, areas for vaginal drainage or when normal flora is killed by occlusion of arteries leading to necrosis of body itching, and notify MD. massive antibiotic therapy. systems, invasive procedures and lines, dental pro- Inspect wounds, IV sites, cath- May indicate local secondary cedures, nosocomial infections, lack of recognition eter sites, invasive devices and infection or inflammation. of infection, lack of prophylactic treatment, sup- lines, changes in drainage or .A. body fluids. rainfection Reduces the risk of opportun- Defining characteristics: elevated temperature, ele- Maintain aseptic or sterile technique as warranted. istic infection and chances of vated WBC count, positive blood cultures, cross-contamination. reddened, draining IV sites Obtain urine, blood, sputum, Assists with identification of wound, and invasive Iindcathe- source of infection, causative ter specimens for culture and organism, and antibiotic of sensitiviry and Gram stain as choice to enable prompt and warranred. effective treatment.

Reposition patient every 2 Frequent changes in position hours; encourage coughing and and breathing exercises en- deep breathing. hance pulmonary toilet and may help to prevent pneumonia. 36 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation Administer antibiotics as or- Antibiotics may be started dered. prior to receiving final culture reports based on the likelihood Patient will have normal temperature and vital of the infective organism. Spe- signs. cific antibiotics are determined by the culture information. Patient will exhibit no overt symptoms or signs of infection.

Information, Instruction, 0 Patient will be able to recall instructions accu- Demonstration rately.

INTERVENTIONS RATIONALES Patient will seek prophylactic antibiotic therapy prior to any procedure and will have no Instruct patient to cover mouth Prevents spread of infection and nose during coughing/sneezing. from airborne organisms. Good evidence of reinfection. Instruct in handwashing and dis- handwashing reduces spread of posal of contaminated materials. infection. Infection control Anxiety procedures limit contamination [See MI] and spread of infective materials. Related to: change in health status, fear of death, threat to body image, threat to role functioning, Instruct patient in good dental Avoids trauma to gums which pain hygiene to use soft tooth- may promote reinfection. brush; to avoid water pik Water pik and toothpi& may Defining characteristics: restlessness, insomnia, and toothpicks; to obtain cause bleeding and promote regular dental exams. infection. anorexia, increased respirations, increased heart rate, increased blood pressure, difficulty concen- Instruct patient to take tempera- Temperature elevations may trating, dry mouth, poor eye contact, decreased ture every day for 1 month post indicate infeaion/reinfec- discharge. tion. energy, irritability, crying, feelings of helplessness Knowledge dejcit Prepare patient for surgery as Surgery may be required to warranted. remove necrotic tissue or limbs [See MI] and to remove purulent material in order to enhance healing. Related to: lack of understanding, lack of under- Surgery may be required to re- standing of medical condition, lack of recall place damaged heart valves due to vegetative infection. Defining characteristics: questions regarding problems, inadequate follow-up on instructions Instruct patient in obtaining Prophylaxis will be required given, misconceptions, lack of improvement of prophylactic antibiotic therapy for any invasive procedure due prior to procedures. to likelihood of reinfection. previous regimen, development of preventable complications CARDIOVASCULAR SYSTEM 37

INFECTIVE ENDOCARDITIS

Trauma to valves predispose epithelia1 surface to injury (valvular insufficiency, ventricular septal defects, artificial valves, and indwelling catheters and lines) c Platelets and fibrin deposit c Microscopic platelet-fibrin thrombi (known as NBTE-nonbacterial thrombotic endocarditis)

J, Bacteria lodge on endocardiumlvalves c Bacteria increase Platelets, fibrin, RBCs, and PMN leukocytes deposited c Vegetations formed 7c I Vegetations embolize Valvular tissue deformed Inflammation adjacent to vegetation J, 4 c Arteries occlude Valves incompetent Immunologic antibodies inhibit PMNs c Humoral immunity system stimulated CHF Cellular immunity system decreased e J Ruptured perforated cusps Hypergammaglobulinemia

J, J, Myocardial abscess Cryoglobulins increase e Hypersensitivity reaction Rupture to pericardial sac c c Allergic vasculitis Pericarditis c 4 Petechiae Tamponade Arthritis Mydgias Janeway's lesions Roth's spots Osler's nodes I c c J, J, e c Cerebral Cardiac Pulmonay s;L La Perbheral TIA Myocardial ischemia Pulmonary embolus Bowel infarction Renal infarction Claudication to extremities CVA Myocardial infarction Dyspnea Mesentery infarct Glomerulonephritis Arterial insufficiency Mycoric cerebral Anysm. CHF Splenic infarction Renal insufficiency Pain Confusion Pericarditis Radiating pain Renal failure Pulselessness Weakness Cardiac tamponade Fever Flank pain Cyanosis Mental changes Chest pain Abdominal pain Hematuria Pallor Hemiparesis Radiating pain Oliguria Mottling Hemiplegia Nausea, vomiting Azotemia Aphasia Sweating, diaphoresis Albuminuria Convulsions Dyspnea Coma This Page Intentionally Left Blank CARDIOVASCULAR SYSTEM 39

lems. The mean arterial pressure, or MAP (or Hypertension MABP) is the average pressure attempting to push the blood through the circulatory system and Essential hypertension, which is an elevated blood pressure of unknown origin, and secondary hyper- should be greater than 60 mmHg in order to ade- tension, which is an elevated blood pressure quately perfuse organs. resulting from a known cause, will cause inflam- Elevated blood pressure may occur as a result of mation and necrosis in the arterioles which then emotional stress with as much as 40 mmHg result in decreased blood flow to vital body increase, and may also result from ventilatory organs, and places stress on the heart and vessels. insufficiency, post-seizures, electroconvulsive ther- Uncontrolled hypertension is associated with per- apy, intracerebral injury, CNS disorders due to the manent damage to body systems. Blood pressure is mass,ive stimulation of catecholamines, coronary considered to be hypertension if the systolic pres- artery bypass surgery, myocardial infarction, heart sure is greater than 140 mmHg or the diastolic failure, renal insufficiency, eclampsia/toxemia, pressure is greater than 90 mmHg, and is classi- endocrine disorders, and some drugs. fied based on the severity from a high normal to malignant hypertension. Hypertensive crisis is Risk factors include: ages between 30 and 70 years defined as a sustained increase in diastolic blood of age, race (black), use of birth control pills, obe- pressure above 120 mmHg, which is high enough sity, familial history, smoking, stress, diabetes mellitus, and sedentary lifestyle. to cause irreversible damage to organs and tissue death. Treatment is aimed at lowering blood pressure by Hypertension may result from several origins- use of antihypertensive medications, diuretics to increase urinary output, and by eliminating factors adrenal origin (as in pheochromocytoma, Cushing’s disease, brain tumor, etc.), renal origin that promote the elevation of blood pressure. A (as in pyelonephritis), cardiovascular origin (as in “stepped care” regimen is used most often, with step one involving the use of thiazide diuretics and atherosclerosis or coarctation of the aorta, etc.), or calcium ion antagonists; step two involves the sup- unknown origin which accounts for the majority plemental use beta-adrenergic blockers; step of all known hypertension. of three includes vasodilators; and step four involves Untreated, hypertension will result in death due to guanethidine. cerebrovascular accident, congestive heart failure, intracerebral hemorrhage, kidney failure, or dis- MEDICAL CARE secting aneurysms. Diuretics: chlorothiazide (Diuril), spironolactone Systolic blood pressure is the pressure that the (Aldactone), chlorthalidone (Hygroton), heart pumps against to force blood from the left hydrochlorothiazide (Esidrix, HydroDiuril), side of the heart to the aorta and to major arteries. triamterene (Dyrenium), metolazone (Zaroxolyn, Diastolic blood pressure is the pressure required to Diulo), ethacrynic acid (Edecrin), furosemide permit filling of the ventricles before the next sys- (Lasix) to promote diuresis and block reabsorption tole cycle. The pulse pressure, which is the value of sodium and water in the kidney of the difference between the systolic and diastolic pressures, may be used to indicate perfusion prob- Calcium ion antagonists: verapamil (Calan), diltiazem (Cardizem), nifedipine (Procardia), 40 CRITICAL CARE NURSING CARE PLANS

nitrendipine to produce vasodilation on vascular turia for possible indication of nephrosclerosis; smooth muscle thyroid profile used to identify hyperthyroidism Adrenergic inhibitors: reserpine, methyldopa which may lead to vasoconstriction and hyperten- (Aldomet), propranolol (Inderal), prazosin sion; aldosterone level used to identify primary hydrochloride (Minipress) used to impair synthe- aldosteronism; urine VMA to identify elevation of sis of norepinephrine, suppression of sympathetic catecholamine metabolites which may indicate outflow by central alpha-adrenergic stimulation, pheochromocytoma or blocking of preganglionic to postganglionic Radiographic testing: IVP may be used to iden- autonomic transmission ti$ presence of kidney disease; renal arteriogram Vasodilators: hydralazine (Apresoline), minoxidil may be used to show renal artery stenosis or other (Loniten), nadolol (Corgard) to relax smooth causes of hypertension muscle of arterioles and reduce peripheral vascular resistance and thus, blood pressure NURSING CARE PLANS ACE inhibitors: captopril (Capoten) used to Rid for decreased cardiac output lower total peripheral resistance by inhibiting Related to: vasoconstriction, increased preload, angiotensin-converting enzyme increased afterload, ventricular hypertrophy, Electrolytes: potassium chloride (KCI, K Dur, K ischemia tabs) to replace potassium lost through diuresis Defining characteristics: elevated blood pressure, Chest x-ray: shows any enlargement of the heart decreased cardiac output, decreased stroke volume, and pulmonary vein, presence of pulmonary increased peripheral vascular resistance, increased edema or pleural effusion systemic vascular resistance Electrocardiography: used to monitor for changes in rate and rhythm, conduction abnormalities, left Outcome Criteria ventricular hypertrophy, ischemia, electrolyte Patient will have no elevation in blood pressure abnormalities, drug toxicity, and presence of dys- above normal limits and will have adequate car- rhythmias diac output, and will maintain blood pressure Laboratory: cholesterol levels and lipid profile within acceptable limits. used to determine cholesterol and triglyceride INTERVENTIONS RATIONALES levels and their pertinence to atherosclerosis; elec- Monitor blood pressure every 1-2 Changes in blood pressure may trolyte profiles used to monitor for hypokalemia hours, or every 5 minutes during indicate changes in patient and hypernatremia which may be prevalent due to active titration of vasoactive status requiring prompt atten- diuretic therapy; CBC used to identify potential drugs. Measure pressure in both tion. Comparing pressures in renal failure and polycythemia; glucose levels used arms using appropriate size of both sides provides information cuff. When possible, obtain as to amount of vascular in- to identify potential causes of hypertension; BUN pressures lying, sitting, and volvement. Blood pressure may and creatinine levels used to identify renal standing. vary depending on body position dysfunction; urinalysis used to identify proteinuria and postural hypotension may for possible indication of renal disease and hema- result in syncope. CARDIOVASCULAR SYSTEM 41

INTERVENTIONS RATIONALES Infarmatian, Instruction, Demonstration Monitor EKG for dysrhythmias, Decreases in cardiac output conduction defects, and for may result in changes in car- heart rate and rhythm changes. diac perfusion causing dys- INTERVENTIONS RATIONALES Treat as indicated. rhythmias. Instruct on fluid and diet Restrictions can assist with requirements and restrictions decrease in fluid retention Observe skin for color, temp- Peripheral vasoconstriction of sodium. and hypertension, thereby im- erature, capillary refill time, may result in pale, cool, proving cardiac output. and diaphoresis. clammy skin, with prolonged capillary refill time due to Instruct on medications, ef- Promotes knowledge and com- cardiac dysfunction and de- feas, side effects, contra- pliance with drug regimen. creased cardiac output. indications, signs to report.

Auscultate lungs for adventi- Crackles (rales) or wheezing tious breath sounds. may indicate pulmonary con- Prepare patient for surgery if Pheochromocytoma may require gestion due to cardiac warranted. surgical intervention for re- failure as a result of in- moval of the tumor in order creased blood pressure. to correct hypertension.

Ausculate heart tones. Hypertensive patients often have S4 gallops due to atrial Discharge or Maintenance Evaluation hypertrophy. Ventricular hypertrophy may result in Patient will normotensive, with adequate car- s3 gallops. be diac output and index. Administer thiazide, loop, or Thiazides are used to reduce potassium-sparing diuretics as blood pressure in patients with Medications will be taken as ordered with no ordered. normal renal function and these side effects. limit fluid retention. Loop diuretics inhibits reabsorption of Patient will have stable heart rate, rhythm, and sodium and chloride and are used heart tones, with no adventitious breath sounds. in patients who have renal dysfunction. Potassium-sparing di- Patient will be able to verbalize instructions uretics are used in conjunction accurately. with thiazides to decrease the amount of potassium lost. Risk for altered tissue perjkion: cardiopul- Administer sympathetic inhibi- These drugs reduce blood pres- monary, cerebral, renal, gastrointestinal, tors as ordered. sure by decreasing peripheral and perapherul resistance, reducing cardiac output, inhibiting sympathetic Related to: increased catecholamine stimulation, activity, and suppressing the increased blood pressure, decreased cardiac output, release of renin which is a decreased baroreceptor sensitivity, changes in cere- potent vasoconstrictor. brospinal fluid pressure, angiotensin and Administer vasodilators as May be used in severe hyper- aldosterone stimulation, sodium intake, environ- ordered. tension to increase coronary mental factors, genetic factors, strain on arterial blood flow and decrease after- wall, atherosclerosis load to improve cardiac output.

Administer antiadrenergic drugs Prevents blood vessels from as ordered. constricting and increasing blood pressure. 42 CRITICAL CARE NURSING CARE PLANS

Defining characteristics: increased blood pressure, Instruction, Information, retinopathy, retina1 hemorrhage, headache, Demonstration epistaxis, tachycardia, rales, S3 or S4 gallops, restlessness, bruits to femoral, carotids, abdominal INTERVENTIONS RATIONALES aorta, blurred vision, chest pain, shortness of Instruct patient in signs/ Promotes knowledge and compli- breath, optic disc papilledema, seizures, coma, nys- symptoms to report to MD, such ance with treatment. Promotes tagmus, mental changes as headache upon rising, in- prompt detection and facilitates creased blood pressure, chest prompt intervention. pain, shortness of breath, in- Outcome Criteria creased heart rate, weight gain of > 2 lblday or 5 Ib/wk, edema, Patient will achieve and maintain adequate tissue visual changes, nosebleeds, dizziness, syncope, muscle cramps, perfusion to all body systems. nausedvomiting, impotence or INTERVENTIONS RATIONALES decreased libido. Monitor for sudden onset of May indicate dissecting aortic chest pain. aneurysm. Discharge or Maintenance Evaluation

Monitor EKG for changes in rate, Decreased perfusion may result Patient will have adequate tissue perfusion to all rhythm, dysrhythmias, and con- in dysrhythmias due to decrease duction defects. Treat as in- in oxygen. body systems. dicated. Patient will be mentally lucid, with no confu- Monitor hemodynamic parameters Provides immediate information sion or neurological deficits. closely and titrate vasoactive regarding efficacy of medication drugs as warranted. and status of hypertension. Patient will have adequate urinary output with no hematuria, and renal function studies will be Observe for shift of point of Shift occurs in cardiac enlarge- within normal limits. maximal impulse (PMI) to left ment.

0 Patient will be able to recall accurately the infor- Auscultate over peripheral ar- Atherosclerosis may cause bruits teries for bruits. by obstructing blood flow. mation instructed.

Observe extremities for swelling, Bedrest promotes venous stasis Anxiety erythema, tenderness, pain, pos- which can increase the risk of [See MI] itive Homans’ sign, positive thromboembolus formation, Ac- Pratt’s sign. Observe for de- tual vegetation emboli can mi- Related to: change in health status, fear of death, creased peripheral pulses, pal- grate and occlude peripheral threat to body image, threat to role functioning, lor, coldness, cyanosis. arteries, leading to tissue pain ischemia and necrosis. Defining characteristics: restlessness, insomnia, anorexia, increased respirations, increased heart rate, increased blood pressure, difficulty concentrating, dry mouth, poor eye contact, decreased energy, irritability, crying, feelings of helplessness CARDIOVASCULAR SYSTEM 43

Knowledge Aficz't INTERVENTIONS RATIONALES Related to: lack of understanding, lack of under- Instruct patient in medications, Promotes understanding chat standing of medical condition, lack of recall dose, effects, side effects, con- side effects are common and may traindications, and signs/ subside over time, and facili- Defining characteristics: questions regarding symptoms to report to MD. tates compliance. problems, inadequate follow-up on instructions Instruct in dietary needs and Patient may need to increase given, misconceptions, lack of improvement of restrictions, such as limiting dietary potassium if placed on previous regimen, development of preventable caffeine and sodium, or increas- diuretics; caffeine should be complications ing potassium and calcium. limited due to the direct srimu- lant effect on the heart; sodium should be limited due to Outcome Criteria the potential for fluid retention. Additional calcium has Patient will be able to verbalize and demonstrate been shown to lower blood pressure. Excessive intake of fat understanding of information given regarding and cholesterol are additional condition, medications, and treatment regimen. risk factors in hypertension. Low fat diets can decrease BP through prostaglandin balance. Information, Instruction, Demonstration Instruct on hypertension, ef- Promotes understanding of the fects on the blood vessels, disease process and enhances INTERVENTIONS RATIONALES heart, brain, and kidneys. In- compliance with treatment. struct on normal values for BI? Determine patient's baseline of Provides information regarding knowledge regarding disease pro- patient's understanding of cess, normal physiology, and condition as well as a baseline Instruct on maintaining medica- Assist patient to understand function of the heart. from which to base teaching. tion regimen to keep blood pres- need for life-long compliance sure well controlled, and in to reduce incidence of CVA, MI, Monitor patient's readiness to Promotes optimal learning en- keeping medical appointments. cardiac and renal dysfunction. learn and determine best methods vironment when patient shows Lack of compliance is the major to use for learning. Attempt willingness to learn. Family reason for failure of anti- to incorporate family/significant members may assist with help- hypertensive therapy. other in learning process. Rein- ing the patient to make in- strucdreinforce information as formed choices regarding his Instruct on ways to modify risk Risk factors contribute to dis- needed. treatment. Anxiety ot large factors, such as smoking, obe- ease and complications associ- volumes of instruction may sity, high Fat diets, stressful ated with hypertension, as well impede comprehension and lifestyle, etc. as exacerbate symptoms. Nico- limit learning. tine increases catecholamine release and increases heart Provide time for individual in. Promotes relationship between rate, blood pressure, and myo- teraction with patient. patient and nurse, and estab- cardial oxygen demand. blishes trust. Instruct in self-monitoring for Provides reinforcement and the Instruct patient on procedures Provides knowledge and pro- blood pressure; technique to be ability to monitor response to that may be performed. motes rhe ability to make used post discharge. medical regimen. informed choices. Instruct to take diuretics in Decreases incidence of nocturia. am. 44 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RA'TIBNALES Discharge or Maintenance Evaluation

Monitors effectiveness of diure- Instruct to weigh daily at Patient will be able to verbalize understanding of same time on same scale. tics and for fluid retention. condition, treatment regimen, and signs/symptoms to report. Instruct on leg exercises and Decreases venous pooling that position changes. can be potentiated by vasodila- Patient will be able to correctly perform all tasks tors and prolonged time in one prior to discharge. position. Patient will be able to verbalize understanding of Instruct to avoid hot baths, These promote vasodilation and cardiac disease, risk factors, dietary restrictions, saunas, hot tubs, and alcohol when combined with diuretics, intake. may increase chance of orthosta- and lifestyle adaptations. tic hypotension and syncope.

Instruct to avoid over-the- Some drugs contain sympathetic counter medications unless pre- stimulants that can increase scribed by MD. blood pressure or may cause drug interactions.

Instruct to rise slowly, allow- Assist body to equilobrate and ing time between position adjust in order to decrease the changes. risk of syncope.

Provide printed materials when Provides references for patient possible for patiendfamily to and family to refer to once dis- review. charged, and can enhance the understanding of verbally- given instructions.

Demonstrate and instruct on Self-monitoring promotes self- technique for checking pulse independence and can provide rate and regularity. Instruct timely intervention for abnor- in situations where immediate malities or complications. action must be taken. Heart rates that exceed set parameters may require further medical alteration in medications or regimen.

Have patient demonstrate all Provides information that skills that will be necessary patient has gained a full for post-discharge. understanding of instruction and is able to demonstrate correct information. CARDIOVASCULAR SYSTEM 45

HYPERTENSION

Increased TPR, PVR, CO Decreased baroreceptor sensitivity Sympathetic stimulation c Impaired myocardial oxygen c c Increased workload on heart Chronic hypertension Angiotension/aldosterone release Increased myocardial oxygen consumption c Decreased renal blood flow Changes in CSF pressures Decreased renal oxygenation c Decrease in cerebral perfusion c Dyspnea on exertion Decrease in cerebral oxygen supply Ischemia of renal tissues Ventricular hypertrophy c Renidaldosterone secretion Chest pain Memory impairment Increased blood pressure c Dull headache in a.m. c Cardiac decompensation Vertigo, tremors Nocturia Coronary artery disease c Sodium/water retention Myocardial infarction Cerebral edema Increased blood volume Cardiac failure c Decreased GFR Retina1 hemorrhage, blurred vision c TIAs, epistaxis Azotemia Cerebral hemorrhage Renal failure Cerebral aneurysm Cerebral thrombosis, CVA This Page Intentionally Left Blank CARDIOVASCULAR SYSTEM 47

Thrombop hlebi tis 1251 Fibrinogen uptake test: a radioactive scan performed after radioactive fibrinogen is injected, Thrombophlebitis occurs when a clot forms in a which concentrates in the area of clot formation; vein secondary to inflammation or when the vein not sensitive to thrombi high on the iliofemoral is partially occluded from some disease process. As region or with inactive thrombi a general rule, two out of the following three fac- Anticoagulants: heparin, coumadin, warfarin to tors occur prior to the formation of a prolong clotting time to prevent further clot for- thrombus-blood stasis, injury to the vessel, and mation altered blood coagulation. Deep vein thrombosis, or DVT, pertains to clots NURSING CARE PLANS that are formed in the deep veins and may result in complications such as pulmonary embolus and Alteration in tissue pe+ion: peripheral postphlebotic syndrome, or chronic venous insuf- Related to: impaired blood flow, venous stasis, ficiency. This can be a residual effect of venous obstruction thrombophlebitis in which the veins are partially occluded or valves in the vessels have been dam- Defining characteristics: pain, tissue edema, aged. This chronic insufficiency may cause decreased peripheral pulses, prolonged capillary increased venous pressure and fluid accumulation refill time, pallor, cyanosis, erythema, paresthesia in the interstitial tissues, which results in chronic edema, tissue fibrosis, and induration. Outcome Criteria

DVT may be asymptomatic, but usually produces Patient will have improved peripheral perfusion, side effects such as fever, pain, edema, cyanosis or with palpable and equal pulses, normal skin color, pallor to the involved extremity, and malaise. temperature, and sensation, and have no evidence Superficial vein thrombophlebitis causes may -of edema. include trauma, infection, chemical irritations, fre- INTERVENTIONS RATIONALES quent IVs, and recreational drug abuse. Observe lower extremities for Findings may help to differen- edema, color, and temperature. tiate between superficial The goals in treatment of thrombophlebitis are to Measure calf circumference every thrombophlebitis and deep vein control thrombotic development, relieve pain, shift. Monitor for capillary thrombosis. Measurements can improve blood flow, and prevent complications. refill time. facilitate early recognition of edema and changes. Ederna, redness, and warmth are indi- MEDICAL CARE cative of superficial phlebitis whereas DVT usually is Venography: used to visualize the vascular system exhibited by cool pale skin. and locate any impairment in blood flow DVT may prolong capillary refill time. Plethysmography: a non-invasive measurement of changes in calf volume that corresponds to chang- Observe extremity for prominence Superficial veins may become of veins, knots, bumps, or distended because of backflow ing blood volume as a result of impairment in stretched skin. through veins. Evidence of blood flow thrombophlebitis to superficial veins may be visible or easily palpable. 48 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Information, Instruction, Maintain bedrest. Activity limitation may mini- Demonstration mize the potential for dislodgment of the dot. INTERVENTIONS RATIONALES Instruct on avoidance of rubbing May promote risk of dislodging Elevate legs while in bed or Reduces swelling and increases or massaging extremity involved. clot and causing embolization. sitting in chair. venous return. Some experts believe that elevation may Avoid crossing legs, prolonged Positions tend to restrict cir- actually enhance the release positions with legs dangling, culation and increases venous of thrombi. or knees bent. stasis, and increases edema.

Observe for positive Homanb Homan’s sign may or may not Instruct in deep breathing Promotes emptying of large sign (pain in calf upon dorsi- be present consistently and exercises. veins by increasing negative flexion of foot). should not be used as a sole pressure in the thorax. indicator of thrombophlebitis. Instruct on maintaining fluid Dehydration promotes increased Perform active or passive ROM Promote increased venous blood intake of at least 2 Llday. viscosity of blood, and in- return and decrease venous exercises while at bedrest. creases venous stasis. stasis. Prepare patient for surgery if Surgical intervention may be Apply TED hose after acute phase Assists to minimize postphle- warranted. required if circulation is se- is over. Remove for at least 1 botic syndrome and increases verely compromised. Recurrent hour every shift. blood flow to deep veins. Re- episodes of thrombi may require moval allows time for compres- a vena caval umbrella to filter sion of veins to be relaxed. out thrombi going to lung.

Apply warm moist soaks or- Promotes vasodilation and may as Instruct on lying in a slightly Promotes blood flow to depend- dered. improve venous return and de- reversed trendelenburg position. ent extremities; preferable to crease in edema. have extremities full of blood as opposed to empty. Administer anticoagulants as Heparin is used initially be- ordered. cause of its action on thrombin formation and the removal of the intrinsic pathway to pre- Discharge or Maintenance Evaluation vent hrther clot formation. Coumadin is usually used for Patient will have palpable pulses of equal long-term therapy. strength to all extremities.

Monitor laboratory studies for Monitors efficacy of anticoagu- Skin will be within normal limits of coloration, PT, PTT,AMT, and CBC. lant therapy and potential for temperature, and sensation. dot formation due to hemoconcentration/dehydration. Patient will be able to recall all instructions accurately. Patient will have no complications from anticoagulation therapy. CARDIOVASCULAR SYSTEM 49

Risk for impaired skin integrity INTERVENTIONS RATIONALES Related to: edema, venous stasis, bedrest, surgery, Monitor any drainage tubes for Provides indication of decreas- pressure, altered circulation and blood flow, altered amounts and character of draining or increasing wound drainage. Use ostomy bags over tubes age and assessment of healing metabolic states when drainage is massive. process. Collection of drainage in bags facilitates more Defining characteristics: skin surface disruptions, accurate measurement of fluid incisions, ulcerations, wounds that do not heal loss and prevents excoriation of skin from copious drainage.

Outcome Criteria Use skin prep, moisture barrier, Provides protection to skin or benzoin to skin prior to tape and reduces potential for skin Patient will have no evidence of impairment to application. Use hypoallergenic trauma. Reduces potential for skin tissues. tape or Montgomery straps to se- skinlwound disruption when cure dressings. frequent dressing changes are Patient will have surgical wound approximated and required. well-healed with no evidence of infection. INTERVENTIONS RATIONALES Information, Instruction, Monitor extremities for presence Provides prompt assessment and Demonstration - of ulcers, wounds, symptoms of treatment for impaired tissues. decreased circulation. INTERWNTIONS RATIONALES Instruct to avoid scratching, Injuries may damage tissues If surgery is required, change Prevents drainage accumulations hitting or bumping legs, or that may deteriorate into ulcer dressing using aseptic or ster- from excoriating skin, provides other injurious activities. formation. ile technique as warranted. assessment to monitor for chan- Leave wound open to air as soon ges in wound appearance and de- Instruct on signslsymptoms of Provides prompt notification as is feasible, or apply light teriorationlimprovement, and infection to woundlskin and to to enhance prompt treatment. dressing. prevents wound from contamina- report to nurselMD. tion. Allowing air to reach wound facilitates drying and Instruct on cleansing incision Reduces skin surface contami- promotes the healing process. area post discharge. nants and prevents infection. Sutures may be abrasive to skin or get caught on garments and irritation may be reduced Discharge or Maintenance Evaluation with a light gauze dressing. Patient will have approximated, healed surgical Cleanse wound as ordered with Various agents can be used to each dressing change. remove exudate or necrotic ma- wound with no drainage, erythema, or ederna to terial from wound to promote site. healing. Any packing of the wound should be done using Patient will be able to recall instructions sterile technique to reduce accurately. the risk of contamination. Patient will be compliant with avoiding injurious Prompt recognition of problems Monitor wound for skin integ- activities, and will seek medical help when injury rity to incision and surround- with healing may prevent exa- ing tissues, noting increases cerbation of wound. Increased occurs. and changes in characteristics drainage or malodorous drainage of drainage. may indicate infection and delayed wound healing. 50 CRITICAL CARE NURSING CARE PLANS

Alteration in comfort INTERVENTIONS RATIONALES [See MI] Provide time for individual in- Promotes relationship between teraction with patient. patient and nurse, and estab- Related to: inflammation, impaired flow, blood blishes trust. intermittent claudication, venous stasis, lactic acid in tissues, surgical procedures, fever Instruct patient on procedures Provides knowledge and that may be performed. promotes the ability to make Defining characteristics: complaints of pain, ten- informed choices. derness to touch, aching, burning, restlessness, facial grimacing, guarding of extremity Instruct on signslsymptoms of Provides knowledge and assists possible complications, such as patient to understand health Knowledge deficit pulmonary emboli, venous insuf- care needs. ficiency, and venous stasis ul- Related to: lack of understanding, lack of under- cers. standing of medical condition, lack of recall Instruct on care to lower ex- Chronic venous stasis may occur tremities and to notib MD for and promotes risk of infection Defining characteristics: questions regarding prob- development of any lesion. and/or ulcer formation. lems, inadequate follow-up on instructions given, misconceptions, lack of improvement of previous Instruct patient in medications, Promotes understanding that regimen, development of preventable compli- dose, effects, side effects, con- side effects are common and may traindications, and signs/ subside over time, and facili- cations symptoms to report to MD. tates compliance.

Instruct on leg exercises and Decreases venous pooling that Outcome Criteria position changes. Assist with can be potentiated by vasodila- setting up activity program tors and prolonged time in one Patient will be able to verbalize and demonstrate post-discharge. position. Exercise may assist understanding of information given regarding con- in developing collateral circu- dition, medications, and treatment regimen. lation and enhances venous return. Information, Instruction, Instruct to rise slowly, allow- Assist body to equilobrate and ing time between position adjust in order to decrease the Demonstration changes. risk of syncope.

INTERVENTIONS RATIONALES Instruct to balance rest with Rest decreases oxygen demands Determine patient’s baseline of Provides information regarding activity. of compromised tissue and knowledge regarding disease pro- patient‘s understanding of decreases potential for emboliza- cess, normal physiology, and condition as well as a baseline tion of thrombus. Balancing rest function. from which to base teaching. with graduated activity prevents exhaustion and impairment of Monitor patient’s readiness to Promotes optimal learning en- tissue perfusion. learn and determine best methods vironment when patient shows to use for learning. Attempt willingness to learn. Family Instruct on proper application Improper application may cause to incorporate family/significant members may assist with help- of TED stockings. a tourniquet-like effect and other in learning process. Rein- ing the patient to make in- impede circulation. struct/reinforce information as formed choices regarding his needed. treatment. Anxiety or large Avoid valsalva-type maneuvers. Increases venous pressure in the volumes of instruction may Provide increased fiber to diet leg which increases potential impede comprehension and and administer stool softeners for thrombophlebitis. limit learning. as warranted. CARDIOVASCULAR SYSTEM 51

INTERVENTIONS RATIONALES Instruct on anticoagulation Promotes compliance with medi- therapy-dosage, effects, side cal regimen and decreases poten- effects, when to administer, tial for improper dosage and other medications to avoid. adverse drug interactions. Aspirin and salicylates decrease prothrombin activity, vitamin K increases prothrombin activity, antibiotics may interfere with vitamin K synthesis, and barbiturates can potentiate anticoagulant effect.

Instruct on importance of keep- Promotes compliance with treating MD appointments for follow- ment and decreases potential for up laboratory studies. non-therapeutic levels of anticoagulation therapy.

Provide printed materials when Provides references for patient possible for patientlfamily to and family to refer to once dis- review. charged, and can enhance the understanding of verbdly- given instructions.

Discharge or Maintenance Evaluation

Patient will be able to verbalize understanding of condition, treatment regimen, and signs/symptoms to report. Patient will be able to correctly perform all tasks prior to discharge. Patient will be able to verbalize understanding of safety precautions, correct dosage and administration of all medications, and activity limitations. 52 CRITICAL CARE NURSING CARE PLANS

THROMBOPHLEBITIS

Narrowing of vein s Platelet aggregation s Venous obstruction s Decrease in blood flow s I I I Venous stasis Vein wall abnormality Abnormal clotting s Inflammation JI Edema 3. Movement of the thrombus within circulation s Migration and lodging in pulmonary vasculature Pulmonary embolism J Respiratory insufficiency Ventilation/perfusion mismatching s Cardiovascular collapse 4 Death ~ CARDIOVASCULAR SYSTEM 53

brain syndrome, irreversible brain damage, absent Intra-Aortic Balloon Pump femoral pulses, trauma that has resulted in internal bleeding, active bleeding ulcers, blood dyscrasias, or previous aortofemoral or aortoiliac bypass The intra-aortic balloon pump (IABP) is an grafts. advanced procedure that is used in the manage- Because the potential for complications is high, ment of cardiovascular problems that are this procedure should be utilized only by person- refractory to routine medical therapeutics. An nel well-versed and competent in all aspects of the intra-aortic balloon catheter (IAB) is inserted into IABP function and troubleshooting complications. the descending aorta, most commonly by way of the femoral artery. The IAB is then attached to Two of the major complications associated with the IABP which inflates and deflates the balloon the use of the IABP are compromise of the left cir- in synchronization with the cardiac cycle. The bal- culation and difficulty with weaning the patient loon inflates during diastole when the aortic valve from the IABP. closes and increases the aortic pressure when the blood distally to the balloon is forced back towards the aortic valve. The coronary arteries are Oxygen: to increase available oxygen supply supplied with additional blood to improve coronary blood flow and perfusion and to decrease Nitrates: (nitroglycerin, isosorbide dinitrate, preload. Deflation occurs prior to the onset of sys- Nitro-bid, Nitrostat) used to relax vascular smooth tole and decreases the aortic pressure and muscle to produce vasodilation, decrease preload, ventricular resistance and makes it easier for the decrease afterload, decrease venous return, decrease ventricle to contract and expel its normal volume peripheral vascular resistance, decrease oxygen of blood, thus decreasing afterload. This counter- demand pulsation and displacement of blood decreases Beta-blockers: (propranolol, metoprolol, nadolol, myocardial oxygen demand by decreasing myocar- atenolol, timolol, pindolol) used to reduce dial workload and increases coronary perfusion myoca.rdia1 oxygen demand by blocking and cardiac output. catecholamine and sympathetic induced increases Indications for use of IAB counterpulsation in heart rate, contractility and blood pressure; include cardiogenic shock, valvular disease, slows AV node conduction; decreases sodium and intractable chest pain resistant to medical water retention by reduction of renin secretion; treatment, prophylactic support during coronary decreases platelet aggregation and may reduce angiography or anesthesia induction, papillary vasospasm muscle rupture, ventricular septal defects, compli- Calcium-channel blockers: (verapamil, nifedipine, cations of acute myocardial infarctions, weaning diltiazem) used for decreasing myocardial oxygen from the cardiopulmonary bypass, septic shock, demand and to enhance relaxation in hypertrophic and as a bridge to cardiac transplantation. ardiomyopathies, reduces blood pressure and Counterpulsation is contraindicated in patients afterload, and help prevent coronary spasm from with severe aortic insufficiency, dissecting decreased oxygen supply aneurysms, peripheral vascular disease, organic 54 CRITICAL CARE NURSING CARE PLANS

Sympathomimetic drugs: (doparnine, Intropin) NURSING CARE PLANS used for treatment of hypotension in normovolemic states and in the treatment of Altered tissue perfusion: cardiopulmonary, severe heart failure and cardiogenic shock cerebral, gastrointestinal, renal, peripheraL Placement of LAB: necessary for counterpulsation Related to: cardiac failure, tissue ischemia, to begin vasoconstriction, hypovolemia, shunting, depressed ventricular function, dysrhythmias, conduction Cardiac catheterization: used to define lesions and defects, hypoxia, reduction or interruption of evaluate their severity, to provide information on blood flow ventricular function, and to allow for measurement of heart pressures and cardiac output Defining characteristics: visual disturbances, paresthesias, mental changes, change in level of Labwork: PT, PTT, and platelets are obtained to consciousness, confusion, restlessness, pulse and monitor anticoagulation status; general chemistry blood pressure changes, changes in cardiac output, profiles and renal profiles are monitored every day changes in peripheral resistance, impaired oxygena- for chemical imbalances and impending hepatic or tion of myocardium, chest pain, cardiac renal problems; cardiac isoenzymes are used to dysrhythmias, changes in EKG (S-T segment, T monitor for heart damage; CBC and differentials wave, U wave), LV enlargement, dyspnea, short- are done every day to monitor for infection and ness of breath, tachypnea, palpitations, nausea, changes in hematologic status; cultures of blood, vomiting, slow digestion, oliguria, anuria, urine and sputum are done for temperature eleva- electrolyte imbalance, cold, clammy skin, tions greater than 102 degrees to assess for decreased peripheral pulses, mottling, cyanosis, infection/suspected organisms diaphoresis Arterial blood gases: used to assess oxygenation status Outcome Criteria Chest x-ray: used daily to monitor placement of Blood flow and perfusion to vital organs will be IAB and watch for migration, to assess preserved and circulatory function will be enlargement of the heart and/or pulmonary ves- maximized. sels, and to assess pulmonary fluid status and atelectasis Patient will be free of dysrhythmias and hemodynamic parameters will be within normal limits. Electrocardiography: reveals changes with atrial and ventricular enlargement, rhythm and conduc- INTERVENTIONS RATIONALES tion abnormalities, ischemia, electrolyte Monitor vital signs every 15 to IABP timing is based on heart abnormalities, drug toxicity, and presence of dys- 30 minutes until stable, then rate, and when rate changes > rhythmias every hour. Notify MD of devi- 10 beatslminute, adjustments ations from parameters. in timing are necessary to Pacemakers: either temporary or permanent, used ensure optimal counterpulsation. Dysrhythmias hamper optimal in anticipation of lethal dysrhythmias and/or con- oxygenation and function of duction problems the IABP. CARDIOVASCULAR SYSTEM 55

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Monitor mean arterial blood Assesses volume status to help terload. Late deflation en- pressure every hour. monitor for efficacy of counter- croaches on the next systole pulsation. MABP can be calcula- and increases afterload. ted by adding 113 (systolic BP- IAB cannot be left in patient diastolic BP) + diastolic Bl? longer than 30 minutes without MABP is a function of cardiac movement of balloon due to output and systemic vascular thrombus formation on the IAB. resistance. Levels < 60 have little, if any, perfusion to brain. Provide adequate amounts of Underinflation of IAB can re- gas (CO2 or helium) in IAB; sult in subtherapeutic effects Obtain pulmonary artery pres- Provides information as to refill IAB every 2 hours or from minimizing blood displace- sures every hour. fluid status and heart pres- more often if fever present. ment. Increased body tempera- sures. PA systolic pres- ture increases the normal loss sures represent RV pressures of gas from the balloon. with normals ranging from 20- 30 mmHg. PA diastolic pres- Notify MD if augmentation can- Signals problems with catheter sures reflects the LVEDP and not be maintained, afterload is pump, or patient requiring imme- is an indirect measurement not reduced, or if reddish- diate attention. Discoloration of LV function with normals brown fluid noted in tubing of in IAB tubing signifies that a ranging 10-20 mmHg. PCWP IAB. fracture in the catheter has oc- reflects the LA pressure and curred and the fluid is actually is used to assess LV filling blood. At this point, prepare pressures with normals rang- for removal of the catheter. ing from 4- 12 mmHg. Determine level of conscious- Mental changes will result as Measure cardiac outputlcardiac Directly measures the volume ness, mental changes, neurolo- tissue perfusion to brain de- index and perform hemodynamic of cardiac output in Llmin, gical deficits. creases. measurements every 1-4 hours. and gives calculated information regarding preload and Monitor urine output every hour. Low cardiac output will cause afterload. Normal CO should Notify MD if < 30 cclhr, or decreased tissue perfusion to range from 4-8 Llmin and > 200 cclhr in the absence of kidneys and oliguria. Migration CI from 2.5-4 L/min/m2. SVR diuretics or fluid challenge. of the IAB can partially or to- which represents afterload tally occlude the renal arteries should range between 900- leading to oliguria or anuria. 1400 dyneslseclcm5. Increased urine may indicate problems with other body systems, Monitor for malfunction of Improper timing of balloon can such as SIADH. IAB and IABP and correct prob- promote complications and wor- blems rapidly. Manually flut- sen condition. Early inflation Monitor presence and equality Decreased or absent pulses may ter IAB prn pump failure. leads to regurgitation into of peripheral pulses, extremi- indicate migration of IAB and the left ventricle or premature ty color, temperature, and sen- possible occlusion of arteries. closing of the valve, and in- sations. Notify MD of problems. creases afterload. Late inflation decreases augmentation and Elevate head of bed no more than Flexion greater than this may reduces coronary perfusion. 30 degrees. Do not flex invol- cause catheter to kink and Early deflation allows the pres- ved leg. fracture. sure to rise to normal end- Reduces complicarions from im- diastolic levels preceding sys- Assist with ROM to uninvolved mobility. tole which does not reduce af- leg as needed, and with flexionl extension of involved foot. 56 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Urinary output will be within normal limits. Monitor generd chemistry, Provides information about Minimal activity will be tolerated without renal profile, and CBC. potential blood loss and infec- shortness of breath or extreme fatigue. tion; chemistry profiles provide information about impending . Medications will be administered with no unde- hepatic or renal insufficiency. sirable effects. Risk for injktion Information, Instruction, Demonstration Related to: invasive lines, catheters, puncture wounds, invasive procedures, environmental expo- INTERVENTIONS RATIONALES sure from devices left in place for extended Instruct patiendfarnily on pro- Provides knowledge and allows periods of time cedure, benefits, risks, post- patient to make an informed procedure care. choice. Defining characteristics: disruption of skin surfaces, redness, drainage, elevated temperature Instructldemonstrate ROM to Provides activity as tolerated uninvolved leg, and flexionl while on IABP extension to foot of involved Outcome Criteria leg. Patient will be free of infection with no fever or Prepare patiendfamily for IABP may be necessary to in- placement on IABP, post- crease cardiac output, and chills. procedure care. decrease afterload and preload in order to decrease the work- All invasive lines will be free of erythema, edema, load on the damaged heart. and drainage. INTERVENTIONS RATIONALES

Discharge- or Maintenance Evaluation Inspect all invasive lines for Invasive lines provide entry signs of infection andlor bleed- route for pathogens. Patiendfamily will be able to verbalize correct ing. information regarding care, risks, and benefits. Change site dressing using Insertion site provides a Patient will have optimum perhsion to all body sterile technique every day. direct route for infection, Notify MD for signs of infec- and must be monitored to pre- systems. tion. vent complications.

Cardiac output will be within normal limits. Monitor temperature every 2-4 Sudden temperature increases hours. Obtain cultures of urine, may indicate infective pro- Patient will be able to accurately demonstrate sputum, and blood for evaluation cess. Cultures can isolate exercises. as warranted. the specific pathogen so as to enable specific antibiotic Patient will report no episodes of chest pain or therapy to be ordered. shortness of breath. Change IV tubinglarterial line Decreases the incidence of In- Hemodynamic parameters and vital signs will be tubing per protocol, using a- fection. Bacteria begins to within normal limits. septic technique. Change peri- grow within 24 hours in IV so- pheral lines every 3 days and lution. Replacement of IV lines Lung sounds will be clear and free of pm. prevents phlebiris and risks of adventitious breath sounds with optimal infective complications. oxygenation. CARDIOVASCULAR SYSTEM 57

Instruction, Information, INTERVENTIONS RATIONALES Demonstration Test all body fluids for pre- Anticoagulation may place sence of occult blood. patient at risk for bleeding. INTERVENTIONS RATIONALES Inform patient of need for Facilitates knowledge and pa- Monitor insertion site for Bleeding tendencies are in- bleeding, hemorrhage, or hema- creased due to concomitent use changing peripheral lines, so- tient comprehension and com- lutions, and care to sites. pliance with treatment. toma. Apply pressure dressing of systemic anticoagulants and if warranted, and notify MD patient is at risk for bleed- for sustained bleeding from ing. Instruct patient to notify May indicate infection. site. nurse for pain to invasive sites, PT, PTT, and platelets provide or other symptoms of infection. Monitor PT, PTT, platelets, and CBC. information about coagulation; CBC provides information about Discharge or Maintenance Evaluation potential blood loss. Administer IV solutions and IV solutions and volume expan- Patient will have no signs of infection to invasive volume expanders as indicated. ders may be required to treat line sites. rapidly decreasing circulating volume due to exsanguination. Peripheral lines will be changed within 3 days to avoid risk of infection. Administer packed RBG, blood, Hemorrhagic volume losses may or platelets as warranted. be life-threatening. Replace- Patient will have no signs of systemic infection. ment of platelets may be necessary to provide normal coagu- Riskfirflz4id volume &@it lation. Related to: potential blood loss from Administer vitamin K or prota- May be required to return coag- oozing/draining sites of invasive lines mine sulfate if warranted. ulation times to normal or reverse effects of heparin. Defining characteristics: bleeding from puncture sites and wounds, actual blood loss as measured by Instruction, Information, hemoglobin/hematocrit, hypotension, tachycardia Demonstration

Outcome Criteria INTERVENTIONS RATIONALES Instruct patient to report any Prompt observation of complica- Patient will have no significant blood loss from noted bleeding or oozing on body. tions can result in prompt invasive lines. treatment. INTERVENTIONS RATIONALES Instruct patient to avoid any Prevents accidental injury and activity that may promote bleed- decreases chance of hemorrhage. Measure all sources of intake Provides information to evalu- ing. and output. ate fluid status.

Weigh daily. Weight gain over 24 hours usually indicates fluid gain. Fluid imbalance can be approximated as 1 Ib = 500 cc fluid.

Monitor vital signs and hemo- Tachycardia, hypotension, and dynamic pressures. changes in hernodynamics may indicate volume depletion. 58 CRITICAL CARE NURSING CARE PLANS

Discharge or Maintenance Evaluation

Patient will be able to verbalize signs/symptoms of bleeding to report. Patient will be compliant in avoidance of safety concerns. Patient will have stable hemodynamic status with no over hemorrhage from any site. CARDIOVASCULAR SYSTEM 59

by the pacemaker and is measured in millivolts Pacemakers (mV), with the smaller number relating to the Artificial cardiac pacemakers are used to provide most s'ensitivity. Pacemakers are used for varying an electrical stimulus to depolarize the heart and degrees of heart block, sick sinus syndrome, sinus cause a contraction to occur at a controlled rate. node dysfunction, overriding of some cardiac dys- The function of the pacemaker, or pacer, is to rhythniias, prophylactically during diagnostic maintain the heart rate when the patient's own testing, myocardial infarctions, congestive heart intrinsic system is unable to do so. The stimulus is failure due to rhythm disturbances, after open produced by a pulse generator and delivered via heart surgery or in congenital anomalies of the electrodes/leads that are implanted in the heart. epicardium or endocardium. The electrodes may Temporary pacers are used when the duration of be unipolar or bipolar and the proximal end need is short and permanent pacers are placed for attaches to the pulse generator. In the unipolar life-long use. Temporary pacemakers can be placed electrode, one wire, positioned in the heart, senses via a transthoracic approach during open heart and stimulates the electrical heart activity and is surgery, transvenous approach into the right connected with the negative terminal on the pulse atrium or right ventricle, or transcutaneously generator. The other electrode, or ground, is (exteraal pacer) with skin electrodes while await- attached to the positive terminal on the pulse gen- ing placement of an internal pacemaker. erator. This type of lead usually requires a lower threshold of stimulation. The bipolar electrode Placement of the temporary pacemaker can be has both the sensing and ground electrode in the performed at the bedside in cases of emergency, catheter, and provides better contact with the but use of fluoroscopy is recommended when fea- heart muscle. In the event that one of the bipolar sible to ensure proper placement. External wires malfunctions, it can still be used as a unipo- pacemaker electrodes can either be placed on the lar lead. The pacemaker will produce a pacer chest, or one to the anterior and one posterior to spike on the EKG prior to the depolarized wave- the chest. form and this indicates pacemaker capture. Synchronous pacing, known as demand pacing, is Continuous observation for problems with the commonly used because the pacer is able to sense pacemaker should be performed to ensure that the patient's heart impulse. If the patient's rate failure to pace, failure to capture, and failure to falls below the rate set on the pacer, the pacer is sense are treated promptly. able to sense this and send an impulse to the The pacemaker rate is set depending on the desired chamber of the heart and cause the rate to patient's requirements. The optimal setting is one remain at the preset level. Dual chamber synchro- in which the lowest rate that controls the particu- nous pacing, or AV sequential, is the closest to lar dysrhythmia and provides for adequate cardiac normal physiologic function and facilitates the output. The stimulation threshold is the minimal atrial kick. amount of electrical energy required to stimulate Asynchronous, or fEed-rate, pacing provides the heart to produce a 1: 1 capture, and is impulses to the atrium, ventricle, or both regard- measured in milliamperes (mA). The sensitivity less of the patient's intrinsic rate. This should be control reflects the size of the wave that is sensed used solely for those occasions when no electrical activity is present to avoid potential lethal compet- itive dysrhythmias. 60 CRITICAL CARE NURSING CARE PLANS

Pacemakers are classified by a 5-letter code devel- Outcome Criteria oped by the Inter-Society Commission for Heart Disease in which letters are used to denote the Patient will be free of dysrhythmias with adequate chamber paced, the chamber sensed, response to cardiac output to perfuse all body organs. sensing, programmable functions and antitachy- INTERVENTIONS RATIONALE dysrhythmia functions. Monitor EKG for changes in Observation for pacemaker mal- Several complications may occur as a result of rhythm, rate, and presence of function promotes prompt treat- pacemakers-pneumothorax, hemothorax, dysrhythmias. Treat as india- ment. Pacer electrodes may ir- ted. ritate ventricle and promote myocardial perforation, hematoma, bleeding, dys- ventricular ectopy. rhythmias, pulmonary embolism, electrical microshock, cardiac tamponade, coronary artery Keep monitor alarms on at all Provides for immediate detec- times, with rate limits set 2-5 tion of pacemaker failure or laceration, failure to pace, failure to sense, and beats above and below set rate. malfunction. failure to capture. Obtain and observe rhythm strip Identifies proper functioning every 4 hours and prn. Notify of pacemaker, with appropriate MEDICAL CARE MD for abnormalities. capture and sensing.

Chest x-ray: used to evaluate placement of lead Monitor vital signs every 15 Assures adequate perfusion and wires minutes until stable, then cardiac output. every 2 hours. Electrocardiography: used to monitor for heart rhythm problems, dysrhythmias, and for Monitor for signs of failure Potential causes are low volt- function/malfunction of pacemakers to capture and correct problem. age, battery failure, faulty connections, catheter or wire Surgery: for placement of permanent pacemakers fracture, improper placement of catheter, or fibrosis at NURSING CARE PLANS tip of catheter. Monitor for signs of failure Potential causes are lead dis- Alteration in tissue perfision: to sense patient’s own rhythm lodgment, battery failure, low curdiopulmonay, cerebral and correct problem. sensitivity, catheter wire fracture, or improper placement of Related to: cardiac dysrhythmias, heart blocks, catheter. tachydysrhythmias, decreased blood pressure, Monitor for signs of failure Potential causes are battery decreased cardiac output to pace and correct problem. failure, lead dislodgment, disconnection, or catheter lead Defining characteristics: decreased blood fracture. pressure, decreased heart rate, decreased cardiac output, changes in level of consciousness, mental Ensure that all electrical Prevents potential for micro- changes, cold clammy skin, cardiopulmonary equipment is grounded. Avoid shock and accidental electrocu- touching equipment and patient tion. Electric current seeks arrest at same time. Patients should the path of least resistance, not use radios, shavers, etc. and the potential for stray current to travel through the electrode into the patient’s heart may precipitate ventricular fibrillation. ~ CARDIOVASCULAR SYSTEM 61

INTERVENTIONS RATIONALES INTERTENTIONS RATIONALES Place a dry rubber glove over Provides insulation to prevent Protect patient from microwave Environmental electromagnetic exposed terminals or leads. stray current contact. Static ovens, radar, diathermy, elec- interference may impair demand Wear rubber gloves when hand- electricity may pass from person trocautery, TENS units, etc. pacemaker function by disrupting ling the electrodes, terminals, to person through the leads. the electrical stimulus. etc. If the patient experiences Disconnection prior to DC coun- Pacemaker batteries should not Patients may be totally depen- cardiopulmonary arrest, the tershock prevents pacer damage be changed while the pacer is dent on the pacemaker for their pacemaker should be turned off and potential of diversion of in use. In cases of hardship, rhythm and cardiac output and and disconnected from the pa- electrical current. batteries should be changed as loss of time incurred to change tient for ventricular fibrilla- quickly as possible, wearing the battery may result in life- tion. After defibrillation, rubber gloves, and using utmost threatening consequences. the pacemaker should be recon- caution to avoid touching the nected, turned on, and output battery terminals. should be raised to 20 mA, rate above GO. Monitor for musde witching or May indicate lead has dislodged hiccoughs. and migrated to chest wall or diaphragm after perforation of Information, Instruction, heart. Demonstration

~~~ Monitor for sudden complaints May indicate perforation of the INTERVENTIONS RATIONALES of chest pain, and auscultate pericardial sac, and impending for pericardial friction rub or cardiac tamponade. Instruct on need for pacemaker, Provides knowledge, decrezses muffled heart tones. Observe procedures involved, expected fear and anxiery, and provides for JVD and pulsus paradoxus. outcomes, etc. baseline for further instruction. Monitor for dizziness, syncope, During ventricular pacing, AV weakness, pronounced fatigue, synchrony may cease and cause Instruct in checking pulse rate Provides patient with some edema, chest pain, palpitations, a sudden decrease in cardiac every day for 1 month, then control over situation. As- pulsations in neck veins, or output. May indicate “pace- every week, and to notify MD if sists in promoting a sense dyspnea. maker syndrome” or failure rate varies more than 5 beats/ of security. Allows for of the pacer to function which minute. prompt recognition of devi- results in decreased perfusion. ations from preset rate and potential pacemaker failure. Limit movement of the extremi- Prevents accidental disconnec- ty involved near insertion site. tion and dislodgment of lead Instruct on activity limita- Full range of motion can be wires. tions: avoid excessive bend- recovered in approximately ing, stretching, lifting more 2 months after fibrosis If pacemaker is used concurrent- Inflation of pulmonary artery than 5 pounds, strenuous acti- stabilizes the pacemaker ly with pulmonary artery catheter catheter balloon for capillary vities, or contact sports. lead. Excessive activity obtain wedge pressure only as MD wedge pressures may dislodge may cause lead dislodgment. orders. pacer lead wires and cause pacemaker malfunction. Instruct to avoid shoulder- May promote irritation over strap purses, suspenders, or implanted generator site. Monitor patient for low blood May impair the pacemaker stim- firing rifle resting over gen- sugar levels, use of glucocor- ulation thresholds. erator site. ticoids or sympathomimetics, mineralocorticoids, or anesthe- Instruct to wear a medic-alert Provides information about the tics. bracelet with information about patient, his condition, and the type of pacemaker and rate. pacemaker should he be incapa- citated and cannot speak for himself. 62 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Outcome Criteria Instruct to notify MD if radi- Therapy can cause failure of Patient will have healed wound sites without ation therapy is needed and to the silicone chip in the pacer wear a lead shield. with repeated radiation. signs/symptoms of infection.

Instruct to avoid electromag- May affect the function of the INTERVENTIONS RATIONALES netic fields, magnetic resonance pacemaker and alter the pro- Inspect pacemaker insertion Prompt detection of problems imaging, radio transmitters, arc grammed settings. Sometimes site for erythema, edema, warmth, promotes prompt treatment. welding equipment, large running these magnetic fields will drainage, or tenderness. motors, or large ungrounded affect the pacemaker function power tools. If patient notices only if direct contact is made Change dressing daily, or per Allows for observation of site dizziness or palpitations, he and once distance is placed hospital protocol, using sterile and detection of inflammation should try to move away from between the patient and the technique. or infection. Sterile technique the area, and if symptoms per- equipment, normal function of is recommended due to the close sist, to seek medical attention. the pacemaker resumes. If proximity of the portal to the Late model microwave ovens are programmed settings are altered heart increasing the potential no longer thought to be a threat the pacer will require repro- for systemic infection. due to tighter seals preventing gramming. Hyperbaric oxygen leakage of energy. chambers may also affect pacer Pacemaker lead wires should be Avoids potential for accidental- function. coiled and taped securely to ly disconnecting pacemaker from patient; pulse generator should generator, or dislodging leads be secured to avoid pulling. from heart. Discharge or Maintenance Evaluation

Patient will be free of dysrhythmias and able to Information, Instruction, maintain cardiac output within normal limits. Demonstration

Patient will be able to recall accurately all INTERVENTIONS RATIONALES instructions given. Instruct on wound care to pacer Promotes compliance with care site; to avoid taking showers to decrease potential for infec- Patient will be able to recall and adhere to all for 2 weeks after pacer insertion. Moisture can promote bac- activity restrictions. tion. terial growth.

Permanent pacemaker function will be without lnstruct to observe for and re- Provides for prompt recognition complication, with no lead dislodgment or com- port to MD the following symp- of complications and facilitates petitive rhythms noted. toms: redness, drainage, remper- prompt treatment. ature greater than 100 degrees, Alteration in skin interity pain or tenderness to site, or swelling at site. Related to: insertion of temporary or permanent pacemaker, alteration in activity Instruct to avoid constrictive May cause discomfort at incision dothing until site has healed. site from pressure and rubbing Defining characteristics: disruption of skin tissue, against skin. insertion sites Instruct on need for pacemaker Pulse generators may require re- removal/replacement. moval for battery replacement, fracture of lead wires, pacemaker failure, etc. CARDIOVASCULAR SYSTEM 63

Discharge or Maintenance Evaluation INTERVENTIONS RATIONALES Patient will have well-healed incision with no Monitor for dyspnea, chest pain, May indicate puncture of the pallor, cyanosis, absent or dim- lung and pneumothorax. signs/symptoms of infection. inished breath sounds, tracheal deviation, and feeling of impen- Patient will be able to recall accurately all ding doom. instructions given. Monitor for muscle twitching and May indicate perforation of the Patient will be able to demonstrate appropriate hiccoughs. Notify MD. heart with pacing to the chest wound care prior to discharge. wall or diaphragm. Potential for injury Observe for signslsymptoms of May indicate perforation of the Related to: pacemaker failure, hemothorax or cardiac tamponade-pericardial pericardial sac and impending pneumothorax after insertion, bleeding, lead friction rub, pulsus paradoxus, cardiac tamponade. muffled heart tones, JVD. migration, heart perforation Defining characteristics: decreased cardiac output, Discharge or Maintenance Evaluation hemorrhage, diaphoresis, hypotension, restlessness, dyspnea, cyanosis, chest pain, muscle twitching, Patient will have no complications associated hiccoughs, muffled heart sounds, jugular vein dis- with pacemaker insertion. tention, pulsus paradoxus Patient will have clear breath sounds, with no Outcome Criteria inadequacy of oxygenation. Patient will be free of infection or hemorrhage. Patient will be free of any complications that may be associated with pacemaker insertion. Alteration in comfort [See MI] INTERVENTIONS RATIONALES

~ Monitor for bleeding at pacer Bleeding at incisional site Related to: pacemaker insertion or transcutaneous site. Apply pressure dressings may occur based on the patient’s pacing as warranted. coagulation status. Pressure dressings or manual pressure may Defining characteristics: communication of pain, be required to control bleeding. facial grimacing, restlessness, changes in pulse and blood pressure Monitor for pulse presence at Hemorrhage may promote tissue site distal to pacer insertion. edema and compression to ar- Anxiety terial blood flow resulting in diminished or absent pulses. [See MI] Related to: change in health status, fear of death, Monitor for hypotension, dia- May indicate puncture of the phoresis, dyspnea, and restless- subclavian vasculature and po- threat to body image, threat to role functioning, ness. tential hemothorax. pain Defining characteristics: restlessness, insomnia, anorexia, increased respirations, increased heart rate, increased blood pressure, difficulty concentrating, dry mouth, poor eye contact, decreased energy, irritability, crying, feelings of helplessness 64 CRITICAL CARE NURSING CARE PUNS

Impaired physical mobility INTERVENTIONS RATIONALES Related to: pain, limb immobilization Monitor for progression and im- Physical therapy may be re- provement in stiffnedpain. quired if immobility results Defining characteristics: inability to move as are severe. desired, imposed restrictions on activity, decreased muscle strength and coordination, limited range of Apply trapeze bar to bed. Allows for easier movement by allowing patient to assist with motion movement in bed.

Reposition every 2 hours and Prevents potential for immobili- Outcome Criteria prn. ty hazards such as pressure areas and atelectasis. Patient will regain optimal mobility within limitations of disease process, and will have increased strength and function of limbs. Information, Instruction, Demonstration INTERVENTIONS RATIONALES Evaluate patient$ perception of Psychological and physical im- INTERVENTIONS RATIONALES degree of immobility. mobility are interrelated. Psy- Encourage deep breathing exer- Facilitates lung expansion and chological immobility is used as cises every 1-2 hours; avoid decreases potential for atelec- a defense mechanism when they forceful coughing. tasis. Coughing may dislodge have no control over their body, pacemaker lead. and this can lead to dispropor- tionate fear and concern. Changes in body image promote psychological immobility and Discharge or Maintenance Evaluation may result in emotional handi- caps. Patient will regain optimal mobility of all joints with no signs or symptoms of complications. Maintain bedrest for 24-48 hours Provides time for stabilization after permanent pacer inserted. of leads and decreases potential Patient will be able to demonstrate and recall for dislodgment. instructions regarding deep breathing and range of

Immobilize extremity proximal Prevents potential for dislodg- motion exercises. to pacer insertion site with arm ment of lead due to movement. board, sling, etc. Disturbance of body image Related to: presence of pulse generator, loss of Resume range of motion exercises Promotes gradual increase of 5 days after permanent pacer inactivity. Stretching should control of heart function, disease process sertion to affected extremity. be avoided until lead wire Provide ROM to unaffected extre- has been secured in heart by Defining characteristics: fear of rejection, fear of mity as warranted. fibrotic changes. ROM reaction from others, negative feelings about body, prevents stiffness of should- refusal to participate in care, refusal to look at ers and joint immobility. wound Encourage extension/dorsiflexion Promotes venous return, pre- exercises to feet every 1-2 vents venous stasis, and de- hours. creases potential for thrombophlebitis. CARDIOVASCULAR SYSTEM 65

Outcome Criteria Information, Instruction, Demonstration Patient will accept change in body image and deal constructively with situation. INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Discuss potential for mood Facilitates identification that changes, anger, grief, etc. af- feelings are not unusual and Evaluate level of patient’s May identify extent of problem ter discharge, and to seek help must be recognized in order to knowledge about disease process, and interventions that will be if persisting for lengthy time. effectively deal with them. treatment, and anxiety. required.

Evaluate the extent of loss to Depending on the time frame for Identify support groups for pa- Provides ongoing support for the patiendfamily, and what it patient teaching prior to the tient/family to contact. patient and family and allows means to them. insertion of the pacemaker, the for ventilation of feelings. patient may not have received adequate information, and may Consult counselor/therapist as May require further interven- have difficulty dealing with warranted. tions to resolve emotional or changes in his body appearance psychological problems. as well as generalized health condition and loss of control. Discharge or Maintenance Evaluation Evaluate stage of grieving. Provides recognition of appropriate versus inappropriate behavior. Prolonged grief Patient will be able to effectively deal with body may require further care. image disturbances in present situation.

Observe for withdrawal, manipu- May suggest problems with ad- Patient will be able to talk with family, lation, noninvolvement with care, justment to health condition, therapist, or others about emotional or psycho- or increased dependency. Set grief response to the loss of logical problems. limits on dysfunctional behav- function, or worry about others ior and help patient to seek accepting patient’s new body Patient will be able to problem-solve and iden- status. Patients may deal with positive behaviors that will tify short- and long-term goals within assist with recovery. crises in the same manner as previously dealt and may need reasonable expectations of clinical situation. redirection in behaviors to facilitate recovery and accep- Knowledge deficit tance. [See MI]

Provide positive reinforcement Promotes trust and establishes Related to: lack of understanding, lack of under- during care and with instruc- rapport with patient as well as standing of medical condition, lack of recall, new tion and setting goals. Do not provides an opportunity to plan health crisis give false reassurance. for rhe future based on reality of situation. Defining characteristics: questions regarding

Provide opportunity for patient Promotes self-esteem and facili- problems, inadequate follow-up on instructions to take active role in wound tates feelings of control of given, misconceptions, lack of improvement of care. body and health. previ0u.s regimen, development of preventable complications Provide reassurance that pace- Promotes knowledge and decreases maker will not alter sexual ac- fear. tivity. 66 CRITICAL CARE NURSING CARE PLANS

PACEMAKERS

Myocardial damage Incompetent valves Coronary flow compromise s Loss of elasticity of muscle fibers s Conduction aberrancies I Cardiac dysrhythmias (bradydysrythmias, SSS, tachydysrythmias, heart blocks, atrial fibrillation) I Pacemaker insertion s Implanted lead(s) identifies lack of stimuli 4 Electrical stimulus produced I Myocardium depolarized 4 Potential problems with pacemaker (disconnections, movement of electrodes, battery failure) s

I I I Failure to capture Failure to pace Failure to sense J s J Lethal dysrhythmias s Death CARDIOVASCULAR SYSTEM 67

fraction. This is the ratio of stroke volume com- pared to the end-diastolic volume and an ejection fraction greater than 55 reflects a good operative risk. Ejection fraction less than 25% is usually Coronary artery disease treatment requires the considered inoperable because of the high mortal- maximization of cardiac output and this can be ity associated with it. accomplished by improvement in heart muscle function and increase of blood flow through coro- The surgery is performed via a median sternotomy nary artery bypass grafting and/or valvular incision which provides exposure of the heart and replacements. Open heart surgery is commonly avoids the pleural spaces. A cannula is placed in a performed for three-vessel disease, valve dysfunc- vein and an artery and then attached to the tion and congenital heart defects and requires cardiopulmonary bypass machine whereby the blood to be diverted from the heart and lungs to diverted blood is mechanically oxygenated and cir- facilitate a bloodless operative field. culated to the other parts of the body. The machine, which is operated by a trained perfusion- In coronary artery bypass graft (CABG) surgery, a ist, substitutes for left ventricular pumping and graft from the arms or legs is anastomosed to the creates a blood-gas exchange. After the patient’s aorta with the distal portion to the involved coro- body temperature has been cooled to around 86 nary artery to bypass the diseased obstruction and degrees, the aorta is cross-clamped and a cold car- supply adequate blood flow to the heart. The dioplegic solution, usually containing dextrose, internal mammary artery is also being utilized for potassium, magnesium and inderal, is placed CABG surgery because the patency rate is 90-95% around the heart and injected into the coronary over a 5-10 year time period, and there are less arteries. This causes an electromechanical arrest problems with differences in lumen size since an and provides an inert operative site. Cross-clamp artery is then anastomosed to an artery without durations longer than 3 hours usually result in the need for routing from the aorta. In valvular severe complications for the patient. After the surgery, incompetent or leaking valves are replaced grafts have been completed or valves replaced, per- with prosthetic ones. fusion is slowly discontinued and cannulas are Not all patients with coronary artery disease are removed when arterial blood pressure and cardiac functioning are adequate. Two atrial and ventricu- candidates for CABG surgery. It is usually recom- lar pacing wires are placed, as well as arterial lines, mended for those patients with intractable angina, pulmonary artery catheter, left atrial line, and signs of ischemia, or an increased risk of coronary mediastinal or pleural chest tubes. ischemia/infarction as a result of angiographical studies. Complications may occur in almost every Common complications associated with CABG body system and may be a result of the disease surgery include perioperative MI, vein graft clo- process or defect, the surgery, or the use of sure, hemorrhage, blood trauma, complement cardiopulmonary bypass, and so the decision for activation, coagulation abnormalities, fluid shifts, surgery is a multi-faceted one. increased catecholamine levels, fat emboli, microemboli, dysrhythmias, pericarditis, postperi- One of the most important factors in the decision of candidacy for CABG surgery is the ejection 68 CRITICAL CARE NURSING CARE PLANS cardiotomy syndrome, embolism, pneumonia, Chest x-ray: used to identify heart size and posi- atelectasis, hemothorax, pneumothorax, and post- tion, pulmonary vasculature, pulmonary changes, cardiotomy delirium. Other complications that are verifies position of endotracheal tube, pacing seen less often include stress ulcer, renal failure, wires, and hemodynamic catheters; monitors for respiratory failure, cardiac tamponade, cardiogenic bar0 trauma shock, endocarditis, gastrointestinal bleeding, Cardiac catheterization: used to evaluate abnor- mediastinitis, and paralytic ileus. mal pressures preop, to assess for pressure gradients across the valves, and to locate and mea- MEDICAL CARE sure coronary lesions Pulmonary function studies: used to ascertain baseline pulmonary function NURSING CARE PLANS Laboratory: hemoglobin/hematocrit used to mon- Risk for decreased cardiac output itor oxygen-carrying capability, need for blood Related to: myocardial depression, dysrhythmias, replacement, and to monitor for dehydration electrolyte imbalances, hypovolemia, status; electrolytes used to monitor for imbalances hypervolemia, myocardial infarction, coronary which can affect cardiac function; BUN and crea- artery spasm, vasoconstriction, impaired contrac- tinine used to monitor renal function; liver profile tility, alteration in preload, alteration in afterload, used to monitor liver function and perfusion; glu- hypo perfusion, microemboli, hypoxia, damaged cose used to monitor for presence of diabetes, myocardium, use of while on ventilatory nutritional alterations, or organ dysfunction; car- PEEP support diac enzymes and isoenzymes used to monitor for presence of acute or perioperative myocardial Defining characteristics: elevated blood pressure, infarction; coagulation profiles used to determine elevated mean arterial pressure greater than 120 baseline and monitor for coagulation problems; mmHg, elevated systemic vascular resistance antibody or complement levels used to monitor greater than 1400 dyne-seconds/cm5, cardiac for postpericardiotomy syndrome or Dressler’s output less than 5 L/min or cardiac index less syndrome; type and crossmatch for blood to have than 2.7 L/min/m2, tachycardia greater than 110, available blood products on hand in case of hem- cold, pale extremities, absent or decreased periph- orrhage; ACT used to monitor heparinization eral pulses, EKG changes, hypotension, S3 or S4 gallops, decreased urinary output, diaphoresis, Arterial blood gases: used to monitor oxygenation orthopnea, dyspnea, crackles (rales), jugular vein and assess acid-base balance and ability to wean distention, edema, chest pain off mechanical ventilation Electrocardiography: used to observe for changes Outcome Criteria in cardiac function, presence of conduction problems, dysrhythmias, or ischemic changes Vital signs and hernodynamic parameters will be within normal limits for patient, with no Echocardiography: used to evaluate wall motion dysrhythmias noted. of the heart CARDIOVASCULAR SYSTEM 69

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Monitor vital signs, especially Tachycardia may occur as a res- Measure left atrial pressure Determines the left ventricular heart rate and blood pressure. ponse to pain, anxiety, blood and pulmonary artery wedge pres- end-diastolic volume; increases Notify MD of abnormalities. and fluid deficit, and stress, sures. in pressure may indicate conges- Blood pressure should be taken/ but rates over 130 increases tive heart failure or pulmonary monitored every 15 minutes until myocardial oxygen consumption edema, and decreases may indi- stable, or every 5 minutes dur- and workload on the heart, de- cate low blood volume. Trends ing active titration. creasing cardiac output. In- and changes in values are of creased blood pressure may pro- more importance than single mote alterations in heart pres- readings. Left ventricular dys- sures and increase the risk of function can elevate left heart complications, as well as pla- filling pressures without a rise cing pressure on suture lines in right heart pressures. of new grafts. Hypotension may result from fluid deficit, dys- Monitor urine output hourly and Urine output is an indication rhythmias, and cardiac failure, notify MD if less than 30 cclhr. of adequate cardiac output and as well as predispose peripheral renal perfusion. vein grafts to close. Observe for decreased peripheral May indicate low cardiac output. Evaluate hypotension that is May indicate cardiac tamponade pulses, cool or cold moist skin, not responsive to fluid bolus, in a heart that is unable to or cyanosis. tachycardia, and distant heart fill adequately to maintain sounds. cardiac output. Tamponade usu- Monitor for changes in level of Cerebral perfusion is dependent ally occurs immediately post-op consciousness, mental status on adequate cardiac output. Hy- but may occur later during re- changes, restlessness, or con- poperfusion or microemboli may covery period. fusion. result in CNS deficits.

Monitor hemodynamic pressures Assists with recognition of Monitor for JVD, peripheral ede- May indicate present or impend- every 1 hour and prn. Maintain complications and allows for ma, and pulmonary congestion. ing congestive heart failure. pressures with titration of va- manipulation of cardiac pres- Auscultate for crackles (rales). soactive drugs per MD ordered sures by use of fluids and parameters. medications. Vasoconstriction Observe for shortness of breath, May indicate hypoxia and de- is the cause of elevated SVR, decreases in oximetry, or dyspnea. creased cardiac output. and with increases in SVR, may indicate left ventricular dys- Monitor EKG for cardiac conduc- Lethal dysrhythmias may occur function. Cardiac output then tion disturbances, dysrhythmias, as a result of electrolyte im- becomes dependent on outflow or changes in ratelrhythm. balances, myocardial ischemia resistance. or infarction, or problems with electrical conduction, with an Measure cardiac outpudcardiac Cardiac output is a measurement associated drop in cardiac out- index every 1-2 hours immedi- that is equal to the product of put. ately post-op. the stroke volume and the heart rate. Cardiac indexes above 3.0 Monitor for complaints of se- May indicate a perioperative or Ymin/m2 are usually adequate vere chest pain. postoperative myocardial infarc- except in cases of septic shock. tion. Adequate cardiac output relates to the adequacy of function of Provide for uninterrupted rest Prevcnts fatigue and increased other body organs. After CABG periods and assist with care as workload on the heart leading surgery, most patients require needed. to decrease in cardiac output an increase in CO to meet the and perfusion. stress imposed by the operation and the accompanying increase in oxygen consumption. 70 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Outcome Criteria Administer IV fluids as ordered. Maintains fluid status and hydration, as well as provides ac- Patient will be free of pain or pain will be cess for emergency medications. controlled to patient’s satisfaction.

Administer blood products as or- Blood or packed red cells may be INTERVENTIONS RATIONALES dered. required to maintain adequate Evaluate complaints of pain- Pain may be perceived in differ- oxygen-carrying capability, and type, location, intensity based ent ways by each individual and adequate circulating volume for on 0- 10 scale. Compare preoper- is important to differentiate cellular activity. Platelet func- ative pain perceptions with post- incisional pain from other types tion and count is decreased operative pain. of chest pain. CABG patients with use of cardiopulmonary by- usually do not have severe dis- pass and proportional to the comfort to the chest incision duration of bypass and depth but may have increased discom- of hypothermia during surgery. fort with donor sire pain. Severe pain should be investiga- ted for possibility of compli- Information, Instruction, cations. Demonstration Monitor vital signs. Heart rates usually increase INTERVENTIONS RATIONALES with pain but bradycardia may occur especially in severely Attempt to reverse any contrib- These may precipitate a low CO damaged myocardium. Blood pres- uting factor such as untreated state. sure may be increased with in- DKA or endocrine dysfunction. cisional pain, but can also be labile or decreased when chest Prepare patient for placement Promotes knowledge and pain is severe or if myocardial on IABP. decreases fear. ischemidnecrosis occurs.

Evaluate complaints of pain in May be indicative of develop- Discharge or Maintenance Evaluation legs or abdomen, or vague non- ment of thrombophlebitis, infec- specific complaints, especially tion or GI dysfunction. Patient will have maximal cardiac output and if associated with changes in mental status or vital signs. stable hemodynamic pressures. Patient will have adequate perfusion of all body Monitor for complaints of pain May result from stretching of and/or paresthesia to ulnar the brachial plexus during posi- sys tems. area of the hand, and possibly tioning of the arms during sur- pain to shoulders and arms. gery and generally resolves over Patient will be able to recall instructions time without specific treatment. correctly. Observe for anxiety, irritabili- Nonverbal cues may indicate the Alteration in comfort ty, crying, restlessness, or in- presence of pain. somnia. Related to: mediastinal, leg, or arm incisions, myocardial infarction, angina, inflammation, Administer analgesics as soon as Pain results in muscle tension, tissue damage discomfort is noticed, or pro- which can decrease circulation phylactically prior to painful and intensify pain perception. Defining characteristics: communication of dis- procedures. Medication given prior to procedures known to cause pain may comfort or pain, restlessness, irritability, increased facilitate cooperation with pro- heart rate, increased blood pressure CARDIOVASCULAR SYSTEM 71

INTERVENTIONS RATIONALES Defining characteristics: dyspnea, tachypnea, apnea, ventilation/perfusion mismatching, abnor- cedures and allow for easier chest movement with respiratory mal ABGs, pain, increased hemodynamic therapy. pressures, oxygen saturation less than 90%, adventitious breath sounds, hypoxia, hypoxemia Provide back rubs, position chan- Promotes relaxation and helps to ges, and diversionary activities. redirect attention away from discomfort, thereby reducing the Outcome Criteria amount of analgesic required. Patient will be eupneic with clear breath sounds, Encourage deep breathing, visu- Promotes decrease in stress alization, or guided imagery. and may reduce analgesic need. and have no evidence of hypoxia/hypoxemia. INTERVENTIONS RATIONALES Information, Instruction, Monitor respiratory rate and Respiratory rates may be in- Demonstration depth, presence of dyspnea, use creased by pain, fever, blood of accessory muscles, nasal flar- loss, fluid loss, anxiety, hy- ing, and increasing respiratory poxia, or gastric distention. INTERVENTIONS RATIONALES work effort. Decreases in rate may occur Instruct on methods to reduce Supporting extremities and the with use of narcotic analgesics. strain on muscles when position- maintenance of good body align- Prompt recognition of potential ing. ment reduce muscle tension and complications can promote provide comfort. prompt treatment.

Auscultate lung fields for di- Breath sounds are frequently di- Discharge or Maintenance Evaluation minished or absent breath sounds minished immediately post-op as or for adventitious sounds. a result of atelectasis. Loss of breath sounds in a previously Patient will be comfortable, pain-free, and be ventilated lung may indicate a able to recall methods for stress reduction and partid or total lung collapse, pain coiitrol accurately. especially when chest tubes have recently been discontinued. Ad- Patient will be able to identify differences ventitious breath sounds may in- between postoperative and preoperative chest dicate fluid or secretions have accumulated in the interstitial pain. spaces or airways resulting in a partial occlusion of the air- Patient will be able to maintain optimal body way. alignment and minimize muscle tension. 1 Evaluate chest expansion for Unilateral incomplete chest ex- Risk for inefective breathing symmetry. pansion may indicate that air or patternhmpaired gas exchange fluid is preventing complete expansion of the pleural space, Related to: inadequate ventilation, possibly a pneumothorax. ventilatiodperfusion mismatching, abnormal Administer oxygen by cannula Provides supplementd oxygen to ABGs, pain, blood loss, atelectasis, pneumothorax, or mask as warranted. decrease the workload on the hemothorax, increased pulmonary vascular resis- heart and to maximize oxygen de- tance, increased capillary permeability, chemical livery to under-perfused tissues. mediators, decrease in surfactant 72 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Observe for pallor or cya- Cyanosis of lips, nailbeds, or port post-CABG due CO their me- nosis, especially to mucous earlobes, or generalized duski- chanism of breathing. Ventila- membranes. ness may indicate hypoxia as a tors provide controlled amounts result of heart failure or pul- of oxygen and tidal volumes, and monary dysfunction. Pallor is COPD patients have their inert frequently noted immediately drive to breathe removed by the postoperatively due to blood use of ventilation. Occasion- loss or insufficient blood re- ally with use of the cold car- placement. dioplegic solution, the phrenic nerve is injured resulting in a Observe for presence of cough Endotracheal tube intubation loss of function of the dia- and sputum character. may promote throat irritation phragm which is necessary for which can result in coughing, 60% of the spontaneous tidal but cough may also indicate volume for the patient. impending pulmonary congestion or infection. Purulent sputum Suction patient every 2-4 hours Removes mucous thar may occlude may reflect pneumonia. and prn. Use pulmonary toilette airways. Saline instillation and hyperoxygenate prior to and helps to liqueg secretions to Encourage deep breathing ex- Promotes expansionlre-expansion after suaioning. facilitate easier removal. Oxy- ercises, inspiratory spirometer, of airways. Adventitious breath gen concentration drops drastic- or coughing exercises. sounds may indicate presence of ally with suaioning procedures secretions or fluid in lungs. and leaves the patient compromised with an increased oxygen Observe for signs of respiratory May indicate impending pneumo- consumption. distress, tachycardia, extreme thorax or hemothorax, expecially restlessness and feeling of im- after chest tube removal. May Auscultate breath sounds pre- Provides for comparison of pending doom. require reinsertion of chest and post-suctioning. breath sounds to evaluate for tubes. improvement. Occasionally, suctioning will move secretions Monitor respiratory status and CABG patients are placed on me- up the bronchial tree and may ventilatory settings every 1-2 chanical ventilation support cause a partial or total occlu- hours while on ventilator. until awake from anesthesia. sion of an airway. Decreases in FI02 is initially 100% and then previously venrilated lung gradually decreased, while main- fields may indicate this pheno- raining an adequate PaO2 above menon has occurred. 90. FIO2 should be decreased to .50 as rapidly as possible to Monitor use of amiodarone and Some drugs can exacerbate pul- prevent actual pulmonary changes protamine sulfate. Observe for monary problems by their method that occur with high levels of respiratory impingement. of action. oxygen. Tidal volumes are usually maintained between 10-15 cclKg of ideal body weight to allow for less interference with venous return.

Assist with weaning from ven- Weaning is usually performed by tilatory support. Monitor for reducing the rate and then a hemodynamic instability and de- trial on a T-bar or CPAP mode. creasing oxygen saturation. Patients who have a history of Monitor ABGs as ordered. smoking or COPD often have prolonged need for ventilatory sup- CARDIOVASCULAR SYSTEM 73

Information, Instruction, Patient will be compliant with respiratory regi- Demonstration men, and will be able to recall all instructions accurately. INTERVENTIONS RATIONALES Alteration in skin integrity Prepare patient for placement Lengthy instruction may not be on mechanical ventilation if prudent or possible depending Re1ate:d to: insertion of temporary or permanent warranted. on the severity of the situation. If oxygenation cannot be pacemaker, alteration in activity, surgical incisions, maintained with the use of sup- puncture wounds, drains plemental oxygen, the only alternative is intubationlventi- Defining characteristics: disruption of skin tissue, lation. insertion sites

Prepare patient for insertion Prolonged endotracheal intuba- of tracheostomy after 10 days tion may result in tracheal or Outcome Criteria of ETT intubation/ventilation. nasal necrosis or rupture of cuff. Tracheostomy is con- Patient will have healed wound sites without sidered to prevent ulceration signs/symptoms of infection. into arteries or other vital tissues, but may need to be INTERVENTIONS RATIONALES avoided due to potential for contamination of sternotomy Inspect pacemaker insertion Prompt detection of problems wound from secretions. site for erythema, edema, warmth, promotes prompt treatmenr. drainage, or tenderness. Instruct patient on need for Promotes lung expansion and ambulation, movement, change prevents pulmonary congestion. in position. Observe all incisions for heal- Chest incisions usually heal ing and progress. Notify MD first due to minimal amounts Instruct on need for respira- Reassures patient that com- for incision4 areas that are of muscle tissue involved. Do- tory treatments, coughing, deep plying with aggressive pul- not healing, areas that have nor sites have more muscle tis- breathing. monary regimen will not Cause reopened or dehisced, edema- sue, usually are more lengthy injury to surgical sites. tous and erythematous tissues, incisions and have poorer cir- bloody or purulent drainage, or culation thereby requiring a Prepare patient for reinsertion Promotes re-expansion of lung hot painful areas. longer healing process. Signs of chest tubes as warranted. by removing accumulated fluid, may indicate a failure to heal, blood, or air, and restores or the development of complica- normal negative pressure in the tions that require further in- pleural cavity. tervention.

Culture drainage from wound as Identifies causative organism Discharge or Maintenance Evaluation warranted. that may result in local or systemic infection, and allows for identification of suitable Patient will be free of dyspnea with adequate antimicrobial therapy. ABGs and oxygenation, and without evidence of cyanosis or pallor. Change dressings daily, or per Allows for observation of site Patient will have clear breath sounds to all lung hospital protocol, using sterile and detection of inflammation fields with no lung collapse. technique. or infection. Sterile technique is recommended due to the close proximity of the portal to the heart increasing the potential for systemic infection. 74 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALFB Potential for injury Utilize steri-strips to sup- Maintains approximation of heal- [See Pacemakers] port incisions when sutures are ing wound edges to facilitate Related to: pacemaker failure, hemothorax or removed. healing of skin tissues. pneumothorax after insertion, bleeding, lead migration, heart perforation Provide adequate nutritional Maintains adequate circulating and fluid intake. volume, assists to meet energy Defining characteristics: decreased cardiac output, requirements to facilitate hemorrhage, diaphoresis, hypotension, restlessness, tissue healing and perfusion. dyspnea, cyanosis, chest pain, muscle twitching, hiccoughs, muffled heart sounds, jugular vein dis- Information, Instruction, tention, pulsus paradoxus Demonstration Anxiety INTERVENTIONS RATIONALES [See MI] Instruct on wound care to wound Promotes compliance with care Related to: change in health status, fear of death, sites. to decrease potential for infcc- threat to body image, threat to role functioning, tion. Moisture can promote bacterial growth. pain

Instruct to observe for and re- Provides for prompt recognition Defining characteristics: restlessness, insomnia, port to MD the following symp- of complications and facilitates anorexia, increased respirations, increased heart toms: redness, drainage, temper- prompt treatment. rate, increased blood pressure, difficulty concen- ature greater than 100 degrees, trating, dry mouth, poor eye contact, decreased pain or tenderness to site, or swelling at site. energy, irritability, crying, feelings of helplessness

Instruct to avoid constrictive May cause discomfort at incision Knowledge &+it clothing until site has healed. site from pressure and rubbing [See MI] against skin. Related to: lack of understanding, lack of under- Instruct to avoid tub baths Effort needed to get in and out standing of medical condition, lack of recall until allowed by MD. of tub requires use of pectoral and arm muscles which may con- Defining characteristics: questions regarding prob- tribute to placing undue stress lems, inadequate follow-up on instructions given, on suture lines of sternotomy. misconceptions, lack of improvement of previous regimen, development of preventable compli- Discharge or Maintenance Evaluation cations

Patient will have well-healed incision with no Impairedphysical mobility signs/symptoms of infection. [See Pacemakers] Patient will be able to recall accurately all Related to: pain, limb immobilization instructions given. Defining characteristics: inability to move as Patient will be able to demonstrate appropriate desired, imposed restrictions on activity, decreased wound care prior to discharge. muscle strength and coordination, limited range of motion CARDIOVASCULAR SYSTEM 75

Disturbance of body image [See Pacemakers] Related to: presence of pulse generator, loss of control of heart function, disease process, presence of scarslwounds Defining characteristics: fear of rejection, fear of reaction from others, negative feelings about body, refusal to participate in care, refusal to look at wound This Page Intentionally Left Blank CARDIOVASCULAR SYSTEM 77

The goal for treatment is to remove or repair the Aortic Aneurysm aneurysm and restore vascular circulation. An aneurysm is a localized dilation of an artery Aneurysms are generally monitored until their size that may occur as a congenital anomaly or as a reaches 6 cm or greater, and then surgical result of arteriosclerosis and high blood pressure. intervention is indicated to prevent complications There are three types of aneurysms found-saccu- such as rupture, stroke, or organ ischemia. Dacron lar in which the vessel distention protrudes from grafts are used to help establish blood flow. one side; fusiform in which the distention involves the entire circumference of the vessel; and dissect- MEDICAL CARE ing in which a tear occurs in the intimal layer of the artery and with pressure, blood splits the wall Oxygen: to increase available oxygen supply producing a hematoma that separates the medial Electrocardiography: used to monitor heart layers of the aortic wall. In dissecting aneurysms, rhythm and rate for changes associated with generally the separation of the layers does not decreases in perfusion, dysrhythmias, and for signs completely encircle the lumen but may run the of left ventricular hypertrophy entire length of the vessel. Chest x-ray: used to observe for increase in aortic Factors that may precipitate aneurysm formation diameter, right tracheal deviation, and pleural effu- include atherosclerosis, hypertension, syphilis, sions Marfan’s syndrome, cystic medial necrosis, trauma, congenital abnormalities, and pregnancy. Abdomiinal x-ray: used to visualize aneurysm Aneurysms that result from Marfan’s syndrome CT scans: used to visualize vessel wall thickness, usually involve the first portion of the aorta, and lumen size, length of the aneurysm, and any mural result in aortic insufficiency. Syphilitic aneurysms thrombi usually occur in the ascending thoracic aorta. Angio-aortography: used to visualize lumen, Abdominal aortic aneurysms (MA)usually involve extent of disease, extent of collateral circulation, that part of the aorta between the renal and iliac arteriovenous fistulas, extent of dissection, and arteries, and thoracic aortic aneurysms (TAA) double I umens occur mainly in the ascending, transverse or Ultrasound: used to visualize the vessels and descending aorta with a prevalence toward men aneurysm non-invasively, amount of blood flow, between 60 and 70 years of age. Mycotic and velocity of blood flow aneurysms occur as a result of weakness in the vessel from an infective process, such as endocardi- Laboratory: CBC used to monitor for decreases in tis, and usually involve the peripheral arteries, but hemoglobin and hematocrit and for increases in have been known to affect the aorta. leukocytes; BUN and creatinine used to monitor for renal dysfunction; urinalysis used to monitor AAA as a result of arteriosclerosis may be asympto- hematuria and proteinuria to detect renal compro- matic until they become large enough to palpate, mise large enough to cause pressure and pain, or until leaking or rupture occurs. Frequently, rupture of Surgery: necessary to replace aneurysm with the AAA leads to vascular collapse and shock, and dacron graft andlor repair the aneurysm ultimately, death if not treated. 70 CRITICAL CARE NURSING CARE PLANS

NURSING CARE PLANS INTERVENTIONS RATIONALES Monitor for pain especially onsei Abrupt severe tearing pain in Alteration in tissue pe&ion: of sudden sharp pain, and notify chest radiating to shoulders, cardio ulrnonary, cerebral, gastrointestinal, MD. neck, back, and abdomen is in- per+ Rerad renal dicative of aortic dissection and requires prompt interven- Related to: arterial occlusion, aneurysm, dissecting tion. Low back pain may indicate impending rupture. aneurysm, or operative complications Defining characteristics: pulsating mass, bruits, Observe for dysphagia. Aneurysm may exert pressure on esophagus. thrills, abdominal pain, low back pain, nauseahorn- iting, syncope, chest pain, cough, hoarseness, Observe for voice weakness, Aneurysm may exert pressure dysphagia, dyspnea, shortness of breath, pallor, loss hoarseness, paroxysmal cough, on laryngeal nerve or on the or dyspnea. trachea. of pulses, paresthesias, paralysis Auscultate for bruits over ar- Indicates diminished blood teries; observe and palpate gent- flow indicative of aneurysm. Outcome Criteria ly for thrill over abdomen. A large aneurysm will have Auscultate for cardiac murmurs. a palpable mass and thrill. Patient will achieve and maintain hernodynamic An aortic murmur will be stability, with all body systems adequately perfused, present if the aneurysm in- and in the absence of pain, volves the aortic ring. INTERVENTIONS RATIONALES Administer antihypertensives as Hypertension may exacerbate ordered to maintain BP within decreased tissue perfusion Monitor blood pressure in upper Normally systolic BP in thigh acceptible parameters. and compromise cardiovascular and lower extremities. is greater than in the arm, but status. is reversed much of the time with abdominal aneurysms. Prepare patient for surgery as Surgical intervention may be indicated. mandatory if circulation is Monitor other vital signs and Hypertension may exacerbate compromised. hemodynamic parameters. cardiac and peripheral perfusion instabiliry.

Monitor pulses in both wrists Pulse differences may be noted Information, Instruction, as well as in both legs. between wrists and between legs Demonstration if the aneurysm interferes with circulation to that particular INTERVENTIONS RATIONALES extremity. Instruct on disease process, Reduces anxiety and promotes need for surgery, postoperative knowledge and compliance. Observe for the 5 P’s-pain These may be associated with care. to extremity, pallor, pulse- thrombosis of the AAA. lessness, paresthesia, and Monitor vital signs and hemo- Hypertension may exacerbate paralysis. Notify MD. dynamic parameters. Maintain bleeding due to pressure on blood pressure at MD-ordered suture lines, and hypotension parameters. may not provide enough blood flow to keep graft open. Hypotension, tachycardia, and decreased hemodynamic pressures may indicate hypovolemia or hemorrhage. CARDIOVASCULAR SYSTEM 79

~ ~~ ~~~ INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation Auscultate lung fields for ad- Bedrest promotes atelectasis Patient will have stable vital signs and hemody- ventitious breath sounds. As- and decreased lung expansion sist patient with cough, deep which may lead to pneumonia. namic pressures. breathing exercises, incentive spirometry. Patient will be pain free.

Monitor oxygen saturation by Maintenance of adequate Patient will be alert, oriented, and able to verbal- oximetry. Administer oxygen oxygenation necessary for ade- ize instructions accurately. as ordered. quate tissue perfusion. Patient will have adequate perfusion to all body Monitor peripheral pulses every Pulselessness indicates de- systems. hour for 24 hours, then every 4 creased or no blood flow. hours, for color, temperature, Occlusion of peripheral ar- Lung fields will be clear and patient eupneic. capillary refill, and presence teries leads to ischemia and of pulses. Notify MD if absent. necrosis. Alteration in comfort

Measure circumference of abdo- Significant differences be- Related to: pressure exerted on various structures men or legs and notify MD of tween extremities or from day by aneurysm, infringement on nerves, surgical pro- significant changes. to day may indicate hemorrhage. cedures Monitor EKG for changes and dys- Decreases in tissue perfusion Defining characteristics: pain to abdomen, lower rhythmias. may cause cardiac decompensation, MIs, and dysrhythmias. back, hips, scrotum, chest, shoulders, neck, and back; nauseahomiting, increases in blood pressure, Monitor I&O every hour and Surgical procedures may result increased heart rate, facial grimacing, moaning, notify MD if < 30 cdhr. in decreased renal blood flow shortriess of breath due to length of cross damp time during aneurysm repair. Outcome Criteria Do not elevate head of bed > Higher flexion may cause flex- 30-45 degrees. ion at femoral artery site and may impede blood flow. Patient will be free of pain, with no associated deviations of vital signs. Auscultate abdomen for bowel Most major thoracoabdominal sounds. Monitor NG aspirate surgical patients develop an INTERVENTIONS RATIONALES for amount and characteristics. ileus and require decompression Monitor vital signs, and notify Pain may increase heart rate, of bowel with nasogastric tube. MD for unstable vital signs that increase blood pressure or de. do not change with analgesia. crease blood pressure, but Monitor patient for diarrheal May indicate bowel ischemia due instability may occur from stools and notify MD. to length of surgical procedure a variety of other causes. and decreased perfusion to gut. Assess for dull abdominal pain, May indicate impending rupture Observe for mental changes, May be due to repair of lower backache, lower badc pain. of abdominal aortic aneurysm. confusion, restlessness, and ascending and thoracic aortic headache. aneurysms. Assess fOr sudden severe pain to May indicate aortic dissection or abdomen that may radiate to back, rupture of AAA and hips, or scrotum, and is associ- requires immediate surgical ated with nausea, vomiting, and intervention. MI should also be hypotension. ruled out. 80 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Information, Instruction, Demonstration Assess for sudden tearing-type May indicate thoracic aortic of pain to chest that may ra- aneurysm. INTERVENTIONS RATIONALES diate to shoulders, neck, and back. Instruct in relaxation tech- Helps to decrease pain and niques, deep breathing, guided anxiety and provides dis- Observe for difficulty in swal- May indicate that aneurysm imagery, visualization, etc. traction from pain. lowing or talking. Assess for is placing pressure against voice hoarseness or cough. esophagus, laryngeal nerve, Instruct in activity alterations Decreases myocardial oxygen Observe for shortness of breath. or trachea. and limitations. demand and workload.

Instruct in medication effects, Promotes knowledge and com- Assess for pain to extremities, May indicate claudication of side effects, contraindications, pliance with therapeutic with mottling/cyanosis/pallor, peripheral arteries as a result and symptoms to report. regimen. Alleviates fear. pulselessness, or paralysis. of enlarged aneurysm placing pressure on vasculature. Para- lysis may indicate acute throm- Instruct patient to request Pain promotes muscle tension, bosis of the AAA. pain medication when pain be- and may impair circulatory comes noticeable and not to status and impair healing Assess for complaints of pain May be an early sign of impen- wait until pain is severe. process. that are vague or involve unre- ding complications, such as lated areas of body. thrombophlebitis or ulcer. Instruct in methods of splinting Supports surgical incision abdomen when coughing or deep to allow patient to expand Administer analgesics as ordered. Provides pain relief/reduction, breathing. lungs to prevent atelectasis, Medicate prior to painful proce- decreases anxiety, and reduces and minimizes pain level. dures as warranted. the workload on the heart and vasculature. Comfort and coop- Instruct in using pillows to Promotes comfort and reduces eration with painful procedures maintain body alignment and muscle tension and strain. may be enhanced by prior medi- support extremities. cation administration.

Maintain bedrest with position Reduces oxygen consumption Discharge or Maintenance Evaluation of comfort. and demand. Patient will report pain being absent or relieved Maintain relaxing environment Reduces competing stimuli which to promote calmness. reduces anxiety and assists with with medication administration. pain relief. Medication will be administered prior to pain Provide back rubs, reposition- Promotes relaxation and may re- becoming severe. ing every 2 hours and prn, and direct attention from pain. encourage diversionary activity. Analgesics may be reduced in Patient will be able to recall instructions on dosage and frequency by mini- medications accurately. mizing pain level. Activity will be modified in such a way as to prevent increased pain. CARDIOVASCULAR SYSTEM 81

Risk for impaired skin integrity [See Thrombophlebitis] Related to: edema, bedrest, surgery, pressure, altered circulation and blood flow, altered metabolic states Defining characteristics: skin surhce disruptions, incisions, ulcerations, wounds that do not heal Knowledge &ficit [See MI] Related to: lack of understanding, lack of understanding of medical condition, lack of recall Defining characteristics: questions regarding problems, inadequate follow-up on instructions given, misconceptions, lack of improvement of previous regimen, development of preventable complications 82 CRITICAL CARE NURSING CARE PLANS

AORTIC ANEURYSM

Degeneration of artery J, Weakening of arterial wall 3 Blood pressure increases tension and weakened areas 3 3 Loss of smooth muscle cells Thrombi line the surface of the aneurysm

3 J, Dissection of artery Lumen decreases

3 J, Increased pressures Pressure increases 3 4 Intima tears Aneurysm ruptures 3 Blood enters artery media 3 Media continues to tear further 3 Thin-walled channel created 3 Channel ruptures I 3 Hemorrhage 3 Cardiovascular compromise and collapse J, Death RESPIRATORY SYSTEM 83

Adult Respiratory Distress Syndrome (ARDS) Chronic Obstructive Pulmonary Disease (COPD) Pulmonary Embolism Pneumonia Pneumothorax Status Asthmaticus Mechanical Ventilation This Page Intentionally Left Blank RESPIRATORY SYSTEM 85

problems, and chest x-rays may be normal or Adult Respiratory show minimal diffuse haziness. The fluid leakage increases and lymphatic flow increases with the Distress Syndrome CARDS) acute phases with widespread damage to Adult respiratory distress syndrome (ARDS) is also pulmonary capillary membranes and known as shock lung, wet lung, white lung, or inflammation. Increases in intra-alveolar edema acute respiratory distress syndrome, and occurs leads to capillary congestion and collagen forma- frequently after an acute or traumatic injury or ill- tion. Surfactant production and activity decreases, ness involving the respiratory system. The body which causes decreased functional residual capac- responds to the injury with life-threatening respi- ity, increased pulmonary shunting with widening ratory failure and hypoxemia. A-a gradients, decreased pulmonary compliance, and ventilation/perfusion mismatching results. ARDS is usually noted 12-24 hours after the ini- Chest x-rays will then show the ground glass tial insult or 5- 10 days after sepsis occurs. appearance and finally a complete white-out of Dyspnea with hyperventilation and hypoxemia are the lung. usually the first clinical symptoms. Adventitious breath sounds frequently are not present initially. The chronic phases occurs when the endothelium thickens; Type I cells, which are the gas-exchange Some of the most common precipitating factors pneumocytes, are replaced by Type I1 cells, which are trauma, aspiration, pneumonia, near-drown- are responsible for producing surfactant, and ing, toxic gas inhalation, sepsis, shock, DIC, along with fibrin, fluid and other cellular material oxygen toxicity, coronary artery bypass, pancreati- form a hyaline membrane in place of the normal tis, fat or amniotic embolism, radiation, head alveoli. injury, heroin use, massive hemorrhage, smoke inhalation, drug overdose, or uremia. Mortality is The goals of treatment are to improve ventilation high (60-70%) despite treatment and often, and perfusion, to treat the underlying disease patients who do survive, may have chronic resid- process that caused the lung injury, and to prevent ual lung disease. In some cases, patients may have progression of potentially fatal complications. normal pulmonary function after recovery. Oxygen therapy with high levels of oxygen, mechanical ventilatory support with PEEE and The latent phase of ARDS begins when the pul- fluid and drug management are required. monary capillary and alveolar endothelium become injured. The insult causes complement to MEDICAL CARE be activated, as well as granulocytes, platelets, and the coagulation cascade. Free oxygen radicals, Laboratory: cultures to identify causative organ- arachidonic acid metabolites and proteases are isms when bacterial infection is present and to released into the system. Humoral substances, identify proper antimicrobial agent; C5A levels such as serotonin, histamine and bradykinin, are increase with disease process; fibrin split products released. This results in red blood cell and high increase; platelets decrease; lactic acid levels plasma protein leakage into the interstitial spaces, increase due to increased capillary permeability and Chest x-ray: used to evaluate lung fields; early x- increased pulmonary hydrostatic pressure. Initially, rays may be normal or have diffuse infiltrates; there may be little evidence of respiratory later x-rays will show bilateral ground glass 86 CRITICAL CARE NURSING CARE PLANS appearance or complete whiting-out of lung fields; Inefective airway clearance assists with differentiation between ARDS and [See Mechanical Ventilation] cardiogenic pulmonary edema since heart size is Related to: interstitial edema, increased airway normal in ARDS resistance, decreased lung compliance, pulmonary Oxygen: to correct hypoxia and hypoxemia secretions Arterial blood gases: to identify acid-base prob- Defining Characteristics: dyspnea, tachypnea, lems, hypocapnia, hypercapnia, and hypoxemia, cyanosis, use of accessory muscles, cough with or and to evaluate progress of disease process and without production, anxiety, restlessness, feelings effectiveness of oxygen therapy of impending doom Ventilation: to provide adequate oxygenation and Anxiety ventilation in patients who are unable to maintain [See Mechanical Ventilation] even minimal levels Related to: health crisis, effects of hypoxemia, fear Pulmonary function studies: used to evaluate of death, change in health status, change in envi- lung compliance and volumes which are normally ronment decreased; physiologic dead space is increased and Defining characteristics: apprehension, restless- alveolar ventilation is compromised ness, fear, verbalized concern Knowledge deficit [See Mechanical Ventilation] Ineffective breathing pattern Related to: lack of information, inability to [See Mechanical Ventilation] process information, lack of recall Related to: decreased lung compliance, Defining characteristics: verbalized concerns and pulmonary edema, increased lung density, questions decreased surfactant Decreased cardiac output Defining characteristics: use of accessory muscles, dyspnea, tachypnea, bradypnea, altered ABGs Related to: increased positive airway pressures, Impaired gas excbange sepsis, dysrhythmias, increased intrapulmonary edema, left ventricular failure [See Mechanical Ventilation] Defining characteristics: tachycardia, cardiac Related to: intra-alveolar edema, ateleccasis, venti- output less than 4 L/min, cardiac index less than lation/perfusion mismatching, decreased arterial Llminlm2, cold clammy skin, decreased PO,, decreased amount and activity of surfactant, 2.5 blood pressure alveolar hypoventilation, formation of hyaline membranes, alveolar collapse, decreased diffusing capacity, shunting Outcome Criteria

Defining characteristics: tachypnea, cyanosis, use Patient will be hemodynamically stable. of accessory muscles, tachycardia, restlessness, mental changes, abnormal arterial blood gases, intrapulmonary shunting increased, A-a gradient changes, hypoxemia, increased dead space RESPIRATORY SYSTEM 87

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Monitor vital signs every 1-2 Mechanical ventilation and the Monitor for peripheral or depen- May indicate fluid excess that hours, and prn. use of PEEP increase the dent edema, or distended neck results in venous congestion and intrathoracic pressures which veins. leads to respiratory failure. results in compression of the large vessels in the chest and this Auscultate lung fields for adven- Bronchovesicular sounds heard causes decreased venous return to titious breath sounds. over entire lung fields result the heart and decreased blood when lung density increases. pressure. Crackles and rhonchi may be auscultated in pulmonary edema. Obtain PA pressures every hour, PA pressures will be elevated but cardiac output/index every 4 wedge pressure will be normal. Monitor intake and output every Identifies fluid imbalances and hours, and calculate other hemo- This is the classic marker to dif- hour. Notify MD if urine less possible sources. dynamic values. ferentiate between cardiogenic than 30 cclhr. and non-cardiogenic pulmonary Weigh every day. Weight gains of > 2 Ibs./day or 5 edema. Most ARDS patients Ibs.lweek indicate fluid reten- have adequate cardiac function at tion. least initially, unless decreases in COlCI are due to PEEP. Monitor for vocal fremitus. May be present due to increased lung density resulting from pul- Monitor for mental changes, May indicate decreased cardiac monary. edema. decreased peripheral pulses, cold output and decreased perfusion. or clammy skin. Monitor vital signs. Tachycardia and elevated blood pressure may result from fluid excess and heart failure.

Restrict fluids as warranted. May be required to help with fluid balance regulation. Discharge or Maintenance Evaluation . Patient will have adequate perfusion and cardiac Discharge or Maintenance Evaluation output/index within normal limits for physio- Paiient will have no edema or weight gain. logic condition. Patient will be eupneic with no adventitious Patient will have no mental status changes or breath sounds to auscultation. peripheral perfusion impairment. fluid volume &+kit Risk for fluid volume excess Risk for Related to: fluid shifts, diuretics, hemorrhage Related to: interstitial edema, increased pulmonary fluid with normal intravascular Defining characteristics: decreased blood pressure, volume, transfusions, resuscitative fluids oliguria, anuria, low pulmonary artery wedge pressures Defining characteristics: edema, dyspnea, orthopnea, rales, wheezing Outcome Criteria

Outcome Criteria Patient will achieve and maintain a normal and balanced fluid volume status and be hemodynami- Patient will be hemodynamically stable, with no cally stable. signs of pulmonary edema. 88 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Monitor vital signs every 1-2 Tachycardia, hypotension and hours, and prn. decreases in pulse quality may indicate fluid shifting has resulted in volume depletion. Temperature elevations with diaphoresis may result in increased insensible fluid loss.

Monitor intake and ouput every Continuing negative balances hour, and notify MD of signifi- may result in volume depletion. cant fluid imbalances.

Weigh daily. Changes in weight from day to day may correlate to fluid shifts that may occur.

Observe skin turgor and hydra- Decreases in skin turgor, tenting tion status. of skin, and dry mucous membranes may indicate fluid volume deficits.

Administer IV fluids as ordered. Replaces fluids and maintains circulating volume.

Monitor labwork for sodium and Diuretic therapy may result in potassium levels. hypokalemia and hyponatremia.

Discharge or Maintenance Evaluation Patient will achieve normal fluid balance.

Patient will be hemodynamically stable, with no weight change. Patient will have urine output within normal limits. ~ RESPIRATORY SYSTEM 89

ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)

Triggering event c Cellular damage 3 Increased capillary permeability 3 Plasma proteins leak into interstitial spaces I Inflammatory !ells aggregate Lymph flb blocked Fibrin and cell debris aggregate 3 c Hyaline membrane formed Increased interstitial fluid c c Decreased oxygen diffusion Non-cardiogenic pulmonary edema 4 c Hypoxemia J-receptors activated c 3 Alveolar collapse Tachypnea c 3 Decreased lung compliance Decreased PaC02 3 3 Shunting through non-ventilated Hypoxemia areas of lungs 3 c Increased A-a gradient Decreased PaO2 3 3 Increased work of breathing Increased dyspnea I IWorsening hypoxemia c Circulatory collapse 3 Organ failure c DEATH This Page Intentionally Left Blank RESPIRATORY SYSTEM 91

bouts of cor pulmonale, or right-sided heart fail- Chronic Obstructive ure, resulting in peripheral edema. Pulmonary Disease The most common precipitating factors for COPD include cigarette smoking, air or environ- (I: 0 P D) mental pollution, allergic response, autoimmunity, and genetic predisposition. Treatment is aimed at Chronic obstructive pulmonary disease (COPD) avoidance of respiratory allergens and irritants, is irreversible condition in which airways become controlling bronchospasms, and improving airway obstructed and resistance to air flow is increased clearance. during expiration when airways collapse. COPD is usually further subdivided into other diseases such as bronchitis and emphysema, and actually COPD refers to these simultaneous disease entities. Laboratory: cultures used to identify causative organisms and determine appropriate antimicro- Emphysematous changes include enlarging of the bial therapy; CBC used to identify presence of air spaces distally to the terminal bronchioles, and infection with elevated white blood cell count, concurrent changes in alveolar walls. Capillary and to monitor for increases in RBCs and hemat- numbers decrease in the remaining walls and may ocrit as the body tries to compensate for oxygen sclerose. Gas exchange is decreased due to the transport requirements; alphal-antitrypsin levels reduction in available alveolar surfaces as well as used to identify deficiency that may be present if decreased perfusion to non-ventilated areas. patient has heredity predisposition; theophylline Ventilation/perfusion mismatching occurs and levels used to monitor for therapeutic levels functional residual capacity is increased. The and/or toxicity anteroposterior diameter of the chest is often enlarged due to the loss of elasticity and increased Pulmonary function studies: used to evaluate pul- air trapping in the airway supportive structures. monary status and function, and to identify These type A patients are often called “pink airway obstruction, increased residual volume, puffers” because of the increased response to total lung capacity, compliance, decreased vital hypoxemia. Symptoms include dyspnea and capacity, diffusing capacity, and expiratory increase in breathing effort, which result in a volumes with emphysema patients; increased well-oxygenated, or pink, patient who displays residual volume, decreased vital capacity and overt dyspnea, or puffing. forced expiratory volumes with normal static compliance and diffusion capacity with bronchitis Bronchitis is usually associated with prolonged patients exposure to lung irritants, which results in inflammatory changes and thickening of bronchial walls, Chest x-ray: used to identify hyperinflation of and increases in mucous production. The patient lungs, flattened diaphragm, or pulmonary hyper- exhibits a chronic productive cough due in part to tension; used to identify barotrauma that may the increase in size of mucous glands and decrease occur, increased antero-posterior chest diameter, in cilia. These type B patients are often called large retrosternal air spaces, or secondary cardio- “blue bloaters” because their response to vascular complications with right-sided heart hypoxemia is reduced, with increasing PaC02 failure levels and cyanosis. These patients frequently have 92 CRITICAL CARE NURSING CARE PLANS

Electrocardiography: used to identify Defining characteristics: dyspnea, tachypnea, dysrhythmias associated with this disease; tall p bradypnea, bronchospasms, increased work of waves in inferior leads, vertical QRS axis, atrial breathing, use of accessory muscles, increased dysrhythmias, right ventricular hypertrophy, sinus mucous production, cough with or without pro- tachycardia, and right axis deviation ductivity, adventitious breath sounds Oxygen: used to improve hypoxemia; liter flow Inefective breathing pattern should be low in order to maintain the patient's [See Mechanical Ventilation] respiratory drive; PaO, may be acceptable at 55- Related to: pain, increased lung compliance, 60 mmHg to avoid hypoventilation and maintain decreased lung expansion, fear, obstruction, function decreased elasticity/recoil fluids: used to maintain hydration and for IV Defining characteristics: dyspnea, tachypnea, use administration of medical therapeutics of accessory muscles, cough with or without pro- Bronchodilators: xanthines and sympathomimet- ductivity, adventitious breath sounds, ics are used to relieve bronchospasms and help to prolongation of expiratory time, increased promote clearance of mucoid secretions mucous production, abnormal arterial blood gases Antibiotics: used to treat respiratory infections Impaired gas exchange [See Mechanical Ventilation] Arterial blood gases: used to identify acid-base disturbances, presence of hypoxemia and hyper- Related to: obstruction of airways, bronchospasm, capnia, and to evaluate responses to therapies air-trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to Chest physiotherapy: percussion and postural move secretions, hypoventilation drainage are used to facilitate mobilization of secretions and promote clearance of airways Defining characteristics: hypoxemia, hypercapnia, mental changes, confusion, restlessness, dyspnea, Corticosteroids: used to decrease secretions and vital sign changes, inability to tolerate activity, res- reduce inflammation in the lungs; use of steroids piratory acidosis is controversial Anxiev Psychological treatment: use of anti-anxiety [See Mechanical Ventilation] agents to decrease fear and anxiety related to dyspnea, without sedation to depress the respiratory Related to: threat of death, change in health drive; psychotherapy may be required to enable status, life-threatening crises patients to cope with their ongoing disease process Defining characteristics: fear, restlessness, muscle tension, helplessness, communication of NURSING CARE PLANS uncertainty and apprehension, feeling of Ingective airway clearance suffocation [See Mechanical Ventilation] Activity intolerance Related to: bronchospasm, fatigue, increased work Related to: fatigue, weakness, increased effort and of breathing, increased mucous production, thick work of breathing, inadequate rest, hypoxia, secretions, infection hypoxemia RESPIRATORY SYSTEM 93

Defining characteristics: dyspnea, decreased Information, Instruction, oxygen saturation levels with movement or activ- Demonstration ity, increased heart rate and blood pressure with movement or activity, feelings of tiredness and INTERVENTIONS RATIONALES weakness Instruct on techniques to save Helps CO decrease energy expen- energy expenditure: shower diture and fatigue, which may Outcome Criteria stools, arm and leg rests, gather- result in increased dyspnea. ing required articles and placement within reach, etc. Patient will be able to tolerate minimal activity without respiratory compromise. Provide patient with exercise Promotes independence and self- regimen protocol. worth; increases tolerance to exercises.

~~~ ~ INTERVENTIONS RATIONALES Instruct on breathing exercises to Promotes effective respiratory be performed with activicy. patterns during exertion. Monitor for patient’s response to Identifies patient’s ability to activity changes. , compensate for increases in activity and provides baseline date Discharge or Maintenance Evaluation from which to plan care. Patient will be able to tolerate activity without Monitor vital signs before, Increases in heart rate greater excessive dyspnea or hemodynamic instability, during, and after increased activ- than lolminute or respiratory ity levels. rate greater than 32 may Patient will be able to perform ADLs within indicate that patient has reached his maximal activity limit and limits of disease process. further activity may result in circulatorylrespiratory Patient will be able to recall information accu- dyshnction. rately, and will be able to utilize relaxation and breathing techniques effectively. Plan activities to ensure patient Decreases potential for dyspnea obtains adequate amounts of rest and provides rest to prevent Patient will be compliant with prescribed exer- and sleep. excessive fatigue. cise regimens. Assist patient with activities as Conserves energy and decreases warranted. oxygen consumption and dysp- Ineffective individuaUfamily coping nea. [See Mechanical Ventilation] Gradual increases facilitate Increase activity gradually and Related to: changes in lifestyle and health status, encourage patient participation. increased tolerance to activity by balancing oxygen supply and sensory overload, fear of death, physical demand, and patient cooperation Gmitations, inadequate support system, inadequate may facilitate feelings of self- coping mechanisms, continual dyspnea worth and adequacy. Defining characteristics: inability to meet role Administer inhalers as ordered Helps prevent dyspnea by per- prior to activities. forming activities at peak time of expectations, inability to meet basic needs, medication effects. constant worry, apprehension, fear, inability to problern-solve, anger, hostility, aggression, inappropriate defense mechanisms, low self-esteem, insomnia, depression, destructive behaviors, vacillation when choices are required, delayed decision-making, muscle tension, fatigue 94 CRITICAL CARE NURSING CARE PLANS

Risk for infiction food, increased metabolism due to disease process, decreased level of consciousness, fatigue, increased Related to: disease process, inability to move sputum, medication side effects secretions, decreased cilia function, immunosuppression, poor nutrition Defining characteristics: actual inadequate food intake, altered taste, altered smell sensation, Defining characteristics: increased temperature, weight loss, anorexia, absent bowel sounds, chills, elevated white blood cell count, inability to decreased peristalsis, muscle mass loss, changes in move secretions bowel habits, abdominal distention, nausea, vomiting

INTERVENTIONS RATIONALES Knowledge &+it Monitor for increased dyspnea, Yellow or green sputum, with Related to: lack of information, lack of recall of sputum color and character increased viscosity usually information, cognitive limitations changes, cough, and temperature indicates infection. Prompt elevation. recognition facilitates prompt Defining characteristics: request for information, treatment. statement of misconception, statement of Obtain sputum specimen for Identifies the causative organism concerns, development of preventable complica- culture and sensitivity as ordered. and provides information regarding appropriate antimicrobial tions, inaccurate follow-through with instructions agent required.

Administer antibiotics as Controls and clears the infection Outcome Criteria ordered. and any secondary infections in che bronchial tree. Improvement Patient will be able to recall information should be noted within 24-48 accurately and will follow through with all instruc- hours after antimicrobial agent has begun. tions.

Monicor for abrupt changes in May indicate presence of other body systems; cardiac secondary infeccion or resistance abnormalities and alteration in to ordered antibiotics. INTERVENTIONS RATIONALES heart sounds, increasing pain, Superinfections, systemic bac- Assess knowledge of COPD dis- Identifies level of knowledge and changes in mental status, recur- teremia, inflammatory cardiac ease process, medicacions, and provides baseline from which CO ring temperature elevations. conditions, meningitis or treatments. plan teaching. encephalitis may occur. Instruct on medication effects, Promotes knowledge and com- Provide adequace rest time for Helps to facilitate healing and side effects, contraindications, pliance with treatment regimen. patient. natural immunity. and signslsymptoms to report.

Discharge or Maintenance Evaluation Instruct in proper technique for Proper technique, including using and cleaning inhalers. appropriate time intervals Patient will exhibit no signs/symptoms of sec- between puffs, facilitates effective ondary infection. delivery and therapeutic effect. Instruct on need to avoid smok- May initiate and exacerbate Altered nutrition: less tban body ing and other respiratory bronchial irritation which can requirements irritants. resulr in increased mucous pro- [See Mechanical Ventilation] duction and airway obstruction. Instruct on effective coughing Effective coughing reduces Related to: dyspnea, inability to take in sufficient RESPIRATORY SYSTEM 95

INTERVENTIONS RA'IIONALES INTERVENTIONS RATIONALES techniques; postural drainage, fatigue and facilitates removal of Assist patientlfamily to set redis- Provides a plan for patient and chest physiotherapy, etc. secretions. Percussion and pos- tic goals for long- and facilitates self-involvement with tural drainage help to mobilize short-term. realistic goals and methods to tenacious secretions. meet them. Fosters independence and reduces anxiety. Instruct to drink 10-12 glasses of Maintains hydration and pro- water per day. motes easier mobilization of secretions. Discharge or Maintenance Evaluation

Instruct on use of supplemental COPD patients will rarely Patient will be able to recall information regard- oxygen at low flow rates, and require more than 2-3 Llmin to reasons to avoid increasing flow maintain their optimum oxy- ing disease process and treatment regimen. indiscriminately. genation levels. Increasing flow rates will increase their PaOz but Patient will be able to recall accurately the may decrease their respiratory signs/symptoms for which to notify MD, the drive and may result in drowsi- effects and side effects of medications, and ness and confusion. proper procedure for using inhalers. Instruct on oxygen safery: avoid- Promotes physical and environ- ing flammable objects, use of mental safety. Patient will be able to demonstrate accurately vaseline or other petroleum proper cough techniques, pursed-lip breathing, products, and ambulation with and proper positioning to facilitate breathing. tubing.

Instruct on avoiding sedative or Sedative may result in respiratory Patiendfamily will be able to access support sys- antianxiety drugs as warranted. depression and impair cough tems effectively. reflexes.

Instruct on avoiding people with Prevents exposure to other infec- infections; encourage patient to tions, and decreases potential for obtain influenza and pneumonia incidence of upper respiratory vaccinations as warranted. infections.

Instruct on activity limitations, Helps decrease fatigue, optimizes methods to conserve energy and activity level within range of promote rest, pursed-lip breath- disease process, and reduces dys- ing, etc. pnea and oxygen consumption.

Instruct on signslsymptoms to Provides for prompt recognition notify MD: increased tempera- of infection to facilitate prompt ture, change in sputum color or intervention prior to respiratory character, increasing dyspnea. failure.

Instruct to continue with follow- Provides for monitoring of pro- up medical care. gression of disease, presence of complications, or exacerbations, and facilitates changes in medical regimen to concur with current medical condition.

Provide patient/family with Support groups may be required information regarding support to provide emotional assistance groups, such as the American and respite for caregiver(s). Lung Association, etc. 96 CRITICAL CARE NURSING CARE PLANS

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (C 0 P D)

(smoking, pollution, infection) 4 Inff ammation 4 Alphal-antitrypsin inhibited s Elastase production 4 Lung elastin broken down I 1 I EMPHYSEMA CHRONIC BRONCHITIS (Pink Puffers) (Blue Bloaters)

Increased response to hypoxemia Decreased response to hypoxemia c c Terminal air spaces enlarged Hypertrophy and hyperplasia of mucus glands 4 s Destruction of alveolar walls Goblet cell metaplasia s s Loss of elastic recoil Increased mucus production and viscosity

J, c Increased air trapping Mucus plugs in airways decrease airway size

s 4 Airways collapse, decreasing gas exchange surface Bronchial wall thickening increased s s Decreased resistance to lung expansion Increased airway resistance, decrease Increased lung volumes in vital capacity and expiratory flow rates 4 4 Ventilationlperfusion mismatching Hypoxemia 4 c Air sacs replaced by bullae Increased PaCO2 4 s Increased dyspnea and work of breathing Increased pulmonary constriction

Hypoxia 4 Further pulmonary constriction Increased pulmonary artery pressures 4 (See Next Page) RESPIRATORY SYSTEM 97

C 0 P D continued Pulmonary hypertension 4 Right ventricular strain 4 Right ventricular hypertrophy 4 Right ventricular failure Cor Pulmonde 4 Left ventricular failure 4 Circulatory collapse J Death This Page Intentionally Left Blank RESPIRATORY SYSTEM 99

chest pain, and cough with hemoptysis. Other symptoms may be present, such as A pulmonary embolus (PE) usually results after a lightheadedness, diaphoresis, cyanosis, pleural fric- deep vein thrombus partially or totally dislodges tion rubs, S, split, tachypnea, tachycardia, anxiety, from the pelvis, thigh, or calf. The clot then lodges mental changes, gallops, dysrhythmias, rales, and hypot:ension, but are dependent on the size of the in one or more of the pulmonary arteries and obstructs forward blood flow and oxygen supply to embolus and presence of infarction or complica- the lung parenchyma. Pressure is backed up and tions. results in increased pulmonary artery pressures and vascular resistance, right ventricular failure, tachy- MEDICAL CARE cardia, and shock. Alveolar dead space is increased Laboratory: PTTs done daily to monitor heparin which results in ventilation/perfusion mismatching therapy; LDH may be elevated in pulmonary and decreased PaO,. The embolus releases chemi- embolus, but other diagnoses must be ruled out; cals that decrease surfactant and increase fibrin split products usually increase consistently bronchoconstriction. Hyperventilation due to with PE; CBC may show increased hematocrit carbon dioxide retention results in decreased due to hemoconcentration, and increased RBCs PaCO,. Fat embolism, septic embolism, or amniotic fluid embolism are rarely causes of PE and Chest x-ray: used to rule out other pulmonary when they are, usually occlude smaller arterioles or diseases; shows atelectasis, elevated diaphragm and capillaries. A pulmonary embolus is classified as pleural effusions, prominence of pulmonary artery, being massive when more than half the pulmonary and occasionally, a wedge-shaped infiltrate com- artery circulation is occluded. monly seen in pulmonary embolism Infarction of the pulmonary circulation occurs less Nuclear radiographic testing: lung scans are used than 10 per cent of the time and usually results to show perfusion defects beyond occluded vascu- when the patient has an underlying chronic car- lature; xenon ventilation scans are used to diac or pulmonary disease. Pulmonary infarcts differentiate between pulmonary embolism and may be reabsorbed and fibrosis may cause scar COPD, and together with perfusion scans, will tissue formation. Usually collateral pulmonary cir- reveal ventilation/perfusion mismatchl:; culation maintains lung tissue viability. Pulmonary angiography: used as a definitive test The main risk factors that may predispose when other tests do not ensure the diagnosis in pulmonary embolism formation are bedrest, high-risk patients; identifies intra-arterial filling immobility, cardiac disease, venous disease, preg- defects and obstruction of pulmonary artery nancy, malignancy, fractures, estrogen branches contraceptives, obesity, burns, blood dyscrasias, Electrocardiography: used to reveal right axis surgery, and trauma. Thrombus formation occurs deviation, right-sided heart strain, right bundle with blood flow stasis, coagulopathy alterations, branch block, tall peaked P waves, ST segment and damage to the endothelium of the vessel walls, depression and T wave inversion, as well as and these three factors are known as Virchow’s supraventricular tachydysrhythmias triad. Phlebography: used to identifj. deep vein throm- The most common signs/symptoms are dyspnea, bosis in legs 100 CRITICAL CARE NURSING CARE PLANS

Oxygen: to provide supplemental oxygen to main- Defining characteristics: dyspnea, use of accessory tain oxygenation muscles, shallow respirations, tachypnea, increased Pulmonary artery catheterization: used to place work of breathing, decreased chest expansion on catheter to enable hemodynamic monitoring and involved side, cough with or without productivity) to assess response to therapies adventitious breath sounds

Arterial blood gases: used to assess for hypoxemia Outcome Criteria and acid-base imbalances Thoracentesis: may be used to rule out empyema Patient will be eupneic with clear lung fields and if pleural effusion is noted on chest x-ray arterial blood gases within normal limits. Beta-blockers: used in pulmonary hypertension to dilate the pulmonary vasculature to increase tissue INTERVENTIONS RATIONALES per fusion Monitor respiratory status for In PE, respiratory rate is usually Cardiac glycosides: used only if absolutely manda- changes in rate and depth, use of increased. The effort of breath- tory during the acute hypoxemia phase due to the accessory muscles, increased ing is increased and dyspnea is work of breathing, nasal flaring, ofien the first sign of PE. potential for lethal dysrhythmias or cardiac failure and symmetrical chest expansion. Depending on the severity and location of the PE, depth of res- Analgesics: used to alleviate pain and discomfort pirations may vary. Chest Anticoagulants: heparin is used initially in the expansion may be decreased on the affected side due to atelecta- treatment of PE, with change to coumadidwar- sis or pain. farin PO for 3-6 months Provide supplemental oxygen via Provides oxygen and may Thrombolytics: streptokinase or urokinase nasal cannula or mask. decrease work of breathing. enhances conversion of plasminogen to plasmin to Monitor for presence of cough Bloody secretions may result prevent venous thrombus and character of sputum. from pulmonary infarction or abnormal anticoagulation. A dry Antiplatelet drugs: aspirin and dipyridamole used cough may result with alveolar to prevent venous thromboembolism congestion. Auscultate lung fields for adven- Breath sounds may be dimin- Surgery: embolectomy may be performed to titious breath sounds andlor ished or absent if airway is remove the clot; umbrella filter may be placed or rubs. obstructed due to bleeding, clot- surgical interruption of the inferior vena cava may ting, or collapse. Rhonchi or be performed to prevent migration of clots into wheezing may result in conjunction with obstruction. the pulmonary vasculature Auscultate heart sounds. Splitting of S, may occur with NURSING CARE PLANS pulmonary embolus. Encourage deep breathing and Improves lung expansion and Inefective breathing pattern effective coughing exercises. helps to remove secretions which may be increased with PE. Related to: increase in alveolar dead space, physiologic lung changes due to embolism, bleeding, increased secretions, decreased lung expansion, inflammation RESPIRATORY SYSTEM 101

Information, Instruction, 4 L/min or cardiac index less than 2.7 L/min/m2, Demonstration cold, pale extremities, EKG changes, hypotension, S, split sounds, S3 or S4 gallops, dyspnea, crackles INTERVENTIONS RA'TIONALES (rales), chest pain Prepare patientlfamily for place- May be required if respiratory Risk fir altered tissue p&ion: cardiopuL- ment on mechanical ventilation. distress is severe. monaly, peripheral, cerebral Instruct on avoiding shallow Eupnea decreases potential for respirations and splinting. atelectasis and improves venous Related to: impaired blood flow, alveolar return. perfusion and gas exchange impairment, occlusion

Prepare patiendfamily for bron- May be required to remove of the pulmonary artery, migration of embolus, choscopy as warranted. mucous plugs andlor clots in hypoxemia, increased cardiac workload order to clear airways. Defining characteristics: dyspnea, chest pain, Discharge or Maintenance Evaluation tachycardia, dysrhythmias, productive cough, hemoptysis, edema, cyanosis, syncope, jugular vein Patient will be able to maintain his own respira- distention, weak pulses, hypotension, convulsions, tions without mechanical assistance. loss of consciousness, restlessness, hemiplegia, coma Patient will be eupneic, with no adventitious lung or heart sounds. Outcome Criteria Patient will be able to recall all information accurately. Patient will be hemodynamically stable, eupneic, Impaired gas exchange with no alterations in perfusion to any body system. [See Mechanical Ventilation] Related to: atelectasis, airway obstruction, alveolar collapse, pulmonary edema, increased secretions, INTERVENTIONS RA'TIONALES active bleeding, altered blood flow to lung, shunt- Monitor vital signs and notify Hypoxemia will result in ing MD for significant changes. increased heart rate as the body tries to compensate for the Defining characteristics: dyspnea, restlessness, decrease in perfusion. anxiety, apprehension, cyanosis, arterial blood gas Monitor EKG for rhythm distur- Hypoxemia, right-sided heart changes, hypoxemia, hypoxia, hypercapnia, bances and treat as indicated. strain, and electrolyte imbalances decreased oxygen saturation may induce dysrhythmias. for decreased cardiac output Auscultate for S, or S4 heart Increases in heart workload may Risk sounds. result in heart strain and failure [See Heart Failure] as perfusion decreases, and may result in gallop rhythm. Related to: dysrhythmias, cardiogenic shock, heart failure Monitor for presence of periph- Presence of deep vein thrombus eral pulses and notify MD for may occlude the circulation and Defining characteristics: elevated blood pressure, significant changes. result in diminished or absent elevated mean arterial blood pressure, elevated sys- pulses. temic vascular resistance, cardiac output less than Assess for Homan's and Pratt's Presence of these signs may or signs. may not be related to PE. 102 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Assess skin color, temperature Impairment of blood flow may and capillary refill. induce pallor or cyanosis to the slun or mucous membranes. Cool clammy skin or mottling may indicate peripheral vasocon- strictiodshock.

Monitor for restlessness or May indicate occlusion, impaired changes in mental status or level cerebral blood flow, hypoxia, or of consciousness. development of stroke.

Information, Instruction, Demonstration

INTERVENTIONS RATIONALES Prepare patient for insertion of May be required to monitor pulmonary artery catheter. hemodynamic status and assess response to therapy.

Prepare patient for surgery as Surgical intervention may be warranted. required if patient develops recurrent emboli in spite of treatment, or if anticoagulant therapy cannot be given. Ligation of the vena cava or insertion of an umbrella filter may be necessary.

Instruct on thrombolytic agents Streptokinase, urokinase, or as warranted. alteplase (t-PA) may be required if the pulmonary embolus is massive and compromises hemodynamic stability.

Discharge or Maintenance Evaluation

Patient will have adequate tissue perfusion to all body systems. Patient will have stable hemodynamic parameters and vital signs will be within normal limits. Oxygenation will be optimal as evidenced by pulse oximetry greater than 90% and adequate ABGs. RESPIRATORY SYSTEM 103

PULMONARY EMBOLISM

Embolus obstructs blood flow

Chemicals released Pulmonary pressures increased Alveolar dead space increased 4 4 c Bronchoconstriction Pulmonary vasoconstriction Ventilation perfusion Pulmonary hypertension mismatch 4 J, J, Decreased Pa02 Right ventricular failure Increased airway resistance 4 Decreased lung compliance

Decreased cardiac output 4 Hypotension 4 Pulmonary vasoconstriction c W Decreased tissue perfusion -Decreased PaOZ c Cardiopulmonary collapse c Death This Page Intentionally Left Blank RESPIRATORY SYSTEM 105

influenza, malnutrition, smoking, alcoholism, immuriosuppressive therapy, aspiration, sickle cell Pneumonia is an acute infection of the lung's ter- disease, head injury or coma. minal alveolar spaces and/or the interstitial tissues Aspiration pneumonia occurs after aspiration of which results in gas exchange problems. The gastric or oropharyngeal contents, or other chemi- major challenge is identification of the source of cal irritants into the trachea and lungs. Stomach the infection. Pneumonia ranks as the sixth most acid damages the respiratory endothelium and common cause of death in the United States. may result in non-cardiogenic pulmonary edema, When the infection is limited to a portion of the hemorrhage, destruction of surfactant-producing lung, it is known as segmental or lobular pneumo- cells, and hypoxemia. The pH of the aspirated material determines the severity of the injury with nia; when the alveoli adjacent to the bronchioles are involved, it is known as bronchopneumonia, pH less than 2.5 causing severe damage. and when the entire lobe of the lung is involved, it Morbidity is high even with treatment. is known as lobar pneumonia. In pneumonia's early stages, pulmonary vessels Pneumonia may be caused by bacteria, viruses, dilate and erythrocytes spread into the alveoli and mycoplasma, rickettsias, or fungi. The causative cause a reddish, liver-like appearance, or red hepa- organism gains entry by aspiration of oropharyn- tization, in the lung consolidation area. geal or gastric contents, inhalation of respiratory Polymorphonuclear cells then enter the alveolar droplets, from others who are infected, by way of spaces and the consolidation increases to a grey the blood stream, or directly with surgery or hepatization. The leukocytes trap bacteria against trauma. the alveolar walls or other leukocytes so that more organisms are found in the increasing margins of Viral types are more common in some areas, but the consolidation. The macrophage reaction identification of causative organisms may be diffi- occurs when mononuclear cells advance into the cult with limited technology. alveoli and phagocytize the exudate debris. Patients who develop bacterial pneumonia usually Diagnosis may be assisted with the observation of are immunosuppressed or compromised by a sputum characteristics, with bacterial pneumonia chronic disease, or have had a recent viral illness. having mucopurulent sputum, viral and mycoplas- The most common type of bacterial pneumonia is mic pneumonias having more watery secretions, pneumococcal pneumonia, in which the organism pneurnococcal pneumonia having rust-colored reaches the lungs via the respiratory passageways sputum, and Klebsiella noting dark red mucoid and result in the collapse of alveoli. The inflam- secretions. matory response that this generates causes The initial signs/symptoms are sudden onset of protein-rich fluid to migrate into the alveolar shaking chills, fever, purulent sputum, pleuritic spaces and provides culture media for the organ- chest pain that is worsened with respiration or ism to proliferate and spread. coughing, tachycardia, tachypnea, and use of Frequently pneumonia is predisposed by upper accessory muscles. respiratory infections, chronic illness, cancer, Staphylococcal pneumonia is frequently noted surgery, atelectasis, chronic obstructive pulmonary after influenza or in hospitalized patients with a disease, asthma, cystic fibrosis, bronchiectasis, 106 CRITICAL CARE NURSING CARE PLANS nosocomial superinfection following surgery, Chest x-ray: used to demonstrate small effusions trauma, or immunosuppression. Pleural pain, dys- and abscesses, pulmonary consolidations, and pnea, cyanosis, and productive coughing with empyema; may be clear with mycoplasma pneu- copious pink secretions are common symptoms. monia Streptococcal pneumonia occurs rarely with the Oxygen: used to supplement room air, and to exception as a complication after measles or treat hypoxemia that may occur influenza. Klebsiella pneumonia is virulent and necrotizing, and is usually seen with alcoholic or Antibiotics: used in the treatment after culture severely debilitated patients. Pneumonia that is results are obtained to eradicate the infective caused by Hemophilus influenzae occurs after organ ism viral upper respiratory infections, or concurrently Thoracentesis: used to remove fluid if pleural with bronchopneumonia, bronchitis, and bronchi- fluid is present; assists in the diagnosis of pleural olitis. Sputum is usually yellow or green, and empyema patients have fever, cough, cyanosis, and arthralgias. Viral pneumonia may be caused by influenza, Surgery: may be required for open lung biopsy or adenoviruses, respiratory syncytial virus, treatment of effusions and empyema; rhinoviruses, cytomegalovirus, herpes simplex bronchoscopy with bronchial brushing may be virus, and childhood diseases; it is usually milder. indicated for progressive pneumonias that are Symptoms include headache, anorexia, and occa- unresponsive to medical treatment sionally mucopurulent sputum that is bloody. Nerve blocks: intercostal blocks may be required MEDICAL CARE to control pleuritic pain Laboratory: white blood cell count may be NURSING CARE PLANS normal or low but usually is elevated with polymorphonuclear neutrophils; cultures of sputum, Inefective airway clearance blood, and CSF may be obtained to identify the Related to: inflammation, edema, increased secre- causative organism and antimicrobial agent best tions, fatigue suited for eradication; electrolytes may show decreased sudium and chloride levels; serology and Defining characteristics: adventitious breath cold agglutinins may be done for identification of sounds, use of accessory muscles, cyanosis, dysp- viral titers; sedimentation rate is usually elevated nea, cough with or without production

Pulmonary function studies: used to evaluate ven- Outcome Criteria tilation/perfusion problems; volumes may be decreased due to alveolar collapse; airway pressures Patient will maintain patency of airway, have clear may be increased; lung compliance may be breath sounds, and will be able to effectively clear decreased secretions. Arterial blood gases: to evaluate adequacy of oxygen and respiratory therapies, as well as to identify acid-base imbalances and acidotic/alkalotic states RESPIRATORY SYSTEM 107

INTERVENTIONS RATIONALES Alteration in comfort [See MI] Monitor respiratory status for Tachypnea and hyperpnea are changes, increased work of frequently noted with Related to: inflammation, dyspnea, fever, breathing, use of accessory mus- pneumonia. coughing cles, and nasal flaring. Defining characteristics: pleuritic chest pain wors- Observe for symmetrical chest Unilateral pneumonia will result expansion. in asymmetrical chest movement ened with respiration or cough, muscle aches, due to decreased lung compli- joint pain, restlessness, communication of ance on the affected side and pain/discomfort because of pleuritic pain.

Observe for cyanosis andlor May indicate impending or pre- Risk for altered nutrition: less than body mental status changes. sent hypoxemia. requirements [See Mechanical Ventilation] Assess vocal fremitus. Increased fremitus is noted over consolidated areas in pneumonia. Related to: increased metabolic demands, fever, Decreased or absent fremitus may indicate that a foreign body infection, abnormal taste sensation, anorexia, is obstructing a large bronchus. abdominal distention, nausea, vomiting Percuss chest for changes. Percussion may be dull over Defining characteristics: actual inadequate food consolidated areas or in areas of intake, altered taste, altered smell sensation, atelectasis. weight loss, anorexia, nausea, vomiting, abdominal Auscultate lung fields. Fine crackles or bronchial breath distention, decreased muscle mass and tone sounds are noted in lobar pneumonia; in other types of Risk firfluid volume d$cit pneumonia, bronchial sounds are rarely heard. Wheezes may indi- [See ARDS] cate aspiration of a solid object. Related to: fluid loss from fever, diaphoresis, or Inspiratory stridor may indicate the presence of an obstruction to vomiting, decreased fluid intake a large bronchus. Defining characteristics: decreased blood pressure, Assist with bronchoscopy as May be required to remove oliguria, anuria, low pulmonary artery wedge warranted. mucous plugs and prevent or improve atelectasis. pressures

Assist with thoracentesis as May be required to drain puru- Risk forfluid volume excess warranted. lent fluid. [See ARDS] Related to: inflammatory response, pulmonary Impaired gas exchange edema [See Mechanical Ventilation] Defining characteristics: rales, crackles, wheezing, Related to: inflammation, infection, pink ftothy sputum, abnormal arterial blood gases ventilation/perfusion mismatching, fever, changes in oxyhemoglobin dissociation curve Knowledge de$cit Related to: lack of information, competing stim- Defining characteristics: dyspnea, tachycardia, uli, misinterpretation of information cyanosis, hypoxia, hypoxemia, abnormal arterial blood gases Defining characteristics: request for information, failure to improve, development of preventable complications 108 CRITICAL CARE NURSING CARE PLANS

Outcome Criteria

Patient will be able to verbalize and demonstrate understanding of information.

INTERVENTIONS RATIONALES

Instruct on need for vaccines for Influenza increases the chance of influenza and pneumonia. secondary pneumonia infection; vaccinations help to prevent the occurrence and spread of infective process.

Instruct in continued need for Patient is at risk for recurrence of coughing and deep breathing. pneumonia for 6-8 weeks following discharge.

Instruct in importance of contin- Helps prevent complications and uing with follow-up medical recurrence of pneumonia. care.

Instruct in need to quit or avoid Smoking destroys the action of smoking. the cilia and impairs the lungs’ first line of defense against infection.

Discharge or Maintenance Evaluation

Patient will be able to accurately verbalize understanding of all instructions. Patient will be compliant in avoiding smoking. Patient will not have preventable complications from illness. RESPIRATORY SYSTEM 109

PNEUMONIA

Airborne pathogenic or direct contact spread t c 1 Defect in defense and immunity Virulent microorganisms Overwhelming exposure I I I Infectious organism lodges in bronchioles c Alveolar collapse 4 Inflammation of interstitial tissues of lungs c Vascular engorgement of alveoli with fluid c RBCs and fibrin move into alveoli c Fibrin accumulates Disintegration of RBCs and fibrin c Exudate digesjed by enzymes 4 Action provides excellent culture media to increase spread of organisms c Consolidation

Removal of pathogenic mucus by Continued infection despite use of coughing, suctioning, or macrophagic action antimicrobial therapy 4 JI RESOLUTION Abscess formation c Necrosis of pulmonary tissues c Overwhelming sepsis c DEATH This Page Intentionally Left Blank RESPIRATORY SYSTEM 111

A hemothorax not only results in cardiopulmonary effects, but also may involve A pneumothorax occurs when free air accumulates problems with hemorrhagic shock. The rate at in the pleural cavity benveen the visceral and pari- which shock may occur depends on the source etal areas, and causes a portion or the complete and rapidity of bleeding. lung to collapse. Pressure in the pleural space is The severity of a pneumothorax, no matter what normally less than that of atmospheric pressure the origin, relates to the degree of collapse. A but following a penetration injury, air can enter small partial pneumothorax may resolve by itself the cavity from the outside changing the pressure when the air is reabsorbed. In cases where collapse within the lung cavity and causing it to collapse. is more than 20-30 percent, a closed, water-seal Air can also migrate to the area when the esopha- drainage system and insertion of a chest tube via a gus is perforated or a bronchus ruptures, leaking lateral intercostal space is required. In cases where air into the mediastinum (pneumomediastinum). rapid re-expansion is desired, 15-25 cm H20 suc- Barotrauma related to mechanical ventilatory sup- tion may be added to the drain system. port using high levels of PEEP leads to alveoli rupture and collapse. Gas formation from gas- A pneumothorax may result spontaneously or forming organisms can also result in with trauma, such as a penetrating chest wound, pneumothorax. gunshot wound, knife wound, or after a procedure such as insertion of a centrally placed venous Pneumothorax may occur spontaneously in cases catheter line. Some symptoms of pneumothorax where a subpleural bleb or emphysematous bulla include abrupt onset of pleuritic chest pain, short- ruptures due to chronic obstructive pulmonary ness of breath, decreased or absent breath sounds, disease, tuberculosis, cancer, or infection and this tachycardia, tachypnea, hyperresonant percussion, is the most common reason in otherwise healthy shock, and hypotension. individuals. A tension pneumothorax is a life- threatening emergency and occurs when air is MEDICAL CARE permitted into the pleural cavity but not allowed to escape, resulting in increased intrathoracic pres- Laboratory: hemoglobin and hematocrit may be sure and complete collapse of the lung. It decreased with blood loss compromises the opposite lung because of increas- Chest x-ray: used to evaluate air or fluid accumu- ing pleural pressures and causes a mediastinal shift lations, collapse of lungs, or mediastinal shifts; a which interferes with ventilation and venous visceral pleural line may be visualized return. Severe shortness of breath, hypotension, and shock ensues, and emergent treatment of Arterial blood gases: vary depending on the sever- needle thoracentesis must be performed to relieve ity of the pneumothorax; oxygen saturation the pressure until a chest tube can be placed. usually decreases, Pa02 is usually normal or decreased, and PaCOz is occasionally increased A hemothorax occurs when the lung collapse is due to accumulation of blood. Blood accumula- Chest tube: placement required to facilitate re- tions usually occur from the pulmonary expansion of the collapsed lung and to permit vasculature, the intercostal and internal mammary drainage of fluid from lung arteries, the mediastinum, the spleen or the liver. Thoracentesis: needle thoracentesis is required for 112 CRITICAL CARE NURSING CARE PLANS

the immediate management of a tension INTERVENTIONS RATIONALES pneumothorax to relieve the pressure in the pleura by removing air and/or fluid Application of a dressing seals the chest wall defect, while the Surgery: thoracotomy with excision or oversewing valsalva maneuver helps to expand the lung. of the bullae may be required if the patient develops 2 or more pneumothorax on one side Observe for paradoxical move- May indicate flail chest and ments of the chest during impaired ventilation. Procedures respiration; if present, stabilize help to stabilize the area to facili- NURSINQ CARE PLANS the flail area with a sandbag or tate improved respiratory pressure dressing, and turn to the exchange. lnefective breathing pattern affected side. Related to: air andlor fluid accumulations, pain, Place patient in semi-sitting Promotes lung expansion and decreased lung expansion position. improves ventilatory efforts. Prepare patient for and assist Intercostal tube placement is Defining characteristics: dyspnea, tachypnea, use with insertion of chest tube. required when a pneurnothorax of accessory muscles, nasal flaring, decreased chest is greater than 20-30% in order expansion, cyanosis, abnormal arterial blood gases to facilitate re-expansion of the lung. Instruction, when feasible, reduces patient anxiety and Outcome Criteria improves cooperation. Once chest tube is inserted, Prevents air leaks and disconnec- Patient will be eupneic, with adequate ensure that connections are tight- [ions at the connector sites. oxygenation, and will maintain adequate ABGs. ened and taped securely per hospital protocol.

Monitor water-seal drainage bot- Fluid must be maintained above INTERVENTIONS RATIONALES tles to ensure fluid level is above the end of the tube to prevent air drain tube. from being sucked into lung and Monitor respiratory status for Physiologic changes that result resulting in further collapse. increase in rate, decrease in from the lung collapse may cause depth, dyspnea, or cyanosis. respiratory distress and may lead Maintain prescribed level of suc- Usually 15-25 cm H,O pressure to hypoxia. tion to drainage system. suction is sufficient to maintain intrapleural negative pressure and Auscultate breath sounds. Breath sounds may be absent in facilitate fluid drainage and re- areas where atelectasis occurs, expansion of the lung. and may be decreased with partially collapsed lung fields. Observe the water-seal drainage Bubbling should occur during system for bubbling. expiration and demonstrates that Observe for symmetrical chest Moderate to severe pneumotho- the pneumothorax is vented expansion. rax will result in asymmetrical through the system. Bubbling chest expansion until the lung is should diminish and finally cease fully re-expanded. as the lung re-expands. If no Observe for position of trachea. Tracheal deviation away from the bubbling is present in system, afTected lung occurs in tension this may indicate either complete pneumothorax. re-expansion of the lung or obstruction in the chest Listen for sucking sounds with Indicates an open pneumothorax tubeldrainage system. inspiration; if present, apply which impairs ventilation. occlusive dressing over wound During inspiration air moves Monitor drainage system for Continuous bubbling may result while patient performs valsalva into the pleural space and col- continuous bubbling and ascer- from a large pneumothorax or maneuver. lapses lung; with expiration, air tain if the problem is patient- or from air leaks in the drainage moves out of the pleural space. RESPIRATORY SYSTEM 113

~~ INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES system-centered. Clamp chest system. When the tube is Place chest drainage system Promotes drainage of air and tube near the patient's chest. clamped as described and bub- below the level of the chest, and fluid, and prevents kinking and bling ceases, the problem is coil tubing carefully to avoid occlusion of tubing. patient-centered with potential kinking. air leak at the insertion site or within the patient. If the bub- Obtain chest x-rays daily. Identifies the presence of pneu- bling continues, the le& is mothorax and resolution or within the drainage system. deterioration.

If patient has insertion site air Provides a seal and corrects the If chest tube is accidentally Provides a seal over chest wound removed, apply vaseline-impreg- leak, apply vaseline-impregnated air leak problem. to prevent pneumothorax from nated gauze and pressure or gauze around site, and reassess recurring worsening. Prompt dressing, and notify MD. the problem. treatment may prevent cardiopulmonary impairment. If patient has drainage system air Determines the location of the If chest tube becomes acciden- leak, ascertain the location by problem and corrects air leaks at Disconnection may result in tally disconnected from tubing, clamping the tube downward the connectors. atmospheric air entering the reconnect toward the system by increments. as cleanly and quickly pleural space and worsening or possible. causing pneumothorax. Secure connections. as Observe dressing over chest tube Observe for fluid tidaling. Fluctuation of the fluid within Excessive drainage on dressing insertion site for drainage and !he tubing, or tidaling, demon- may indicate malposition of the notify or strates pressure changes during MD for significant chest tube, infection, other drainage. problem. inspiration and expiration, and is normally 2-10 cm during inspi- Assure that chest tube clamps (2 Provides for emergencies which ration. Increases may occur for each tube) are present in may require clamping of the during coughing or forceful expi- patient's room and are taken tube. ration but continuous increases with patient when transported in tidaling may indicate a large out of unit. pneumothorax or airway obstruction. Assist with removal of chest tube Once lung is re-expanded and as warranted, and apply vaseline- fluid drainage has ceased, chest Monitor fluid drainage for char- Provides for prompt detection of impregnated gauze and dry tubes are removed. Gauze pro- acter and amount, and notify hemorrhage and prompt inter- sterile dressing over site, and vides a seal over the open wound MD if drainage is greater than vention. Some drainage systems change per hospital protocol. to prevent recurrence of pneu- 100 cc/hr for more than 2 hours. have the potential for auto- mothorax. transfusion, and this should be done per hospital policy. Monitor patient for changes in May indicate recurrent pneu- respiratory status, oxygenation, mothorax and requires prompt Strip chest tubes gently, if at all, Some facilities and physicians chest pain, dyspnea, or presence intervention and reinsertion of per hospital protocol. avoid milking, or stripping, of of subcutaneous emphysema. intercostal tube. the tubes due to the potential for suction to draw lung tissue into Information, Instruction, the orifice of the tube and damage the tissue, as well as rup- Demonstration turing of small blood vessels. The procedure changes intrathoracic INTERVENTIONS RATIONALES pressure which may result in chest pain or coughing. Instruct on function of chest Provides knowledge and Stripping may be required to tubeldrainage system. decreases patient anxiety maintain drainage when large Instruct patient to avoid pulling Prevents obstruction of tube and blood clots or fibrin strands are or lying on tubing. facilitates drainage. present or if the drainage is viscid or purulent. 114 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES

Instruct on signslsymptoms to Promotes prompt recognition of report to nurse: dyspnea, chest problems that may require pain, changes in sounds of bub- prompt intervention. bling from drainage system.

Discharge or Maintenance Evaluation

Patient will be eupneic with no adventitious breath sounds. Patient will have symmetrical chest expansion and midline tracheal placement with no episodes of dyspnea. Patient will achieve and maintain re-expansion of lung with no recurrence or complications. RESPIRATORY SYSTEM 115

PNEUMOTHORAX

Air enters pleural cavity J, Pleural pressure increased above atmospheric pressure J, Lung collapses J, High pressure gradient between alveolus and adjacent vascular sheet 4 Decreased Pa02 Increased PaC02 4 Air moves along pulmonary vessels to mediastinum 44

Mediastinal shifting 4 Interference with ventilation and venous return J, Increased pulmonary pressures Low PCW, high CVP 4 Shock J, Cardiovascular collapse 4 DEATH This Page Intentionally Left Blank RESPIRATORY SYSTEM 117

Wheezing may occur not only with asthma, but Status Asthmatieus with chronic obstructive pulmonary disease, congestive heart failure, pulmonary embolism, and Status asthmaticus is a critical emergency that tuberculosis, and these diagnoses should be ruled requires prompt intervention to avoid acute and out. possibly fatal, respiratory failure. In this condition, the asthmatic attacks are unresponsive to medical Patients who have status asthmaticus suffer pro- therapeutics, with severe bronchospasms creating nounced fatigue due to the continuous efforts of decreased oxygenation and perfusion. breathing, and they easily become dehydrated due to the hyperpnea. The patient usually has dysp- During an acute asthmatic attack, the individual nea, tachypnea, wheezing, tachycardia, pulsus may demonstrate varying degrees of respiratory paradoxus, and severe anxiety. The goals of treat- distress depending on the duration of the attack, ment include ventilatory support and and the severity of spasm. The underlying cause of maintenance of adequate airways, and the preven- asthma is still as yet unknown, but is thought to tion of respiratory failure or barotrauma. be due to imbalances in adrenergic and cholinergic control of the airways, and their response to the allergens, infections, or emotional factors with which they come in contact. Intrinsic asthma Laboratory: CBC and sputum specimens usually occurs when the triggering factors are irritation, show eosinophilia infection, or emotions, and extrinsic asthma Chest x-ray: used to observe for infiltrates or occurs when precipitated by allergic or hyperinflation to the lungs; may be used to visual- complement-mediated factors. Asthma may be ize pneumothorax, hemothorax, or drug-induced by aspirin, indomethacin, tartrazine, pneumomedias tinum propranolol, and timolol. Arterial blood gases: to identify problems with In asthma, the airways are narrowed due to the oxygenation and acid-base balance bronchial muscle spasms, edema, inflammation of the bronchioles, and thick, tenacious mucous pro- Spirometry: to provide information about severity duction. The narrowing leads to areas of of an attack, and to assess for improvement with obstruction and these become hypoventilated and therapy; FEV, is the forced expiratory volume for hypoperfused. Eventually a ventilation/perfusion 1 second and is usually < 1500 cc during an asth- mismatch occurs and may lead to hypoxemia and matic attack and will increase 500 cc or more if an increasing A-a gradient. When PaCO, rises to treatment is successful the point of respiratory acidosis, the patient is Oxygen: to provide supplemental available oxygen then considered to be in respiratory failure. Bronchodilators: used to relax bronchial smooth The three most common causes of status asthmati- muscle to dilate bronchial tree to facilitate air cus are allergen exposure, noncompliance with exchange medication regime, and respiratory infection exposure. Environmental factors, such as excessively Beta-adrenergic agents: ephedrine, epinephrine, hot, cold, or dusty areas, may initiate status asth- isoproterenol, metaproterenol, terbutaline; used to maticus because of the effect they have on the air relax bronchial smooth muscle that is breathed. 118 CRITICAL CARE NURSING CARE PLANS

Corticosteroids: used to decrease inflammatory INTERVENTIONS RATIONALES response and decrease edema and maintenance of therapeutic 10-20 mcg/ml. Symptoms may Antibiotics: used when infective process is docu- levels. Observe patient for indicate theophylline toxicity, anorexia, nausea, vomiting, which will require titration of the mented; usually bacterial infection is not a abdominal pain, nervousness, drug dosage. common precipitating factor restlessness, and tachycardia. Mechanical ventilation: necessary when respira- Administer sympathomimetics as Epinephrine is usually given SQ tory failure is present and hypoxemia persists ordered. every 20-30 minutes for 3 doses as needed to relieve broncho- despite medical therapy constriction. Terbutaline is usually not the first drug of IPPB: used to assist the patient with deep inspira- choice in acute situations due to tion to facilitate more productive coughing of the delayed onset of action, but thick mucous and to deliver medication by an is frequently used after the aerosol route patient shows improvement. Assist/administer inhalation ther- Nebulizers and intermittent posi- apy as ordered. tive pressure breathing treatments may be used in mild Inefective airway clearance to moderate episodes but should not be used during acute attacks Related to: airway obstruction, edema of bronchi- because of the potential for bronchospasm in response to the oles, inability to cough or to cough effectively, aerosol agent. excessive mucous production Information, Instruction, Defining characteristics: adventitious breath Demonstration sounds, dyspnea, tachypnea, shallow respirations, cough with or without productivity, cyanosis, anx- INTERVENTIONS RATIONALES iety, restlessness Monitor for side effects, such as May occur as adverse reactions tachycardias, tremors, nausea, from medications. May require Outcome Criteria vomiting, or bronchospasm. change in specific drug used.

Patient will maintain patency of airway and will be able to effectively clear secretions. Discharge or Maintenance Evaluation Patient will maintain patent airway and be able INTERVENTIONS RATIONALES to cough and clear own secretions. Patient will have clear breath sounds with no Administer bronchodilators as Nebulizers are usually the first ordered. line treatment for asthma. adventitious sounds or airway compromise. Aminophylline is frequently prescribed to relax bronchial smooth Patient will have adequate oxygenation. muscle and mediates histamine Impaired gm excbange release and cAMD degradation, which facilitates improved air [See Mechanical Ventilation] flow. Related to: bronchospasm, inflammation to Monitor lab levels for attainment Therapeutic levels range between bronchi, hypoxemia, fatigue RESPIRATORY SYSTEM 119

Defining characteristics: dyspnea, tachypnea, hypoxia, hypoxemia, hypercapnia, restlessness, anxiety, abnormal ABGs, dysrhythmias, decreased oxygen saturation Anxiety [See Mechanical Ventilation] Related to: dyspnea, change in health status, threat of death

Defining characteristics: fear, restlessness, muscle tension, apprehension, helplessness, sense of impending doom 120 CRITICAL CARE NURSING CARE PLANS

STATUS ASTHMATICUS Hyperactive airways 11 Mucosal edema + bronchial musde constrictionhpasm 4 Mucus plugs 4 Inflammatory response J,

Decreased Pa02 Hypoxia 4 Increased airway resistance Increased work of breathing

Dehydration CO2 retention Tachypnea 4 11 Wheezing Decreased PaCO2 Increased mucus plugs 4 4 Hypoxia Increased CO2 production Respiratory alkalosis J, J, s

Decreased PaO2 Respiratory acidosis Hypoxemia

J, I Bght ventricular strain Reactive pulmonary hypertension 11 Ventricular failure 4 Cardiac dysrhythrnias

Cardiovascular compromise d c Cardiopulmonary collapse - 4 DEATH RESPIRATORY SYSTEM 121

FIO, and exhaled tidal volumes are more Mechanical Ventilation accurate. Mechanical ventilation is used as an artificial High-frequency ventilation is used when other adjunct to maintain and optimize ventilation and methods have not been successful in oxygenation oxygenation in those patients that are unable to and ventilation of the patient. It uses lower tidal do so on their own for whatever the reason. It is volumes and increased respiratory rates to decrease utilized when other adjuncts are ineffective to reg- the incidence of barotrauma and cardiac decom- ulate oxygen and carbon dioxide levels and pensation. Frequencies range from 60-200 provide for an adequate acid-base balance. timedmin, and in high-frequency oscillation, movement of air to and from the airway is Major types of ventilators include negative external pressure and positive pressure ventilators. The performed at 600-3000 cycledmin. external type is very rarely seen today, such as the PEEC or positive end-expiratory pressure, is used “iron lung” used for the treatment of polio and to improve oxygen exchange in persistent hypox- the chest ventilator used for home treatment of emia when increases in FIO, have not improved neuromuscular diseases. These ventilators apply the situation. PEEP produces an increased func- pressure against the thorax that is less than room tional residual capacity (FRC) which increases the air, in order to accomplish ventilation by changes available lung alveoli surface for oxygenation by in lung pressures. There are no requirements for maintaining the alveoli in an open position. High artificial airways and are fairly easy to use. The levels of PEEP may contribute to the incidence of patient must remain in or under the unit and, as barotrauma and hemodynamic compromise, and such, activity is limited, and the negative pressure is most effective when maintained for lengthy exerted may result in venous pooling and periods of time. To this end, a special PEEP ambu decreased cardiac output. bag must be used to maintain the pressure in order to maintain the beneficial effects. Positive pressure ventilators are further subclassified according to the factor that initiates the inspiratory phase, and what factor causes the MEDICAL CARE inspiratory phase to cease. Pressure-cycled ventila- Laboratory: CBC, transferrin, albumin, prealbu- tors use oxygen or compressed air valves to deliver min, electrolytes used to monitor infection, a gas volume until a preset pressure limit is imbalance, and nutritional status; cultures done to achieved. As the lung compliance and airway resis- identify infective organism and specify antimicro- tance changes, inspired tidal volumes, alveolar bial agent required for eradication ventilation and FIO, changes also. The alarm systems for this ventilator are sometimes inadequate Intubation: artificial airway is required for and the ventilator cannot compensate for leaks mechanical ventilation that may occur in the system. Arterial blood gases: used to determine levels of Volume-cycled ventilators, currently the most oxygen, carbon dioxide, and pH to identify acid- common found in intensive care settings, deliver a base disturbances, hypoxemia, and to monitor for preset gas volume to the patient regardless of changes in respiratory status airway resistance or compliance. Most have safety Respiratory treatments: used to instill varied features to limit excessive airway pressures, and agents into the lungs to reduce spasm, increase 122 CRITICAL CARE NURSING CARE PLANS

hydration and liquification of secretions, and to INTERVENTIONS RATIONALES facilitate removal of secretions obrurator airways are useful only Ventilatory management: ventilator settings are in emergency situations and changed periodically based on patient condition must be replaced as quickly as possible. These are easier to and arterial blood gas analysis to ensure optimum insert than endotracheal tubes, ventilation and oxygenation but stimulate vomiting and cannot be used in conscious Tracheostomy performed when nasal or oral intu- patients. The trachea may acci- bation is impossible, or after significant time of dentally be intubated and the nasal/oral intubation on a prolonged ventilator esophagus may be perforated. Endotracheal intubation requires patient advanced training and skill, and may be accidentally placed in rhe esophagus, develop leaks that NURSING CARE PLANS may decrease oxygenation, and Inefectiue airway clearance over time, may necrotize tissues. Artificial airways may become Related to: thick tenacious secretions, airway occluded by mucous, blood, or obstruction, edema bronchioles, inability to other secretions; endotracheal of tubes may become twisted or cough or to cough effectively, presence of artificial compressed, or severe spasms airway may occlude airway. Defining characteristics: adventitious breath Monitor tube placement for Tube migration may occur with migration; place marking on coughing, re-taping, or acciden- sounds, dyspnea, tachypnea, shallow respirations, tube and note length and posi- tally, with the potential for cough with or without productivity, cyanosis, tion at least every 8 hours; tube improper placement resulting in fever, anxiety, restlessness should be adequately secured to hypoxia. Comp’arison of previous maintain placement. placement guidelines will provide prompt recognition of differ- Outcome Criteria ences and changes, and facilitate prompt intervention.

Patient will maintain patency of airway, have clear Prepare for placement on If routine medical therapeutics breath sounds, and will be able to effectively clear mechanical ventilation as war- are not effective in controlling secretions. ranted. the spasms, hypoxemia, and hypoxia, respiratory failure will ensue, and mechanical ventilation will be required to assure INTERVENTIONS RATIONALES adequate oxygenation and perfusion. Monitor airway for patency and Artificial airways will be required provide artificial airways as war- if patient cannot maintain Auscultate lung fields for pres- Proper tube placement will result ranred. Prepare for mechanical patency. Oropharyngeal airways ence of breath sounds, changes in equal bilateral breath sounds ventilation. hold tongue anteriorly but may in character, and presence to all and symmetrical chest expansion. precipitate vomiting if lengrh is lobes; observe for symmetrical Adventitious breath sounds, such nor accurately measured. chest expansion. as rhonchi and wheezes, may Nasopharyngeal airways are more indicate airflow has been easily tolerated in conscious obstructed by occlusion of the patients but may cause tube or migration into an inap- nosebleeds and may easily propriate position. Absence of become occluded. Esophageal breath sounds to left lung fields RESPIRATORY SYSTEM 131

INTERVENTIONS RATIONALES Patient will have clear breath sounds with no adventitious sounds or airway compromise. may indicate intubation of the right main stem bronchus. Patient will not have any aspiration Suction patient every 2-4 hours Patients who are intubated fre- complications. and prn, being sure to hyperoxy- quently have ineffective cough genate patient prior to, during, reflexes or are sedated and have Patient will be able to adequately perform and after procedure; limit active some muscular involvement that coughing. suctioning to 15 seconds or less may impair coughing, and suc- at a time; use pulmonary toilette tioning is required to remove Impaired gas exchange instillation as needed. their secretions. Suctioning time should be minimized and hyper- Related to: bronchospasm, mucous production, oxygenation performed to reduce edema, inflammation to bronchial tree, the potential for hypoxia. hypoxemia, fatigue Position patient in high-Fowler’s Promotes maximal lung expan- or semi-Fowler’s position. sion. Defining characteristics: dyspnea, tachypnea, hypoxia, hypoxemia, hypercapnia, confusion, rest- Turn patient every 2 hours and Repositioning promotes drainage prn. of pulmonary secretions and lessness, cyanosis, inability to move secretions, enhances ventilation to decrease tachycardia, dysrhythmias, abnormal ABGs, potential for atelectasis. decreased oxygen saturation by oximetry Administer bronchodilators as Promotes relaxation of bronchial ordered. smooth muscle to decrease Outcome Criteria spasm, dilates airways to improve ventilation, and maximizes air exchange. Patient will have arterial blood gases within normal range for patient, with no signs of ventila- Information, Instruction, tion/perfusion mismatching. Demonstration

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Instruct on splinting abdomen Promotes increased expiratory Monitor pulse oximetry for Oximetry readings of 90 corre- with pillow during cough efforts. pressure and helps to decrease oxygen saturation and notify late with PaO, of 60. Levels discomfort. MD if .c 90. below 60 do not allow for adequate perfusion to tissues and Instruct on alternative types of Minimizes fatigue by assisting vital organs. Oximetry uses coughing exercises, such as quad patient to increase expiratory light waves to identify differ- thrusts, if patient has difficulty pressure and facilitates cough. ences between saturation and during coughing. reduced hemoglobin of the Instruct on deep breathing Promotes full lung expansion tissues and may be inaccurate in exercises. and decreases anxiety. low blood flow states.

Perform chest percussion and Mobilizes secretions and facili- Monitor transcutaneous oxygen Measures the oxygen concentra- postural drainage as warranted. tates ventilation of all lung fields. tension if available. tion of the skin, but may cause burns if monitor site 1s nor Discharge or Maintenance Evaluation rotated frequently. Slun, blood flow and temperature may affect these readings. Patient will maintain patent airway and be able to cough and clear own secretions. 124 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERSENTIONS RATIONALES

Provide oxygen as ordered. Provides supplemental oxygen to Use PEEP ambu bag when SUC- despite increasing levels of benefit patient. Low flow oxy- tioning patient. oxygen by producing an gen delivery systems use some increased functional residual room air and may be inadequate capacity which then increases the for patient's needs if their tidal available lung alveoli surface for volume is low, respiratory rate is oxygenation. PEEP may predis- high, or if ventilation status is pose the patient to barotrauma unstable. Low flow systems with elevated levels. Ambu bags should be used in patients with that are capable of maintaining COPD so as to not depress their PEEP levels are required because respiratory drive. High levels of short intervals minimize the ben- oxygen may cause severe damage eficial effects of PEEP. to tissues, oxygen toxicity, increases in A-a gradients, Information, Instruction, microatelectasis, and ARDS. Demonstration Monitor for changes in mental May indicate impending or pre- status, restlessness, anxiety, sent hypoxia and hypoxemia. INTERVENTIONS RATIONALES headache, confusion, dysrhythmias, hypotension, tachycardia, Prepare patient for placement on May be necessary to maintain and cyanosis. mechanical ventilation as war- adequate oxygenation and acid- ranted. base balance. Monitor ABGs for changes Provides information on mea- andlor trends. sured levels of oxygen and Assist with respiratory Provides information to carbon dioxide as well as acid- therapists measurements of facilitate early detection of base balance. Promotes prompt oxygen analyzing, lung compli- oxygen toxicity. intervention for deteriorating ance, viral capacity, and A-a airway status. PaO, alone does gradients. not reflect tissue oxygenation; ventilation must be adequate to Discharge or Maintenance Evaluation provide gas exchange. Patient will have arterial blood gases within Administer oxygen as ordered. Oxygen by itself may not always normal limits for patient. correct hypoxia of tissues and restore perfusion. Patient will be eupneic with adequate oxygena- Monitor for signs/symptoms of Oxygen toxicity may result when tion and no signslsymptoms of oxygen toxicity. oxygen toxicity (nausea, vomit- oxygen concentrations are greater ing, dyspnea, coughing, than 40% for lengthy durations Inefective breathing pattern retrosternal pain, extremity of time, usually 8 to 24 hours, paresthesias, pronounced fatigue, and may cause actual physiologic Related to: fatigue, dyspnea, secretions, or restlessness). changes in the lungs. Progressive inadequate oxygenation, respiratory muscle weak- respiratory distress, cyanosis, and ness, respiratory center depression, decreased lung asphyxia are late signs of toxicity. Oxygen concentrations should be expansion, placement on mechanical ventilation maintained as low as possible in order to maintain adequate Defining characteristics: dyspnea, tachypnea, PaO,. bradypnea, apnea, cough, nasal flaring, cyanosis, shallow respirations, pursed-lip breathing, changes Limit PEEP (positive end-expira- PEEP is used to improve oxygen tory pressures) to 5-20 cm H,O. exchange in persistent hypoxemia in inspiratorylexpiratory ratio, use of accessory muscles, diminished chest expansion, barrel chest, abnormal arterial blood gases, fremitus, anxiety, decreased oxygen saturation RESPIRATORY SYSTEM 125

Outcome Criteria INTERWNTIONS RATIONALES Patient will be eupneic, with adequate the tube should be 2-3 cm above the carina. oxygenation, and will maintain adequate ABGs within normal limits. If ETT is placed orally, daily Prevents tissue necrosis from changes from side to side of pressure of tube against teeth, mouth should be routinely lips, and other tissues. Oral tubes performed. promote saliva formation, cause INTERVENTIONS RATIONALES nausea and vomiting if rnove- ment of tube stimulates retching, Prepare patient for placement on Promotes knowledge and and prevents the patient from mechanical ventilation and intu- reduces fear. May promote closing his mouth without biting barion procedures. cooperation. down on the tube. Assist with intubation of patient; Placement of an artificial airway Suction patient as needed, Suctioning is required to remove auscultate all lung fields for (endotracheal tube [ETT] or making sure to hyperoxygenate secretions because the patient is breath sounds. tracheostomy) is required for before, during, and after proce- unable to do so on his own. mechanical ventilation support. dure. Utilize sterile normal saline Effective coughing is decreased Nasotracheal intubation may be for pulmonary toilette instilla- because of the inability to preferred to prevent oral discom- tion prior to suctioning increase intrathoracic pressure fort and necrosis, but is procedures as warrantedlordered. when the glortis is restricted associated with a high incidence from air. Suctioning places of sinus disease. patient at risk for inadequate Hyperoxygenate patient and aus- Prolonged difficulty in place- oxygenation and decreased perfu- cultate for bilateral breath sounds ment of the tube may result in sion. Hyper-oxygenation helps to and observe for bilateral symmet- hypoxia. If symmetrical chest limit this sudden decrease in rical chest expansion. expansion is not observed, or if available oxygen. Mucous pro- breath sounds cannot be heard duction is usually increased with bilaterally, this may indicate placement of ETT due to ciliary improper placement of the tube movement being impaired and into the right main bronchus or the body's response to the foreign esophagus, and correction of this tube. Pulmonary toilette is con- problem must be addressed troversial but may be helpful to promptly. liquefy secretions to facilitate easier removal. Utilize low pressure endotracheal High pressure cuffed tubes may tubes for intubation. promote tracheal necrosis or Restrain patient as warranted and Prevents accidental extubation in result in a tracheal fistula. as per hospital protocol. sedated or confused patients.

Maintain airway; secure tube Artificial airways may become Monitor ventilator settings at Ventilator settings are adjusted with tape or other securing occluded by mucous or other least every 2-4 hours and prn; based on the disease process and device. secretory fluids, may develop a FIO, should be analyzed periodi- patient's condition to maintain cuff leak resulting in inability to cally to ensure correct amount is optimal oxygenation and ventila- maintain pressures suficient for being maintained; tidal volume tion while the patient is unable ventilation, or may migrate to a should ideally be 10-15 cc/Kg to do so on his own. Oxygen position whereby adequate oxy- body weight; airway pressures percentages may not be corn- genation is impaired. Tubes (peak inspiratory pressure and pletely accurate and analysis should be adequately secured to plateau pressure) should be noted must be performed to ensure prevent movement, loss of for identification of trends; inspi- proper amounts arc being deliv- airway, and tracheal damage. ratory and expiratory ratio; sigh ered. Exhaled tidal volumes volume and rate. should be monitored and Obtain chest x-ray afrer ETT is Radiographic confirmation of changes may indicate changes in inserted. tube placement is mandatory; lung compliance or problems with delivering specific volumes. 126 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Increases in airway pressures may Increasing volumes of air indicate bronchospasm, presence required to maintain ventilatory of mucoid and other secretions, pressures, or increasing cuff pres- obstruction of the airway, pneu- sures may indicate cuff leak and mothorax, or ARDS with high will require replacement of pressure levels and disconnection airway to maintain oxygenation. of tubing, inadequate cuff pressure or non-synchronous Auscultate for adventitious May indicate migration of breathing with low pressure breath sounds, subcutaneous airway tube. Movement from levels. I:E ratio should be 1:2 but emphysema, or localized whea- trachea into tissue may cause may be altered to improve gas ing. mediastinal or subcutaneous exchange. Sighs, when used, are emphysema and/or pneumotho- commonly 1 112 times the rax. Intubation of the bronchus volume of a normal breath, 2-6 may result in decreased unilateral times per hour to facilitate chest expansion with decreased expansion of alveoli to reduce the breath sounds, and localized potential for atelectasis. wheezing. Movement of the tube Ventilator settings may be inad- to the level of the carina may vertently changed, or due to result in excessive coughing, forgetfulness, increased oxygena- diminished breath sounds, and tion used for suctioning inability to insert suction procedure may not be turned catheter. down to ordered amounts. This Monitor ABGs for trends, and Maintains adequate oxygenation may result in oxygen toxicity or change ventilator settings as and acid-base balance. inadequate ventilation. ordered.

Observe for temperature of ven- Intubation bypasses the body’s Observe breathing patterns and Increased or decreased ventila- tilator circuitry; drain tubing natural warminglhumidifying note if patient has spontaneous tion may be experienced by away from the patient as action, and requires increased breaths in addition to ventilatory ventilator patients who may try warranted. temperature and moisturizing breaths. to compensate by competing of the delivered oxygen. The wirh ventilatory breaths. temperature of the ventilator Tachypnea may result in respira- circuitry (and the delivered tory alkalosis; bradypnea may oxygen) should be maintained at result in acidosis with increased approximately body temperature PaC02. to avoid hyperthermic reactions. Temperature increases and Observe patient for non-synchro- Asynchrony with the ventilator humidification promote conden- nous respirations with ventilator decreases alveolar ventilation, sation of water in tubing which (“fighting the ventilator”). increases intrathoracic pressures, may restrict adequate volume Administer sedation or and decreases venous return and delivery. Drainage of fluid sedationlneuromuscular block- cardiac output. Pavulon paralyzes toward the patient or toward the ade, as ordered. all muscles in body to facilitate reservoir may promote bacterial synchrony with ventilation sup- infestations. port. Patients may be completely alert when paralyzed, so sedation Monitor airway cuff for leakage, Proper cuff inflation is done with is MANDATORY prior to noting amount of air volume in the least amount of air to ensure administration of Pavulon. cuff and cuff pressures at least a minimal leak with maintenance Often, a sedation cocktail of every 4-8 hours and prn. of adequate ventilatory pressures narcotics andlor benzodiazepines and tidal volumes. Cuff pressures may be titrated wirh better should be less than 25 cm H,O results to achieve adequate seda- to prevent tracheal necrosis. tion. RESPIRATORY SYSTEM - 127

Information, Instruction, Impaired verbal communication Demonstration muscular ~ Related to: intubation, artificial airway, INTERVENTIONS RATIONALES paralysis

Prepare patient for placement of Prolonged ventilatory support via Defining characteristics: inability to speak, inabil- rracheostomy as warranted. nasal or oral endotracheal tube ity to communicate needs, inability to make may lead to necrosis of tissues due to pressure exerted by the sounds tube. Tracheostomy is more comfortable for the patient, decreases Outcome Criteria the airway resistance, and may reduce the amount of dead space. Patient will achieve a method to communicate his Observe for pulsarion of May indicate close proximity to needs. tracheostomy with neck vein innominate vessels that may lead pulsation and notify MD. to necrosis and erosion into vessels and result in hemorrhage. INTERVENTIONS RATIONALES Assess for cuff lehge and Cuffs which have leaks that changelnorify MD for change of enable a patient to have the Evaluate patient’s ability to speak Patient may be fluent in sign airway. ability to speak, in which air may or communicate by other means. language, or able to communi- be felt at the nose andlor mouth, cate in wriring to make needs changing pressures with ventila- known. tion, andfor decreased exhaled volumes require change in order Ensure that call lighr is placed Provides patient with concrete to maintain adequate oxygena- within easy reach of patient at all evidence that he may call for tion and ventilation. times, and that the light system assistance and that the nurse will is flagged to denote patient‘s be available to meet his needs. Obtain chest x-rays every day Facilitates recognition of tube impairment. Flagging system ensures that and prn while patient is migration, atelectatic changes, personnel not familiar with the intubated. presence of pneumothorax, or patient will be alerted ro his other significant changes. inability to speak.

Insure that neostigmine bromide These reverse effects of Make eye contact with patient at Communication may be possible or edrophonium chloride is pancuroniurn. all times; ask questions that may if patient is able to nod head yes available. be answered by nodding of the or no, or blink eyes in sequence. head; provide paper and Writing may be illegible due to Discharge or Maintenance Evaluation writing utensils, magic slate, or disease process or sedation, and communication board for may frustrate and farigue patient. communication. Patient will be able to maintain own airway and expectorate sputum. Information, Instruction, Patient will have arterial blood gases within Demonstration normal limits of patient disease process. INTERVENTIONS RATIONALES Patient will be eupneic with no adventitious ~ ~~ breath sounds. Instruct patient in using tongue Provides alternate merhod to to make clicking noise, or in communicate with nurse and Patient will have artificial airway intact with no tapping table or side rails to gain helps to allay fear of abandon- nurse’s attention as a secondary menr. signs/symptoms of complications. means of calling for assistance. 128 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES ~ ~~~ ~~ ~~ Instruct family members in talk- Promotes understanding for the concerns. Do not give false sively begin work on emotional ing with patient to provide family and assists in incorpor- reassurance. barriers. False reassurance tends information about issues of con- ating family into the patient's to minimize patient's feelings cern to patient, and help them to care to mainrain contact with resulting in impaired trust and deal with the awkwardness of a reality. increased anxiety. one-sided conversation. Provide support and encourage- Family's anxiety may be commu- menr to family members and nicated to the patient and result Discharge or Maintenance Evaluation assist them in dealing with their in increased anxiery levels. own fearslconcerns.

Patient will be able to speak or make needs Discuss safety precautions Provides concrete answers to help known. involved with ventilatory sup- decrease anxiety and fear of the port; emergency power source, unknown, and to relay emer- Patient will develop an adequate alternative emergency oxygen and equip- gency plans for patient. means of communication and be able to utilize ment, alarm systems, etc. communication to make needs known. Ensure that patient's call light is Provides reassurance that nurses placed within easy reach at all will be available to assist with Patient's family will be able to recognize their times, and that alternative meth- patient's needs, and decreases own contribution to the patient's recovery. ods of summoning assistance anxiety. have been discussed. Anxiety Administer antianxiery medica- Helps to reduce anxiety to a Related to: ventilatory support, threat of death, tions as ordered. manageable level when other change in health status, change in environment, techniques have failed. life-threatening crises Information, Instruction, Defining characteristics: fear, restlessness, muscle Demonstration tension, apprehension, helplessness, communication of uncertainty, sense of impending doom, INTERVENTIONS RATIONALES worry Instruct in use of relaxation tech- Promotes reduction in stress and niques and guided imagery. anxiety, and provides opportunity for patient to control his Outcome Criteria situation.

Patient will have decreased anxiety and be able to Consult psychiatrist, psycholo- Patient may require further inter- function at acceptable levels with anxiety-produc- gist, or counselor as warranted. vention for dealing with emotional problems. ing stimuli. INTERVENTIONS EWTIONALES Discharge or Maintenance Evaluation

~ ~~ Evaluate patient's perception of Identifies problem base and facil- Patient will be able to verbalize concerns and crisis or threat to self. itates plan for intervention. fears and be able to rationally deal with them in Monitor for changes in vital May indicate patient's level of appropriate ways. signs, restlessness, or facial response to stressors and level of tension. anxiety. Patient will be able to function with anxiety reduced at a manageable level. Encourage patient to express Promotes verbalization of con- fears and concerns and provide cerns, and allows time for information pertinent to those identification of fears to progres- RESPIRATORY SYSTEM 129

~~ Patient will be able to utilize methods to reduce INTERVENTIONS RATIONALES anxiety. ~~ Provide opportunities for patient Provides opportunity to gain Inefective individ~ul...amiiycoping to make decisions regarding his some sense of control of his life, care, when feasible. decreasing anxiety, and assisting Related to: change in health status, change in abil- in coping skills. ity to communicate, sensory overload, change in Discuss current problems and Identifies actual problems and environment, fear of death, physical limitations, assist with problem-solving to assists patiendfamily ro find real inadequate support system, inadequate coping find solutions. solutions to facilitate increasing self-control and self-esteem. mechanisms, threat to self, pain Discuss feelings of blame, either Blaming oneself or others pro- Defining characteristics: inability to meet role on self, or on others. longs inability to cope and expectations, inability to meet basic needs, worry, increases feelings of hopelessness. apprehension, fear, inability to problem solve, hos- Remain non-judgmental of Anger and hostile feelings may tility, aggression, inappropriate defense choices patiendfamily may make. promote resolution of stages of mechanisms, low self-esteem, insomnia, Adopt a non-threatened attitude grief and loss, and should be when anger and hostility are regarded as an important step in depression, destructive behaviors, vacillation when expressed. Set limits on unac- that process. Limits must be set choices are required, delayed decision making, ceptable behaviors. to prevent destructive behavior muscle tension, headaches, pain that will impair patienr’s self- esteem. Outcome Criteria Discuss feelings of anger at God, Spiritual beliefs are questioned religious alienation, lack of when threats of death occur, and meaning to life, etc. may affect patient’s ability to Patient will be able to recognize problems with cope with and problem-solve coping and be able to problem-solve adequately. during crises.

Information, Instruction, INTERVENTIONS RATIONALES Demonstration Evaluate patient’dfamily’s coping Provides baseline information to skills and ability to verbalize establish interventions best suited INTERVENTIONS RATIONALES problems. to the patient/family/situation. Assess rapport of family members Actions of the family may be Coping abilities that the patient with patient. Involve the family helpful, but the patienr may per- has utilized previously may be members in the care of the ceive these as being used in the current crisis to pro- patient when feasible. over-prorective or smothering. vide a sense of control. Helping with patient’s care may Discuss concerns and fears of loss Identifies needs for intervention enhance the family’s feelings of of control with patient, and pro- and helps to establish a trusting importance and control of the vide feedback. relationship. situation.

Monitor for dependence on May indicate patient’s need to Provide information to the Identifies opportunities for other others, inability to make deci- depend on others to allow time patient and family regarding resources that may be available, sions, inability to involve self in to regain ability for coping with other agencies and personnel and provides means of control care, or inability to express con- crises, and promotes feeling of who may assist them with their over situation. cerndquestions. safety. Patient may be afraid to crisis. make any decision in which his tenuous condition could be compromised. 130 CRITICAL CARE NURSING CARE PLANS

Discharge or Maintenance Evaluation INTERVENTIONS RATIONALES

Patient/family will be able to recognize ineffec- Maintain good handwashing Handwashing is the most tive coping behavior and regain emotional technique and isolation precau- important step in preventing tions when warranted. nosocomial infection. Patients equilibrium. may require isolation based on their diagnosis to prevenr trans- Patient/family will be able to adequately prob- mission of infection to or from lem-solve during crises. the patient.

Patiendfamily will be able to recognize options Screen visitors who are ill Patients are already immuno- and resources for use post-hospitalization. themselves. compromised and at risk for development of infection.

Patient/family will be able to make appropriate, Maintain sterile technique for all Reduces spread of infection. informed decisions and be satisfied with dressing changes and suctioning. choices. Administer antibiotics as Required to treat infective organ- POten tidfo r infection ordered. ism. Related to: intubation, disease process, immuno- Information, Instruction, suppression, compromised defense mechanisms Demonstration Defining characteristics: increased temperature, INTERVENTIONS RATIONALES chills, elevated white blood cell count, purulent Instruct patientlfamily in proper Reduces risk of transmission of sputum handwashing and disposal of infection to others. contaminated secretions, tissues, etc. Outcome Criteria Instruct family to avoid visiting Patient is already immuno-com- Patient will have no evidence of infective process. if they have upper respiratory promised and is at risk for infections. infection.

Instruct patientlfamily on antibi- Provides knowledge and INTERVENTIONS RATIONALES otics: effects, side effects, enhances cooperation with contraindications, and treatment. Evaluate risk factors that would Intubation and prolonged foodsldrugs to avoid. predispose patient to infection. mechanical ventilation predispose patient to nosocomial Discharge or Maintenance Evaluation infection. Age, nutritional status, chronic disease progression and invasive procedures and lines also Patient will be free of fever, chills, purulent predispose patient to infection. drainage, or other indicators of infective process. Monitor sputum for changes in Purulent, malodorous sputum characteristics and color; culture indicates infection. Cultures may Patient will be able to recall information accu- sputum as warranted. be required to identify causative organism and to prescribe appro- rately regarding antibiotics and infection control priate antibiotics. procedures. Monitor trachcostomy site for Purulenr drainage indicates infec- Patiendfamily will be able to recognize risk fac- redness, foul odor, or purulent tion. Cultures may be required to drainage; culture site as identiFy causative organism and tors and avoid further compromise of patient. warranted. to prescribe appropriate antibiotics. RESPIRATORY SYSTEM 131

Altered oral mucous membrane Information, Instruction, Demonstration Related to: oral intubation, increased or decreased saliva, inability to swallow, antibiotic-induced INTERVENTIONS RATIONALES fungal infection Instruct on antifungals as Provides knowledge. Defining characteristics: oral pain or discomfort, warranted. stomatitis, oral lesions, thrush Instruct patient in utilizing oral Provides a sense of control CO the suction equipment when feasible, patient, and facilitates removal of if patient has copious oral excessive secretions. Outcome Criteria secretions. Patient will be free of oral pain and mucous mem- Discharge or Maintenance Evaluation branes will remain intact. Patient will have intact oral mucous membranes, with no evidence of infection. INTERVENTIONS RATIONALES Patient will be able to recall instructions accu- 0 bserve mouth for missing, Teeth may be chipped or rately. loose, or chipped teeth; bleeding, knocked out during intubation sores, lesions, necrotic areas, or process and loose teeth may pose Patient will be able to adequately remove secre- reddened areas. a potential for aspiration. Identification of lesions or other tions by use of suction equipment. problems may facilitate prompt intervention. Patient will be compliant with performance of oral care. Move oral endotrached tube to Decreases potentid for pressure other side of mouth at least daily and ultimately, ulceration of lips Altered nutrition: less than body and prn. or mucous membranes. requirements Provide oral care at least every 8 Promotes cleanliness, reduces hours and prn. odor, and reduces potential envi- Related to: intubation, inability to swallow, inabil- ronment for bacterial invasion. ity to take in food, increased metabolism due to disease process, surgery, decreased level of Swab mouth with mouthwash Removes transient bacteria, every 4-8 hours and prn. reduces odor, and helps to consciousness stimulate circulation to oral membranes. Defining characteristics: actual inadequate food intake, altered taste, altered smell sensation, Apply lip balm every 2-4 hours Prevents drying and cracking of and pm. lips. weight loss, anorexia, absent bowel sounds, decreased peristalsis, muscle mass loss, decreased Suction patient’s ord cavity fre- Removes excessive saliva and muscle tone, changes in bowel habits, nausea, quently if patient is unable to mucous which may facilitate handle secretions. bacterial growth. vomiting, abdominal distention

Observe for white patches on May indicate presence of fungal tongue and mucous membranes, infection (thrush) which will Outcome Criteria and notify MD. require anti-fungal solution, such as Nystatin. Patient will have adequate nutritional intake with no weight or muscle mass loss. 132 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Evaluate ability to eat. Some patients with water every 8 hours, before and tube maintains patency. tracheostomies are able to eat, after medication administration while those patients who are via the tube, and prn. endouacheally intubated must be kept NPO due to the posi- Aspirate gastric residuals every 4- Increasing residuals may indicate tioning of the epiglottis, and will 8 hours, and decrease or hold decreased or absent peristalsis require enteral or parenteral feedings per hospital protocol. and lack of absorption of alimentation. required nutrients which may require another form of nutri- Weigh every day. Continued weight loss will result tional support. in catabolic metabolism and impaired respiratory function. Use food coloring to tint feed- Helps to identifj aspiration of ings. Do not use red coloring. feedings when suctioned. Be Observe for muscle wasting. May indicate muscle stores aware that the food coloring may depletion which can impair res- cause false readings on occult piratory muscle function. blood tests on stools. Red coloring should be avoided due to similarity of blood color and this Observe for nausea, vomiting, Ventilator patients may develop may impair ability to differenti- abdominal distention and palpa- GI dysfunction from ate bleeding problems. bility, and stool characteristics. analgesicslsedatives, bedrest, trapped air, and stress, which Instill warm cranberry juice, Helps to dissolve clogged partic- may result in ileus formation. carbonated cola, or mixture of date matter to maintain patency monosodium glutamate and of tube. Test stools and gastric contents Stressors of ventilation and pres- water in enteral tube for signs of for guaiac. ence in ICU may predispose occlusion. patient to the formation of a stress ulcer resulting in GI bleed- Administer antidiarrheal medica- Osmolality imbalances may ing. tions as warranted. result in diarrhea requiring antidiarrheds for control. Obtain calorie count and assess- Establishes imbalances between Changing strengths or types of actual nutritional intake and ment of metabolic demands feedings may be helpful. based on disease process. metabolic needs. Administer metodopramide as Medication helps to stimulate Monitor lab work as warranted; Evaluates need for andlor ade- ordered. gastric motility and may be help- electrolytes, creatinine, quacy of nutritional support. BUN, ful to increase absorption. albumin and prealbumin, glucose levels. Administer parenteral alimenta- Provides complete nutritional tion fluids as warranted via support without dependence on Administer enteral solutions at Bolus feedings may result in infusion pump. GI function for absorption. continual rate by infusion pump dumping syndrome. Continuous Additives are based upon lab as warranted. infusion feedings are generally work and patient requirements. better tolerated and have better Increases in protein and nitrogen absorption. Enteral feeding for- may be prescribed for increased mulas vary depending on the metabolic demands of the nutritional needs of the patient. patient. The use of enteral formulas require a functioning GI system. Administer intralipids as ordered, Provides additional caloric bene- if not admixed with TPN soh- fits as well as a source of essential Determine patency of enteral Oral or nasal tubes may migrate tion. fatty acids. Lipids may be uti- feeding tubes at least every 8 with coughing, resulting in lized for respiratory failure to hours. Flush with 20-30 cc of improper placement and poten- help decrease CO, retention. tial for aspiration. Flushing of ~ RESPIRATORY SYSTEM 133

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation Change solution at least every 24 Some additives may be unstable Patient will maintain baseline weight with no hours, as well as tubing. after 24 hours, and prolonged infusion with same solution may loss of muscle mass. promote bacterial growth. Patient will maintain adequate nutritional status Monitor lab work per hospital Requirements for electrolyte with use of nutritional support, and will experi- protocol; general chemistry, renal replacement or alteration in for- ence no complications from support. profile, CBC, urine or blood mula may be changed based on glucose levels. this information. High dextrose Patient will show no signs of malnutritional content in TPN solutions may require additions of insulin to status. meet metabolic demands if pan- Patient will be able to recall information accu- creatic disease, hepatic disease, or diabetes are present. rately. Do not stop TPN abruptly; Rebound hypoglycemia may Patient will maintain a normal nitrogen balance taper over several dayslhours per result if dextrose concentrations and immunity will not be compromised. protocol. are abruptly changed. Dysfinctionud ventihtory wean response Information, Instruction, Demonstration Related to: fever, pain, muscle fatigue, sedation, anemia, electrolyte imbalance, sleep deprivation, INTERVENTIONS RATIONALES poor nutrition, cardiovascular lability, psychological instability Insert nasogastric feeding tube as Smaller lumen is less irritating warranted, utilizing small to nasal mucosa, and decreases Defining characteristics: inability to wean, lack or weighted tube. Obtain chest the incidence of gastroesophageal x-ray or KUB post procedure. reflux. Radiographic inadequacy of spontaneous respirations, negative confirmation of placement is inspiratory force or pressure < -20 cm H,O, PaO, necessary due to the potential for < 60 mmHg on FIO, > 50%, PaCO, > 40 aspiration when patients may mmHg, tidal volume < cc/Kg, vital capacity < have impaired gag reflex. 5 10 cc/Kg, minute ventilation > 10 L/min Maintain elevation of the head of Helps prevent potential the bed at least 30 degrees at all aspiration. times. Outcome Criteria

Assist with placement of central Centrally-placed intravenous Patient will be able to be weaned from ventilatory venous catheter for TPN admin- lines may enable higher istration. Obtain chest x-ray post concentrations of amino acids to support successfully with arterial blood gases procedure. be utilized. Radiographic confir- within normal limits. mation of placement, as well as ruling out hemo- or pneumotho- INTERVENTIONS RATIONALES rax post procedure, is mandatory. Monitor vital signs. Temperature elevations increase Instruct in need for supplemental Promotes knowledge, decreases metabolism and oxygen demand. nutritional support, procedures fear of the unknown, and facili- Unstable heart rate and rhythm to be performed, and tests that tates cooperation with results in increased workload on will be required. procedures. Provides opportunity the heart, increased oxygen con- for patient to make informed sumption and demand. Process choices. of weaning will increase work- 134 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

load and may compromise an Attempt to wean only during the Crises that may occur with already-stressed body and should day and after the patient has had respiratory deterioration and not be attempted until these a resthl sleep period. Avoid failure to wean may be handled factors have been corrected. activity during weaning. more efficiently when sufficient Once weaning process has medical personnel are available, begun, significant changes in usually during the day. Fatigue heart rate and rhythm, respira- may predispose patient to failure tory rare, and blood pressure due to the need for stamina to may indicate a need to slow or withstand the effort of sponta- discontinue weaning due to res- neous breathing. Activity piratory compromise. increases oxygen demand and consumption. Monitor EKG for dysrhythmias Ventilatory support decreases and treat as warranted. venous return to the heart, Evaluate patient’s emotional Weaning process may result in increases PVR and SVR. status and ability to cope with anxiety due to fear of failure to Hypoxemia and pH imbalances weaning. wean andlor ability to breathe may result in dysrhythmias from spontaneously. cardiac compromise. Prior to attempt, assess weaning Attainment of parameters facili- Monitor nutritional status. Protein, carbohydrate and fat parameters to ensure patient tate best chance for successful Evaluate labwork: CBC, transfer- concentrations can alter the abil- meets requirements for successful weaning and ensures that neuro- rin, albumin, prealbumin, ity to maintain oxygenation. weaning: NIF > -20 cm H,O, muscular control is adequate for electrolytes, etc. Increased fat concentration prior vital capacity > 10-15 cclKg, maintenance of spontaneous to weaning may assist in decreas- PaO, > 60 mmHg on FIO, < ventilation. If carbon dioxide ing potential for CO, retention 40%, resting minute ventilation retention is chronic, pH is more and decrease in respiratory drive. < 10 L/min, PaCO, c 40 indicative of weaning readiness. Labwork may be used to verify mmHg, tidal volume > 5 cdKg. adequacy of nutritive state. Assess patient for resolution Calcium imbalances can decrease of Factors may promote respiratory the function of the diaphragm, disease process, absence of inspi- insufficiency and compromise and phosphorus may affect 2, 3- ratory muscle fatigue, absence of which may result in unsuccessful DPG and ATP function, affect fever, absence of hemodynamic weaning. instability, absence of sedative respiratory muscle function and red cell membrane stability. agents or respiratory suppres- sanrs, presence of spontaneous Stay with patient until stable, Respiratory deterioration may respirations, pulmonary shunt < once weaning process has begun. occur rapidly and physical pres- 20%, and adequate hemoglobin Observe for use of accessory ence is required to observe and hematocrit. muscles, non-synchronous respi- patient to facilitate prompt inter- Suction patient and perform ratory pattern, or skin color vention. May indicate Removes secretions that may chest physiotherapy, percussion changes. deterioration in respiratory compromise weaning process and status, resulting in inability to and postural drainage as war- promotes improved pulmonary wean. ranted prior to disconnection conditions. from ventilator. Monitor oxygen saturation per Oximetry provides identification Utilize T-bar/T-piece adaptor oximetry and notify MD if read- of tissue oxygen desaturation as Provides oxygen via endotracheal ordered. (Usually on T-bar for ing less than 90% per pulse which usually coincides with tube or tracheostomy with 10-30 minutes per hour oximetry, or sustained reading decreases in arterial blood gases. patient spontaneously breathing. initially.) less than 60% per mixed venous Oximetry does not give indica- oxygen oximetry; obtain ABGs tion of increased CO, levels and Utilize SIMV/IMV mode on Provides ventilatory support to per protocol. these must be verified with ventilator as ordered. (Usually patient with gradually decreasing ABGs. rate decreased by 1-2 ventilator breaths and increase of breathslminute every 15-30 spontaneous breaths. Facilitates minutes.) gradually increasing respiratory RESPIRATORY SYSTEM 135

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

workload. If weaning is not the peak of the inspiratory effort. lungs so that patient will exhale tolerated, may increase PaCO, or cough as tube is removed ro and decrease pH. prevent aspiration of any secretions that may be remaining after Utilize PS (pressure support) as Assists patient to overcome suctioning. ordered. (Usually 3-5 initially airway resistance and support and may increase to 20, with spontaneous breathing by Administer humidified oxygen at Provides moisture and oxygen to gradual lowering as IMV/SIMV increasing respiratory muscle prescribed amount. increase available oxygen, helps rate lowered.) function. to reduce swelling, and facilitates liquification of secretions for Utilize CPAP (continuous posi- Patient exhales against continu- easier removal. tive airway pressure) as ordered. ous positive pressure to prevent (Usually 2-5 cm H,O.) atelectasis and improve arterial Monitor for dyspnea, May indicate partial obstruction oxygen tension. bronchospasm, laryngospasm, or of airway. Deep breathing helps stridor. Encourage deep breaths to expand lungs and facilitates Monitor for MD-set parameters Alterations in vital signs and and coughing. movemenr of secretions. or respiratory rate > 30, increas- hemodynamic may result from ing PA pressures, heart rate > insufficient ventilation and respi- Monitor for persistent hoarseness Transient hoarseness and sore 110 with new or increased ratory compromise and indicates and sore throat. throat is normal post-extubarion ectopic activity, blood pressure > intolerance of attempts to wean. but persistent symptoms may 20 mmHg from baseline, indicate vocal cord paralysis or SaO, < 90%, tidal volumes c glottis edema. 250 cc; if significant changes occur, place back on ventilator as per protocol.

Gradually increase time off venti- The patient's progress will lator with each successful increase as fatigue decreases, attempt. Once patient is able to respiratory muscle function Information, Instruction, tolerate 1-2 hours off ofventila- improves, and patient is emo- tor at a time, weaning may be tionally ready to wean. Demonstration advanced more rapidly. - INTERVENTIONS RATIONALES Determine patient's emotional Weaning may result in excessive sratus and ability to cope with anxiety due to fear of failure Instruct on weaning process Decreases fear and anxiety, pro- weaning process. and/or the ability to breathe and procedures based on MD motes cooperation, and increases spontaneously. protocol. potential for successful weaning attempt. Extubate patient when he is able Emergency equipment should to maintain an airway and his be easily available in case Knowledge deficit spontaneous respirations are able reintubation is required due to to maintain oxygenation and bronchospasm, laryngospasm, or Related to: change in health status, situational ventilatory status per protocol. respiratory deterioration. Intubation equipment should crisis, lack of information, misinterpretation of remain at the bedside post-extu- information, stress, inability to recall information, bation for 4-24 hours or per lack of understanding protocol. Defining characteristics: verbalized questions To extubate, increase oxygen and Removes secretions that may suction secretions from trachea, potentially be aspirated upon regarding care, inadequate follow-up on instruc- nose and mouth. removal of tube. tions given, misconceptions, lack of improvement, development of preventable complications Deflate cuff and remove tube at Promotes full inflation of the 136 CRITICAL CARE NURSING CARE PLANS

Outcome Criteria INTERVENTIONS RATIONALES

Patient will be able to verbalize and demonstrate Instruct family on ventilatory Reduces fear, enables the family understanding of information given regarding support procedures-function of to have sense of security about all equipment, how to trouble- problems that may arise, and condition, treatment regimen, and medications. shoot problems, and personnel to assures them that medical assis- contact in case of an emergency. tance can be easily obtained in Information, Instruction, an emergency. Demonstration Instruct family on procedures for Promotes knowledge, enhances suctioning, tracheostomy care, proper technique for care, and INTERVENTIONS RATIONALES and administration of breathing decreases fear. treatments as ordered. Determine patient’s baseline of Provides information regarding Instruct family on infection con- Decreases potential for infection knowledge regarding disease patient’s understanding of condi- trol techniques. and/or spread of biohazardous process, normal physiology and tion as well as a baseline from materials. function of body systems, and which to plan teaching. medical treatment regimens. Instruct patientlfamily on Promotes prompt recognition of signslsymptoms to notify MD or potentially dangerous problems Monitor patient’s readiness to Patient’s physical condition may medical personnel. to facilitate prompt intervention. learn and determine best meth- not facilitate participation in ods to use for teaching. Attempt learning, with cognition af€‘ected Have patientlfamily perform Provides assurance that care is to incorporate family members by high stress levels or disease return demonstration of all tasks able to be performed with proper in learning process. Reinstrucd process. Family members may be instructed. technique, and allows for correc- reinforce information as needed. fearful of equipment and envi- tion of erroneous methods. ronment which may hamper their ability to learn. Instructions Ensure that prior to discharge, all Reduces anxiety with discharge. may require repetitive teaching equipment required will be set due to competition with other up in home. stimuli. Instruct on all safety concerns; Promotes sense of security that Provide time for individual inter- Promotes relationship between back-up power and equipment. emergency situations can be action with patient. patient and nurse, and establishes handled. trust. Discharge or Maintenance Evaluation Instruct on specific disease Provides knowledge to enable process that has required ventila- patient to make informed tory support, procedures that choices, and provides knowledge Patiendfamily will be able to accurately recall may be required, diagnostic tests base on which to build for fur- instructions. to be performed, and plans for ther teaching. weaning off ventilator. Patient/family will be able to demonstrate all

Instruct on medications perti- Provides knowledge and facili- tasks with appropriate proper methods. nent to patient‘s care. tates compliance with regimen. Patiendfamily will be able to recall emergency Discuss potential for ventilator Unsuccessful weaning attempts numbers, and signs/symptoms for which to dependence and alterations that may foster depression and atti- notify medical personnel, and can accurately may be required in lifestyle. tude of “giving up.” Practical Encourage setting of short- and solutions and trouble-shooting demonstrate back-up power and equipment. long-term goals. problems that may arise, well as Patiendfamily will be able to follow infection as participation in setting of realistic goals may enhance control procedures. self-worth and self-control. Patiendfamily will be able to problem-solve and set realistic goals. NEUROLOGICAL SYSTEM 137

NEUROLOGICAL SYSTEM CYA Head Injuries Spinal Cord Injuries Guillain-Bard Syndrome Status Epilepticus Meningitis VentriculostomylICP Monitoring Endarterectomy This Page Intentionally Left Blank NEUROLOGICAL SYSTEM 139

In addition to the disease processes discussed ear- CUA lier, cardiac dysrhythmias, alcohol use, cocaine or A cerebrovascular accident, or stroke, occurs when other recreational drug use, smoking, and the use a sudden decrease in cerebral blood circulation as of oral contraceptives may predispose patients to a result of thrombosis, embolus, or hemorrhage strokes. leads to hypoxia of brain tissues, causing swelling Strokes may cause temporary or permanent losses and death. When circulation is impaired or inter- of motor function, thought processes, memory, rupted the small area of the brain becomes speech,, or sensory function. Difficulty with swal- infarcted and this changes membrane permeability lowing and speaking, hemiplegia, and visual field resulting in increased edema and intracranial pres- defects are stations of this disease. Treatment is sure (ICP). The clinical symptoms may vary aimed at supporting vital functions and ensuring depending on the area and extent of the injury. adequate cerebral perfusion, and prevention of Thrombosis of small arteries in the white matter major complications or permanent disability. of the brain account for the most common cause of strokes. A history of hypertension, diabetes MEDICAL CARE mellitus, cardiac disease, vascular disease, or ather- CT scans: used to identify thrombosis or hemor- osclerosis may lead to thrombosis, which causes rhagic stroke, tumors, or hydrocephalus; may not ischemia to the brain supplied by the vessel reveal changes immediately involved. Skull x-rays: may show calcifications of the Embolism is the second most common cause of carotids in the presence of cerebral thrombosis, or CVA, and happens when a blood vessel is partial calcification of an aneurysm in subarach- suddenly occluded with blood, air, tumor, fat, or noid hemorrhage; pineal gland may shift to the septic particulate. The embolus migrates to the opposite side if mass is expanding cerebral arteries and obstructs circulation causing edema and necrosis. Brain scans: used to identify ischemic areas due to CVA but usually are not discernible until up to 2 When hemorrhage occurs, it is usually the sudden weeks after injury result of ruptured aneurysms, tumors, or AV malformations, or involves problems with Angiography used to identify site and degree of hypertension or bleeding dyscrasias. The cerebral occlusion or rupture of vessel, assess collateral bleeding decreases the blood supply and blood circulation and presence of AV malforma- compresses neuronal tissue. tions Patients who have strokes frequently have had MRI: used to identify areas of infarction, hemor- prior events, such as TIAs (transient ischemic rhage, and AV malformations attacks) with reversible focal neurological deficits Ultrasound: may be used to gather information lasting less than 24 hours or RINDS (reversible regarding flow velocity in the major circulation ischemic neurological deficits) lasting greater than 24 hours but leaving little, if any, residual neuro- Lumbar puncture: performed to evaluate ICP and logical impairment. to identify infection; bloody CSF may indicate a hemorrhagic stroke, and clear fluid with normal 140 CRITICAL CARE NURSING CARE PLANS pressure may be noted in cerebral thrombosis, Outcome Criteria embolism, and with TIAs; protein may be elevated if thrombosis results from inflammation Patient will have improved or normal cerebral perfusion with no mental status changes or EEG: may be used to help localize area of injury complications. based on brain waves Laboratory: CBC used to identify blood loss or INTERVENTIONS RATIONALES infection; serum osmolality used to evaluate Measure blood pressure in both Cerebral injury may cause oncotic pressures and permeability; electrolytes, arms. variations in blood pressure glucose levels, and urinalysis performed to identify readings. Hypotension may result from circulatory collapse, and problems and imbalances that may be responsible increased ICP may result from edema or clot formation. Surgery: endarterectomy may be required to Differences in readings between remove the occlusion, or microvascular bypass arms may indicate a subclavian may be performed to bypass the occluded area, artery blockage. such as the carotid artery, aneurysm, or AV Maintain head of bed in elevated Helps to improve venous malformation position with head in a neutral drainage, reduces arterial pres- position. sure, and may improve cerebral Corticosteroids: used to decrease cerebral edema perfusion. Anticonvulsants: used in the treatment and pro- Provide calm, quiet environment Bedrest may be required to phylaxis of seizure activity with adequate rest periods prevent rebleeding after initial between activities. hemorrhage. Activity may Analgesics: used for discomfort and pain; aspirin increase ICI? and aspirin-containing products are Administer anticoagulants as May be warranted to improve contraindicated with hemorrhage ordered. blood flow to cerebral tissues and to prevent further clotring and TPA: use is controversial because of risks of embolus formation. These are uncontrolled bleeding contraindicated in hypertension due to the potential for hemorrhage.

NURSING CARE PLANS Administer antihypertensives as Hypertension may be transient ordered. when occurring during the CVA, Alteration in tissue perfusion: cerebral but chronic hypertension will Related to: occlusion, hemorrhage, interruption of require judicious trearmenr to prevent further tissue ischemia '\\cerebralblood flow, vasospasm, edema and damage. 1 Oefining characteristics: changes in level of con- Administer vasodilators as Helps to improve collateral circu- sciousness, mental changes, personality changes, ordered. lation and to reduce the memory loss, restlessness, combativeness, vital sign incidence of vasospasm. changes, motor function impairment, sensory impairment NEUROLOGICAL SYSTEM 141

Information, Instruction, INTERVENTIONS RATIONALES Demonstration Evaluate patient‘s response to Inability to follow simple com- INTERVENTIONS RATIONALES simple commands. mands may indicate receptive aphasia. Instruct on use of stool softeners Valsalva maneuvers increase ICP and avoidance of straining at and may result in rebleeding. Evaluate patient‘s ability to name Inability to do so indicates stool. Stool softeners help to prevent objects. expressive aphasia. straining. Evaluate patient’s ability to write May indicate patient’s disability Prepare patient for surgery as May be required to treat problem simple sentences or his name. with receptive and expressive warranted. and prevent further complica- aphasia. tions. Avoid talking down to patient or Intellect frequently remains making patronizing comments. unimpaired after injury.

Impaired verbal com munication When asking questions, use yes Provides for method of commu- or no type questions initially, and nication without necessity of Related to: weakness, loss of muscle control, cere- progress as patient is able. response to large volumes of bral circulation impairment, neuromuscular information. As patient impairment progresses, the intricacy of questions may increase.

Defining characteristics: inability to speak, inabil- Provide a method of communi- Allows for communication of ity to identify objects, inability to comprehend cation for patient, such as a needs and allays anxiety. language, inability to write, inability to choose writing board, or communication board to which patient may and use appropriate words, dysarthria point.

Outcome Criteria Information, Instruction, Demonstration Patient will be able to communicate normally or will be able to make needs known by some form INTERVENTIONS RATIONALES of communication. Consult with speech therapy. May be required to identify cog- INTERVENTIONS RATIONALES nition, function, and plan interventions for recovery. Evaluate patient’s ability to speak Provides a baseline from which Assist patientlfamily to Provides method for patient to to begin planning intervention. or understand language. identify and use methods for communicate his needs. Determination of specific areas communication. of brain injury involvement will- preclude what type of assistance will be required. Discharge or Maintenance Evaluation Assess whether patient suffers Aphasic patients have dificulty from aphasia or dysarthria. using and interpreting language, Patient will be able to communicate effectively. comprehending words, and Patient will be able to understand communica- inability to speak or make signs. Dysarthric patients can under- tion problem and access resources to meet needs. stand language, but have problems forming or pronounc- Impaired physical mobility ing words as a result of weakness [See Head Injuries] of paralysis of the oral muscles. 142 CRITICAL CARE NURSING CARE PLANS

Related to: weakness, paralysis, paresthesias, INTERVENTIONS RATIONALES impaired cognition return to function level. Sensory Defining characteristics: inability to move at will, impairment affects balance and muscle incoordination, decreased range of motion, positioning. decreased muscle strength Evaluate environmene for safety Promotes safety and decreases hazards, such as temperature potential for injury. Senso y -perceptual alterations: visual, extremes. kinesthetic, gustatory, tactile, oyactory Information, Instruction, Related to: neurological trauma/deficit, stress, Demonstration altered reception of stimuli ~~ ~ Defining characteristics: behavior changes, disori- INTERVENTIONS RATIONALES entation to time, place, self, and situation, diminished concentration, inability to focus, alter- Instruct patient to observe feet Visual and tactile stimulation when standing or ambulating, helps to retrain movement and to ation in thought processes, decreased sensation, and to make a conscious effort to experience sensations. paresthesias, paralysis, altered ability to taste and reposition body parts. Assist with smell, inability to recognize objects, muscle inco- sensory stimulation to non-use ordination, muscle weakness, inappropriate side. communication Discharge or Maintenance Evaluation

Outcome Criteria * Patient will be alert and oriented to all phases. Patient will achieve and maintain alertness and Patient will be able to understand changes in orientation with acceptable behavior and functional ability and residual neurological motor/sensory function. deficits. Patient will be able to compensate for dysfunc- INTERVENTIONS RATIONALES tional abilities. Risk for impaired swallowing Assess patient’s perceptions and May help decrease distortions of reorient as necessary. thought and identify reality. Related to: neuromuscular impairment Assess for visual field defects, Visual distortion may prevent Defining characteristics: inability to swallow visual disturbances, or problems patient from having realistic with depth perception. perception of his environment. effectively, choking, aspiration

Assist patienr by placing objects Allows for recognition of people in his field of vision. and objects, and decreases Outcome Criteria confusion. Patient will be able to swallow effectively with no Limit amount of stimuli. Avoid May create sensory overload and excess noise or equipment. confusion. incidence of aspiration.

Observe patient for non-use of May create self-care deficiencies. extremities. Test for sensatiod Loss of sensation or inability to awareness and ability to discern recognize objects may impair position of body. NEUROLOGICAL SYSTEM 143

INTERVENTIONS RATIONALES Self-care deficit: bdthing, dressing, feeding, toileting Evaluate patient’s ability to swal- Provides baseline information low, extent of any paralysis, from which to plan interventions Related to: weakness, decreased muscle strength, ability to maintain airway. for care. muscle incoordination, paralysis, paresthesia, Maintain head position and sup- Helps to prevent aspiration and pain, functional impairment port, head of bed elevated at least facilitates ability to swallow. 30 degrees or more during and Defining characteristics: inability to perform after feeding. ADLs, inability to feed self, inability to maintain Place food in the unaffected side Allows for sensory stimulation personal hygiene, inability to dresdundress self, of mouth. and taste, and may assist to trig- inability to take care of toileting needs ger swallowing reflexes. Provide foods that are soft and These types of foods are easier to Outcome Criteria require little, if any, chewing, or control and decrease potential for provide thickened liquids. choking or aspiration. Patient will be able to meet self-care needs within Assist with stimulation of May help to retrain oral muscles own ability level. tongue, cheeks, or lips as war- and facilitate adequate tongue - ranted. movement and swallowing. INTERVENTIONS RATIONALES

Monitor intake and output, and Insufficient nutrient intake orally Evaluate level of neurological Provides baseline from which to caloric intake. may result in the need for alter- impairment and patient’s abilities plan care for patient needs. nate types of nutritional support. to perform ADLs. May be required if oral intake is Administer tube feedings/TPN Assist patient with ADLs as Assistance may reduce levels of as warranted/ordered. insufficient. needed and encourage patient to frustration but patient will have perform tasks he may be capable more self-esteem with tasks he of doing. may complete. Information, Instruction, Alter plans of care keeping in Assists patient with safety con- Demonstration mind patient’s visual, motor, or cerns and allows for some degree sensory deficits. of independence. INTERVENTIONS RATIONALES Utilize self-help devices and Allows patient to perform task Instruct to use straw for drinking Helps to strengthen facial and instruct patient in their use. and improves his self-esteem. liquids. Maintain swallowing oral muscles to decrease potential Establish a bowel regime, using Medications may be helpful precautions identified by speech for choking. stool softeners, suppositories, etc. when establishing a bowel regime therapists. Offer bedpan or bedside com- and to regulate function. Encourage family to bring Familiar foods may increase oral mode ar regular intervals. Retraining will allow the patient patient’s favorite foods. intake. to gain independence and fosters self-esteem. Discharge or Maintenance Evaluation Information, Instruction, Demonstration

Patient will be able to eat and swallow normally. ~~~ ~~ INTERVENTIONS RATIONALES Patient will be able to ingest an adequate amount of nutrients without danger of aspiration. Consult physicaVoccupationa1 May be required to assist wlth therapist. development of therapy plan and Patient will be able to follow instructions and to identify methods for patient strengthen muscles used for eating/swallowing. to compensate for neurological defi ci ts. 144 CRITICAL CARE NURSING CARE PLANS

Discharge or Maintenance Evaluation

Patient will be able to perform self-care activities by himself or with the assistance of a caregiver. Patient will be able to understand and identify methods to facilitate meeting self-care needs. Patient will be able to access community resources to meet continuing needs. NEUROLOGICAL SYSTEM 145

CVA

Cerebral hemorrhage Occlusion of major vessel Other causes of ischemia by embolism c Cerebral infarction tI Ie Decreased flow of blood to brain

J, Hypoxia c Cerebral edema c Vascular congestion c Compression of tissue c Impaired hnction I I I Anterior cerebral artery Middle cerebral artery Posterior cerebral artery 4 e c Confusion Arm paralysis Hemiparesis Impaired thought Hemianopia Ataxia Contralateral paralysis Aphasia Visual problems Urinary incontinence Agnosia Dysphasia Sensory deficits Perception deficits Dysphonia

Return of normal perfusion Continued inadequate blood flow

J, c Decreased edema Further compression of tissues 4 c Function improved Cerebral death This Page Intentionally Left Blank NEUROLOGICAL SYSTEM 1 h7

When injury to the axons and neurons in the hemispheres, brain stem, and diencephalon occur Head injuries, both open and closed, are usually and result in diffuse shearing of white matter with the result of some type of trauma, and include concurrent cerebral edema, dysfunction results in skull fractures, concussions, lacerations, coma. More than half of these patients die, and contusions, andor cerebral hemorrhages. The those who do survive, have severe residual injury can be the result of a direct blow to the dysfunction. Contusions of the brain stem result head, or may involve acceleration/deceleration in coma, as well as cranial nerve dysfunction and injuries. Acceleration, or coup, injuries occur cardiopulmonary instability. when the brain is forced against the cranium. Skull fractures are normally classified as linear, Deceleration, or contrecoup, injuries occur after basilar, or depressed. If a linear skull fracture does the initial impact when the brain is rotated or not puncture the dura mater, the fracture will heal thrown in the opposite direction of the force. without treatment. If the dura is torn, there is an Closed head injuries (CHI) result when a blunt increased chance that the middle meningeal artery trauma to the head causes a neurological deficit or is also punctured, and this will cause an epidural loss of consciousness from bruising, hemorrhage, hematoma. or laceration of brain tissues. This type of injury A basilar skull fracture can occur in the anterior or may be further categorized into mild concussion, posterior fossa, and classic symptoms include cere- classic concussion, diffuse injury with loss of con- brospinal fluid leakage from the nose or ears, or sciousness greater than 24 hours, and diffuse ecchymoses over the mastoid projection or around shearing and disruption of brain structures. the eyes. With basilar fractures, there exists a high A mild concussion occurs when forces on the risk for cranial nerve injury and dysfunction, brain stretch nerve fibers and result in impaired infection, and residual neurological impairment. conduction of nerve responses. Neurological dys- Depressed skull fractures that are not depressed function is temporary with no residual effects. In a more than the thickness of the skull are usually classic concussion, the loss of consciousness is usu- not treated. A depression more than 5 millimeters ally less than 24 hours in length and the patient or more in depth will require surgery in order to experiences disorientation and a degree of retro- relieve the compression on structures. If the dura grade amnesia when consciousness is regained. mater is punctured, the possibility of bone frag- Some patients may experience residual personality ments entering the brain tissue is increased, as well changes or impairment in memory recall. Patients as the potential for infection. may exhibit a focal deficit caused by an injury that occurs to a specific area. Lacerations of the scalp may occur with head injury or skull fractures, and will potentiate the With diffuse closed head injuries, the loss of con- danger of infection. sciousness is greater than 24 hours and the coma may last up to weeks. The patient can exhibit rest- Intracranial hematomas result after trauma to the lessness, withdrawal from painful or noxious head, and frequently occur in conjunction with stimuli, or purposeful movement. Disorientation scalp lacerations, skull fractures, contusions, or and amnesia occur with the return of conscious- penetrating wounds to the head. Subdural ness, and personality changes are permanent due hematomas (SDH) usually are caused by venous to the widespread cerebrum disruption. 148 CRITICAL CARE NURSING CARE PLANS bleeding, most often from the superior sagittal MEDICAL CARE sinus, and involves the area between the dura mater and the arachnoid space. It may be acute, CT scans: used to identify cerebral edema, happening within 24-48 hours of injury, subacute, lesions, hemorrhage, ventricle size, tissue shifts, or within 3-20 days of injury, or chronic, greater infarctions than 20 days from injury, depending on the time X-rays: skull x-rays may be used to identify frac- elapsed from injury to the onset of symptoms. tures or midline shifts, or presence of bone SDH may occur spontaneously if the patient has a fragments, and to evaluate healing or resolution blood dyscrasia or clotting problem. MRI: used to reveal disruption of axonal Epidural hematomas (EDH) are usually caused by pathways and white matter shearing arterial bleeding, generally from the middle meningeal artery, and involve the area above the Angiography: cerebral angiograms may be used to outer dura mater and below the skull. These occur identify circulatory anomalies, shifting of struc- frequently when skull fractures cross the middle tures, hemorrhage, or edema meningeal artery, or transverse or superior sagittal Lumbar puncture: may be used in diagnosis of sinus, and the bleeding causes the dura to be subarachnoid hemorrhage; LP may be contraindi- pulled away from the skull. A posterior fossa cated in some cases EDH is usually caused by a venous bleed and may result in delayed symptoms due to the slow Laboratory: electrolyte imbalances may increase oozing. With EDH, the patient may have a brief ICP or alter mental status; CBC to evaluate blood episode of unconsciousness, followed by a varying loss and hydration status; drug toxicology studies length of lucid behavior prior to neurological to identify drugs that may be responsible for con- deterioration and increased intracranial pressure. sciousness level changes; anticonvulsant drug levels to monitor therapeutic maintenance levels Intracerebral hemorrhage (ICH) into the brain may occur hours or days after a closed head injury, Arterial blood gases: used to evaluate hypoxemia and many result after rupture of an aneurysm, AV and acid-base imbalances that can increase ICP; malformation, tumor, or vessel that has been intracranial hematomas may result in respiratory weakened from hypertension. If the hemorrhage alkalosis, or metabolic acidosis if patient is also in occurs in the internal capsule of the brain, paraly- shock sis will ensue. Symptoms vary depending on site, Diuretics: may be used to draw water from brain size, cerebral edema, and blood accumulation rate. cells in order to decrease cerebral edema and ICP Head injuries .can result in varying severity from Steroids: may be used to decrease inflammation absence of neurological dysfunction to death, and and edema each injury must be considered potentially critical. Cervical spine injury evaluation may be required Anticonvulsants: may be required to treat and/or depending on the mechanisms of the closed head prevent seizure activity injury. NEUROLOGICAL SYSTEM 149

NURSlN6 CARE PLANS INTERVENTIONS RATIONALES Alteration tissue perfision: cerebral inability to stay awake unless in stimulared, or disorienration. Related to: hemorrhage, hematoma, lesions, cere- Lack of response to stimuli may indicate that damage has bral edema, metabolic changes, hypoxia, occurred to the midbrain, pons, hypovolemia, cardiac dysrhythmias and/or medulla. If a minimal amount of damage has occurred Defining characteristics: disorientation, in the cerebral cortex, the patient confusion, changes in mental status, combative- may be uncooperative or drowsy. ness, inability to focus on topic, amnesia, memory Assess patient’s best verbal Identifies speech ability and ori- loss, restlessness, inability to follow commands, response to questions and entation levels. increased intracranial pressure, vital sign changes, whether wordslsentences are impaired motor function, impaired sensory func- appropriate. tion Assess ability to follow simple Identifies ability to respond to commands, noting purposeful stimuli when patient is unable to and non-purposeful movements open eyes or cannot speak. Outcome Criteria bilaterally. Purposeful movement, such as holding up two fingers or Patient will achieve and maintain consciousness, squeezing and releasing hands when instructed to do so, can and will have normal cognition and motor func- help identify awareness and the tion. ability to respond appropriately!. Abnormal posturing may indi- INTERVENTIONS RATIONALES cate diffuse cortical damage, and the absence of any movement to Assess patient for cause of Establishes plan of care and iden- one side of the body usually indi- impairment, problem with perfu- tifies appropriate choices for cates damage has been done to sion, and potential for increased intervention. Depending on the motor tracts of the opposite ICP patient’s conditiodproblem, side of the cerebral hemisph’ re surgical intervention may be f. required. Observe pupils bilaterally, noting Compression of the brain stem equality, size, and reaction to and impairment of the second Evaluate neurological status every Establishes a baseline from which light. Notify MD of significant and third cranial nerves will alter hour initially, then every 1-2 to gauge changes or trends. changes. pupillary response. hours, and notify MD for perti- Alterations in level of conscious- nent changes. See Glasgow ness and behavior, as well as Observe position of eyes, noting Loss of doll’s eyes, or the oculo- Coma Scale below. other symptoms may be helpful any deviation laterally or verti- cephalic reflex, indicates to determine area of damage. cally. Observe for presence of impairment in the function of doll’s eyes. the brain stem. Positions and Assess patient’s arousal or lack of Establishes level of consciousness movement of the eyes may indi- arousal to verbal and noxious which is the single most impor- cate which area of rhe brain has stimuli. tant measure of the patient’s been involved. Problems with status. Extensive damage involv- abduction of the eyes may be an ing the cerebral cortex may result early indication of increased in delayed responses to intracranial pressure. commands, drowsiness and Observe for presence of blink Loss of blinking reflex may indi- reflex. cate injury to the pons and medulla. 150 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Monitor intracranial pressure at Provides immediate information Monitor EKG for rhyrhm and Bradycardia is frequently seen leasr hourly, or use continuous about changes in pressure of the rate changes and treat per hospi- with brain stem injury. monitoring per hospital policy. cerebrospinal fluid and blood to tal protocol. Dysrhyrhmias may become life- facilitate detection of life- threatening and require emergent threatening increases that can intervention. lead to brain deterioration. ICP fluctuates continuously and Assess for presence of cough and Injuries ro the medulla will resulr gag reflexes. maintained increases longer than in impairment of these reflexes and may cause further complica- 10-15 minutes should be reported. tions. Observe for restlessness, moan- Monitor ICP waves. Plateau, or A waves, have rapid May indicate presence of discom- ing, or nonverbal changes in increases and decreases of pres- fort or pain and this may behavior. sure ranging from 15-50 mmHg, increase ICP last from 2-1 5 minutes, and are Observe for presence of seizure Cerebral injury and irritation, usually noted in cerebral dys- activity and provide appropriate hypoxemia, hypoxia, and function caused by shifting of safety precautions. increased ICP may result in the brain. B waves last from 30 seizures. Seizure activity increases seconds to 2 minutes, and are metabolic demands which can usually less significant unless also increase ICI? they occur in runs, which may precede changes to A waves. C Observe for nuchal rigidity. May be present when meninges waves are small and normally are irritated if dura mater has occur at the rate of G/minute, been punctured, or if infection and relate to variances in arterial develops. blood pressure. Elevate head of bed 15-30 Reduces inrracranial pressure and Obtain CSF sample as ordered May be required for diagnostic degrees as indicated. cerebral congestion and edema. and as per hospital protocol. testing or to relieve pressure. Support head and neck in a neu- Movement of the head to either Monitor vital signs; observe for Autoregulation may be impaired tral midline position utilizing side can compress jugular veins widening pulse pressure, blood after cerebral vascular injury. pillows, sand bags, or towels. inhibiting venous drainage and pressure changes, bradycardia, Temperature elevation may can result in increased ICI? tachycardia, apnea, Cheyne- increase cerebral blood flow and Limit suctioning to only when Suctioning procedures can Stokes respiration, or fever. volume, which can increase ICI? needed Widening pulse pressure may . increase intrathoracic, intraab- indicare increasing intracranial dominal, and intracranial pressures. pressure, especially when consciousness level is deteriorating Administer oxygen as warranted. Reduces hypoxemia which may concurrently. Hypotension from resulr in increased ICP hypovolemia may occur when patient has associated multiple If patient requires mechanical Hyperventilation results in respi- trauma. Cardiac dysrhythmias ventilation, monitor hyperventi- ratory alkalosis, which results in may result from brain stem pres- larory status. cerebral vasoconstriction and sure or injury, or may be seen in decreases in ICP cardiac disease. Increasing ICP or Administer sedation and neuro- compression of brain structures Paralping drugs may be ordered muscular paralyzing agents as to prevent sudden rises in may result in loss of spontaneous ICP ordered and warranted. caused by coughing, suctioning, respiration and may require or other muscular acriviry, but mechanical ventilation. Damage should never be given without to the hypothalamus may resulr sedation of patient. in hyperthermia which can result in increased ICE! NEUROLOGICAL SYSTEM 151

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Moniror pulse oximetry and Indicates respiratory insufficiency Patient will be alert, oriented in all phases, with notify MD if levels remain below and impendinglpresent hypoxia. no speech or motor impairment. 90%. Patient will have no sensory impairment. Monitor ABGs as warranted. Identifies acid-base imbalances and presence of hypoxemia. Patient will have stable vital signs and no Elevations in PaCO, will cause vasodilation in the cerebral vas- increase in ICI? culature with a resultant increase in ICP Risk fir inefective breathing pattern

Monitor intake and output Reflects amounts of total body Related to: respiratory center injury, obstruction, hourly. water which influences tissue structural shifting, surgical intervention perfusion. Cerebral injury may result in inappropriate ADH or Defining characteristics: dyspnea, Cheyne-Stokes diabetes insipidus, and may lead respirations, bradypnea, apnea, hypoxia, to hypovolemia. hypoxemia, abnormal arterial blood gases Provide calm, quier environment Helps to reduce ICE Use of without extraneous stimuli, and restraints may be required to provide rest periods between care ensure the patient’s safety, but Outcome Criteria activities. Use restraints only may cause irritation and fighting when absolutely necessary. against the restraints which can Patient will maintain a patent airway with no evi- increase ICE dence of respiratory insufficiency. Administer osmotic diuretics as Drugs remove water from areas INTERVENTIONS RATIONALES ordered. in the brain that maintain an - intact blood-brain barrier, and Observe respiratory status for Changes from patient’s baseline helps to reduce ICE rate, depth, rhythm, irregularity, may indicate pulmonary compli- chest expansion and symmetry, cations or involvement of brain Information, Instruction and absence. injured areas. Respiratory insuffi- Demonstration ciency may require mechanical ventilation. INTERVENTIONS RATIONALES Mainrain patency of airway. Depending on location of injury, Instruct patient to avoid cough- Activities increase ICP by patient may not be able to main- ing, straining, or any valsalva-like increasing intrathoracic and tain his own airway or maneuvers. intra-abdominal pressures. ventilation and may require artificial means of doing so. Prepare patiendfamily for place- Injury to certain areas of the ment on mechanical ventilation brain may result in insufficient Auscultate breath sounds for May indicate hypoventilation, as warranted. respiratory status and may changes and presence of adventi- obstruction, atelectasis, or infec- require intubation and mechani- tious lung sounds. tion which may impair cerebral cal ventilation to maintain life oxygenation. support. Observe for presence of gag, Lack of these reflexes may impair Prepare parient/family for surgi- Craniotomy or burr holes may cough, and swallow reflexes. the parient’s ability to handle his cal procedures. be necessary to remove bone secretions and may require an fragmenrs, remove a hematoma, artificial airway. Nasopharyngeal stop hemorrhage, remove airways are preferred to avoid necrotic tissue, or elevate a stimulation of the gag reflex depressed skull fracture. which can increase ICP 152 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Alteration in thoughtprocesses

Administer oxygen as warranted. Provides supplemental oxygen to Related to: injury, psychological problems, med- reduce hypoxia and prevent ications desaturation. Defining characteristics: memory deficit, dimin- Elevate head of bed as warranted. Promotes chest expansion and ventilation. ished attention span, inability to focus, disorientation to time, place, person, or situation, Avoid suctioning unless manda- Suctioning may cause hypoxia poor recall, distractibility, personality changes, tory, and observe for changes in and decreases cerebral perfusion, sputum color, consistency, or while increasing ICI? Changes in inappropriate behavior, inability to problem-solve odor. sputum characteristics may indicate impending or presence of infection. Outcome Criteria Patient will be oriented in all phases and will be Information, Instruction, able to recall data. Demonstration INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Evaluate orientation status with Provides a baseline on which to regard to time, place, person, begin and plan interventions. Instruct patient in deep breath- Reduces potential for atelectasis circumstance, and recent events. ing exercises. and/or pneumonia. Observe patient for abiliry to Abiliry to concentrate may be Avoid chest physiotherapy during CPT is concraindicated with concentrate and attention span. diminished due to injury and acute phases. patients with increased ICP this further potentiates anxiety because this potentiates the for the patient. increase. Assist family members to under- Head injury recovery includes Prepare patient/family for intu- time and condition permits, As stand patient’s aberrant behavior, agitation and hostility, anger, and bation/mechanical ventilation instruction may be given. as personality changes, and other disorganized thought sequences. warranted. Provides knowledge and responses. Family members may have diff- decreases fear in patients who are culty dealing with the patient’s awake. changed personaliry and behavior. Discharge or Maintenance Evaluation Encourage family to discuss news Helps to maintain contact with and family occurrences with normal events and assists with Patient will maintain his own airway and be patient. orientation. able to sustain spontaneous respiration. Explain all procedures with clear Patient may have lost the abiliry concise explanations. to reason or conceptualize, and Patient will be able to handle secretions and dis- may require repeated reinforce- pose of them adequately. ment. Retention of information may be decreased and result in Arterial blood gases will be within normal limits further anxiety. for the patient. Reduce competing stimuli when Brain injured patients may be conversing with the patient. overly excitable and become vio- Patient will be able to recall information accu- lent with excess stimulation. rately and be able to demonstrate appropriate Be consistent with srafFassign- Provides atmosphere of stability deep breathing. ments as much as possible. and allows patient some control in situation. NEUROLOGICAL SYSTEM 153

~~~~ ~ ~ ~ ~ INTERVENTIONS RATIONALES Defining characteristics: fever, tachycardia, elevated white blood cell count, shift to the left on Remain with patient during Offers support and helps to calm differential, redness to wounds, purulent drainage episodes of fright or agitation. patient to reduce anxiety to pre- or sputum, nuchal rigidity, bloody or purulent vent loss of control and panic. CSF Assist patient/family to set realis- Helps to maintain a sense of tic goals and instruct in ways to hope for improvement and to control behavior. facilitate rehabilitation. Outcome Criteria

Patient will be free of signs/symptoms of infection.

Information, Instruction, INTERVENTIONS RATIONALES Demonstration Monitor temperature every 2-4 Elevation may indicate develop- INTERVENTIONS RATIONALES hours. ment of infection. Observe wounds, incision lines, Prompt identification of develop- Consult rehabilitation counselor Assists patient with methods to invasive line sites, or other skin ing problems may result in for assistance with cognitive compensate for problems with bre& for drainage, redness, or prompt intervention to prevent training as warranted. concentration, memory, judg- edema. systemic sepsis. ment, and problem-solving. Observe for CSF leakage from Indicates a serious complication Make appropriate referrals TO Additional help may be needed ears and nose, and report to from head injury and may result support groups or counseling as to help with recovery. MD. in meningitis. warranted. Use aseptic or sterile technique Prevents spread of infection. when changing dressings or pro- Discharge or Maintenance Evaluation viding wound care. Utilize good handwashing Prevents nosocomial infections, Patient will regain normal mental skills and be practices. oriented in all phases. Monitor urine output for ade- May identify presence of bacrer- quacy of amount, color, clarity, id infection. Patient will be able to recognize aberrant behav- and presence of foul odor. ior and control negative reactions. Obtain cultures of wound, urine, Identifies the presence of infec- Patient will participate in rehabilitation/counsel- blood, stool, sputum, or other tion and the causative agent, as ing for retraining. body fluidslsurfaces as well as identification of appropri- warranted, and as per hospital ate antimicrobial agent to treat Risk for infiction protocol. infection. Administer antibiotics as May be given prophylactically Related to: trauma, lacerations, broken skin, open ordered. when trauma, surgery, or CSF wounds, invasive procedures, surgery, use of leakage occurs. Appropriate steroids, cerebrospinal fluid leakage, nutritional antibiotic may be ordered after results of culture and sensitivity deficiency are received. 154 CRITICAL CARE NURSING CARE PLANS

Information, Instruction, INTERVENTIONS RATIONALES Demonstration

INTERVENTIONS RATIONALES Evaluate patient’s ability and Identifies impairments and function and injury. allows for identification of Instruct on isolation procedures Isolation may be required based appropriate interventions. as warranted. Instruct visitors on on type of organism grown. Assess patient for degree of Provides a baseline on which to avoiding patient if they have Restriction of ill visitors may immobility. base interventions. Patient may upper respiratory or other type of reduce exposure of an already only require minimal assistance infection. susceptible patient. or be completely dependent on Instruct on deep breathing and Promotes lung expansion and caregivers for all body needs. pulmonary exercises as reduces potential for atelectasis Observe skin for redness, May indicate pressure is being warranted. and pneumonia. Postural warmth, or tenderness. concentrated in one area and drainage is contraindicated if may predispose patient to decu- patient has increased ICE bitus formation. Discharge or Maintenance Evaluation Provide kinetic bed or alternating Helps to promote circulation and pressure mattress for patient. reduces venous stasis and tissue Patient will be normothermic with normal pressure to prevent formation of pressure sores. white blood cell count. Maintain good body alignment Prevents further complications Patient will exhibit no signs/symptoms of infec- and use pillows/rolls to support and contractures. Use of tennis tion. body. Use high-top tennis shoes shoes helps prevent footdrop. and removelreapply every 4-8 Wounds will heal without complications. hours. Impaired physical mobility Perform range of motion exer- Helps to maintain mobility and cises every 4 hours. function of joints.

Related to: trauma, immobilization, mental Provide skin care every 8 hours Helps to promote circulation and impairment, decreased strength, paralysis and prn. Change wet clothing reduces potential for skin break- and linens prn. down. Defining characteristics: inability to move at will, inability to transfer or ambulate, decreased range Instill artificial tears or lubrica- Prevents eye tissues from drying tion ointment to eyes every 4 out. If patient is unable to main- of motion, decreased muscle strength, muscle hours and prn as ordered. tain closed eyes, eye patches or incoordination, footdrop, contractures, decreased tape may be required. reflexes Information, Instruction, Demonstration Outcome Criteria INTERVENTIONS RATIONALES Patient will achieve and maintain an optimal level of motor function. Instruct patient/family in range Helps patient to regain some of motion exercises and mobility control and allows family some aids. involvement in reconditioning program.

Instruct patiendfamily in reasons Promotes understanding and for impairment and realistic goals compliance with treatment regi- for changes in patient’s lifestyle men. as warranted. NEUROLOGICAL SYSTEM 155

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Consult physical andlor occupa- Assists patient with identihing Encourage family to assist with Involves family in parient’s plan tional therapy, as warranted. methods to compensate for feeding as warranted. of care and provides opportunity impairments and provides for for socialization that may post-discharge care. improve intake.

Administer tube feedings as Tube feedings may be required Discharge or Maintenance Evaluation required. during the initial phase after injury until the patient is able to Patient will be able to maintain skin integrity swallow without danger of aspi- with no complications. ration. Elevate the head of the bed at Helps to prevent aspiration Patient will be able to increase muscle strength least 30 degrees while eating or and tone and achieve a functional level of giving tube feedings. muscle function. Auscultate bowel sounds every 4 Quality of bowel sounds may Patient will be able to demonstrate exercise pro- hours. indicate response to feedings or development of an ileus. gram. Consult dietitian as warranted. Provides additional resources to Patient and family will become involved in establish nutrient needs based on recovery programs. many factors including metabolic deman ds . Risk for alteration in nutrition: less tban Monitor serum albumin, preal- Assists in identification of nutri- body requirements bumin, transferrin, iron, renal tional problems, body function, profiles, and glucose levels. and response to nutritional sup- *Relatedto: inability to take in sufficient nutrients, port. inability to chew or swallow, decreased level of consciousness, intubation, increased metabolism Information, Instruction, Demonstration Defining characteristics: weight loss, muscle wast- ~ INTERVENTIONS RATIONALES ing, catabolism Consult speech or occupational May be required ro establish a Outcome Criteria therapy For mechanical problems. functional method of eating for the patient. Patient will be able to ingest sufficient nutrients to Check gastric contents, vomitus, Bleeding may occur from srresses meet metabolic demands, and will experience no and stools for occult blood. resulting from injury or from mechanical erosion. weight loss. Discharge or Maintenance Evaluation INTERVENTIONS RATIONALES Patient will maintain optimal weight. Evaluate patient’s ability to eat, Identifies problems and estab- swallow, chew, etc. lishes data for choices of Patient will be in a positive nitrogen balance, interventions. with laboratory values within normal limits. Weigh every day. Establishes trends and helps to evaluate effectiveness of Patient will be able to ingest food in sufficient interventions. amounts to meet and maintain metabolic Provide small, frequent meals. Improves patient compliance and demands. facilitates digestion. 156 CRITICAL CARE NURSING CARE PLANS

HEAD INJURIES

Brain trauma c Bleeding 1- 1- JI I Bruising of brain Small petechial hemorrhages Laceration of brain tissue c Brain edema Neuronal pathways disrupted c s Compression of blood vessels Cranial nerve dysfunction Blood flow decreased c Brain ischemia c Tissue hypoxia c Arteriolar dilatation Increased capillary pressure Decreased venous return c Celular metabolism impaired c Cellular transport decreased Sodium and water increased c Increased cerebral edema Increased ICP c Shifting of brain structures c Brain tissue destruction Herniation/cornpression of brain and brainstem J. Cardiovascular and respiratory impairment 4 Cardiopulmonary failure c DEATH NEUROLOGICAL SYSTEM 157

HEAD INJURIES

CONCUSSION DIFFUSE INJURY WITH DIFFUSE WHITE MATTER LOG24 HOURS SHEARING WITH DISRUPTION OF AXON/NEURON PATHS

MILD CLASSIC c c c c Stretching of Axonal disruption Coma with purposhl move- Coma with brainstem and nerve fibers ment and restlessness autonomic dysfunction c c c c Loss of nerve Cortical dysfuntion Disorientation Cardiovascular collapse conduction c c c Temporary neuro- Disorientation Retrograde and post-traumatic DEATH logical dysfunction amnesia

J, J, J, Retrograde amnesia Retrograde and post- Increased cerebral edema traumatic amnesia

J, JI e Return to normalcy Potential subtle Increased ICP personality and c memory changes Brain tissue destruction/compression

J, Cardiovascular collapse J, DEATH This Page Intentionally Left Blank NEUROLOGICAL SYSTEM 159

In central cord syndrome, the central gray matter Spinal Cord Injuries of the cord is contused, compressed, or Spinal cord injuries are traumatic injuries to the hemorrhaged. This results in varying degrees of spinal cord caused by contusion, compression, or sensory loss and bowel/bladder dysfunction, and transection of the cord as a result of dislocation of there is more motor loss in the arms than in the bones, rupture of ligaments, vessels, or vertebral legs. In anterior cord syndrome, the injury has discs, stretching of neuron tissue, or impairment occurred to the anterior horn and spinothalamic in blood supply. These lesions are classified as areas resulting in a loss of motor function and being complete or incomplete. Complete lesions painltemperature below the lesion. Sensations of involve the total loss of sensation as well as volun- touch, position, pressure and vibration may be tary motor function, and incomplete lesions maintained. In Brown-Sequard syndrome, as a involve mixed losses of sensation and voluntary result of a transverse hemi-transection of the cord, motor function. motor loss, touch, vibration, pressure, and position are involved ipsilaterally, with a contralateral The flexion, hyperextension and/or rotational loss of pain/temperature sensation. Posterior cord types of injury that result in spinal cord injury are syndrome is exceedingly rare and results in the loss usually caused by trauma, motor vehicle accidents, of light touch below the level of injury, with falls, gun shot wounds, stab wounds, and diving motor function and sensation of pain and temper- injuries, The severity of the injury can vary ature maintained intact. depending on the amount of pathologic changes that are produced. Injury without intervention When spinal lesions at or above T6 level block results in ischemia, edema, hemorrhage, and pro- sensory impulses from reaching the brain, an gressive destruction. After the initial cord excessive and critical autonomic response to a compression, small hemorrhages occur in the cen- stimulus occurs, and this is known as autonomic tral gray matter. The expansion and increase in dysreflexia. It may be precipitated by bowel or number of hemorrhagic areas cause even more bladder distention or by stimulation of the skin or pain receptors. Symptoms may include severe compression, edema, and finally, necrosis of the cord. The cervical area is the most vulnerable part blood pressure increases, pounding headache, pro- of the spine because of the mobility of the head fuse sweating above the lesion, blurred vision, goosebumps, and bradycardia. Treatment is aimed and poor support by the muscles, but cervical at removing the stimulus that causes the problem, fractures do not necessarily cause neurological and treating the hypertensive episode. problems. Spinal shock occurs when there is an abrupt loss The level of the injury relates to how much func- of continuity between the spinal cord and the tional ability is retained. At the C1 to C8 levels, higher nerve centers, with a complete loss of all the patient is a quadriplegic with variances in reflexes and a flaccid paralysis below the level of muscle function from complete paralysis of respi- injury. Normally, this spinal shock lasts 7-1 0 days ratory function to limited use of the fingers. At TI and when it begins resolution, the flaccidity to L1 levels, paraplegia is noted with intact arm changes to a spastic type of paralysis. movement. At L1 and below, there may be mixed dysfunction with bowel and bladder dysfunction. 1 c;n CRITICAL CARE NURSING CARE PLANS

MEDICAL CARE INTERVENTIONS RATIONALES Arterial blood gases: used to identify hypoxemia Monitor EKG for changes in Sympathetic blockade may cause and acid-base imbalances rhythm and conduction, and conduction problems such as treat according to hospital escape rhythms, and vasovagal Radiography: chest x-rays used to identify protocol. reflexes may provoke cardiac arrest. diaphragmatic changes or respiratory complications; spinal x-rays used to identify frac- Monitor hemodynamic parame- Fluid shifts, hypotension, and ters if feasible. hemorrhage may be reflected in ture or dislocation and identifies level of injury lowered pressures and lower cardiac output/index. CT scans: used to identify structural aberrancies and localize injury site Administer oxygen as warranted, Assists in preventing hypoxia ensuring pre-oxygenation prior which can result in vasovagal Magnetic resonance imaging: used to identify to suctioning or prolonged reflex and cardiac arrest. cord lesions, compression, or edema coughing exercises. Administer vasopressors as May be indicated if fluid resusci- Surgery: may be required to align or stabilize frac- warranted. tation is not successful in ture, or repair other traumatic injuries that may be maintaining systolic blood pres- concurrent sure above 90 mmHg. Traction: may be required to align and stabilize Information, Instruction, fracture or dislocation of the vertebral column Demonstration NURSING CARE PLANS INTERVENTIONS RATIONALES Instruct patient in avoidance of May lower blood pressure and Risk jib decreased cardiac output valsalva-type maneuvers. facilitare vasovagal response. Related to: neurogenic shock, sympathetic blockade, spinal shock Discharge or Maintenance Evaluation

Defining characteristics: hypotension, bradycar- Patient will exhibit no episodes of cardiac dia, vasovagal reflex, hypoxia, decreased venous rhythm disturbances. return, decreased hemodynamic pressures Patient will have normotensive blood pressure with stable hemodynamic pressures. Outcome Criteria Patient will have optimal cardiac output and Patient will be able to maintain systolic blood index. pressure above 90 mmHg and have stable vital signs and heart rhythm. Patient will exhibit no hypoxic episodes and ~~ avoid desaturation with procedures. INTERVENTIONS RATIONALES Monitor vital signs, especially Transection of the spinal cord Inneflective breathing pattern blood pressure and heart rate. above the T5 levels may result in Related to: trauma, spinal cord lesions at high vasodilation, decreased venous return, and hypotension. levels, paralysis of respiratory musculature, ineffec- Sympathetic blockade may cause tive coughing, pneumonia, pulmonary edema, bradycardia. pulmonary embolism NEUROLOGICAL SYSTEM lG1

Defining characteristics: dyspnea, use of accessory Information, Instruction, muscles, diaphragmatic breathing, decreased tidal Demonstration volumes, sputum, abdominal distention, abnormal arterial blood gases, apnea, oxygen desaturation INTERVENTIONS RATIONALES

Prepare patientlfamily for place- Hypoxemia that cannot be cor- Outcome Criteria ment on mechanical ventilation rected with addition of as warranted. supplemental oxygen may Patient will maintain adequate oxygenation and require intubation and ventilation to maintain airway and ventilation without evidence of respiratory com- oxygenation. plications. Prepare patient for bronchoscopy May be required to remove INTERVENTIONS RATIONALES as warranted. obstructive secretions.

Assess respiratory status for ade- Spinal cord lesions below C4 Monitor for signslsymptoms of Edema may result from fluid quacy of airway and ventilation, level induces diaphragmatic pulmonary embolism, pneumo- resuscitation efforts, and pneu- rate, character, depth, increased breathing and hypoventilation. nia, or pulmonary edema. monia may develop from work of breathing, or use of immobility and ineffective cough accessory muscles. ability. Pulmonary emboli may result from venous thrombosis as Auscultate lung fields for pres- May reflect the presence of infil- a complication of immobility or ence of adventitious sounds and trates, pneumonia, atelectasis, or hemorrhagic causes. other changes. fluid overload. Instruct family member in tech- Provides information that will be Assist withlmeasure pulmonary Measurement of pulmonary niques to assist patient with used when patient is discharged parameters, such as spontaneous parameters may facilitate prompt coughing, repositioning and facilitates feelings of control tidal volume, vital capacity, and identification of deterioration in frequently, and suctioning tech- over situation and self-esteem. negative inspiratory force. respiratory status. ABGs are niques as warranted. Obtain arterial blood gases as drawn to identify acidlbase dis- warranted. turbances and hypoxemia that Discharge or Maintenance Evaluation may result from restriction of lung expansion and ineffective cough mechanisms. Patient will maintain adequate airway and ventilation. Evaluate patient’s ability to Paralysis of respiratory muscula- cough and assist with abdominal ture may prevent sufficient Patient will exhibit no signs/symptoms of respi- thrusting technique, or quad pleural pressure to be produced ratory complications. coughing, as warranted. to maintain effective cough. External technique can assist Patiendfamily will be able to verbalize patient to cough effectively. understanding of instructions and give adequate Monitor oxygen saturation con- Oximetry assists in identification return demonstration. tinually and notify physician if of deterioration in ventilatory levels stay below 90%. status, allowing for prompt inter- Alteration in temperature regulation vention. Related to: poikilothermism, injury to hypothala- Suction patient only when Suctioning may precipitate vaso- required. Provide humidification vagal reflexes, bradycardia, and mic center or sensory pathways of oxygen and utilize pulmonary cardiac arrest. Liquification of toilette as warranted. environmental air and secretions Defining characteristics: elevated body tempera- may prevent mucous plugs and ture, decreased body temperature, change of thick mucoid secretions. temperature based on environmental temperature 162 CRITICAL CARE NURSING CARE PLANS

Outcome Criteria Outcome Criteria

Patient will achieve and maintain body tempera- Patient will be able to achieve maximum mobility ture above 95 degrees. within limitations of paralysis and will avoid skin breakdown and contractures. INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Monitor temperature every 2 Interruption of the sympathetic hours until stabilized, then every nervous system pathways to the Assess motor strength and func- Identifies level of sensory-motor 4 hours and prn. temperature control center in the tion at least every 4-8 hours, and impairment and evahares resolu- hypothalamus causes body tem- prn. Identify level of tactile sen- tion of spinal shock. Specific perature swings in an effort to sation, ability to move parts of injury level may have partially match environmental tempera- body, spasticity, etc. mixed or occult sensorimotor tures. impairment.

Maintain a slightly cool environ- Hyperthermia may occur during Observe for muscle atrophy and May be noted during flaccid mental temperature. If patient is periods of spinal shock because wasting. paralysis stage of spinal shock. hypothermic, apply warm the sympathetic activity is Encourage independent activity blanket. blocked and the patient does not C1-4 lesions result in quadriple- perspire on paralyzed areas of as able. gia with complete loss of body. respiratory function; C4-5 lesions result in quadriplegia with potential for phrenic nerve Information, Instruction, involvement that may result In Demonstration loss of respiratory function; C5-6 lesions result in quadriplegia INTERVENTIONS RATIONALES with some gross arm movement ability and some sparing of Instruct patienrlfamily regarding Provides knowledge and facili- diaphragmatic muscle involve- variable body temperatures and tates compliance. ment; C6-7 lesions result In methods to maintain comfort. quadriplegia with intact biceps; C7-8 lesions result in quadriple- Discharge or Maintenance Evaluation gia with intact biceps and triceps but no intrinsic hand muscula- Patient will exhibit normal temperature and be ture intact; T1-L2 lesions result able to maintain core body temperature using in paraplegia with variable amounts of involvement to inter- methods discussed. costal and abdominal muscle groups; below L2 lesions result in Impaired physical mobility mixed motor-sensory loss with Related to: spinal cord lesion, trauma, paralysis, bowel and bladder impairment. spasticity, physical restraint, traction Assist withlprovide range of Improves muscle tone and joint motion exercises to all joints. mobility, decreases risk for con- Defining characteristics: contractures, inability to tractures, and prevents muscle move as desired, spastic movements, muscle atro- atrophy. phy, muscle wasting, skin breakdown, redness, Reposition every 2 hours and Decreases pressure on bony pressure areas prn. Utilize kinetic bed therapy prominences and improves as warranted. peripheral circulation. Kinetic beds can immobilize the unstable vertebral column and decrease potential for complications from immobility. NEUROLOGICAL SYSTEM 163

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Ensure proper alignment with Correct anatomic alignment pre- Patient will maintain appropriate body each position. vents contractures and deformities. alignment and maximal function within limit of injury. Utilize footboards or high-top Prevents footdrop. tennis shoes. Patient will avoid complications of immobility. Observe for changes in skin Loss of sensation, paralysis, and Patient will be able to verbalize understanding status and provide frequent skin decreased venous return predis- care. pose the patient for pressure and demonstrate effective therapeutic wounds. modali ties. Assist with/consult physical ther- Exercises help stimulation circu- Patient will exhibit suppleness of joints and apists or occupational therapists lation and preserves joint muscles. to develop plan of care for mobility. patient. Alteration in comfort Maintain cervical traction appa- Cervical traction provides for [See Guillain-Barrt] ratus as warranted. stabilization of vertebral column, reduction, and immobilization to Related to: trauma, surgery, cervical traction maintain proper alignment. Halo bracddevices provide immobi- Defining characteristics: burning pain below lization but can facilitate with lesion, muscle spasms, phantom pain, hyperesthe- active participation with rehabili- sia above lesion level, headaches, communication tation processes. of pain, facial grimacing, irritability, restlessness Observe for redness and swelling Thrombus formation may occur to calf muscles. Measure circum- as a result of immobilization and Risk for impaired skin intepity ference daily if problem is noted. flaccid paralysis. [See Fractures] Information, Instruction, Related to: immobility, surgery, traction appara- Demonstration tus, changes in metabolism, decreased circulation, impaired sensation INTERVENTIONS RATIONALES Defining characteristics: wounds, drainage, red- Instruct family in rehabilitative Facilitates adaptation to patient’s ness, pressure sores, abrasions, lacerations therapy, exercises, and reposition- health status and allows for ing, and involve them with family members to contribute to Sensory-perceptual alteration patient’s care. patient’s welfare. [See CVA] Avoid improper placement of May create pressure resulting in footrests, headrests, or padding pressure sores or necrotic injury. Related to: traumatic injury, sensory receptor and when repositioning patient. tract impairment, damaged sensory transmission Instruct in methods for shifting Improves circulation by reducing Defining characteristics: decreases sensory acuity, weight. pressure to body surfaces. impairment of position relation, proprioception, Administer muscle relaxants as May be required to reduce pain motor incoordination, mood swings, disorienta- warranted. and spasriciry. tion, agitation, anxiety, abnormal emotional responses, changes in stimulation response 164 CRITICAL, CARE NURSING CARE PLANS

Bowel incontinence Information, Instruction, Demonstration Related to: trauma, impairment of bowel innervation, impairment of perception, modifications of INTERVENTIONS RATIONALES dietary intake, immobility Instruct patientlfamily regarding Promotes independence and Defining characteristics: inability to evacuate method for daily bowel program. self-esteem. bowel voluntarily, ileus, gastric distention, hypoac- tive bowel sounds, absent bowel sounds, nausea, Discharge or Maintenance Evaluation vomiting, abdominal pain, constipation Patient will establish and maintain daily bowel pattern. Outcome Criteria Patient will be able to verbalize understanding Patient will be able to establish and maintain and demonstrate appropriate methods to bowel elimination patterns. accomplish bowel care. INTERVENTIONS RATIONALES Patient will be able to avoid complications that may be caused by gastric distention or ileus. Observe for presence of abdomi- Innervation may be impaired as a nal distention. result of the injury with resultant Urinary retention decrease or loss of peristalsis, and potential for development of Related to: traumatic loss of bladder innervation, ileus. Bowel distention may precipitate autonomic dysreflexia bladder atony after spinal shock recedes. Defining characteristics: urinary retention, incon- Auscultate for presence of bowel High-pitched tinkling bowel tinence, bladder distention, urinary tract sounds, noting changes in sounds may be heard when infections, kidney dysfunction, stone formation, character. patient has an ileus, and bowel sounds may be absent during overflow syndrome spinal shock phase.

Evaluate bowel habits, such as Establishes pattern and facilitates Outcome Criteria frequencp character, and amount treatment options. of stools. Patient will be able to achieve and maintain bal- Establish bowel pattern by use of Effectively evacuates bowel. anced intake and output with no signs/symptoms stool softeners, suppositories, or of complications. digital stimulation. INTERVENTIONS RATIONALES Increase dietary bulk and fiber. Promotes peristaltic movement through bowel and improves Monitor intake and output every May identify urinary retention consistency of stool. shift, noting significant differ- from an areflexic bladder. ences in amounts. Provide frequent skin care. Incontinence of stool increases potential for skin breakdown. Observe for ability to void and Spinal shock is exhibited in the palpate for bladder distention. bladder when there is a loss of Insert Foley catheter as sensory perception and the warranted. bladder is unable CO contract and empty itself. Bladder distention may precipitate autonomic dysreflexia. NEUROLOGICAL SYSTEM 165

INTERVENTIONS RATIONALES level of the lesion, bradycardia, piloerection, pupil

______~ ~~~ dilation, nasal congestion, nausea Monitor urinary output for Cloudiness, blood, concentra- changes in color or character. tion, or foul smell may indicate urinary tract infection. Outcome Criteria Administer urinary antiseptic Vitamin C and mandelamine agentdacidifiers as ordered. may be given to acid$ the urine Patient/nurse will be able to recognize signs/symp- to hinder bacterial growth and toms and take appropriate action to prevent prevent stone formation. complications. Information, Instruction, Demonstration INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Observe for hypertension, tachy- Identification of potential Iife- Instruct patiendfamily in meth- Catheterization may be required cardia, bradycardia, sweating threatening complication ods for intermittent catheter- for long-term due to injury and above level of lesion, pallor facilitates prompt and timely ization when warranted. dysfunction to bladder. below level of injury, headache, intervention. Intermittent catheterization is piloerection, nasal congestion, preferred and is performed at metallic tare, blurred vision, specific intervals to approximate chest pain, or nausea. physiological function and may Assess for bowel or bladder dis- May be indicative of precipitat- decrease complications from tention, bladder spasms, or ing factor for autonomic indwelling catheter. changes in temperature. dysreflexia.

Increase fluid intake, when war- Decreases formation of kidney or Monitor vital signs frequently, Hypotensive crisis may occur ranted, up to 3-4 Llday, bladder stones, helps prevent especially blood pressure every 5 once stimulus is removed, but including acidic juices, such as infection, and ensures hydration. minutes during acute phase. dysreflexia may recur and should cranberry juice. be monitored.

Ensure sterile technique for Decreases potential for urinary Palpate abdomen VERY gently Palpation should be done gently, catheter insertions. tract infection. for bladder distention, and irri- if at all, so as to not increase gate catheter VERY slowly with stimulating factor and worsen tepid solution. condition. Irrigation may iden- Discharge or Maintenance Evaluation tify and correct catheter obstruction which may have Patient will have balanced intake and output been predisposing factor. without signs of urinary tract infection. Check for rectal impaction May increase rectal stimulation Patient/family will be able to verbalize VERY gently, and only after and worsen dysreflexia. anesthetic-rype rectal ointment understanding of need for catheterization, and has been applied. will be able to give return demonstration of pro- Position in high-Fowler's position Promotes decrease in blood pres- cedure. in bed. sure to avert intracranial Risk fir dysreflexiu hemorrhage or seizure activity. Administer medications as Atropine may be required to Related to: spinal cord injury at TG level and ordered. increase heart rate if bradycardia above, excessive autonomic reaction to stimulation is present; apresoline, hyperstar, or procardia may be required ro Defining characteristics: hypertension, blurred decrease blood pressure. vision, throbbing headache, diaphoresis above the 166 CRITICAL CARE NURSING CARE PLANS

Information, Instruction, Demonstration

INTERVENTIONS RATIONALES

Instruct patient/farnily on Problem may be lifelong but can signslsymptoms of syndrome, be prevented by avoiding pres- and methods for preventing sure-causing sensation. occurrence.

Administer antihypertensive May be required for long-term drugs as ordered. use to alleviate chronic autonomic dysreflexia by relaxation of the bladder neck.

Prepare patient for nerve block as May be required if dysreflexia is warranted. unresponsive to other treatment modalities.

Discharge or Maintenance Evaluation

Patiendfamily will be able to verbalize understanding of condition and methods to reduce occurrence. Patient will exhibit no signs/symptoms of autonomic dysreflexia, and have no complications. NEUROLOGICAL SYSTEM 167

SPINAL CORD INJURIES

Disease processes Trauma (Loss of function without trauma) (Flexion, hypertension, rotation) c c Contusion Compression Transection of cord c c c Edema to cord Tumor or hernorrhage Incomplete Complete c c c c Increased intradural Muscle weakness Partial dysfunction Total loss of pressure of spinal cord tracts sensory and motor function c c I I I Neurodysfunction 41 I Paralysis of muscles Loss of autoregulation Sympathetic Release of blockade vaso-active substances

c c 4 J, Hypoventilation Poikilothermism Bradycardia Vasodilation c c JI Decreased VC, TV Decreased spinal cord Decreased venous ineffective cough blood flow return Decreased oxygenation c Hypoxia c Spinal shock/vasovagal reflex c Arrest 4 DEATH This Page Intentionally Left Blank NEUROLOGICAL SYSTEM 169

6uillain-Barre Syndrome MEDICAL CARE Lumbar puncture: used in the diagnostic process; Guillain-Barrt syndrome, also known as infectious initially protein levels are normal for the first 48 polyneuritis, polyradiculoneuritis, and Landry- hours but then increase as the disease progresses; Guillain-Barrt-Strohl syndrome, is an acute cell count is usually normal; ICP may be elevated neuropathy in which inflammation and swelling of spinal nerve roots create demyelination and Electromyography: helps to differentiate Guillain- degeneration to the nerves beginning distally and BarrC from myasthenia gravis; in Guillain-Barrt, ascending symmetrically. nerve impulse conduction speed is decreased Demyelination causes nerve impulse conduction Nerve conduction studies: nerve conduction to be delayed. Both dorsal and ventral nerve roots velocity is slowed are involved, so both sensory and motor impair- Plasmapheresis: may be used on an experimental ment is noted. The disease progress may cease at basis to remove circulating antibodies that com- any point or continue to complete quadriplegia promise nerve receptors with cranial motor nerve involvement. Symmetrical muscle weakness occurs and moves Laboratory: white blood cell count is elevated; upward, with associated paresthesias and pain. sedimentation rate is elevated; electrolytes are Dysphagia, facial weakness, and extraocular done to identifjr hyponatremia that may occur due muscle paralysis occur. Blood pressure and heart to problems with volume receptors rate can be affected with marked fluctuations in response to a dysfunctional autonomic nervous NURSING CARE PUNS system. After demyelination stops, remyelination begins and frequently complete function is Risk fir inefective breathing pattern restored in approximately 70% of patients. The [See Head Injuries] recovery phase may last from 4 months to 2 years. Related to: muscle weakness, paralysis, inability to The exact cause of the syndrome is not known but swallow several factors have been known to be associated Defining characteristics: dyspnea, bradypnea, with Guillain-Barrt, such as, viral infections apnea, hypoxia, hypoxemia, abnormal arterial occurring 2-3 weeks prior, vaccinations, surgery, blood gases, inability to handle secretions pre-existing systemic disease, and autoimmune d'iseases. Impaired physical mobility [See Head Injuries] Guillain-Barrt syndrome may cause complications of hypertension, bradycardia, respiratory failure, Related to: neuromuscular impairment, paralysis and cardiovascular collapse. When sacral nerve Defining characteristics: inability to move at will, roots are affected, incontinence becomes a prob- inability to turn, transfer, or ambulate, decreased lem. range of motion, muscle weakness, muscle incoordination, decreased reflexes 170 CRITICAL CARE NURSING CARE PLANS

Risk for alteration in nutrition: less than INTERVENTIONS RATIONALES body requirements Monitor for complaints of Patient may be unable to verbal- [See Mechanical Ventilation] painldiscornfort and for non- ize complaints. verbal indications that patient Related to: neuromuscular impairment, intuba- mqbe in discomfort. tion Administer medication as Reduces or alleviates pain. Defining characteristics: weight loss, muscle wast- ordered. Narcotics may cause respirarory ing, catabolism, inability to take in sufficient depression. nutrients, impaired cough/gag/swallow reflexes Apply hot or cold packs as Helps to alleviate discomfort and warranted. improves muscle and joinr stiff- Impaired verba2 commun ication ness. [See CVA] Use therapeutic touch, massage, Helps to refocus attention away imagery, visualization, or relax- from pain and provides for active Related to: neuromuscular impairment, loss of ation therapies as warranted. participation in relieving pain. muscle control, weakness Defining characteristics: inability to speak, inabil- Discharge or Maintenance Evaluation ity to write Patient will have no complaints of pain or Sensory-perceptual alterations: visualj paresthesias. kinesthetic, gustatory, tactile [See CVA] Patient will be able to communication pain and requests for analgesics. Related to: neuromuscular deficits, altered reception of stimuli, altered sensation, inability to Patient will have pain controlled effectively to communicate, hypoxia his satisfaction. Defining characteristics: paresthesias, hypersensi- Risk for alteration in tissue per-sion: car- tivity to stimuli, muscle incoordination, inability diopulmonary, peripheral, renal to communicate, anxiety, restlessness Related to: autonomic nervous system Alteration in comfort impairment, hypovolemia, electrolyte imbalance, hypoxemia, thrombosis Related to: neuromuscular impairment Defining characteristics: hypotension, hyperten- Defining characteristics: communication of pain sion, blood pressure lability, bradycardia, or discomfort with minimal stimuli, muscle aches, tachycardia, dysrhythmias, altered temperature tenderness, joint pain, flaccidity, spasticity regulation, decreased urine output, anuria, skin breakdown Outcome Criteria

Patient will have no complaints of pain, or pain Outcome Criteria will be controlled to patient's satisfaction. Patient will achieve and maintain normal perfusion of all body systems. NEUROLOGICAL SYSTEM 171

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Monitor vital signs at rest and Severe changes with blood pres- hours, or if significant imbalance shifting, and decreases in vascular with turning. Notify MD of sure may occur as a result of in I&O occurs. tone. significant changes. autonomic dysfunction because of the loss of sympathetic out- Administer IV fluids as ordered. Fluids help to prevent or correct flow to maintain peripheral hypovolemia but impaired vascu- vascular tone. Postural hypoten- lar tone may result in severe sion may occur as a result of hemodynamic lability based on small increases in circulating impaired reflexes which normally readjust pressure during changes volumes. in position. Administer heparin SQlIV as May be given prophylactically ordered, if no contraindications. due to immobilization. Monitor EKG for changes, and Rate changes may occur as a treat dysrhythmias per protocol. result of vagal stimulation and impairment of the sympathetic Discharge or Maintenance Evaluation innervation of the heart. Hypoxemia or electrolyte imbalances may alter vascular tone and Patient will be able to maintain adequate perfu- impair venous return. sion. Monitor temperature of skin and Vasomotor tone changes can Patient will have stable vital signs and hemody- impair the ability to perspire and core body. Observe for inability namic parameters. to perspire. cause temperature regulation problems. The patient’s impaired Patient will have regular cardiac rhythm with no sensation may further promote difficulty with warming and dysrhythmias. cooling the body. Risk for urinary retention Measure hemodynamics if pul- Impairment in vascular tone and monary artery catheter in place, venous return can decrease car- Related to: neuromuscular impairment, immobil- and notify MD for significant diac output. ity changes. Defining characteristics: inability to void, inabil- Observe skin surfaces for redness Decreases in sensation as well as or breakdown. Place patient on circulatory changes may result in ity to completely empty bladder kinetic bed, egg crate mattress, impaired perfusion and facilitate alternating pressure mattress, skin breakdown or ischemia. etc., if warranted Special bedslmattresses help to Outcome Criteria reduce hazards of immobility. Patient will be able to empty bladder with no Observe calves for redness, Venous stasis may increase signs/symptoms of infection or retention. edema, or positive Homan’s or potential for deep vein thrombo- Pratt’s signs. sis formation, and patient may INTERVENTIONS RATIONALES be unaware of discomfort due to paresthesias. Monitor for ability to void. Provides information regarding Measure output carefully. neuromuscular progression. Provide anti-embolic hose or Helps to decrease venous stasis Progression of disease may sequential compression devices to and promotes venous return. predispose patient to retention both leg and remove at least which may lead to urinary once every 8 hours. tract infection or other Monitor hourly intake and Circulating volume may be complications. output. Notify MD if urine decreased by patient’s inability to output is less than 30 cdhr for 2 take in adequate hydration, fluid 172 CRITICAL CARE NURSING CARE PLANS

~~~ INTERVENTIONS RATIONALES Outcome Criteria

Observe and palpate for bladder Bladder may become distended Patient will be able to eliminate soft formed stool distention. as sphincter reflex is involved in on a normal basis. neuromuscular progression.

Insert indwelling catheter as May be required to facilitate ~~~~~ ~~ warranted. urinary emptying until disease INTERVENTIONS RATIONALES process has resolved and bladder control has been achieved. Evaluate elimination pattern, Provides baseline information to Observe for concentrated urine, May indicate presence of urinary normal habits, ability to sense facilitate appropriate intervention presence of blood or pus, infection. urge to defecate, presence of for the patient’s plan of care. changes in clarity or odor. nausedvomiting, presence of painful hemorrhoids, and history Information, Instruction, of constipation problems. Demonstration Observe for abdominal disten- May indicate present or impend- tion, tenderness, or guarding, ing ileus or impaction. INTERVENTIONS RATIONALB nausea, vomiting, and absence of stool. Instruct on need and procedure Promotes understanding and for catheter placement. facilitates patient compliance. Palpate rectum for presence of Manual removal of stool may be stoollimpaction. required, and should be Discharge or Maintenance Evaluation performed gently to avoid vagal stimulation. Other interventions may be necessary to allow for Patient will be able to void suficient amounts bowel elimination. without presence of retention or infection. Auscultate bowel sounds for Diminished or absent bowel Patient will be able to accurately recall informa- presence, pitch, and changes. sounds, or presence of high- tion regarding need and procedure for catheter pitched tinkling sounds may indicate that an ileus has devel- placement. oped.

Patient will be able to achieve bladder control Administer stool softeners, laxa- May be required to stimulate once disease process has resolved. tives, suppositories, or enemas as bowel evacuation and to establish warrantedlordered. a bowel regime until patient is Risk for constipation able to regain normal musculature control. Related to: neuromuscular impairment, bedrest, Insert nasogastric tube as Decompresses abdominal disten- immobility, changes in dietary habits, changes in ordered. Connect with intermit- tion that occurs with ileus environment, analgesics tent suction per hospital policy. formation, and helps prevent nausea and vomiting. Defining characteristics: inability to expel all or Increase fiber in dietltube feed- Helps to promote elimination by part of stool, passage of hard stool, frequency less ings as warranted. adding bulk and helps to regulate than normal pattern, rectal fullness, abdominal fecal consistency. paidpressure, decreased bowel sounds, decreased peristalsis, weakness, fatigue, appetite impairment NEUROLOGICAL SYSTEM 173

Information, Instruction, INTERVENTIONS RATIONALES

Demonstration ~___ Evaluate anxiety level frequently. Determination of severity of INTERVENTIONS RATIONALES Stay with patient during acute patient's anxiety/fear can help to episodes. determine appropriate interven- Instruct on increases in fluid Promotes knowledge and can tion. Nurse's presence during intake, dietary requirements, use help facilitate improvement in acute anxiety may foster feelings of fruits and juices to improve bowel regime. of reassurance and concern for bowel elimination. the patient's well-being. Instruct on needlprocedure for Helps promote understanding to Maintain consistency with nurse Helps to decrease anxiety and nasogastric tube insertion. of complications that may occur assignmenes. builds trust in relationships. with the loss of peristalsis due to the disease process. Patient should be placed near Reassures patient that assistance nurse's station and within visual will be nearby should he be Discharge or Maintenance Evaluation con tact. unable to use call bell. Patient will achieve normal bowel elimination. Provide method for patient to Reduces anxiety and fear of summon assistance. abandonment. Patient will require no bowel aids to facilitate Involve patienc and family in Helps to foster understanding his normal routine. plan of care. Allow patient to and facilitates feelings of control make as many decisions as and improved self-esteem. Patient will regain muscle control and be able to warranted. Improves cooperation with pro- evacuate stool. cedures and care. Patient will be able to utilize dietary modifica- Provide time for patientlfamily Discussion of fears provides tion to maintain bowel regime. to discuss fears and concerns. opportunity for clarification of Offer realistic options and do not misperceptions and for realistic Patient will be able to recall information give false reassurance. methods of dealing with problems. correctly. Administer anti-anxiety medica- Patient$ anxiety may result in Anxz'ev, fear tions or sedation as alterations in hemodynamic sta- warran ted/ordered. bility and may require Related to: disease process, change in health medication to initially deal with status, paralysis, respiratory failure, change in situational crises. Patient may environment, threat of death require medication to facilitare improved ventilation should Defining characteristics: restlessness, mechanical ventilation be war ranted. apprehension, tension, fearfulness, sympathetic stimulation, changes in vital signs, inability to concentrate or focus, poor attention span, uncer- Discharge or Maintenance Evaluation tainty of treatment and outcome, insomnia Patient will be able to deal with changes in Outcome Criteria health status effectively. Patient will be able to control anxiety and Patient will be able to reduce and/or relieve anxi- reduce fear to a manageable level. ety with appropriate methods. Patient will have decreased anxiety and fear. 174 CRITICAL CARE NURSING CARE PLANS

GUILLAIN-B-’ SYNDROME

TRIGGERING EVENT s Immunologic demyelination of perepheral nervous system s Lymphocytes infiltrate into nerve roots, nerves, and CNS J,

Schwann cells deposit myelin around axons with interruption at intervals by the nodes of ranvier J,

Nerve conduction slows as impulses are conducred from node to node instead of along zonal pathway J,

Anterior horn cells in spinal cord degenerate J, Loss of reflexes (usually symmetrical and ascending) J,

Paralysis of muscles Decreaselloss of autonomic reflexes Peripheral volume 4 J, Receptors impaired

Vital capacity decreased BP fluctuations SIADH NIF decreased J, J,

Loss of respiratory muscles Hyponatremia J, J, Apnea Hypovolemia J, 4 Hypoxia D ysrythmias

Remyelination begins s Return of nerve impulse transmission J, Function restored proximally and proceeds in reverse from last area involved upward I I Complete recovery Varying degrees of function restored NEUROLOGICAL SYSTEM 175

rhabdomyolysis and renal failure. Other complica- Status Epilepticus tions may occur as a result of the significantly Seizures occur when uncontrolled electrical elevated metabolic state. impulses from the nerve cells in the cerebral cortex discharge and result in autonomic, sensory, and MEDICAL CARE motor dysfunction. Status epilepticus is a series of Laboratory: glucose levels decreased; electrolytes repeated seizures, a prolonged seizure, or sequen- to identie imbalances that may be precipitating tial seizures longer than 30 minutes in which the factor or result from prolonged seizure activity; patient does not regain consciousness. This seizure enzymes, especially creatine phosphokinase activity has a high mortality rate of up to 30% as elevated after seizure activity; drug screen done to a result of neurological and brain damage. identify potential factor for drug withdrawal; There are three types of status epilepticus: convul- CBC used to identify hemorrhage or infection sive, nonconvulsive, and partial status epilepticus. with shift to the left on differential; drug levels for In the convulsive type, seizure activity may have a medications being given for seizures to evaluate focal onset, but has tonic-clonic, grand mal type therapeutic response and discern toxicity; renal seizures without experiencing alertness between profiles to evaluate renal function; urinalysis to motor attacks. Nonconvulsive seizures are noted identify hematuria or myoglobinuria with a prolonged twilight state and are usually not CT scans: may be done to identify lesions or pre- motor activity. Partial status epilepticus occurs cipitating factors when continuous or repetitive focal seizures occur but consciousness is not altered. Electroencephalogram: used to identify presence of seizure activity Status epilepticus usually occurs in patients with pre-existing seizure disorders who have a precipi- Arterial blood gases: used to identify hypoxia and tating factor occurance. These factors can include acid-base imbalances; usually acidosis seen withdrawal from anticonvulsant medication, alcohol withdrawal, sedative or antidepressant NURSING CARE PLANS withdrawal, sleep deprivation, meningitis, Risk for impaired exchange encephalitis, brain abscesses or tumors, pregnancy, gas [See Mechanical Ventilation] hypoglycemia, uremia, cerebrovascular disease, cerebral edema, or cerebral trauma. Relat'ed to: altered oxygen. supply from repetitive seizures, cognitive impairment, neuromuscular The initial stage causes sympathetic activity impairment increases with a decrease in the cerebral vascular resistance. After 30 minutes, hypotension occurs Defining characteristics: restlessness, cyanosis, with a decrease in cerebral blood flow because of inability to move secretions, tachycardia, loss of autoregulation. The continuing massive dysrhythmias, abnormal ABGs, decreased oxygen autonomic discharges can cause bronchial secre- saturation tions and restriction, with increased capillary Risk for inefective airway clearance permeability and pulmonary edema. [See :Mechanical Ventilation] Dysrhythmias can occur and patients may develop 176 CRITICAL CARE NURSING CARE PLANS

Related to: neuromuscular impairment, cognitive INTERVENTIONS RATIONALES impairment, tracheobronchial obstruction Maintain patent airway and ade- Intubation and placement on Defining characteristics: adventitious breath quate ventilation. mechanical Ventilation may be sounds, dyspnea, tachypnea, shallow respirations, required if seizures cannot be cough with or without productivity, cyanosis, anx- controlled. iety, restlessness Monitor oxygen saturation by Decreases in saturation that oximeter. cannot be improved with supple- Hyperthemia mental oxygen may require [See Pheochromocytoma] mechanical ventilation. Seizure activity increases oxygen con- Related to: continued seizure activity, increased sumption and demand. metabolic state Provide supplemental oxygen as May be required to maintain warranted. desired levels of oxygen. Defining characteristics: fever, persistent tonic- clonic seizure activity, persistent focal seizures, Monitor ABGs for imbalances Metabolic increases may lead to and treat per protocol. lactate formation and acidosis. persistent generalized seizures, tachycardia Administer medications as Valium may be given IV at 5 Risk for fluid volume deficit ordered. mg/min rate to control seizure [See ARDS] activity by enhancing neurotrans- mitter GABA. Ativan 2-4 mg IV Related to: excessive loss of fluid, decreased intake may be given and repeated every 15 minutes as needed for seizure Defining characteristics: hypo tension, tachycar- control. Caution should be exer- dia, fever, weight loss, oliguria, abnormal cised because respiratory and electrolytes, low filling pressures, decreased mental cardiovascular depression can occur. Phenobarbital IV at 60 status, decreased specific gravity, increased serum mg/min may be given to depress osmolality excitation, decrease calcium uptake by nerves, and to Risk fir injury strengthen repression of synapses. Dilantin IV at 50 mglmin rate Related to: seizure activity, increased metabolic may be given to decrease cellular demands influx of sodium and calcium and blocking neurotransmission Defining characteristics: respiratory acidosis, release. metabolic acidosis, hypoxemia, hyperthermia, Maintain patient in seizure-free Once seizures have stopped, anti- hypoglycemia, electrolyte imbalances, renal failure, status. conwlsant drugs must be given rhabdomyolysis, exhaustion, death to prevent recurrence of seizure activity. Outcome Criteria Monitor EKG for dysrhythmias Electrolyte imbalances, too-rapid and treat per hospital protocol. administration of medications, and hypoxia may contribute to Patient will achieve and maintain seizure-free appearance of cardiac dysrhyth- status with optimal oxygenation and ventilation mias that may require without complications. interventional care. Monitor intake and output every Identifies imbalances with fluid 2 hours and prn. status and fluid shifting. NEUROLOGICAL SYSTEM 177

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Monitor labwork for changes Electrolytes may fluctuate Patiedfamily will be able to verbalize and trends. because of cellular movement of ions. Myoglobin may be present understanding of all instructions and comply in urine as a result of prolonged with medical regimen. seizure activity and can lead to renal failure. Drug levels may rise Patient will remain free of seizures and injury. to toxic levels and should be evaluated for therapeutic effec- Patient' will be able to effectively access commu- tiveness. nity resources for help and support. Identify and treat underlying Identification may lead to timely Patient will exhibit no signs of complications. cause of seizures. intervention and treatment. Disturbance in self-esteem Information, Instruction, Demonstration Related to: perception of loss of control, ashamed of medical condition INTERVENTIONS RATIONALES Defining characteristics: fear of rejection, Instruct patient/family in disease Promotes knowledge and facili- concerns about changes in lifestyle, negative feel- process and methods for reduc- tates compliance. ings about self, change in perception of role, tion of seizures. changes in responsibilities, lack of participation in Instruct in drug regimen, effects, Promotes knowledge and helps therapy or care, passiveness, inability to accept side effects, contraindications, prevent lack of cooperation with positive reinforcement, little eye contact, brief and precautions. medication regime with resultant seizure breakthrough activity. responses to questions Presence of side effects may indicate the need for changes in doses or medication type. Outcome Criteria Interactions with other drugs may produce adverse reactions, Patient will be able to participate in own care and such as potentiated anticoagula- have positive perceptions of self. tion effect when dilantin and coumadin are concurrently taken, INTERVENTIONS RATIONALES Instruct in oral care. Prevents gingival hypertrophy that may occur while taking Encourage patient to initiate Participation in care facilitates dilantin. self-care or request assistance. feelings of normalcy.

Instruct on use of medical alert May hasten emergency treatment Discuss patient's perceptions of Provides opportunities to estab- bracelet. in critical situations. illness and potential reactions of lish patient's knowledge base, others to his disease. clear up any misconceptions, and Instruct on methods to promote May facilitate prevention of opportunity to problem-solve safety with activities, such as, injury to self or other if seizures responses to future seizures. driving, using mechanical equip- occur without warning. ment, swimming, or hobbies. Discuss previous success episodes Concentrating on the positive and patient's strengths. experiences may help to reduce Instruct on contact people, com- May provide opportunities for self-consciousness and allow munity resource groups, long-term support and sharing patient to begin to accept condi- counselors, as warranted. ideas with others who have simi- tion. lar problems. 178 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES

~~ ~~ Discuss concerns with family Negative feelings from patient’s members, allowing ample time family may afFect his sense of for members to discuss problems self-esteem. and attitudes.

Consult with counselors, minis- Provides opportunity for parient terial support, or resource to deal with stigma of disease groups. and overcome feelings of inferi- ority.

Discharge or Maintenance Evaluation

Patient will be able to identify ways to cope with negative feelings. . Patiendfamily will be able to discuss concerns and effect realistic problem-solving plans. Patient will become more accepting of self, with increased self-esteem. Patient will be able to effectively access community resources to gain help and support. Grieving [See Amputation] Related to: traumatic injury, loss of physical well- being Defining characteristics: communications of distress, denial, guilt, fear, sadness, changes in affect, changes in ability and desire for communication, crying, insomnia, lethargy NEUROLOGICAL SYSTEM 179

STATUS EPILEPTICUS

Pre-existing seizure disorder (tumors, trauma, encephalopathy) c Seizure activity Rapid succession of action-potentials in cells c Increased sympathetic activity c Increased metabolic demand Increased temperature, pulse, and blood pressure c Decreased ATP Sodium-potassium ATP pump failure e Decreased cerebral vascular resistance Increased cerebral vascular dilation c Increased cerebral metabolic rate c Prolonged seizure state (>30 minutes) c Blood flow becomes pressure dependent Cerebrovascular autoregulation mechanisms fail 4 Increased uptake of metabolic by-products (lactate, ammonia, amino acids) JI Cellular edema 4 Decreased cerebral blood flow Decreased blood pressure 4 Metabolic acidosis c Bronchial constriction Increased oxygen consumption Decreased PaO2 -A Increased PaCO2 Increased pulmonary a-Dysrhythmias pressures This Page Intentionally Left Blank NEUROLOGICAL SYSTEM 181

gitis, LDH elevated with bacterial meningitis, ESR elevated Meningitis is an acute infection of the pia and Radiography: skull and spine x-rays used to iden- arachnoid membrane that surrounds the brain and tify sinus infections, fractures, or osteomyelitis; the spinal cord caused by any type of microorgan- chest x-rays may be used to identify respiratory ism. Bacterial meningitis is frequently caused by infections, abscesses, lesions, or granulomas Streptococcus pneumoniae, Huemophilus injuenzae, or Neisseriu meningitidis. Lumbar puncture: treatment of choice to identify presence of meningitis, help identify type of Organisms are able to thrive because of opportune meningitis, and identify causative organism access during surgery, with invasive monitoring and lines, penetrating injuries, skull fractures, dura Electroencephalogram: may be performed to tears, otitis media, or with septic emboli. Once the show slow wave activity organism begins multiplying, neutrophils infiltrate into the subarachnoid space and forms an exudate. NURSING CARE PLANS The body’s defenses attempts to control the invad- Alteration in tissue perfusion: cerebral ing pathogens by walling off the exudate and [See Ventriculostomy] effectively creating two layers. If appropriate medical treatment is begun early, the outer and inner Related to: increased intracranial pressure layers will disappear, but if the infection persists Defining characteristics: increased ICE changes in for several weeks, the inner layer forms a perma- vital signs, changes in level of consciousness, nent fibrin structure over the meninges. This memory deficit, restlessness, lethargy, coma, meningeal covering causes adhesions between the stupor, pupillary changes, headache, pain in neck pia and the arachnoid membranes and results in or back, nauseahomiting, purposeless movements, congestion and increased ICP papilledema One of the major complications of meningitis is Risk Jor injury residual cranial nerve dysfunction, such as deafness, blindness, tinnitus, or vertigo. Related to: infection, shock, seizures Sometimes these symptoms resolve, but cerebral Defining characteristics: presence of infection, edema may occur and cause seizures, nerve palsy, elevated white blood cell count, differential shift bradycardia, hypertension, coma, and even death. to the left, positive cultures, hypotension, tachy- The main goal of treatment is to eliminate the cardia, tremors, fasiculations, seizures, hypoxemia, causative organism and prevent complications. acid-base disturbances

MEDICAL CARE Outcome Criteria Laboratory: white blood cell count elevation to Patient will be free of infection with stable vital identify infection; cultures to identify the signs. causative organism, CSF analysis to identify infection; urinalysis may show albumin and red and white blood cells; glucose levels elevated in menin- 182 CRITICAL CARE NURSING CARE PLANS

Defining characteristics: headache, muscle INTERVENTIONS RATIONALES spasms, backache, photophobia, crying, moaning, restlessness, communication of pain, muscle ten- Assist with lumbar puncture. Identifies prezence of infection sion, facial grimacing, pallor, changes in vital signs and can differentiate between types of meningitis. CSF with Hyperthemia low white cell counts, less pro- [See Pheochromocytoma] tein elevation, and "glucose levels approximately half that of the Related to: infection process blood glucose level may be indicative of viral meningitis. Defining characteristics: fever, tachycardia, CSF that has an elevated initial pressure, high protein, low glu- tachypnea, warm, flushed skin, seizures cose, cloudy color, and high white cell count indicates baccer- id meningitis.

Administer antimicrobials as Aqueous penicillin G is usually ordered, as soon as possible. the drug of choice, but culture results may indicate a different agent needed to eradicate the organism. Antibiotics are usually given in larger doses at closer intervals in order to facilitate penetration across the blood- brain barrier.

Observe appropriate isolation Prevents spread of infection. techniques up to 48 hours after After antimicrobial therapy has antibiotic regimen has begun. been instituted for 2 days, the patient is not considered infectious.

Administer anticonvulsants as May be required for control of ordered. new seizure activity due to rneningeal irritation.

Discharge or Maintenance Evaluation

Patient will be free of infection with no complications from antimicrobial agents. Patient will be free of seizure activity. Patient will comply with isolation restrictions. Alteration in comfort [See Guillain-Bard] Related to: infectious organisms, circulating toxins, invasive lines, bedrest NEUROLOGICAL SYSTEM 183

MENINGITIS

Infectious organisms gain access to meninges and subarachnoid spaces (viral, bacterial, yeast)

Exudate forms e Meningeal irritation/inflammation c Cortical irritation 4 Cerebral edema c Increased ICP c

Vasculitis Increased infection Petechial hernorrhages Neuritis Hydrocephalus c c 4 c c Cortical Brain abscess Septic emboli Cranial nerve Increased necrosis Septicemias involvement ICP c 4 J, DIC Adrenal Seizures Compression hemorrhage I of brain structures hemorrhage -1 - Hypoxia I-Inadequate perfusion - Shock c DEATH This Page Intentionally Left Blank NEUROLOGICAL SYSTEM 185

until a vicious cycle is established. When ischemia UentriculostomyhCP increases to a certain level, the medulla causes blood pressure to rise in an effort to compensate Monitoring for the increasing ICE but eventually the ICP will The brain is housed in a nondistensible cavity that equal the MAP and precipitate curtailing of cere- is filled to capacity with CSF, interstitial fluid, and bral blood flow, resulting in vascular collapse and intravascular blood, all of which possess very mini- brain death. mal ability for adjustment for increasing ICP is increased when brain volume is enlarged by intracranial pressure. If the volume of any one of mass lesions, tumors, abscesses, hematomas or these constituents increases, there is a reciprocal cerebral edema. Vasodilation and venous outflow decrease in the volume of one or more of the obstructions cause changes in cerebrovascular others, or else intracranial pressure becomes ele- status due to hypoventilation, hypercapnia, vated. Intracranial pressure is normally beween improper position of the head, or maneuvers that 2-15 mmHg or 50-200 cm H,O, and fluctuates increase intrathoracic pressure. CSF volumes may depending on positioning, vital signs changes, increase from decreased reabsorption from an increased intra-abdominal pressure, and stimuli. obstruction, such as with hydrocephalus. There are compensatory mechanisms that assist in Monitoring of ICP can be done from several sites. decreasing intracranial hypertension. The most The lumbar or cervical subarachnoid area is easily changed element is intravascular volume simple to access, but potential for herniation which results from compression of the venous exists. The lateral cerebral ventricles [per ventricu- system and decreases fluid level. The CSF is lostomy] is highly accurate and allows for another element that can be used to compensate withdrawal of CSF and measurement of compli- for increasing pressures. CSF can be displaced ance, but infection to this area is catastrophic. from the cranial vault to the spinal canal, which Subdural sites are most easily inserted but carry increases absorption of CSF by the arachnoid villi, serious infection risks, and an epidural site has less slows production of CSF by the choroid plexus, potential for infection, but lacks accuracy. and decreases ICl? Other compensatory mechanisms may be seen, such as skull expansion The three types of ICP monitoring are epidural in infants whose sutures have not closed, as well as sensor monitoring through a burr hole, subarach- reduction of cerebral blood flow to a small extent, noid screw or bolt monitoring through a twist but these are not desirable. drill burr hole, and ventricular catheter monitoring. Insertion of these may be performed in Although auto-regulatory mechanisms can control surgery or in the intensive care setting, but small increases in ICE rapid or sustained increases requires sterile field maintenance. suppress these compensatory efforts, and decompensation occurs. As the ICP increases, the ICP monitoring may be performed on patients cerebral blood flow decreases because of pressure with head trauma, ruptured aneurysms, Reye’s exerted on vessels. This causes brain ischemia and syndrome, intracranial bleeds, hydrocephalus, or accumulation of lactic acid and carbon dioxide, tumors. A ventriculostomy is a cannula placed in resulting in hypoxemia and hypercapnia. Cerebral the lateral ventricle and connected with a vasodilation ensues which increases blood volume transducer for measurement of pressures of CSF and cerebral edema, which further increases ICE directly, for periodic drainage of CSF, and for withdrawal of fluid for analysis. 186 CRITICAL CARE NURSING CARE PLANS

Cerebral perfusion pressure (CPP) is the difference Laboratory: electrolytes drawn to evaluate imbal- between the mean arterial pressure (MAP) and the ances that may contribute to ICP increases; mean ICE and indicates the pressure in the cere- toxicology screens to identify other drugs that may bral vascular system and approximates the cerebral be responsible for changes in mentation and level blood flow. A CPP of 60 mmHg is the minimum of consciousness; serum levels of drugs to assess value for perfusion to occur, with normal ranges therapeutic response versus toxicity from 80-100 mmHg. Increases in ICP can be manifested by signs such NURSING CARE PLANS as systolic blood pressure elevations, widening Alteration in tissue per-sion: cerebral pulse pressure, bradycardia, headache, nausea with Related to: cerebral edema, space-occupying projectile vomiting, papilledema, changes in level lesions, hemorrhage, substance overdose, hypoxia, of consciousness, pupillary changes, respiratory hypovolemia, trauma changes, and cerebral posturing. Defining characteristics: increased ICE changes in MEDICAL CIIRE vital signs, changes in level of consciousness, memory deficit, restlessness, lethargy, coma, Surgery: may be required for traumatic injuries stupor, pupillary changes, headache, nausea/vomit- and/or placement of ICP monitoring device ing, purposeless movements, papilledema Arterial blood gases: may be used to identify acid- base imbalances, hypoxemia, and hypercapnia; Outcome Criteria frequently patients are hyperventilated to keep PaC02 between 25-28 Patient will have stable vital signs and mentation with no signs or symptoms of increased ICP Osmotics: mannitol used to create osmotic diuresis in an attempt to decrease ICP INTERVENTIONS RATIONALES

Barbiturate therapy: pentothal or nembutal used Monitor for changes in level of Alterations in levels of conscious- to place patient in coma to produce burst-suppres- consciousness or mentation, ness are among the earliest signs sion on the EEG and to reduce metabolic activity speech, or response to of increasing ICP and can facili- commandslquestions. tate prompt intervention. Paralyzing drug therapy: pancuronium may be Progressive deterioration may used to decrease metabolic requirements but must require emergent care. be used in conjunction with sedatives since drug Monitor vital signs at least every As ICP increases, blood pressure only paralyzes muscles and does not change level hour, and prn. elevates, pulse pressure widens, bradycardia may occur changing of awareness to tachycardia as ICP progres- Adrenocorticosteroids: decadron has less sodium- sively worsens. Tachypnea is seen as an early sign but slows with retaining properties and is used to assist with increasingly longer periods of decreasing edema apnea. Fever may indicate hypo- thalarnic damage or infection CT scans: used to identify lesions, hemorrhage, which can increase metabolic ventricular size, structural shifting, ischemic event demands and further increase (may be several days prior to visibility on scan) ICE NEUROLOGICAL SYSTEM 187

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Perform pupillary checks, noting Increased ICP or expansion of a Elevate head of bed 30-45 Decreases cerebral edema and equality, position, response to clot can cause shifting of the degrees as warranted. congesrion, thereby decreasing light, and nystagmus every 1-2 brain against rhe oculomotor or ICI? hours and prn. optic nerve which causes pupil- Maintain head placement in Moving head from side to side lary changes. Early increased ICP may be signified by impairment neutral, or midline, position compresses jugular veins and using rolled towels or sandbags as increases ICE! of abduction of the eyes as a result of injury to the fifth cra- warranted. nial nerve. Absence of the doll’s Avoid excess stimuli in room; All stimulation increases ICP and eyes reflex may indicate brain allow visitation when warranted. should be limited to necessary stem dysfunction and poor prog- tasks only in the presence of nosis. Uncal herniation produces intracranial hypertension. Family ipsilateral pupillary changes. members may have calming effect on patient and may facili- Monitor neurological status uti- GCS facilitates identification of tate decreased ICl? lizing the Glasgow Coma Scale arousabilig and level and appro- (GCS). priateness of responses. Motor Avoid suctioning unless manda- Minimizes hypoxia and acid-base response to simple commands or tory, and when necessary, limit disturbances. Hyperoxygenation purposeful movement with srim- active suctioning to 15 seconds prior to, during, and after proce- uli assist with identification of or less. dure may also minimize problem. Abnormal posturing, complications. decerebrare and decorticate, may indicate diffuse cortical damage. Provide continuous monitoring Provides for prompt recognition Inability ro move one side of the of oximetry. of deterioration in patient‘s abil- body may indicate damage to the ity to maintain saturation which opposite side’s cerebra hemi- allows for prompt intervention. sphere. Apply oxygen at ordered concen- Supplemental oxygen decreases Monitor EKG for changes in Brain srem pressure or injury trations; prepare for mechanical hypoxemia which results in hearr rate and rhythm, and treat may result in rate changes, nor- ventilation as warranted. increased ICI? Mechanical venri- as per hospital protocol. mally bradycardia, or cardiac larion may be required if dysrhythmias. space-occupying lesions shift and destroy respirarory cenrer enerva- Observe for presence of blink, Reflex changes may be indicative tion. gag, cough, and Babinski of injury at the mid brain or reflexes. brain stem level. Lack of blink Administer medications as Diuretics andlor mannirol may reflex indicates damage to the ordered. be used to draw water from cere- pons and medulla. Cough and bral cells ro decrease edema and gag reflexes that are absent may ICP. Steroids may be used to indicate damage at medulla and decrease rissue edema and presence of Babinski reflex indi- inflammation. Anticonvulsanrs cates pyramidal pathway injury. may be used prophylactically and for the rreatment of seizures. Observe for nuchal rigidity, May indicate meningeal irrita- Sedatives or analgesics may be tremors, fasiculations, twitching, tion from a break in the dura or used ro control restlessness or seizures, irritabiliv, or restless- the development of an infection. agitation. ness. Seizures may occur from increased ICP, hypoxia, or cerebral irritation. 188 CRITICAL CARE NURSING CARE PLANS

Information, Instruction, INTERVENTIONS RATIONALES Demonstration If ICP is increasing, ensure that Hyperventilation results in respi- INTERVENTIONS RATIONALES airway is patent, and prepare for ratory alkalosis that causes placement on mechanical ventila- cerebral vasoconstriction, Observe continuous intracranial Increases above 25 mmHg that tion. decreases cerebral blood volume, pressure monitoring for fluctua- are sustained for at least 5 min- and can decrease ICP Levels of tions that are sustained, and for utes may indicate severe PaCO, are usually kept from 25- the presence of A, B, and C intracranial hypertension. A 35 to decrease ICE but if waves. waves, or plateau waves, have allowed to go below 25, may elevations from 60-100 mmHg adversely affect ICP. and then drop sharply, and often Prepare patientlfamily for use of Used as a last ditch effort, pento- coincide with headaches or dete- barbiturate therapy to produce barbiral or other drugs are given rioration. Cellular hypoxia is coma. to produce complete unrespon- most likely to occur during A siveness, to reduce metabolic waves, and sustained A waves activity, and decrease ICP indicate irreversible brain damage. B waves have elevations up to 50 mmHg and occur every 1.5-2 minutes in a sawtooth-type Discharge or Maintenance Evaluation pattern. B waves can precede A waves andlor appear in runs, and Patient will exhibit no complications due to occur with decreases in compen- ICP monitoring. sation. C waves are rapid, rhythmic, and may fluctuate Patient will have ICP stabilized and controlled. with changes in respiration or blood pressure, and are not of Patient will have appropriate actions taken to clinical significance. control increasing ICP Measurelobtain the mean ICP Provides direct measurement of every hour and prn; set alarms changes in ICP and cerebral per- Risk fir infiction for sustained elevations above fusion status. [See Head Injuries] ordered limits. Related to: invasive monitoring, lack of skin Calculate CPP and do not allow CPP = MAP - MiCP; normal integrity, increased metabolic state, intubation, CPP to fall below 50 mmHg. CPP is 80-100 mmHg, and levels below 50 mmHg decrease compromised defense mechanisms cerebral blood flow and perfusion, which frequently Defining characteristics: increased temperature, precipitates death. chills, elevated white blood cell count, differential shift to the left, drainage, presence of wounds, Recalibrate ICP monitoring Ensures accuracy of readings. device to level of foramen of positive cultures Munro (eye canthus level approximately) every 4 hours and prn suspicious readings or position changes.

Assist with removal of specified May be required to decrease amounts of CSF through ven- severe ICP and prevent hernia- triculostomy utilizing sterile tion from structural shifting. technique. NEUROLOGICAL SYSTEM 189

Defining characteristics: changes in vital signs, mental status changes, restlessness, anxiety, sensory deficits, confusion, decreased level of conscious- Carotid endarterectomy is the removal of a thrombus or plaque from the carotid artery to reduce ness the risk of stroke in patients who have had a tran- Rid for decreased cardiac output sient ischemic attack (TIA). Circulation is [See Spinal Cord Injuries] augmented by increasing blood flow from the internal carotid artery. The surgery is not without Related to: vasospasm, surgery, stroke risk of its own due to the potential for shearing off Defining characteristics: hypotension, hyperten- pieces of plaque or material resulting in a stroke. sion, heart rate changes, decreased cardiac outputhndex, changes in systemic and peripheral Initially, the major postoperative problem may be vascular resistance, mental status changes, hypoxia controlling labile blood pressures that occur because of impairment in carotid sinus reflexes. Risk for injury These blood pressure variances also predispose the Related to: surgery, predisposing health factors, patient to a stroke. injury to cranial nerves Respiratory insufficiency may occur if the trachea is compressed or shifted by a growing hematoma Defining characteristics: muscle weakness, nerve at the wound site, or by lack of responses to injury, airway obstruction, hypoxia, dysphagia, hypoxia with impairment of carotid body facial weakness, asymmetry of face, facial droop- function. ing, vocal cord paralysis Outcome Criteria

Surgery: performed as described above Patient will exhibit no complications from surgery and will have all cranial nerve function Vasoactive drugs: may be required to control maintained. blood pressures Laboratory: CBC used to identify potential bleeding problems, occult bleeding into neck; INTERVlENTIONS RATIONALES electrolytes used to identify imbalances Observe for deviation of tongue May indicate hypoglossal nerve toward side of operation, or damage. to Arterial blood gases: used identify hypoxemia weakness of tongue muscles. and acid-base imbalances Observe for dysphagia, dyspha- May indicate bilateral hypoglos sia, or impairment of upper sal palsy. NURSING CARE PLANS airway. Alteration in tissue perfision: cerebral Observe for facial asymmetry, May indicate facial nerve damage. [See CVA] drooping at corner of mouth, and inability to manage salivary Related to: occlusion, hemorrhage, vasospasms, secretions. cerebral edema, interruption of blood flow, Monitor for changes in voice May indicate vocal cord paraly- surgery quality and sound. sis, injury to the vagus nerve, or recurrent laryngeal nerve. 190 CRITICAL CARE NURSING CARE PLANS

Discharge or Maintenance Evaluation

Patient will have facial symmetry and normal voice modulation. Patient will exhibit no signs/symptoms of cranial nerve injury. Patient will be free of any airway compromise and have stable vital signs. Alteration in skin integrity [See Cardiac Surgery] Related to: surgical wounds, invasive lines, immobility Defining characteristics: presence of wounds, drainage, redness, swelling, abrasions, pressure, lacerations, bruises, open skin GASTROINTESTINAL/HEPATICSYSTEMS 191

Gastrointestinal Bleeding Esophageal Varices Hepatitis Pancreatitis Acute AbdomedAbdorninal Trauma Liver Failure This Page Intentionally Left Blank GASTROINTESTINAL/HEPATICSYSTEMS 193

The goal of treatment is initially prevention and Gastroint estinal Bleeding- treatment of shock, with fluid volume Gastrointestinal bleeding may be massive and replacement. Maintenance of circulating blood acute or occult and chronic in nature. GI bleeding volume is imperative to prevent myocardial infarc- results when irritation of the mucosal lining tion, sepsis, and death. Endoscopic examination is results in erosion through to the submucosal layer. the primary diagnostic procedure utilized. Once Upper GI hemorrhage is considered to be a bleed the lesion has been identified, treatment with from any site proximally to the cecum, and all Pitressin infusion may be used to control bleeding. ulcerative bleeding is arterial with the exception of a tear that cuts across all vessels, malignant MEDICAL CARE tumors, and in patients with esophagitis. Laboratory: CBC to identify changes in blood When erosion into an artery occurs, it usually pro- volume and concentration, but may be normal duces two bleeding sites because of arterio-arterial during rapid loss because of the lapsed time anastomoses. When the bleeding occurs at the required for equilibration of intravascular with ulcer base artery, it may be a life-threatening emer- extravascular spaces; MCV is useful to identify prolonged chronic loss with iron deficiency; B,, gency. and folic acid levels used to identify anemia type; Bleeding may occur from the lower gastrointesti- reticulocyte count may identify new RBC forma- nal tract as well. Causes of lower GI bleeding tion which occurs with an old bleed; platelet include hemorrhoids, diverticulosis, inflammatory count, PT, PTT, and bleeding times to evaluate bowel disease, rectal perforation, or intussuscep- clotting status and platelet dysfunction; BUN and tion. creatinine to evaluate effect on renal status; elec- Acute upper GI bleeding may result from many trolytes to evaluate imbalances and treatment; causes, such as gastritis, peptic ulcer, stress, drugs, ammonia levels may be used to identify liver dys- hormones, trauma, head injuries, burns, and function; gastric analysis to determine presence of esophageal varices. blood and assess secretory activity of gastric mucosa; amylase elevated if duodenal ulcer has Differential diagnosis between gastric and duode- posterior penetration; pepsinogen level to help nal ulcers must be obtained. Duodenal ulcers identify type of bleeding, with elevation seen in usually account for approximately 80% of all duodenal ulcer, and decreased levels seen in gastri- ulcers noted and rarely become cancerous. Gastric tis; stool specimens for guaiac ulcers, on the other hand, may become cancerous and are more likely to bleed. Arterid blood gases: may be used to show acid-base imbalances, compensation for decreased Initial presenting symptoms of a GI bleed are blood flow; initially respiratory alkalosis changing either hematemesis, melena, or hematochezia. An to metabolic acidosis as metabolic wastes accumu- acute bleed will have more than 60 cc/day of black late tarry stool and usually greater than 500 cc, whereas occult bleeding is normally 15-30 cc/day. Esophagogastroduodenoscopy(EGD): primary Stools can be positive for occult blood up to 12 diagnostic tool utilized for upper GI bleeding to days after an acute bleed. Of all GI hemorrhages, visually identify lesion; can be performed as soon 80% usually stop spontaneously. as lavage controls bleeding 194 CRITICAL CAFE NURSING CARE PLANS

Angiography: used when bleeding cannot be Sucralfate: used to help heal ulcer by forming cleared for endoscopy; can identify bleeding site protective barrier at site and allow for injection of vasopressin for active Surgery: required in less than 10% of patients; mucosal bleeding may be necessary for control of hemorrhage Radiography: chest x-rays may be done to evaluate for free aidperforation; upper GI series may be NURSING CARE PLANS done after endoscopy, but is never done before since the contrast media will adhere to mucosa Fluid volume deficit and prevent further examination; may be done to Related to: gastrointestinal bleeding identify other diagnosis; barium enema may be done once lower GI bleeding is stopped; radionu- Defining characteristics: hypotension, tachycar- clide scanning, such as Red Cell Tags, identify dia, decreased skin turgor, weakness, decreased source of bleeding, but may take an extended time urinary output, pallor, diaphoresis, decreased cap- for results to show illary refill, mental changes, restlessness, decreased filling pressures Electrocardiogram: used to identi+ changes in heart rate and rhythm and identify conduction Outcome Criteria problems or dysrhythmias that may occur with fluid shifting or electrolyte imbalances Patient will have no further bleeding and vital Blood products: blood, plasma, and platelets may signs will be stable. be required for replacement based on severity of bleed INTERVENTIONS RATIONALES Nasogastric tubes: large bore NG tube or Ewald tube is usually inserted to allow for iced/saline Monitor vital signs, including Patients with major GI blood lavage, confirmation of bleeding, and for decom- orthostatic changes when feasi- losses will present with supine pression of stomach ble. hypotension and resting tachycardia greater than 1lolmin, Levophed: may be used in solution with saline for orthostatic DBP decreases of at lavage when plain saline is not effective in least 10 mmHg, and orthostatic pulse increases of at least 1 Yrnin. stopping bleeding due to its vasoconstrictor effects Changes in vital signs may help approximate amount of blood Vasopressin: may be used for direct infusion into loss and reflect decreasing circu- the gastric artery to control bleeding, or via intra- lating blood volume. venous route for specified length of time Monitor hemodynamic parame- Facilitates early identification of Antacids: used to alter pH so that platelets can ters when possible. fluid shifts. CVP values between 4-18 cm H,O are considered aggregate and stop bleeding, and to prevent diges- adequate circulating volume. tion of raw mucosal surfaces Insert nasogastric tube for acute Facilitates removal of gastric con- Histamine antagonists: used to inhibit gastric bleeding episodes, and monitor tents, blood, and clots, relieves drainage for changes in bleeding gastric distention, decreases acid secretion; commonly used are cimetidine, character. nausea and vomiting, and pro- ranitidine, pepcid, and aid vides for lavaging of stomach. Blood that is left in stomach can be metabolized into ammonia and can result in neurologic encephalopathy. GASTROINTESTINAL/HEPATICSYSTEMS 195

INTERVENTIONS RATIONALES INTERYENTIONS RATIONALES

Actively lavage stomach via NG Saline solution is utilized to fused, a 3 point increase in the tube per hospital protocol with reduce wash-out of electrolytes hematocrit may be noted. If this cold or room temperature saline that may occur with use of water. elevation is not noted, continued until return is light pink or clear. Flushing facilitates removal of bleeding should be suspected. clots to assist with visualization Administer albumin as ordered. May be used for volume expan- of bleeding site, and may assist sion until blood products are with control of bleeding through available. vasoconstrictive effect. The current consensus of opinion is that Administer vasopressin as Intra-arterial infusion may be differences between using cold ordered. required for severe active bleed- versus room temperature solu- ing and patient must be tions is negligible, and in fact, monitored closely for develop- iced solution may actually inhibit ment of complications from the platelet function by lowering infusion. Rates are usually 0.1 - core body temperature. 0.5 Unitslmin into the artery supplying blood or peripherally May indicate further bleeding or Notify physician if bleeding at 0.3-1.5 Unidmin. clears and then becomes bright renewed bleeding. red again. Administer histamine blockers Histamine blockers decrease acid andlor omeprazole as ordered. production, increase pH, and Monitor intake and output, Helps facilitate estimation of decrease gastric mucosal irrita- including amounts of lavage fluid replacement required. tion. Omeprazole can completely solution, bloody aspirate, blood Lavage amounts facilitate inhibit acid secretion. products, and vomitus. estimation of the magnitude of bleeding based on the volume of Administer sucralfate as ordered. Decreases gastric acid secretion solution needed to clear the gas- and provides a protective layer tric return, and how long lavage over the ulcer site. May decrease is required before the aspirate or inhibit absorption of other clears. medications.

Administer IV fluids through Facilitates rapid replacement of Administer antacids as ordered. Facilitates maintenance of pH large bore catheters as ordered. circulating volume prior to level to decrease chance of Many facilities recommend at availability of blood products. rebleeding. least two lines for active bleed- Solutions of choice are normal Hemoglobin and hematocrit ing. saline or Lactated Ringer’s, and Monitor labwork for changes should be run wide open until andlor trends. help to identify blood replace- blood pressure is stabilized, and ment needs, but may nor initially titrated to match volume require- change as a result of loss of ments after that. plasma and RBCs. BUN levels greater than 40 in the presence Administer blood transfusions, Fresh whole blood may be of normal creatinine may signify fresh frozen plasma, platelets, or ordered when bleeding is acute major bleeding, and BUN whole blood as ordered. and patient is in shock so as to should normalize within 12 ensure that clotting factors are hours after bleeding has ceased. not deficient. Packed red blood cells are utilized most often for replacement, especially when fluid shifting may create overload. Frequently, fresh frozen plasma (FFP) will be concurrently administered to replace clotting factors and facilitate cessation of an acute bleed. For each unit of blood that is trans- 196 CRITICAL CARE NURSING CARE PLANS

Information, Instruction, Alteration in comfort Demonstration [See MI]

INTERVENTIONS RATIONALES Related to: muscle spasms, ulceration, gastric mucosal irritation, presence of invasive lines Administer antibiotics when May be indicated when infection Defining characteristics: verbalization of pain, ordered. is thought to be the cause of the gastritis or ulcer. facial grimacing, changes in vital signs, abdominal guarding Assist with and prepare patient EGD provides direct visualiza- for EGDlsclerotherapy. tion of an upper GI bleeding Anxiety site, and a sclerosing substance may be injected at site to stop [See MI] bleeding or prevent a recurrence. Related to: change in environment, change in Prepare patient for surgery. May be required to control gas- health status, fear of the unknown, life-threatening tric hemorrhage. Vagotorny, crisis pyloroplasty, oversewing of the ulcer, and total or subtotal gas- Defining characteristics: tension, irritability, rest- trectomy may be procedure of choice based on severity of lessness, anxiousness, fearfulness, tremors, bleeding. tachycardia, tachypnea, diaphoresis Risk for altered tissue perfksion: gastroin- Discharge or Maintenance Evaluation testinal, cerebral, cardiopulmonary, renal, peripheral Patient will have stable fluid balance with Related to: hypovolemia, hypoxia, vasoconstrictive normal vital signs and hemodynamic therapy parameters. Defining characteristics: decreased blood pressure, Patient will have adequate urine output. tachycardia, decreased peripheral pulses, decreased Patient will have no complications from fluid or hemodynamic pressures, abnormal ABGs, abdorn- blood replacement therapy. inal pain, decreased urine output, confusion, mental status changes, dyspnea, headache Patient will have labwork within normal limits. Patient will have no active bleeding or occult Outcome Criteria blood in stools. Patient will have adequate tissue perfusion to all Altered nutrition: less tban body body systems. requirements [See DKA]

~~ ~ ~~ Related to: nausea, vomiting, nasogastric tube INTERVENTIONS RATIONALES

~~ ~______~~~ Defining characteristics: inability to ingest Perform neurological checks Decreases in blood pressure may adequate amounts of food, weakness, fatigue, every 4 hours and prn. Notify result in decreased cerebral perfu- physician of changes in menta- sion that may cause confusion. weight loss tion or level of consciousness. Increases in ammonia levels from GASTROINTESTINAL/HEPIC SYSTEMS 197

INTERVENTIONS RATIONALES Knowledge deficit [See ~~ ~~ MI] residual blood may result in cere- to: bral encephalopathy. Related lack of information, lack of understanding of medical condition, lack of recall Monitor for complaints of May indicate ischemia and increasing severity of abdominal necrosis from vasoconstrictive Defining characteristics: verbalized questions pain, as well as pain radiating to medication which may result regarding disease, care or instructions, inadequate shoulders. when catheter is displaced, or may indicate peritonitis or fur- follow-up on instructions given, misconceptions, ther bleeding. development of preventable complications

Monitor EKG for changes and Decreased blood pressure, elec- treat according to hospital proto- trolyte imbalances, hypoxemia, cols. or response to cold injectate solution may cause cardiac dysrhythmias or changes with perfusion loss.

Palpate peripheral pulses for Decreased circulating blood presence and character of pulses. volume may result in peripheral Monitor for changes in color and vasoconstriction and shunting to temperature of extremities. core.

Monitor urine output for Renal perfusion may be affected decreases or changes in color or by hypovolemia. specific gravity. Notify physician for abnormalities.

Monitor for complaints of chest Myocardial ischemia and infarc- pain. tion may result if hypovolemic state decreases perfusion to crisis state.

Provide continuous pulse oxirne- Facilitates early identification of try and notify physician for level hypoxia and allows for timely below 90%. intervention.

Discharge or Maintenance Evaluation

Patient will have stable vital signs and hemodynamic parameters. Patient will have adequate and stable intake and output. Patient will have ABGs within normal limits, with no respiratory insufficiency or distress noted. Patient will have equally palpable pulses with equal color and temperature bilaterally to .. extremities. 198 CRITICAL CARE NURSING CARE PLANS

GASTROINTESTINAL BLEEDING

ACUTE BLOOD LOSS (variceal bleeding, coagulation abnormality, cancer, ulcer, gastritis, Mdlory-Weiss tears)

Decreased circulating blood volume Acid-peptide activity 4 J Hypovolemia Increased pepsin action J J Attempts of body for autoregulation Digestion of mucosal surfaces Increased pulse and BP Mucosal injury J Decreased platelet aggregation 4 Absorbtion of nitrogen products from gastrointestinal tract 4 Sodium and potassium reabsorbed Hypernatremia and hyperkalemia

d Cardiac dysrythmias Overload of renal Iand hepatic systems

Renal insufficiency Portal hypertension

4 4 Renal Failure Shunting of -metabolites from the liver 4 Serum ammonia increases 4 Hepatic encephalopathy Tissue hypoxia 4 I J Cardiovascular compromise J DEATH GASTROINTESTINAUHEPATIC SYSTEMS 199

be elevated, stools for guaiac, bilirubin may be elevated if cirrhosis is a factor

Esophageal varices are twisting, dilated veins that Esophlagogastroduodenoscopy (EGD): used to are found in the gastrointestinal tract, but most identify and sometimes treat variceal bleeding frequently develop in the submucosal areas of the with sclerotherapy lower esophagus. Most esophageal varices occur as Radiography: arteriogram used to identify tortu- a result from liver disease and portal hypertension ous portovenous vessels; chest x-ray used to and the development of collateral esophageal identify other complicating problems with respira- veins. When these veins become eroded, the ensu- tory system ing rupture causes extensive vigorous bleeding that is difficult to control. Arterial blood gases: may be used to identify acid- base imbalances; may show metabolic acidosis Normally, the patient does not exhibit symptoms with bleeding until coughing, vomiting, alcohol, c:' gastritis causes the varices to bleed. Mortality rates are high Nasogastric tube: used to keep stomach clear of (above 60%) due to other complications of liver blood and for lavage, but must be inserted dysfunction, sepsis, or renal failure. Blood loss cautiously so as to refrain from increasing bleeding may be sudden, massive, and life-threatening, with Balloon tamponade: Sengstaken-Blakemore (SB) shock and hypovolemia occurring. or Minnesota tube is a multi-lumen tube that Nearly all patients with esophageal varices have at exerts pressure on part of the stomach and against least one of the precipitating factors of cirrhosis, bleeding varices to help control bleeding, and portal vein thrombosis, hepatic fibrosis, schistoso- allows for removal of stomach contents; caution miasis, hepatic venous outflow obstruction, or must be exercised since placement of this tube can splenic vein or superior vena caval abnormalities. create complications such as airway occlusion or esophageal rupture The initial goal of treatment is to replace blood loss and prevent shock from hypovolemia. Balloon Visopressin: may be used as infusion through tamponade, utilizing the Sengstaken-Blakemore or superior mesenteric artery or a peripheral vein to Minnesota tube, may be required to produce decrease splanchnic blood flow and promote hemostasis. hemostasis; may induce water intoxication or accentuate cardiac disease by increasing systemic Complications that occur in conjunction with vascular resistance bleeding may become irreversible and lethal, such as hepatic coma, renal failure, myocardial infarc- Nitroglycerin: may be used in conjunction with tion, or congestive heart failure. vasopressin to balance systemic vasoconstriction Vitamin K: may be used to counteract increased MEDICAL CARE prothrom bin time Laboratory: hemoglo bin and hematocrit Cathartics: magnesium citrate or sorbitol may be decreased, BUN increased, liver function tests may used to decrease risk of ammonia-induced be abnormal due to liver involvement and disease, neuroencephalo pathy sodium may be elevated, clotting studies may be abnormal due to liver involvement, ammonia may 200 CRITICAL CARE NURSING CARE PLANS

Surgery: may require distal splenorenal shunt, Risk for injury mesocaval and portocaval anastomoses, or devas- Related to: utilization of balloon tamponade to cularization of the varices all in the effort to lower control esophageal bleeding pressure in the portal system Defining characteristics: increased bleeding, NURSING CARE PLANS exsanguination, tube migration, air leakage, esophageal necrosis, encephalopathy, airway [Care plans in GI bleeding section also apply to occlusion, asphyxia this diagnosis] Risk for alteration in tissue per-ion: cere- Outcome Criteria bral, cardiopulmona? gastroin testinal, renal, and periphera Patient will be free of complications and injury to self. [See Infective Endocarditis]

Related to: variceal bleeding ~ INTERVENTIONS RATIONALES Defining characteristics: decreased peripheral pulses, hypotension, tachycardia initially, brady- Examine Sengstaken-Blakemore Facilitates easier detection of cardia, cold and clammy skin, diaphoresis, mental (or other type tube) balloons by leaks by escaping air bubbling, status changes, lethargy, pallor, abnormal ABGs, testing inflation of balloons with and ensures balloons are patent air while tube is underwater. prior to insertion of tube into decreased oxygen saturation, decreased urine patient. output Refrigerate tube prior to inser- Chilling firms the tube to facili- Risk for decreased cardiac output tion, and assist physician with tate easier placement. [See Cardiogenic Shock] insertion of tube into patient’s noselmouth by encouraging Related to: variceal bleeding, hemorrhage, exsan- swallowing small sips of water. guination Ensure that tube is patent in Proper positioning is crucial to stomach by auscultating stomach ensure that the gastric tube is not Defining characteristics: decreased peripheral for injected air bolus. inflated in the esophagus. pulses, hypotension, tachycardia, cold and clammy Obtain KUB x-ray after place- Verifies correct anatomical place- skin, decreased urinary output, mental status ment and securing of tube. ment. changes, pallor When placement is verified, Applies pressure against the Risk for inflective individual coping inflate the gastric balloon with cardia to attempt to control [See Mechanical Ventilation] air and gently pull the tube back bleeding. Marking the tube facil- against the gastroesophageal itates prompt detection of Related to: bleeding disorder, alcohol abuse, junction. Secure tube, marking accidental migration. location at the nares, and clamp hepatic disease the gastric balloon.

Defining characteristics: history of excessive alco- Balloon tubes should be Facilitates stable position of tube hol usage, anxiety, fear, hostility, manipulative adequately secured with some and prevents migration due to behavior, guilt, rationalization, blaming behavior device [frequently used is a foot- peristalsis or coughing, while ball helmet with face guard] with exerting appropriate pull/pressure slight traction to the balloon on anatomical sites. tube. GASTROINTESTINAL/HEPATICSYSTEMS 20 1

INTERVENTIONS RATIONALES Information, Instruction, Demonstration Attach a y-connector to the Maintains sufficient pressure to esophageal balloon opening, with tamponade bleeding with pres- a syringe on one side, and a sure lower than level that may INTERVENTIONS RATIONALE5 manometer to the other. Fill result in esophageal ischemia and balloon with air until manometer necrosis. Instruct patientlfamily regarding Promotes knowledge and facili- reading is between 25-35 mmHg need for balloon tamponade, tates compliance. Decreases fear and clamp balloon. procedure of insertion, what to of the unknown. expect, etc. Connect gastric port to intermit- Facilitates removal of old blood tent suction and irrigate every from stomach, allows observation Observation of patient should be Deterioration in patientk status hour. of changes in bleeding, and constant. can occur rapidly and continuous relieves gastric distention. observation facilitates prompt intervention to prevent injury. Insert nasogastric tube above the Facilitates removal of salivary level of the esophageal balloon secretions and monitors for and connect to intermittent suc- bleeding above the esophageal Discharge or Maintenance Evaluation tion. If tamponade tube has an balloon, and reduces aspiration esophageal suction port, attach it risk. Patient will have bleeding from varices to intermittent suction. controlled with no injury or complication from Clearly identify and label each Proper identification may pre- treatment modalities. port, checking connections vent accidental deflation or frequently, and have scissors and improper irrigation. If the Patient will be able to comply with treatment. resuscitative equipment at esophageal balloon migrates to bedside. the hypopharynx, the esophageal Patitent will have stable vital signs and balloon must be cut immediately oxygenation. and removed to prevent airway obstruction.

Monitor for complaints of chest May indicate complication or pain. esophageal rupture.

Monitor respiratory status for May result from tube migration any changes, decrease in oxygen and asphyxia. saturations, or changes in mental status.

Keep head of bed elevated at Prevents regurgitation and least 30 degrees at all times. decreases nausea.

Compare character and amounts Facilitates identification of cessa- of drainage coming from each tion of bleeding, as well as lumen. potentially identifying level of bleeding site.

Deflate esophageal balloon for Decreases risk for esophageal 30 minutes every 12 hours, or as mucosal ischemia and indicated per hospital protocol. damage. 202 CRITICAL CARE NURSING CARE PLANS

ESOPHAGEAL VARICES

Obstruction in portal system 9 Increased pressure in portal vein 9 Normal circulation disrupted 9 Collateral channels form Blood bypasses liver 9 Portal hypertension increases 9 Esophageal veins become varicosed and torturous 9 Portal hypertension increases Contributing factors cause inflammatiodirritation 9 Esophageal varicosities rupture 9 Massive hemorrhage 9 Hypovolemic shock 9 DEATH GASTROINTESTINAL/HEPATICSYSTEMS 203

immunity and offers protection to people who are at high risk.

Acute hepatitis is an infection of the liver that usually is viral in origin but may be induced by drugs or toxins. There are currently five types of hepatitis, denoted HAV, HBV, NANB or hepatitis Laboratory: CBC shows decreased RBCs as a C, HDV, and HEV, with HAV being the most result of decreased lifespan from enzyme common type. Hepatitis B, or HBV, is more alterations or from hemorrhage; white blood cell severe and because it can be acquired from expo- count usually shows leukocytosis, atypical sure to individuals who are asymptomatic, the lymphocytes, and plasma cells; liver function stud- potential for transmission is increased many-fold. ies are abnormal, up to 10 times normal values in some cases, albumin decreased, blood glucose may Hepatitis A, or HAV, is transmitted via fecal-oral be decreased or elevated transiently due to liver route, with poor sanitation practices, with conta- dysfunction; Anti-HAV IgM presence shows either mination of food, water, milk, and shellfish, or currenc infection or after 6 weeks may indicate oral-anal sexual practices. HAV patients may immunity; hepatitis B surface antigen and hepati- exhibit no acute symptoms or have symptoms that tis Be antigen show presence of HBV; Anti-HBc are related to other causes. in serum indicates carrier status; Anti-HBsAg Hepatitis B, or HBV, is transmitted via blood and indicates HBV immunity; antidelta antibodies present without HBsAg indicates HDV; urine blood products, breaks in the skin or mucous bilirubin elevated; prothrombin time may be ele- membranes, or from an asymptomatic carrier with vated with liver dysfunction Hepatitis B surface antigen (HBsAg). Liver biopsy: may be used to delineate type of Hepatitis C, or Non-A, Non-B hepatitis, is trans- hepatitis and degree of liver necrosis mitted via intravenous drug use, sexual contact, blood or blood products, and from asymptomatic Liver scans: may be performed to identify level of carriers. parenchyma1 damage Hepatitis D, or HDV, is transmitted through the same routes as HBV but must have hepatitis B NURSING CARE PLANS surface antigen to replicate. Activity intolerance Hepatitis E, or HEV, is seen in developing coun- tries and not encountered in the United States. It Related to: infective process, decreased endurance is transmitted through food or water contamina- Defining characteristics: easy fatiguability, tion. lethargy, malaise, decreased muscle strength, reluc- Once the disease has been contracted, treatment is tance to perform activity symptomatic. Prophylactic therapy may assist in Outcome Criteria prevention of hepatitis from developing after being exposed to the virus. Immune globulin (IG) Patient will achieve and maintain ability to is generally given to provide temporary passive perform normal activities without intolerance and immunity. Hepatitis B vaccine provides active fatigue. 204 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Related to: changes in health status, changes in physical status, imposed physical isolation, inade- Maintain bed rest and quiet Decreases energy expenditure quate support system environment, allowing rest peri- that is needed for healing. ods in between activities. Activity can decrease hepatic Defining characteristics: feelings of loneliness, blood flow and prevent circula- feelings of rejection, absence of family tion and healing to liver cells. memberslfriends, sad, dull affect, inappropriate Reposition every 2 hours and Decreases potential for skin behaviors provide good skin care. breakdown. Alteration in nutrition: less than body Increase activities as patient is Assists with return to optimal requirements able to tolerate. activity levels while enabling patient to have some measure of [See Liver Failure] control over the situation. Related to: metabolism changes, anorexia Monitor labwork for liver hnc- May assist with identification of tion studies. appropriate levels of activity. Defining characteristics: nausea, vomiting,

Administer medications as war- Sedatives and antianxiety drugs anorexia, abdominal pressure, malabsorption of ranted. may be required to effect needed fats, altered metabolism of protein, carbohydrates, rest. Caution should be taken to and fat, weight loss, fatigue, edema ensure drugs used are not hepatotoxic. Risk for infiction [See Transplants] Information, Instruction, Demonstration Related to: leukopenia, immunosuppression, malnutrition, exposure to causative organisms INTERVENTIONS RATIONALES Defining characteristics: increased white blood Administer antidotesltherapeutic Removal of substance may cells, differential with a shift to the left, fever, treatment modalities to remove restrict amounts of tissue chills, hypotension, tachycardia, positive cultures causative agent with toxic damage. hepatitis. Risk for impaired skin intepity Instruct patient/fmily on disease Promotes knowledge and facili- [See Liver Failure] process and need for extended tates compliance with treatment. rest. Related to: bile salt accumulations on skin

Discharge or Maintenance Evaluation Defining characteristics: jaundice, pruritus, itching, scratching Patient will be able to verbalize understanding of disease process and treatment program. Patient will be able to perform usual activities without fatigue.

Patient will be able to gradually increase level of activities performed. Social isolation [See Transplants] GASTROINTESTINAL/HEPATICSYSTEMS 205

Knowledge &fieit INTERVENTIONS RATIONALES

Related to: lack of information, lack of recall, Instruct on avoidance of recre- May jeopardize recovery from unfamiliarity of resources, misinterpretation of ational drugs or alcohol. infection and increases liver dys- information received function. Consult with counselors, minis- May be required for assistance Defining characteristics: questions, requests for ters, drug or alcohol treatment with substance withdrawal and information, statements of misperceptions, devel- facilities as warranted. for long-term support once dis- opment of preventable complications charged. Outcome Criteria Discharge or Maintenance Evaluation Patient will be able to verbalize understanding of disease, treatment, and causative behaviors. Patient will be able to accurately verbalize understanding of all instructions given. Patiedfamily will be able to modify environ- INTERVENTIONS RATIONALES ment to control spread of disease.

Discuss patient’s perceptions of Identifies knowledge base and Patient will be able to effectively access commu- disease process. misconceptions to facilitate nity resources for treatment programs and appropriate teaching plan. discharge follow-up care. Instruct on disease process, pre- Types of isolation will vary vention and transmission of according to type of hepatitis Patient will be able to effectively manage med- disease, and isolation require- and personal situation. Family ical regimen with follow-up from physician. ments. members may require treatment depending on type of hepatitis.

Instruct in appropriate home Dirty environment and poor sanitation. sanitation methods may be responsible for transmission of the disease.

Instruct on activity limitations. Complete resumption of normal activity may not take place until liver returns to its normal size and patient begins to feel better and this may take up to several months.

Instruct on all medications, side Promotes knowledge and facili- effects, effects, contraindications, tates compliance. Some and dangers of administration of medications are hepatoroxic or over-the-counter drugs without are metabolized by the liver, physician approval. increasing its workload.

Instruct to refrain from blood Most states do not allow anyone donation. who has a history of any type of hepatitis to donate blood or blood products to prevent possible spread of the infection. 206 CRITICAL CARE NURSING CARE PLANS

HEPATITIS

(viruses; IV drug use; contaminated food, water, or blood; alcohol) PRECIPITATING FACTORS 4 Inflammation to liver 4 Liver cell destruction 6 Liver enlargement 6 Necrosis of liver acini cells 4 Mononuclear infiltrates I I 1 Autolysis Decreased ability to remove 6 toxins from blood stream J Anorexia, nausea, vomiting, Increased bilirubin levels urticaria, rashes, arthralgias 4 Darkened urine, jaundice I I I Scarring of liver I I I Regeneration of liver cells Continued hepatic failure 4 4 Return to normal health Encephalopathy after period of recuperation J Coma 4 DEATH GASTROINTESTINAL/HEPATICSYSTEMS 207

weight loss, jaundice, diaphoresis, dehydration, Pancreatitis and poorly defined abdominal mass may also be encountered. Acute pancreatitis is a life-threatening inflammatory response to an injury, in which pancreatic Pseudocysts and abscesses in and around the pan- enzymes are abnormally activated and these creas may occur as a result of localized necrosis, enzymes destroy tissues in and surrounding the and may exert pressure on the stomach or colon. pancreas by autodigestion. Precipitating factors for They may develop slowly and may result in fistula the abnormal activation may be caused by effects formation. ethanol and its metabolite, acetaldehyde, of The goal of therapy is to maintain adequate circu- diseases the biliary tract, obstruction of the of latory fluid volume with electrolyte replacement, common bile duct, bile reflux into the pancreatic pain relief, treatment of infection and treatment of duct, ischemia, trauma, infections, surgical or hyperglycemia. invasive procedures, neoplasms, metabolic aberrations, use of oral contraceptives, corticosteroids, thiazide diuretics, or antihypertensives, or stimula- MEDICAL CARE tion of vasoactive substances. Obstruction may result in widespread edema to the pancreas, which Laboratory: serum amylase is elevated up to 40 increases pressure in the pancreatic system. This times the normal limit in the early stages and then increase in pressure results in the rupture of the decreases over 2-3 days; urine amylase elevated ducts which allows the enzymes to spill into the and lasts longer than serum amylase; elevated glu- cells, and begin the autodigestion process. cose, bilirubin, alkaline phosphatase, lactic dehydrogenase, aspartate transferase, potassium, Trypsin activates the pancreatic enzymes, triglycerides, cholesterol, and lipase; decreased phospholipase A, elastase, and kallikrein. Trypsin albumin, calcium, sodium, and magnesium; white may cause edema, necrosis, and hemorrhage in the blood cell counts from 8,000-20,000 with pancreas. Elastase may attack the walls of smaller increased polymorphonuclear cells; hematocrit blood vessels and facilitate hemorrhage. may exceed 50%; prothrombin time may be Phospholipase A allows damage to the acinar cell increased; fat content in the stool increased; amy- membrane to occur, and may alter coagulation. lase-creatinine clearance ratio may indicate Vasomotor changes and increases in vascular per- pancreatic disease; renal profiles used to evaluate meability may be caused by kallikrein, and this renal function and hypovolemia may also be the cause of the pain experienced with pancreatitis. If the disease is allowed to progress, CT scans: used to identify size, shape, density, the inflammation leads to massive hemorrhage, masses, or infiltrates in the pancreas destruction of the pancreas, diabetes mellitus, aci- Ultrasonography: used to identify neoplasms, dosis, shock, coma, and death. edema, inflammation, cysts, abscesses, or One of the predominant symptoms of this disease infiltrates in the pancreas, but cannot confirm the is the unrelenting abdominal pain located in the diagnosis of pancreatitis epigastric and/or periumbilical areas that may Angiography: helps to visualize early pancreatic radiate to the chest and back. Nausea, continuous tumors or problems with vasculature vomiting, low-grade fever, anorexia, diarrhea, 208 CRITICAL CARE NURSING CARE PLANS

Endoscopic retrograde cholangiopancreatography decreased bowel sounds, anorexia, increased (ERCP): used to directly visualize the pancreatic metabolism, lack of adequate food ingested duct system by use of endoscopy and radiography; used to identify cysts, calculi, stenosis, pancreatic Fluid volume dtlficit and biliary duct disease when other diagnostic [See DKA] tools are not conclusive Related to: nausea, vomiting, fever, diaphoresis, Surgery may be necessary to drain abscesses or nasogastric drainage, fluid shifting, diarrhea pseudocysts, or to anastomose the pseudocysts to an adjacent structure to provide internal drainage; Defining characteristics: nausea, vomiting, ascites, chronic pancreatitis may require a pancreaticoje- nasogastric suctioning, hypotension, tachycardia, junostomy to relieve obstruction of the duct to decreased urinary output relieve pain; experimental surgery for transplanta- Risk for impaired gas exchange tion of the pancreas or islet cells may be performed [See Mechanical Ventilation]

NURSING CARE PWNS Related to: complications from disease Alteration in comfort Defining characteristics: altered arterial blood [See MI] gases, dyspnea, use of accessory muscles, tachypnea, bradypnea, cough, sputum Related to: pancreatic obstruction, autodigestion of pancreas, leakage of pancreatic enzymes, Potential for injury inflammation Related to: sepsis, pseudocysts, fistula formation, Defining characteristics: unrelenting epigastric abscess formation, complications from disease pain, patient curled up with both arms over Defining characteristics: fever, abdominal pain, abdomen, nausea, vomiting, tenderness, facial gri- drainage, increased white blood cell count, shift to macing, groaning the left, systemic infection symptoms, DIC, elec- INTERVENTIONS RATIONALES trolyte imbalances

Administer Demerol IV as Demerol is the drug of choice warrantediordered. for pancreatitis. DO NOT Outcome Criteria GIVE Morphine because most opiate-type narcotics cause Patient will be afebrile and have no complications spasms of the Sphincter of from disease. Oddi, increasing patient's pain. Alteration in nutrition: less than body INTERVENTIONS RATIONALES requirements Monitor vital signs at least every Allows for prompt identification [See DKA] 2 hours, and note changes. of early signs of infection to facilitate timely treatment. Third Related to: nausea, vomiting, anorexia, digestive spacing, bleeding, and secretion enzyme leakage, increased metabolic needs, sepsis of vasodilating substances may result in hypotension. Defining characteristics: increases in nausea and vomiting, retching, absent bowel sounds, GASTROINTESTINAL/HEPATICSYSTEMS 209

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Monitor hemodynamic pressures Allows for actual measurement of Prepare patientlfamily members Surgical drainage of abscesses or if possible. cardiac output and other para- for surgical procedures as pseudocyscs may be required. meters to identify fluid shifts and warranted. Long-term replacement may be hemodynamic alterations which Instruct in usage of pancreatic required for exocrine deficiencies may precede systemic complica- enzyme supplements/bile salts. from permanent pancreatic tions. damage. Monitor EKG for cardiac Hypovolemia and electrolyte rhythm, rate, and changes, and imbalances may precipitate car- treat dysrhythmias per hospital diac dysrhythmias. Discharge or Maintenance Evaluation policy.

Auscultate heart sounds for JVD in conjunction with a new Patient will be free of complications from pan- changes, gallops, or murmurs. S, gallop may indicate heart fail- creatitis, and will exhibit timely healing of all ure or pulmonary edema. wounds. Observe for changes in respira- Gram negative sepsis may be tory status, especially when seen symptomatically with Patient will be able to accurately verbalize all occurring concurrently with fever cholestatic jaundice and decreases instructed information. and jaundice. in pulmonary function.

Observe for increasing May indicate formation of complaints of abdominal pain or abscess, especially if symptoms tenderness, chills, fever, or occur while patient is receiving hypotension. vigorous medical treatment. Abdominal rigidity or rebound tenderness may indicate peritonitis.

Observe for presence of May indicate impending DIC as petechiae, continued bleeding, or a result of circulating pancreatic hematoma formation. enzymes.

Measure and monitor abdominal Identifies increases in fluid reten- girth changes. tion and ascites.

Monitor intake and output every Oliguria may occur as a result of 2 hours, noting hematuria, or renal involvement due to significant imbalance. increases in vascular resistance or decreased renal blood flow. Hematuria may occur as a result from circulating pancreatic enzymes. Information, Instruction, Demonstration

INTERVENTIONS RATIONALES

Strict aseptic technique should Failure to maintain technique be maintained when dealing with may result in sepsis, which is invasive lines or dressings. responsible for over 80% of deaths associated with pancreatitis. 210 CRITICAL CARE NURSING CAFE PLANS

PANCREATITIS

Pancreatic duct obstruction or injury 4 Inflammation and edema 4 Increased pressure Rupture of duct 4 Activation of pancreatic proteolytic enzymes

I I I Trypsi; leakage Lipase leakage 4 4 I 1- -7 Elastase digestion Kallikrein Phosolipase A Fat Necrosis of blood vessels 4

Vasodilation Necrosis of 4 acinar cells

Increased permeability 4 4 Ed:ma 1 Hemorrhage Thrombosis Combine with Ca++ s 4 41 Continued release of toxic substances Hypocalcemia systematically and locally I GASTROINTESTINAL/HEPATICSYSTEMS 211

Acute Abdomen/ MEDICAL CARE Surgery: usually the treatment of choice due to Abdominal Trauma potential or presence of peritonitis from injury; When someone is said to have an acute abdomen, procedure is dependent on source of bleeding or it generally indicates that they have a sudden onset contamination of severe abdominal pain that typically requires Laboratory: urinalysis to identify bleeding or uri- surgery to prevent peritonitis from contaminated nary tract injuries; CBC to identify sepsis and materials spilling into the peritoneal cavity. There changes in hematological status; WBC is normally are numerous situations that could be responsible elevated in trauma; differential used to identify for this diagnosis, such as perforation of the shifts to the left; amylase elevated with pancreatic appendix, peptic ulcer, bowel, gallbladder, diverti- injury or gastrointestinal perforations; renal and culi, or abdominal aortic aneurysm, ruptured liver profiles to discern damage to the particular ectopic pregnancy, or an abdominal injury. system; clotting profiles to monitor for coagula- Abdominal injuries may be caused from either tion status; myoglobin levels elevated with crush blunt trauma or penetrating damage. Blunt injuries, peritoneal fluid analysis for bleeding or trauma, with compression of abdominal structures infection against the vertebral column, can result from Radiagaphy: chest and abdominal x-rays used to sports injuries, accidents, or falls, and can be identify pneumothorax, free air below the caused as a result of a direct impact, rotary or diaphragm, foreign body that may have caused shearing forces, or rapid deceleration. Any of these injury, or other complications; loss of psoas mechanisms can cause tearing of body structures muscle outline indicates retroperitoneal bleeding that may involve substantial bleeding into the peritoneal cavity. CT scans: may be used to identify abdominal and retroyeritoneal injuries that may not be overt with Penetrating injuries can cause perforation of the regular x-rays; can identify cysts or abscesses that bowel or hemorrhage from lacerations to major may require surgical intervention vessels. These types of trauma can either be low- velocity, which damages tissues at the injury site, Intravenous pyelogram: used to detect hematuria or high-velocity, in which tissues and organs sur- and trauma to renal structures rounding the penetration path are damaged. Retrograde urethrography/cystography: used to All of the types of injuries discussed have signifi- identify urethral or bladder injury cant potential for critical emergencies, based on Ultrasound: use is limited; may be useful to dis- the severity of the wound, and how much damage tinguish between splenic hematoma from it has caused. Mortality is approximately 10% peritoneal blood or ascites from abdominal trauma due in part to the presence of structures involving many body systems Paracentesis: may be used to identify presence of being located in the abdomen. The goals of imme- pus, blood, or other substance, and may be used diate treatment involve maintaining the for peritoneal lavage to identify effects of abdomi- hemodynamic status, control of hemorrhage, and nal trauma and prevent unnecessary surgical intervention preparation for surgical procedures. 212 CRITICAL CARE NURSING CARE PLANS

NURSING CARE PLANS Information, Instruction, Demonstration Risk for infection INTERVENTIONS RATIONALES Related to: perforation of abdominal structures, laceration of vasculature, open wounds, peritoneal Prepare for surgery as warranted. Surgical intervention may be the cavity contamination treatment of choice to drain abscesses or remove or repair Defining characteristics: fever, trauma, elevated perforated structures. white blood cell count, sepsis Assist with peritoneal aspiration May be performed to remove as warranted. fluid and identify causative Outcome Criteria organism. Change wound dressings as Dressings protect wound and Patient will be free of infection, with stable vital ordered. prevent spread of infection. signs and labwork within normal parameters. Monitor CBC, especially WBC Facilitates assessment of effective- count. ness of antimicrobial therapy, as well as identifies blood loss or changes in infection. INTERVENTIONS RATIONALES Limit visitors as indicated, utiliz- Decreases potential for cross- Monitor vital signs, especially May indicate presence of or ing appropriate isolation contamination. temperature. impending infection and sepsis. precautions as warranted. Decreasing pulse pressure, hypotension and tachycardia may Discharge or Maintenance Evaluation signifj impending septic shock from endotoxic vasodilation. Patient will have stable vital signs and hemody-

Observe skin color, temperature, Patient may have warm, flushed, namic status. and monitor for changes. dry skin in shock's warm phase, Patient will have white blood cell count within changing to cold and clammy pale skin as shock progresses. normal limits.

Obtain blood, urine, sputum, Identifies causative organism and Patient will have negative cultures. drainage, or other cultures as facilitates appropriate selection of ordered. antimicrobial agents. Patient will not exhibit further signs/symptoms

Monitor intake and output every Sepsis may impair renal perfu- of infection. 2 hours. sion and result in oliguria or anuria. Patient will not develop secondary infection.

Administer antibiotics as Cephalosporins and aminoglyco- Family members will adhere to isolation regula- ordered. sides are frequently used to fight tions. these types of infections. for injury Ensure that universal precautions Assists in preventing spread of Risk are utilized, and that sterile or infection by cross-contamination, Related to: trauma aseptic technique is used when as well as preventing other bacte- caring for wounds or inserting rial growth from invasion of Defining characteristics: hemorrhage, peritonitis, invasive lines or catheters. skinlbody. altered arterial blood gases, mental status changes, Administer tetanus toxoid as Decreases risk of development of hypotension, tachycardia, bradycardia, arterial ordered. tetanus. injuries, fractures, electrolyte imbalances GASTROINTESTINAL/HEPATICSYSTEMS . .. 213

Outcome Criteria INTERVENTIONS RATIONALES abdomen or liver may indicate Patient will be free of injury to self, and free of hepatic or splenic vein thrombo- complications that may ensue from trauma. sis, and friction rubs heard over the spleen may indicare infarction or inflammation of spleen. INTERVENTIONS RATIONALES Percuss abdomen for changes, Dullness that is decreased over dullness or tympany. liver may indicate presence of free air below the diaphragm. Monitor vital signs every 1-2 Decreases in blood pressure or Upper abdominal distention and hours, and prn. Check blood changes with orthostatic readings increased tympany over the pressure readings in both arms may indicate impending hypov- stomach may indicate gastric and legs. olemia. Pulse pressures may dilation. Flank area dullness may increase during the latent effects indicate retroperitoneal hemor- of shock or with head injuries, rhage. and may decrease in early stages of shock. Differences benveen Cover protruding abdominal Protects viscera from drying, and right and left sides greater than viscera with saline-soaked sterile positioning prevents additional 20 mmHg may indicate aortic gauze or sterile towels, and posi- protrusion/evisceration. injury. tion patient with knees flexed.

Monitor respiratory status, Injury to lungs or diaphragm Palpate peripheral pulses for Changes in pulse characteristics noting changes in breath sounds. may result in tachypnea and dys- presence, quality, and character. may indicate arterial or venous pnea. Breath sounds that are Notify physician for significant impairment which may require distant or absent may indicate changes. immediate treatment. pneumothorax or hemothorax. Observe for Grey Turner's and Grey Turner's sign is a bluish Observe chest for symmetry, Splinting by patient or obvious Coopernail's signs. discoloration on flank that indi- paradoxical movement, anatomi- deformity or swelling may be cates retroperitoneal bleeding cal deformity, swelling, bruising, seen if ribs are fractured. accumulation in abdomen. or crepitus. Paradoxical movement may indi- Coopernail's sign is ecchymoses cate flail chest. Palpable crepitus on scrotum or labia and may may be present if lung or medi- indicate pelvic fracture. astinum has been punctured. Monitor for complaints of pain May indicate rupture of spleen Auscultate heart sounds for Extra heart sounds or murmurs at the tip of the left shoulder or or irritation of the diaphragm changes or abnormalities. may indicate injury to valves or right shoulder. from blood or other substance heart, and distant, muffled heart with left shoulder pain, and pos- tones may signal cardiac tarnpon- sible liver laceration with right ade. shoulder pain.

Observe abdomen for wounds, Bluish discolorations around the masses, swelling, pulsations, umbilicus may indicate retroperi- Information, Instruction, hemaromas, protrusion of organs toneal bleeding accumulating in Demonstration or viscera, lacerations, and abra- abdomen. An odd number of ~ ~~ ~~ ~ sions; auscultate for bowel bullet holes may indicate the INTERVENTIONS RATIONALES sounds. remaining presence of a foreign ~~~ ~~ objectlbullet in the body. Assist with peritoneal tap and Done to identify intraperitoneal Decreased or absent bowel lavage. bleeding which is diagnosed sounds may indicate ileus or when fluid is analyzed. peritonitis. Abdominal bruits may result when a vessel is par- Instruct on all procedures and Promotes knowledge and tially occluded, venous hums testing; prepare for surgery as decreases anxiety which facilitates auscultated over the upper warranted. compliance with medical regimen. 214 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES weight loss, nitrogen and electrolyte imbalance, decreased albumin and protein levels, vitamin Instruct patientlfmily to notify Abdominal injury signs and deficiencies physician for fever or abdominal symptoms may not appear for pain. several hours to days. Discharge or Maintenance Evaluation

Patient will have no evidence of abdominal injury complication. Patient will have no intraperitoneal bleeding or structural damage to organs. Patient will be compliant with regimen. Patient will have successful surgical intervention with no postoperative complications. Risk fir fluid uolmve &ficz't [See GI Bleeding]

Related to: fluid shifts, hemorrhage, nasogastric suctioning Defining Characteristics: hypotension, tachycardia, decreased urinary output, decreased hemoglobin and hematocrit, decreased filling pressures, electrolyte imbalances, presence of peritonitis Alteration in comfirt [See MI] Related to: trauma, surgery, edema Defining characteristics: grimacing, complaints of pain, restlessness, splinting, shallow respirations, abdominal rigidity Alteration in nutrition: less than body requirements [See DKA] Related to: trauma, surgery, nasogastric suctioning Defining characteristics: abdominal pain, ordered nutritional status of NPO, increased metabolism, GASTROINTESTINAL/HEPATICSYSTEMS 215

ACUTE ABDOMEN/ABDOMTNAL TRAUMA (bowel obstruction, peritonitis, trauma, perforation)

TRAUMA PERFORATION OBSTRUCTION J, 4 J, Hemorrhage from major vessel Subcapsular hematoma Decreased blood flow to major vessels 4 4 J, Hypovolemia Increased pressure Vasoconstriction 4 J, Rupture of organ Vasospasm 4 Decreased oxygenation J, Accumulation of fluids J, ,xra-abdominal pressure increases J, Perforation J, Peritonitis or systemic infection I w SHOCK f- J, DEATH This Page Intentionally Left Blank GASTROINTESTINAL/HEPIC SYSTEMS 217

Fulminant hepatic failure may begin as stage I hepatic encephalopathy, progressing to drowsiness and asterixis, stupor and incoherent communica- The liver plays a vital role by providing multiple tion, finally to stage IV with deep coma. The functions, such as, metabolism of carbohydrates, stages may progress over at little as two months. proteins, and fats, storing fat-soluble vitamins, vit- Distinguishing attributes between acute and amin B,,, copper, and iron, synthesis of blood chronic failure are the presence of cerebral edema clotting factors, amino acids, albumin, and globu- and intracranial pressure increases. lins, detoxification of toxic substances, phagocytosis of microorganisms, and plays a role The goal of treatment is to halt progression of the in glycolysis and gluconeogenesis. Liver function- encephalopathy that occurs with increasing ing can be preserved until up to 75% of the ammonia levels, and is accomplished with use of hepatocytes become damaged or necrotic, at cathartics, decreasing dietary protein, and which time the liver can no longer perform its electrolyte replacement. Even with treatment, normal operation. mortality rates are as high as 90%, depending on the age of the patient and severity of disease. Early hepatic failure presents as a type of cirrhosis of the liver. Liver cells become inflamed and MEDICAL CARE obstructed, which results in damage to the cells around the central portal vein. When the inflam- Laboratory. elevated ammonia levels, liver func- mation decreases, the lobule regenerates, and this tion studies elevated, elevated BUN; electrolytes cycle is repeated until the lobule is irreversibly tested to identify imbalances; serum bilirubin ele- damaged and fibrotic tissue replaces liver tissue. vated; urine bilirubin may be present if direct, serum bilirubin is elevated; albumin decreases and Advanced hepatic failure develops when all com- globulin increases in liver failure; cholesterol is ele- pensatory mechanisms fail, causing the serum vated; PT prolonged; toxicology screens for ammonia level to rise. The already-damaged liver ingestion of alcohol or other drugs that may have is unable to synthesize normal products, so acido- precipitated failure; magnesium level may be low sis, hypoglycemia, or blood dyscrasias develop, with alcoholic cirrhosis and toxic if magnesium and the patient becomes comatose. replacement is used Acute liver failure, also known as fulminant Medication: Neomycin or Kanamycin frequently hepatic failure, may be precipitated by a stress used to prevent intestinal bacteria from converting factor that aggravates a preexisting chronic liver proteidamino acids to ammonia; lactulose or sor- disease. Some stress factors include alcohol intake, bitol used to induce catharsis to empty intestines ingestion of Amanita mushrooms, large amounts to decrease conversion to ammonia; thiazide of dietary protein, gastrointestinal bleeding, and diuretics may be given to decrease fluid retention portacaval shunt surgery. An acute type of liver failure may occur as a result of viral or toxic Hyperalimentation: may be used as diet of choice hepatitis, biliary obstruction, cancer, acute infec- due to ability to control concentration of tive processes, drugs, such as acetaminophen, nutrients, electrolytes, and vitamins isoniazid, and rifampin, severe dehydration, Reye’s syndrome, or shock states. 218 CRITICAL CARE NURSING CARE PLANS

~ Hemodialysis: may be used as a temporary mea- INTERWNTIONS RATIONALES

~~~ ~ sure for severe hepatic encephalopathy Observe for asterixis or other Rapid wrist flapping when arms tremors. are raised in front of body with Liver biopsy: may be done to establish diagnosis hands dorsiflexed may indicate by study of biopsied tissue presence of encephalopathy.

Liver scans: may be used to detect degenerative Provide safe environment for Decreases risk of injury due to cirrhosis changes or identifj. focal liver disease patient. altered consciousness levels. Provide low protein diet. Decreased dietary protein may NURSING CARE PUNS lessen serum ammonia levels. Avoid sedatives and narcotics if May worsen decreasing level of Alteration in thought processes at all possible. consciousness and make identification of cause of decreased Related to: serum ammonia levels, sensorium more difficult. encephalopathy Information, Instruction, Defining characteristics: increased ammonia, Demonstration

increased BUN, mental status changes, decreasing ~ level of consciousness, changes in personality, INTERVENTIONS RATIONALES handwriting changes, tremors, coma Instruct patientlfamily in poten- Provides knowledge and facili- Outcome Criteria tial for altered sensorium and tates family involvement with encephalopathy signs. Reorient maintaining optimal orientation Patient will be conscious and stable, with ammo- patient as needed. level. Provides support with realistic expectations of disease nia levels within normal ranges. process since outcome is poor. INTERVENTIONS RATIONALES Instruct in side effects of drugs Diarrhea will occur, and lactulose Monitor neurological status every Idenrifies onset of problem and used to facilitate decrease in should be titrated to where 1-2 hours, and prn. Notify potential trend. ammonia levels. patient has 3 stools per day. physician for abnormalities. Discharge or Maintenance Evaluation If possible, have patient write As hepatic failure progresses, the name each day and do simple ability to write becomes more mathematic calculation. difficulr, and writing becomes Patient will be awake, alert, and oriented. illegible at pre-coma stage. Inability to perform mental cal- Patient will have serum ammonia levels within culations may indicate worsening acceptable ranges. failure. Patient andlor family will be able to verbalize Administer cathartic agents as Lactulose minimizes formation ordered. of ammonia and other nitroge- understanding of instructions and be able to nous by-products by altering communicate concerns. intestinal pH. Neomycin or Kanamycin help prevent conver- Alteration in nutrition: less than body sion of amino acids into ammonia. Sorbitol-type cathar- requirements tics cause an osmotic diarrhea to Related to: metabolism changes, increased ammo- empty the intestines to decrease ammonia production. nia level

Defining characteristics: anorexia, nausea, vomiting, malabsorption of fats, malabsorption of GASTROINTESTINAL/HEPATICSYSTEMS 219 vitamins, altered carbohydrate, fat, and protein Defining characteristics: presence of ascites, olig- metabolism, malnutrition, weight loss, fatigue, uria, anuria, dry skin, decreased skin turgor, edema, ascites hypotension

Outcome Criteria Impaired skin integrity Relateld to: poor nutrition, renal involvement, bile Patient will be able to achieve positive nitrogen deposits on skin balance and have stable weight. Defining characteristics: edema, ascites, jaundice, pruritus INTERVENTIONS RATIONALES Outcome Criteria Provide diet that has protein in Protein metabolism is altered ordered amounts, with supple- with liver disease and results in mentation of vitamins and other increased ammonia levels. Patient will maintain skin integrity. nurrients. Vitamin/nutrient supplementation may be required due to malabsorption of element. INTERVENTIONS RATIONALES Ensure that patient is positioned Decreases abdominal tenderness Observe skin for changes, abra- Facilitates identification of in sitting position for meals. and fullness, and prevents poten- sions, rashes, scaling, wounds, potential complications. tial for aspiration. bleeding, redness, etc.

Avoid sodium intake of amounts Sodium should be restricted to Turn at least every two hours and Prevents pressure area compro- greater than ordered. less than 500 mg per day to prn. mise of skin. decrease edema and ascites. Apply lotions frequently when Soap may dry skin furrher and If patient is unable to ingest ade- Provides needed nutrients when providing skin care; do nor use result in breach of integrity. quate dietary intake, administer patient is unable to eat. soap when bathing; apply corn- Lotions and other agents may rube feedings or TPN as ordered. starch or baking soda pm. decrease itching.

Administer medications for pru- Decreases itching which may Discharge or Maintenance Evaluation ritus as ordered. cause wounds. Bile salrs rhat are deposited on the skin of parienrs Patient will be able to ingest adequate amounts with hepatic or renal involvement cause chronic and severe of prescribed diet to maintain weighr and pruritus. ammonia levels at acceptable levels.

6 Patient will comply with dietary regimen and Information, Instruction, limitations. Demonstration

Patient will have no complications from enteral INTERVENTIONS RATIONALES or parenteral therapies. Instruct patient in merhods to Helps prevent patienr from decrease itching: soothing mas- scratching during the night and Fluid volume deficit sages, avoidance of extra covers, reduces tendency ro scrarch. [See GI Bleeding] and use of clean white gloves at night. Related to: osmotic changes, hydrostatic pressure Provide attention-diverting activ- May refocus concentration to changes ity. decrease scratching. 220 CRITICAL CARE NURSING CARE PLANS

Discharge or Maintenance Evaluation Risk fir injury

Patient will exhibit no evidence of skin break- Related to: hemorrhage, altered clotting factors, down. esophageal varices, portal hypertension Patient will be able to use discussed methods to Defining characteristics: bleeding, avoid scratching. exsanguination, decreased hemoglobin and hematocrit, decreased prothrombin, decreased Patient will have no complications from lack of fibrinogen, decreased clotting factors VIII, IX, and skin integrity. X, vitamin K malabsorption, thromboplastin release Inefective breathing pattern Related to: increased pressure from ascites, Outcome Criteria elevated ammonia levels, decrease lung expansion, fatigue Patient will exhibit no evidence of bleeding.

Defining characteristics: presence of ascites, weakness, tachypnea, dyspnea, decreased lung INTERVENTIONS RATIONALES expansion, altered arterial blood gases Monitor all bodily secretions for GI bleeding may occur due to presence of blood; test stools and altered clotting factors and Outcome Criteria nasogastric drainage for guaiac. changes that occur with cirrhosis and liver disease.

Patient will maintain effective respiration with Observe for bleeding from punc- May indicate a form of dissemi- normal ABGs and hemodynamics. ture sites, presence of hematomas nated intravascular coagulation or petechiae, or bruising. as a result of altered clotting factors.

INTERVENTIONS RATIONALES Monitor vital signs and hemody- Changes in vital signs may indi- Assist with paracentesis. May be required to remove namic parameters. Avoid rectal cate loss of circulating blood ascitic fluid if respiratory insuffi- temperatures. volume. Vasculature in rectum ciency cannot be corrected by may be susceptible to rupture. other methods. Insert nasogastric tube gently Esophageal vasculature may be Prepare patient for placement of Surgical intervention may be and lavage as ordered. susceptible to rupture. Removal peritoneovenous shunt. required to provide method to of blood from the stomach return accumulations of fluid in decreases synthesis to ammonia. abdominal cavity to the systemic Administer vitamins as ordered. Vitamin K facilitates synthesis of circulation and provides long- prothrombin and coagulation if term ascites relief. liver is functional. Vitamin C may reduce potential for GI bleeding and facilitates healing Discharge or Maintenance Evaluation process.

Patient will be free of shortness of breath and Administer stool softeners as Prevents straining to pass stool needed. which may result in rupture of will have normal lung expansion with optimal vasculature or increase in intra- arterial blood gases and oxygenation. abdominal pressures. GASTROINTESTINAL/HEPATICSYSTEMS 22 1

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Monitor labwork for CBC and Helps to identify blood loss or ones may enhance patient’s abil- clotting factors. impending DIC. ity to accept changes.

Consult with social services, Additional professional and corn- Discharge or Maintenance Evaluation counseling, psychiatric services, munity resources may be minister, or other community required to deal with alcohol or resources. drug rehabilitation, or with per- Patient will have no active bleeding and labwork ceptions of body image. will be within normal limits. Patient will not exhibit any hemorrhagic com- Discharge or Maintenance Evaluation plications from invasive lineltube placement. Patient will be able to verbalize concerns over Disturbance in body image his appearance.

Related to: changes in physical appearance, ascites Patient will be able to verbalize understanding of disease process and changes that may occur. Defining characteristics: presence of ascites, bio- physical changes, negative feelings about body, Patient will be able to effectively utilize methods fear of rejection, fear of reaction from others, fear for coping with changes. of death, fear of the unknown Family will be supportive of patient‘s altered appearance and self-esteem. I Outcome Criteria Patient will be able to effectively access commu- Patient will be able to verbalize concerns and nity resources for continuing needs. accept bodylself perception within situational limits.

INTERVENTIONS RATIONALES

Encourage patient to discuss Validates patient’s feelings and concerns, fears, and questions concerns regarding changes in regarding diagnosis being careful body. to recognize and accept his fears without minimizing them.

Discuss causes of alteration of Validates realistic changes and appearance with patient and allows for reinstruction on areas family members. that may not have been under- stood. Jaundice, bruising, and ascites may be considered unat- tractive by patient andlor family, and may precipitate feelings of low self-esteem and body worth.

Encourage family to support Patient and family may experi- patient without rejection or fear ence guilt, especially if the cause of his appearance. is alcohol or drug-related. Emotional support from loved 222 CRITICAT., CARE NURSING CARE PLANS

LIVER FAILURE

Liver cells inflamed or obstructed I Liver dysfunction due to damaged hepatoves I Hepatic lobule regenerates I Hepatic lobule irreversibly damaged Hepatic tissue becomes necrotic I Fibrotic tissue replaces hepatic tissue 4 Extensive destruction of hepatocyces Liver cannot perform function I Compensatory mechanisms fail Hepatic failure

I-- - ~ I I I I Ammonia remains Liver com resses Liver unable to Liver unable to Liver unable to in circulation vesseP, synthesize clotting synthesize protein/ regulate glucose, Obstructs flow factors amino acid store glycogen & form glyconeogenesis I I I I I Ammonia binds with Portal Blood dyscrasias Decreased fat H ypoglycemia carrier ion hypertension Decreased ability absorption I for coagulation I I I 4 I c Increased Acidosis Esophageal DIC Decreased protein serum varices absorption ammonia I I

Increased hanguination Hemorrhage Increased Decreased Fluid BUN mercap tan secretion shifting of bile to interstitial tissues I I I I I Confusion I Renal impairment Fetor Increased Aldosterone Decreased level secretion of consciousness J, I

Encephalopathy Bile salts Water & sodium Coma deposited rerention s I s J, Cerebral edema Jaundice Edema Increased ICP s 4 s Brainstem herniation Pruritis Ascites s + Respiratory arrest b DEATH HEMATOLOGIC SYSTEM 223

Disseminated Intravascular Coagulation (DIC) HELLP Syndrome Anemia This Page Intentionally Left Blank HEMATOLOGIC SYSTEM 225

underlying problem, correction of shock, acidosis, and sepsis, supportive care to restore circulatory volume and adequate oxygenation of tissues, and lntravascular Coagulation to replace blood loss due to hemorrhage.

Disseminated intravascular coagulation, also Laboratory: prothrombin time to measure known as consumptive coagulopathy, defibrino- (PT) activity level and patency of the extrinsic and final genation syndrome, or DIC, is an acute disorder pathways, increased in DIC; partial thromboplas- that accelerates the activation of the intrinsic tin time (PTT) to measure activity level and and/or extrinsic cascade clotting mechanism and patency of the intrinsic and final pathways, depletes both clotting factors and platelets. DIC is increased in DIC; thromboplastin time increased, usually a complication of another disease process platelet count decreased, fibrinogen usually in which excessive thrombin is produced, convert- decreased showing increased hypercoagability and ing fibrinogen to fibrin, and the fibrin creates decreased bleeding tendency, FSP elevated, usually damaging thrombi in the microcirculation. Fibrin > 10; clotting factor analysis used to identify fac- blocks the capillary flow to the organs and results tors being depleted; CBC used to evaluate anemia in ischemic tissue damage, and as the clotting fac- and RBC fragmentation; BUN and creatinine tors, platelets, and fibrin split products (FSP) are used to assess renal involvement from thrombosis; consumed, hemorrhage and shock results. As the guaiacs on all body fluids to identify occult bleed- fibrin and FSP repolymerize, a secondary fibrin ing; cultures of sputum, blood, urine, CSF and mesh forms in the microcirculation and when other drainage used to identify causative organism blood travels through this, the red blood cells of infection and to ascertain appropriate antimi- become damaged and a hemolytic anemia crobial for therapy can occur. Blood components: used as replacement therapy Some of the precipitating factors include sepsis, for significant blood loss; RBCs given to increase neoplasm necrosis, eclampsia, abruptio placentae, the oxygen-carrying capability; whole blood, saline-induced abortions, retained dead fetus, plasma, plasmanate and albumin used to expand amniotic fluid embolus, hemolysis, giant heman- volume; fresh frozen plasma (FFP) and albumin giomas, systemic lupus erythematosus, used to replace proteins; FFP, cryoprecipitate, and transfusions, trauma, shock, burns, head injuries, fresh whole blood used to replace coagulation fac- transplant rejection, snake bite, fractures, anoxia, tors; platelet concentrate used to replace platelets heat stroke, surgery utilizing cardiopulmonary bypass, and necrotizing enterocolitis. lV fluids: used to treat hypovolemia and shock Bleeding in a patient with no other previous his- Antibiotics: used to treat infection that may cause tory of bleeding or coagulopathy problems should DIC raise questions as to the possibility of the presence Heparin: use is controversial; heparin inhibits of DIC. DIC may be acute or chronic (usually micro thrombi formation by neutralizing free cir- seen with neoplasms) and can vary in severity culating thrombin; shouldn’t be used unless from mild oozing to exsanguination from all ori- bleeding is unmanageable by replacement therapy fices. Treatment is aimed at correction of the of FFP and platelets 226 CRITICAL CARE NURSING CARE PLANS

NURSING CARE PLANS INTERVENTIONS RATIONALES Risk fir impaired gas exchange Identify and treat underlying Treatment of cause and correc- disorder. tion of coagulation problem is [See GI Bleeding] major goal of treatment. DIC is Related to: bleeding, disease most often seen as the complication of an underlying infection, Defining characteristics: decreased Pa02 below malignant disease, trauma, or shock state. 80 mmHg, dyspnea, tachypnea, increased work of breathing, restlessness, irritability, mental status Administer IV fluids as ordered. Large volumes may be required to mainrain circulating volume changes, changes in blood pressure and pulse, due to bleeding, and to maintain decreased hemoglobin and hematocrit hemodynamic status. Risk fir fluid volume &fieit Administer blood and blood by- May be required to replace circu- [See GI Bleeding] products, such as cryoprecipitate, lating blood volume and to help fresh frozen plasma, etc. as correct thrombocytopenia or Related to: blood loss, altered coagulability ordered. hypofibrinogenemia. Administer supplemental oxygen Decreased blood volume impairs Defining characteristics: weight loss, oliguria, as warranted. oxygen carrying capability and abnormal electrolytes, hypotension, tachycardia, supplemental oxygen may be decreased central venous pressures, decreased fill- required ro maintain ing pressures, altered coagulation studies, lethargy, oxygenation. mental status changes Observe patient for petechiae, May be present with impending bruising, overt and occult DIC. Riskfor injury bleeding. Related to: hemorrhage, blood loss, altered Monitor for dyspnea, hemopty- Crackles may be present and coagulability sis, and decreased saturation; patient may exhibit these signs if auscultate lung fields for adventi- microemboli in the pulmonary Defining characteristics: bleeding, tious breath sounds. circulation are present. exsanguination, decreased hemoglobin and hemat- Monitor intake and output. Microemboli or deposits of fibrin ocrit levels, increased fibrin split products, within the renal system may pre- increased prothrombin time, decreased platelet sent as renal insufficiency or failure. count, increased partial thromboplastin time, decreased fibrinogen Administer heparin therapy as Controversial treatment may be ordered. given to disperse clumped clotting factors, but is rarely used Outcome Criteria today. Monitor labwork for coagulation Provides identification of effec- Patient will be free of unexplained bleeding and studies and CBC. tiveness of therapy or worsening will have stable vital signs and hemodynamic pres- of condition. sures. HEMATOLOGIC SYSTEM 227

Discharge or Maintenance Evaluation

Patient will have stable vital signs and hemodynamic pressures. Patient will exhibit no bleeding tendencies or active hemorrhage. Patient will exhibit no complications from other disease processes. Patient will achieve and maintain adequate blood volume. Patient will have underlying disease process corrected. 228 CRITICAL CARE NURSING CARE PLANS

DISSEMINATED INTUVASCULAR COAGULATION (DIC)

Triggering event 4 Activation of extrinsic and intrinsic coagulation cascade 4 Intravascular thrombin produced 4 Increased platelet Fibrinogen converted Inactivation of anti-thrombin aggregation to fibrin by plasmins 4 4 Capillary clotting Thrombin inhibited J, - Clots lysed Depletion of clotting factors P Secondary activation of the fibrinolytic system P Fibrin split products increased J, Inability of blood to clot 4 Hemorrhage 4 Hypovolemia L Shock J, Cardiovascular collapse 4 DEATH HEMATOLOGIC SYSTEM 229

fibrinogen levels is found only in severe forms. H E 11 P Syndrome Decompensated coagulation occurs with other complications such as liver hematoma, abruptio HELLP syndrome is an acute and severe compli- placenrae, renal failure, and pulmonary edema. cation that presents as a multi-organic disease process occurring concurrently with pregnancy- There is usually a low recurrence rate (50/0 or less), induced hypertension (PIH). The initials are and the HELLP syndrome usually resolves with compiled from the symptoms that comprise the delivery of the baby. Treatment involves prophy- syndrome: hemolysis, elevated liver enzymes and laxis against postpartum worsening, curettage of low platelets. These same findings may also be the uterus, and treatment with calcium antagonists associated with DIC and frequently is diagnosed and decadron, as well as intense monitoring for a as such. decline in liver function and for potential for bleeding. PIH usually occurs after the twentieth week of gestation in approximately 5% of all pregnancies, and most often in the primagravida patient. PIH MEDICAL CARE results in increased edema, proteinuria, and hyper- Laboratory: hematocrit used to assess intravascular tension. Although the cause is unknown, theories fluid status; protime and partial thromboplastin often involve immunologic, endocrine, and chori- time used to evaluate clotting; magnesium levels onic villi exposure. used to evaluate therapeutic levels for treatment; HELLP may represent an acute autoimmune state urine collection for protein used to diagnose com- in which the red blood cells lyse, liver enzymes are plications elevated as a result of fibrin thrombi blocking Magnesium: used to prevent and treat convulsions blood flow to the liver, and platelets decrease due by decreasing the neuromuscular irritability and to vasospasm and platelet aggregation. Vasospasm depressing the central nervous system results in increases in systemic and peripheral vascular resistance, which increase blood pressure Antihypertensives: apresoline is the drug of further. Sensitivity to angiotensin I1 is increased, choice; used to relax arterioles and stimulate car- and vasoconstriction may result in increases in vas- diac output and is utilized with diastolic blood cular permeability and hemoconcentration. pressures greater than 110 mmHg The pathological changes in the liver may develop Beta-blockers: occasionally used to control acute due to generalized activation of the intravascular hypertensive crises coagulation process. Fibrin deposits and hemor- Vdium: used to control seizure activity rhagic necrosis develops in periportal areas and may lead to subcapsular hematomas or liver rup- NURSING CARE PLANS ture. A decrease in antithrombin I11 and an for impairedgas excbaage increase in thrombin-antithrombin I11 complex Risk (TAT) and the appearance of fibrin monomers [See GI Bleeding] and D-dimers is found in almost all cases of Related, to: bleeding, disease HELLP, but decompensated intravascular coagula- Defining characteristics: decreased Pa02 below tion with increased PT and PTT and decreased 80 mmHg, dyspnea, tachypnea, increased work of wn CRITICAL CARE NURSING CARE PLANS

~~ breathing, restlessness, irritability, mental status INTERVENTIONS RATIONALE changes, changes in blood pressure and pulse, decreased hemoglobin and hematocrit Monitor vital signs every 1-2 Depression of CNS can result in hours, and prn, especially respi- respiratory insufficiency or paral- Risk for fluid volume deficit ratory status. ysis. Hypothermia may occur [See Bleeding] with toxicity of drug. MgS04 GI should he held for respirations Related to: blood loss, altered coagulability less than 16 per minute. Monitor EKG for changes and Dysrhythmias may occur with Defining characteristics: weight loss, oliguria, dysrhythmias, and treat per hos- administration of magnesium or abnormal electrolytes, hypotension, tachycardia, pital protocol. with its antidote, calcium. decreased central venous pressures, altered coagu- Monitor intake and output every Magnesium sulfate may cause lation studies, lethargy, mental status changes 2 hours. toxicity with large doses and result in renal insufficiency and Risk for injury oliguria.

Related to: administration of magnesium Monitor fetal heart tones every Fetal heart rate may decrease hour. with use of magnesium sulfate. Defining characteristics: CNS depression, venous Assess deep tendon reflexes. Absence of DTRs may indicate irritation, dyspnea, shallow respirations, decreased hyperrnagnesemia and toxicity. oxygen saturation, oliguria, absence of deep Decreased DTRs may occur with tendon reflexes, changes in vital signs therapeutic ranges. Have calcium gluconate at Calcium gluconate is the anti- Outcome Criteria bedside and give as warranted/ dote for magnesium sulfate. ordered.

Patient will receive medication without experienc- Monitor labwork for magnesium Normal levels are 4-7.5mEq/L, ing side effects. levels. with toxic levels above that.

Information, Instruction, INTERVENTIONS RATIONALES Demonstration

Monitor for convulsions or Identifies precipitation of INTERVENTIONS RATIONALES tremors. problem.

Administer magnesium sulfate as Magnesium is used to prevent Instruct on signs and symptoms Facilitates prompt identification ordered. and treat convulsions by decreas- to report to nurselphysician. of problem to allow for timely ing the neuromuscular irritability intervention. and depression of the central Observe IM injection sites for May indicate presence of sterile nervous system. Normally, redness, firm areas, warmth, and abscess from injections which MgSO, is given W,with a load- pain. have a variable rate of absorption ing dose of Grams, followed 3-4 given in this manner. by an infusion of 1-4 Gramslhr. It may be given IM with dosage of 5 Grams in each hip every 4 hours using the 2-tract method. Some facilities add xylocaine to the medication to decrease the pain of IM injections. HEMATOLOGIC SYSTEM 23 1

Discharge or Maintenance Evaluation

Patient will have stable vital signs. Patient will be free of convulsions. Fetal heart rates will remain unaffected and activity will be within normal range. Patient will exhibit no signs of magnesium toxicity or complications from therapy. 232 CRITICAL CARE NURSING CARE PLANS

HELLP SYNDROME

Pregnancy-induced hypertension + DIC J Hem01ysis Fibrin thrombi mobilized Platelet adhesion J, J, J, Abnormal morphology Decreased blood flow to liver Clumping of platelets 4 J, Liver congestion Decrease in circulating J, platelets Elevated liver enzymes

Increased sensitivity to angiotension 11 4 Vasospasm J Vasoconstriction Increased vascular resistance J, Increased arterial blood pressure J Increased vascular permeability J, Edema J Pro teinuria HEMATOLOGIC SYSTEM 233

heart valves or extracorporeal circulation and the destruction of red blood cells. Anemias can also be Anemia is a condition in which the red blood cell precipitated by toxic substance exposure or count, hemoglobin, and hematocrit are decreased. chronic disease processes, such as uremia or This decrease results in a decrease in the oxygen- chronic liver disease. carrying capability and causes tissue hypoxia. As the body tries to compensate, blood is shifted MEDICAL CARE from areas that have a plentiful amount in tissues Laboratory: CBC to help differentiate type of that have low oxygen requirements to those areas anemia-RBCs reduced; hemoglobin decreased that require higher oxygen concentrations, such as with mild considered 10-14 G/dl, moderate 6-10 the heart and brain. G/dl, and severe below 6 G/dl; hematocrit There are several types of anemias; those that are decreased; MCH, MCHC variable dependent on due to decreased red blood cell production, those type of anemia; MCV 80-100 fl with normocytic, that are due to blood loss, and the hemolytic ane- greater than 100 fl with macrocytic, and less than mias caused from G6PD deficiency, 80 fl with microcytic; platelet count usually autoimmunity, or physical causes. Microcytic, or decreased, but may be elevated after hemorrhage; iron deficiency anemia, develops when the trans- RDW increased in iron depletion anemia; B,, portation of iron by transferrin is insufficient to level decreased, folate decreased; serum iron and meet requirements of the erythropoietic cells. TIBC may be decreased; stool guaiac may be posi- Macrocytic, or megaloblastic anemia, occurs tive if blood loss is from GI tract because of a deficiency in vitamin B,, or folic Radiography: chest x-ray to discern pulmonary or acid. Pernicious anemia is a type of megaloblastic cardiac complications; upper and lower gastroin- anemia in which the absence of vitamin B,, as testinal series may be done to identify active or well as lack of the intrinsic factor is noted. current bleeding Normocytic, or aplastic anemia, is caused from the failure of the bone marrow or destruction of bone Bone marrow aspiration: may be performed to marrow by either chemical or physical means. determine type of anemia Autoimmune anemia is an acquired condition that Bone marrow transplants: may be required for involves premature erythrocyte destruction from severe aplastic anemia the person's own immune system. Hemolytic anemia results when erythrocyte destruction is Blood transfusions: may be required to replace increased and cells have a shortened life span. blood volume with hemorrhage Sickle cell anemia is an inherited condition in which hemoglobin S is present in the blood result- NURSINC CARE PLANS ing in sickling and abnormal hemolyzation that Alteration in tissue perfksion: obstructs capillary flow. Thalassemia is a group of cardiopulmonary, renal, cerebral, gastroin- inherited anemias that result from faulty produc- testinah peripheral tion of alpha or beta hemoglobin polypeptides. Related to: altered oxygen-carrying capability, Anemia can occur as the direct result of prosthetic blood loss 234 CRITICAL CARE NURSING CARE PLANS

~~ Defining characteristics: decreased hematocrit and INTERVENTIONS RATIONALES hemoglobin, chest pain, palpitations, pallor, dry mucous membranes, cold intolerance, oliguria, Monitor for complaints of chest May indicate decreased cardiac nausea, vomiting, abdominal pain, abdominal dis- pain, pressure, palpitations, or perfusion from hypoxia or tention, increased capillary refill time, confusion, dyspnea. ischemia. lethargy, changes in pulse rate and blood pressure Administer blood andlor blood Blood replacement may facilitate products as warranted. improved oxygen-carrying ability due to increased number of red Outcome Criteria blood cells and correct volume deficiency.

Patient will have adequate perfusion to all body Monitor labwork for changes. May facilitate identification of systems with stable vital signs and hernodynamics deficiencies and allow for assessment of effectiveness of treatment.

~~ ~~~ ~~ INTERVENTIONS RATIONALES Information, Instruction, Monitor vital signs every 1-2 Facilitates identification of Demonstration hours and prn. changes that may require intervention. INTERVENTIONS RATIONALES

~~~ ~ Monitor neurological status for May be indicative of impaired Maintain environment tempera- Reduction of peripheral perfu- mental confusion or level of con- cerebral perfusion. ture within normal ranges. sion may result in cold sciousness changes. intolerance to vasoconstriction. Auscultate lung fields for adven- Crackles andlor new presence of Excessive heat may cause vasodi- titious breath sounds. Auscultate cardiac gallops may indicate lation and further reduce organ for abnormal heart tones. impending or present congestive perfusion. failure that may have resulted Prepare patientlfamily for surgi- May require transplantation of from the body’s compensatory cal procedures as warranted. bone marrow, or surgical repair mechanism of increasing cardiac for site of bleeding. ourput. Mild anemia can cause exertional dyspnea and palpitations; moderate anemia can cause Discharge or Maintenance Evaluation increased palpitations and dyspnea at rest; severe anemia causes Patient will achieve and maintain adequate per- tachycardia, increased pulse pres- fusion to all body systems. sure, systolic murmurs, intermittent claudication, angina, Patient will have stable vital signs and hemody- congestive heart failure, orthop- namic pressures. nea, and tachypnea.

Administer supplemental oxygen Decreases in red blood cells Patient will exhibit no evidence of GI bleeding. as warranted. decreases oxygen carrying capability since oxygen is bound to Patient will exhibit no signs of complications of the hemoglobin for transport, disease or therapy. and may require supplementation to maintain oxygenarion. Risk for fluid volume deficit [See GI Bleeding] Monitor EKG for changes in Changes may occur with imbal- cardiac rhythm or conduction. ances of electrolytes, with fluid Related to: bleeding shifts, or with hypoxia. Defining characteristics: hypotension, tachycar- HEMATOLOGIC SYSTEM 235

dia, decreased skin turgor, weakness, decreased uri- INTERVENTIONS RATIONALES nary output, pallor, diaphoresis, decreased capillary refill, mental changes, restlessness, Instruct on particular rype of Provides knowledge and facili- anemia that patient has tates compliance. decreased filling pressures developed.

Activity intolerance Instruct on labwork and other Decreases anxiety and fear of the [See COPD] procedures. unknown. Related to: decreased oxygen-carrying capability Instruct on dietary requirements. Increasing iron sources from red meat, egg yolks, dried fruits and Defining characteristics: weakness, lethargy, green leafy vegetables may facilitate correction of anemia. Folic fatigue, dyspnea, activity intolerance, chest pain, acid and vitamin C which aug- palpitations, tachycardia, decreased oxygen satura- ments iron absorption may be tion, increased respiratory rate with exertion, found in green vegetables, whole hypertension grains, citrus fruits, and liver. Instruct on signs and symptoms Decreased leukocyte count may Alteration in nutrition: less than body of which to notify physician. potentiate the risk of infection requirements and patient should seek [See DKA] medical assistance for timely intervention. Related to: inability to absorb required nutrients Instruct on medications, effects, Iron or vitamin B,, replacement for red blood cell production side effects, contraindications, may be necessary for life, and and avoidance of over-the- knowledge regarding therapeutic Defining characteristics: weight loss, activity counter medications without management will increase com- intolerance, dyspnea, fatigue, weakness, loss of physician approval. pliance with treatment and allow muscle tone, anorexia for prompt identification of complications that may require Knowledge deficit changes in dosages, types of' medication, or schedule of Related to: lack of information, unfamiliarity with administration. information, lack of recall, misinterpretation of information Discharge or Maintenance Evaluation

Defining characteristics: questions, communica- Patient will be able to verbalize and demonstrate tion of misconceptions, development of understanding of all instructed information. preventable complications, incorrect follow-up with instructions

Outcome Criteria

Patient will be able to verbalize understanding of disease process, treatment regimen, and procedures, and comply with therapy. 236 CRITICAL CARE NURSING CARE PLANS

ANEMIA

Sickle cell anemia Blood loss, hemolytic destruction/production anemia s (decreased RBC production, lack of intrinsic factor, etc.) Presence of HgB S J

HgB S sensitive to 02 Saturation decreases 4 Sickling of cells 4 Capillary blood flow obstructed 1 I Decrease of normal hemoglobin concentration 4 Decreased oxygen carrying capability J Cellular hypoxia J Oxyhemoglobin dissociation curve shifts to the right 4 Increased oxygen removal by tissues Increased oxygen demand and consumption Redistribution of blood to areas with higher oxygen demands J Hypoxemia 4 Organ dysfunction 4 Organ failure J DEATH RENAL/ENDOCRINE SYSTEMS 237

Acute Renal Failure (ARF) Diabetic Ketoacidosis (DKA) Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK) Syndrome of Inappropriate ADH Secretion (SIADH) Diabetes Insipidus (DI) Pheochromocytoma Thyrotoxicosis (Thyroid Storm) This Page Intentionally Left Blank RENAL/ENDOCRINE SYSTEMS 239

obstruction anpvhere in the system from the Acute Renal Failure (ARF) kidney to the urethra. Some clinical conditions in Acute renal failure (ARF) is noted when there is a which this type of failure is seen includes urethral sudden deterioration in function of the renal obstruction, prostatic hypertrophy, bladder carci- system that may be caused by renal circulation noma, bladder infection, neurogenic bladder, renal failure or glomerular or tubular dysfunction. The calculi, and abdominal tumors. build-up of waste materials that accumulates There are three phases in ARF-an oliguric phase, affects multiple organ systems. a diuretic phase, and a recovery phase. Oliguria occurs when the tubule obstruction and damage ARF can be subclassified according to the etiology of condition, such as prerenal, intrarenal, and makes absorption unstable, and BUN, creatinine, and potassium levels increase. During the diuretic postrenal. Prerenal conditions occur when blood phase, tubular function begins to return but the perfusion is inadequate, such as with hypotension, hemorrhage, myocardial infarction, congestive patient must be monitored for excessive diuresis heart failure, pulmonary embolism, burns, third with loss of electrolytes. When diuresis is no spacing, septic shock, diuretic abuse, or volume longer excessive, the recovery phase begins with gradual improvement in kidney function for up to depletion. This dysfunction causes glomerular fil- one year. There may be a permanent decrease in tration rates to decrease, and decreased renal function that, depending on severity, may reabsorption of sodium in the tubules. require dialysis. Intrarenal renal failure occurs either from damage to the tubular epithelium, known as acute tubular MEDICAL CARE necrosis (ATN), or from damage to glomeruli and the small vessels. This condition causes renal capil- Laboratory: CBC- hemoglobin decreased with lary swelling that decreases the glomerular anemia, RBCs decreased due to fragility, white filtration rate (GFR), or decreased GFR is blood cell count elevated if sepsis or trauma is pre- secondary to the obstruction of the glomeruli by cipitating event; BUN and creatinine elevated edema and cellular debris. ATN is the most with ratio of 10:1 ; serum osmolality increased common type of ARF and is the result of nephro- above 285 mOsm/kg; electrolytes used to show toxins or ischemia. Intrarenal failure may take imbalances, with elevated potassium due to reten- many weeks to repair damage and is usually seen tion, hemolysis, or acidosis; sodium usually with trauma, sepsis, DIC, transfusion reactions, increased, but may be normal; bicarbonate, pH, renal vasculature blockages, heavy metal poison- and calcium decreased; magnesium, phosphorus, ing, and with use of aminoglycosides, penicillins, and chloride increased; complement studies may tetracylines, dilantin, and amphotericin. be used to identify lupus nephritis; serum Glomeruli damage is seen with acute electrophoresis may be used to identify abnormal glomerulonephritis, polyarteritis nodosa, lupus proteins that may damage kidneys permanently; erythematosus, Goodpasture’s syndrome, AS0 titer may be used to diagnose recent strepto- endocarditis, abruptio placentae, abortion, serum coccal infection that could cause poststreptococcal sickness, malignant hypertension, or hemolytic glomerulonephritis; UA: Urine color is dirty, tea- uremic syndromes. colored brown, volume is less than 400 cc/day, specific gravity less than 1.020 indicates renal dis- Postrenal failure may occur as a result of an ease and fixed at 1.O 10 indicates severe renal 240 CRITICAL CARE NURSING CARE PLANS

damage; pH greater than 7.0 seen with UTI, ATN, and chronic renal failure; osmolality less NURSING CARE PUINS than 350 mOsmlkg indicates tubular damage; cre- Fluid volume excess atinine clearance decreased; sodium decreased but Related to: impairment of renal system regulation, may be greater than 40 mEq/L if kidney does not reabsorb sodium; RBCs may be present if infec- retention of water tion, renal stones, trauma, or tumor is cause; Defining characteristics: oliguria, anuria, changes protein of 3 or 4+ indicates glomerular damage, in urine specific gravity, intake greater than 1+ or 2+ may indicate infection or interstitial output, weight gain, elevated blood pressure, nephritis; casts indicate renal disease or infection, edema, ascites, increased central venous pressure, brownish casts and numerous epithelia1 cells indi- neck vein distention, dyspnea, orthopnea, crackles, cate ATN, and red casts indicate acute glomerular muffled heart tones, decreased hemoglobin and nephritis hematocrit, altered electrolytes, increased filling Electrocardiogram: used to identify dysrhythmias pressures, restlessness, anxiety, water intoxication and cardiac changes that may occur with acid-base imbalances or electrolyte imbalance Outcome Criteria

Radiography: KUB to identify size of structures, Patient will have balanced intake and output, cysts, tumors, stones, or abnormal kidney stable weight, stable vital signs and hemodynamic location; chest x-ray to identify fluid overload that parameters, and have effective dialysis when may occur with fluid shifts required. Radionuclide imaging: may be used to identify hydronephrosis, calicectasis, or delayed filling or emptying, or other causes of AW INTERVENTIONS RATIONALES

Retrograde pyelogram: may be used to identify Monitor vital signs and hemody- Hypertension with increases in abnormalities of ureters or renal pelvis namic parameters every 1-2 heart rate may occur when kid- hours. neys fail to excrete urine, Renal arteriogram: may be used to identify changes occur within the renin- angiotensin cascade, or with fluid extravascular irregularities or masses, and provides resuscitation. Hemodynamic visualization of renal circulation pressures can facilitate identification of changes with Magnetic resonance imaging: may be used to intravascular volume. evaluate soft tissue Monitor intake and output every Facilitates identification of fluid CT scans: may be used to detect presence of renal 2 hours and prn, noting balance requirements based on renal or imbalance per 24 hour period. function. Insensible losses can d’isease Estimate insensible losses add up to 800- 1000 cc/day and Dialysis: emergency and chronic dialysis may be through lungs, skin, and bowel. metabolism of carbohydrates can liberate up to 350 cdday of fluid required for ARF; ultrafiltration and CAVH may from ingested foods. also be utilized Weigh daily. Changes in body weight help to Surgery: may be required for renal calculi identify fluid status. Gains over 1 poundlday indicate fluid reten- removal, resection of the prostate, or placement of fistula for long-term dialysis RENWENDOCRINE SYSTEMS 24 1

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

tion. Fluid amounts of 500 cc Hyperkalemia may occur as body are equivalent to 1 pound. attempts to correct acidosis, hypernatremia may indicate total Auscultate lungs for adventitious Adventitious breath sounds, such body water deficit, and hypona- crackles, will be heard with breath sounds. as tremia may result from fluid development of pulmonary overloading or inability to con- edema or congestive heart failure. serve sodium. BUN/crearinine Measure urine specific gravity, Specific gravig is less than 1.010 ratio, which is normally 10: 1 is and note changes in character of in intrarenal failure and signifies greater than 20:l with prerenal urine output. inability to appropriately concen- failure. trate the urine. Monitor urine specimen labwork Urine sodium less than 20 for changes. mEq/L, osmolality above Administer fluids as warranted Prerenal failure is treated with 450 with restrictions per physician fluid replacement, occasionally mOsm/kg, and urine creatinine orders. with use of vasopcessors. above 40 indicates prerenal fail- Management of fluids is based ure. Urine sodium above 40 on replacement of output from mEqlL, osmolality below 350 all sources. mOsm/kg, and urine creatinine below 20 indicates ATN. Administer diuretics as ordered. May be given to convert oliguric phase to nonoliguric phase, to flush debris from tubules, Information, Instruction, decreased hyperkalemia, or foster Demonstration

improved urine output. ~______

'Ihsert Foky catheter as Catheterization eliminates poten- INTERVENTIONS RATIONALES warranted. tial lower GU tract obstruction and provides for accuracy of Identify and correct any Improvement of perfusion, measurement of urine output, reversible reason for ARE enhancing cardiac output and but may not be treatment of hemodynamics, or removal of choice due to potential for infec- obstruction may facilitate recov- tion. ery from ARF and limit residud effects. Observe for presence and charac- Dependent edema may be pre- ter of edema. sent, but pitting edema may not Obtain chest x-rays and compare May be used to identify increas- be discernable until the patient with previous films. ing cardiac silhouette, effusions, has more than 10 pounds of infiltrates, pulmonary edema, or fluid in body. Periorbital edema other complications that may may be the first clinical evidence occur with fluid overload. of edema and indication of fluid shifting. Administer antihypertensives as May be required to treat hyper- warrantedlordered. tension that occurs from Monitor for mental status May indicate impending hypoxic decreased renal perfusion or fluid changes. state, electrolyte imbalances, overload. acidosis, or sepsis. Instruct patient/family on neces- Promotes understanding and Monitor arterial blood gases. May indicate presence of acidosis sity for fluid restriction. facilitates compliance. and facilitate intervention for hypoxemia. Prepare patientlfamily for dialysis Dialysis may be required to treatment as warranted. remove toxic wastes and to cor- Monitor labwork for alterations. Electrolyte imbalances may occur rect electrolyte, acid-base, and from impaired sodium reabsorp- fluid imbalances. tion, fluid overload, or lack of excretion of potassium. 242 CRITICAL CARE NURSING CARE PLANS

Discharge or Maintenance Evaluation INTERVENTIONS RATIONALES

. Patient will achieve and maintain urinary losses without adequate replacement may lead to hypovolemia output within normal limits for character and and shock. amount. Measure intake and output every Facilitates identification of fluid Patient will have stable weight, vital signs, and 1-2 hours, or prn, including loss and replacement require- hemodynamic parameters. insensible fluid losses. Compare ments. for balance at least every 24 Patient will exhibit no respiratory dysfunction hours. and have normal arterial blood gases. Supply allowed amounts of fluid Lack of fluid intake maintenance throughout the day ensuring that may predispose nocturnal dehy- Patient/family will be able to verbalize all fluids are counted. dration. understanding of instructions and comply with Administer IV fluids as ordered. May requite intermittent treatment. fluid boluses to challenge fluid shifting. Patient will have no signs of edema. * Patient will tolerate dialysis procedure without Discharge or Maintenance Evaluation complications. Patient will have stable weight. firfluid volume deficit Risk Patient will have equivalent intake and output. Related to: fluid loss, diuretic phase Patient will have stable vital signs and hemody- Defining characteristics: weight loss, output namic parameters. greater than intake, hypotension, tachycardia, Patient will have urine output within normal decreased central venous pressure, decreased limits. hemodynamic pressures, increased temperature, dilute urine with low specific gravity, oliguria with * Patient will have normal neurological status. high specific gravity, weakness, stupor, lethargy Alteration in tissue perfision: renal, cardio ulmonary, cerebral, gastrointestinal, Outcome Criteria peripR eral Patient will exhibit equivalent intake and output, Related to: fluid shifts, renal obstruction, impair- have stable vital signs and weight, and will have ment of renal function, septic shock, trauma, urine output within acceptable levels. burns, uremia Defining characteristics: oliguria, anuria, dehydra- INTERVENTIONS RATIONALES tion, hypotension, abnormal vital signs, abnormal blood gases, abnormal electrolytes, mental status Monitor vital signs and hemody- Hypovolemia may result in namic pressures. hypotension and tachycardia. changes, lethargy, nausea, vomiting, skin changes

Observe for complaints of thirst, May indicate presence of dehy- dry mucous membranes, poor dration. When extracellular fluid Outcome Criteria skin turgor, or lethargy. or sodium is depleted, the thirst center is activated. Continued Patient will have adequate perfusion to all body systems. RENAL/ENDOCRINE SYSTEMS ~ , 243

INTERVENTIONS RATIONALES INTERWNTIONS RATIONALES

Monitor vital signs and hemody- Hypertension and fluid volume Monitor intake and output every Oliguria, with output less than narnic parameters. increases may increase cardiac 1-2 hours and prn. Measure spe- 400 cclday, and anuria, or no workload, increase myocardial cific gravity and note changes in output, may be seen with fluid oxygen demand, and possibly character of urine. volume excess or decreased per- lead to cardiac failure. Blood fusion states. Decreases in pressure below 70 mmHg inter- urinary output that do not feres with autoregulatory respond to fluid challenges cause mechanisms. renal vasoconstriction and decryased perfusion from Monitor EKG for dysrhythmias Renal failure and electrolyte increased renin secretion. or changes in cardiac rhythm, imbalances may predispose and treat appropriately. patient to dysrhythmias and con- Monitor labwork for electrolyte May have hyperkalemia in olig- duction problems. Hypokalemia changes. uric phase changing to may be reflected with flat T hypokalemia with diuretic phase. wave, peaked P wave, and some- Potassium levels above 6.5 times the presence of a U wave. rnEqlL should be treated as a Hyperkalemia may be reflected medical emergency. with peaked T wave, widened Hypocalcemia produces adverse QRS complex, increased PR cardiac effects and potentiates interval, and flattened P wave. potassium. Hypermagnesemia Hypocalcemia may be may occur with use of antacids manifested with QT prolonga- and cause neuromuscular dys- tion. Treatment of function, or cardiac or potentially-lethal cardiac dys- respiratory arrest. rhythmias may prevent death from complication of renal fail- Maintain oximetry of at least Facilitates oxygenation of tissues ure. 90% by using supplemental in the presence of decreased per- oxygen. fusion and increased workload. Monitor neurological status for Decreased perfusion may result changes in mentation or level of in cerebral perfusion decreases Monitor arterial blood gases. Facilitates measurement of actual consciousness. resulting in lethargy, weakness, oxygen levels and identifies acid- and stupor or from uremic syn- base disturbances that may require further intervention. drome. Administer inotropic agents May be required to improve car- Monitor for peripheral pulse Pallor may be present with vaso- as ordered. diac output, increase myocardial presence and character, skin constriction or anemia, and skin contractility, and improve perfu- color, appearance of mucous may be cyanotic or mottled with sion. membranes, turgor, capillary pulmonary edema or cardiac refill time. failure. Administer glucoselinsulin com- May be used as temporary emer- bination as ordered. gent treatment to decrease serum Auscultate for breath sounds and Fluid overload and decreased potassium by shifting potassium heart tones, and notify physician perhion may result in develop- into the cells. of abnormalities. ment of S, or S4 gallops, and pericardial friction rub may indi- Administer polystyrene sulfonate May be used to lower serum cate the presence of uremic as ordered. potassium by exchanging pericarditis. sodium for potassium in the GI tract. Solutions that also contain Monitor for complaints of May indicate impairment of neu- sorbitol may also decrease potas- numbness, paresthesias, muscle romuscular activity, sium levels by osmotic diarrhea. cramps, tremors, twitching, or hypocalcemia, and potential for hyperreflexia. decreased cardiac perfusion and Administer mannitol as ordered. May be used with muscle trauma function. for osmotic diuresis, but should 244 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

not be given repeatedly if Patient will achieve normalized perfusion of all response is not achieved due to body systems. accumulations of hyperosmolar compounds that may result in Patient will have no long-term effects from per- further renal damage and decreased perfusion. fusion impairment. Patient will have normal urine output with no Information, Instruction, symptoms or signs of ARF. Demonstration Patient will have stable vital signs and hemody- INTERVENTIONS RATIONALES namic pressures. Prepare patiendfamily for dialysis Dialysis may be required to . Patient will have balanced intake and output as warranted. remove toxins and excess fluids with stable weight. from body and maintain life until kidney function is restored. Patient will have precipitating illness Instruct on specifics of peritoneal Peritonea1 dialysis, or PD, may s tabilized/resolved. dialysis. be intermittent, continuous ambulatory peritonea dialysis Alteration in nutrition: less than body (CAPD), or continuous cycling requirements peritoneal dialysis for use overnight. With PD, the peri- Related to: dietary restrictions, hypercatabolic toneum becomes the dialyzing state membrane with dialysate solution infused into the peritonea Defining characteristics: elevated BUN and crea- cavity, allowed to remain there tinine levels, anorexia, nausea, vomiting, distorted for 30 minutes and then siphoned out through a closed taste perception, fatigue, weakness, loss of weight system. The duration of this dial- (dietary restriction), weight gain (non-compliance ysis depends on the severity of with fluid restriction), pain, depression, lethargy, the renal condition and propor- tions of the patient. Peritonitis oral mucosal lesions may occur and antibiotics may be added to the dialysate prophylactically. Outcome Criteria Instruct on specifics of Hemodialysis, or HD, may be Patient will achieve and maintain nutritional hemodialysis. used for chronic renal failure requirements and stable weight. patients as well as acute renal failure patients who require short-term dialysis. Blood passes through a semipermeable mem- INTERVENTIONS RATIONALES brane or kidney, to the dialysate fluid where toxic substances Determine patient’s dietary Identifies nutritional deficiencies, move from the blood to the habits and intake. Perform calo- non-compliance with dialysate solution and are then rie count. restrictions, and metabolic discarded. Requires circulatory requirements. access, ind takes 3-4 hours 3 Provide several small meals rather Decreases nausea that may occur times per week. Complications than 3 large ones. because of diminished peristalsis. may include infection, bleeding, or obstruction of vascular access. RENAL/ENDOCRINE SYSTEMS 245

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Smaller meals may not be as Patient will achieve and maintain desired overwhelming and may facilitate weight. compliance with restrictions.

Give patient high caloric, low Protein requirements for renal Patient will be able to tolerate diet without protein, low potassium, low failure patients are much less nausea/vomiting. sodium diet as ordered. than normal to compensate for their impaired renal function. Patient will exhibit no evidence of mucosal Increased carbohydrates satisfy lesions in mouth. energy requirements while restricting catabolism and pre- Patient will adhere to dietary restrictions. venting acid formation from protein and fat metabolism. Patient will comply with medical regimen and Restriction of potassium, supplementation. sodium, and phosphorus may be required to prevent further renal Risk fir infiction damage. Related to: renal failure, uremia, debilitation, Assist withlencourage frequent Reduces distaste and freshens oral care. oral mucosa that may be septic shock, invasive procedures and lines, malnu- inflamed. trition, impaired immune system Weigh daily. Patient may lose up to 1 pound Defining characteristics: increased white blood per day during NPO status. cell count, shift to the left, BUN greater than 100 Administer vitaminslminerals as Patient may have iron deficiency mg/dl, history of repeated infections, fever, chills, ordered. secondary to protein restriction, cough with or without sputum production, anemia, or impaired GI function and need supplemental iron. wound drainage, hypotension, tachycardia, Calcium may be given to replace impaired skin integrity, wounds, positive blood, levels and facilitate coagulation urine, or sputum cultures, cloudy concentrated and metabolism of bone. Vitamin B complexes are urine required to maintain cell growth. Outcome Criteria Information, Instruction, Demonstration Patient will exhibit no signs or symptoms of infection. INTERVENTIONS RATIONALES

Instruct patientlfamily member Protein and electrolytes are on renal diet. adjusted to prevent uremia and INTERVENTIONS RATIONALES electrolyte imbalances. Instruction provides knowledge and may facilitate compliance. Monitor vital signs and hernody- Systemic vascular resistance namic pressures. decreases, cardiac output inirially Consult dietician andor other May be helphl to discuss choices increases, blood pressure dietary resources. for meals, replacements for foods decreases, and patient has tachy- previously enjoyed but now cardia, tachypnea, and restricted, and to allow patient hypertherrnia with warm flushed some measure of control over his skin in early stages of septic situation. shock. 246 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Obtain urine culture. Urinary tract infections may be differential. potential for infection. CBC asymptomatic initially. will identify presence of infection, and will be helpful to Avoid insertion of invasive lines, Decreases potential of bacteria monitor therapeutic response to catheters, and procedures when- gaining entrance to body and antimicrobials. ever possible. Use aseptidsterile prevents risk of cross-contamina- technique for changing IV sites, tion. dressing changes, or caring for Discharge or Maintenance Evaluation catheters. Patient will be free of infection. Observe wounds for drainage, Allows for identification of detri- noting changes in amount, color, mental changes in wound status Patient will be able to verbalize understanding and character. Change IV sites and facilitates timely interven- of instructions to prevent infection per hospital protocol. tion. Early detection of infection may preclude the development of complications. septicemia. Patient will not develop septic shock. Observe PD return fluid for May indicate presence of peri- cloudiness. tonitis from perforation or loss of Risk for impaired skin integrity albumin. Related to: uremia, malnutrition, immobility Maintain adequate nutrition. Facilitates healing and body metabolism. Defining characteristics: dry skin, edema, Utilize appropriate isolation Prevents cross-contamination presence of wounds, presence of invasive techniques when warranted. and minimizes patient’s risk of lines/grafts/fistulas, uremic frost, bruising, secondary infection. erythema, pruritus, changes in skin texture and Reposition patient every 2 hours, Decreases potential for atelectasis thickness and encourage coughing and and facilitates mobilizing secre- deep breathing. tions to avoid respiratory infection. Outcome Criteria

Obtain cultures as ordered. Facilitates identification of Patient will maintain skin integrity or will have causative organism and allows for appropriate antimicrobial wound healing in a timely manner. treatment.

Administer antimicrobials as May be required to combat ordered. infection. INTERVENTIONS RATIONALES

Observe skin for wounds, pres- Prompt identification allows for Information, Instruction, sure areas, abrasions, drainage, timely intervention. Demonstration redness, rashes. Bathe patient daily using oil in Removes waste products from INTERVENTIONS RATIONALES bath, and scant soap. Provide skin while keeping skin supple skin care with lotion or creams. and moist. Instruct patient to avoid scratch- May precipitate infection and ing and to maintain skin worsen renal dysfunction. Administer antipruritic drugs as Persistent itching may cause integrity. ordered. patient to scratch body to the point of bleeding and medication Monitor labwork, especially BUN should be maintained will help allay strong urge to BUN and creatinine, CBC, and lower than 100 mgldl to decrease RENAL/ENDOCRINE SYSTEMS 247

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

scratch. Open areas of skin are Monitor for presence of acidosis. Acidosis may interfere with more susceptible to infection. absorption of some drugs.

Reposition every 2 hours, Avoid Decreases potential for skin Ensure that nephrotoxic drugs Nephrotoxics will further impair constricting garments. breakdown. are utilized only when absolutely renal failure. necessary. Discharge or Maintenance Evaluation Monitor patient for signs and Excretion of drugs may be hin- symptoms of drug toxicity, and dered by renal failure and result Patient will have clean, dry, intact skin. obtain serum drug levels for spe- in toxic levels with normally safe cific drugs in use. dosages. Patient will be free of itching. Information, Instruction, Patient will have no signs/symptoms of Demonstration infection. INTERVENTIONS RATIONALES Patient will have timely wound healing with no complications. Instruct patient on all medica- Facilitates knowledge and tions being taken, with increases compliance. Risk for injury symptoms to be reported. Give reduced drug dosages with Decreases potential for toxic Related to: altered metabolism and excretion of longer time intervals between reaction to dosage with impaired medications, kidney failure doses. excretion and metabolism. Defining characteristics: decreased cardiac output states, acidosis, decreased protein binding, Discharge or Maintenance Evaluation presence of uremia, competition for binding sites, decreased body stores of fat, decreased GI motility, Patient will comply and tolerate therapeutic reg- changes in gastric pH, electrolyte imbalances, imen with no adverse drug effects noted. decreased protein binding, present renal failure Patient will have serum drug levels within therapeutic ranges. Outcome Criteria Patient will exhibit no signs of toxicity to drugs. Patient will be able to tolerate all pharmacological Patient will have stable renal function. agents without adverse effects on renal or other body systems. Patient will be able to verbalize understanding of all instructions and be able to identify medications being taken. INTERVENTIONS RATIONALES Altered oral mucous membrane Determine methods of action Facilitates understanding of how and excretion of all drugs being uremia may affect drug effects. Related to: uremia, restriction on fluids, lesions, taken, as well as interactions Conditions that reduce renal thrush among them. perfusion limits the amount of drug that the kidney is exposed Defining characteristics: dry mouth, dry mucous to and decreases the amount of membranes, taste distortion, presence of lesions, metabolism or excretion of the inflammation, white patches on mucosa, coated drug. tongue, stomatitis, gingivitis 248 CRITICAL CARE NURSING CARE PLANS

Outcome Criteria Defining characteristics: lack of energy, inability to maintain normal activities, lethargy, disinterest Patient will have moist mucous membranes and be free of oral lesions and inflammation. Anxiety [See MII Related to: change in health status, fear of death, INTERVENTIONS RATIONALES threat to role functioning, threat to body image

Observe mouth and oral cavity at Facilitates identification of prob- Defining characteristics: restlessness, insomnia, least every shift, noting lesions, lem to permit prompt treatment anorexia, increased respirations, heart rate, and/or redness, drainage, vesicles, lacera- and resolution. blood pressure, dry mouth, poor eye contact, tions, or ulcers. decreased energy, irritability, crying, feelings of Differentiate inflammation of the Thrush is initially identified as helplessness mucosa from thrush, and admin- white patches on the tongue and rsrer nystarin suspension as mucosa, and occurs frequently in ordered. the presence of multiple antimicrobial agents as a fungal growth. Nystatin is the drug of choice for thrush.

Provide oral care at least every 2 Removes build-up of debris, hours, with peroxide rinses or moistens mouth, and decreases normal saline as ordered. bad taste.

Use ropical anesthetics as Viscous xylocaine or ordered. Chloraseptic may be used to anesthetize mucosal pain receptors. Discharge or Maintenance Evaluation

0 Patient will be free of oral mucosal lesions and pain. Patient will exhibit no evidence of inflammation or infection to mouth. Patient will be able to swallow without discomfort. Patient will have no taste distortion and will be able to ingest adequate nutrition. Fatigue [See DKA] Related to: anemia, restriction on diet, increased metabolic needs RENAL/ENDOCRINE SYSTEMS 249

ACUTE RENAL FAILURE (ARF)

Decreased renal perfusion Damage to nephrons Glomerular inflammation Obstruction

Decreased GFR 4

Decreased fluid Decreased secretion Increased pulmonary Production of uremic excretion of erythropoietin capillary permeability toxins 4 4 4 4

Increased sodium Decreased RBCs via Left ventricular Urea decomposition resorption dialysis or GI tract dysfunction via GI tract 4 4 4 4

Fluid overload Interference with folic Attempts to compensate Ammonia formed acid utilization for acidosis 4 4 4 4 Increased BP Platelet dysfunction Increased respiratory Small ulcerations Increased hydrostatic rate and depth formed pressures 4 4 4 Decreased neutrophil Metabolic acidosis Calcium and phagocytosis phosphorus deposited on skin and increased capillary fragility 4 4 4 4 Right- ventricular Anemia and coagulopathy Hypoxemia Uremic encephalopathy dysfunction I I I Hypoxemia 4 Organ dysfunction 4 Cardiovascular collapse 4 DEATH This Page Intentionally Left Blank RENAL,/ENDOCRINE SYSTEMS 25 1

dehydration is severe and renal perfusion is Diabetic Ketoacidosis decreased; urinalysis will show positive for glucose KIU and acetone, specific gravity and osmolality may (D be elevated; hemoglobin A1 c helps to differenti- Diabetic ketoacidosis, or DKA, is a critical emer- ate whether episode is due to poor control of DM gency state that is caused by a deficiency of insulin over previous few months or whether episode is in patients with insulin-dependent diabetes melli- incident-related; hematocrit may be elevated with tus. This deficiency can be caused by physiological dehydration; elevation of WBCs may occur in causes, or by failure to take an adequate amount response to hemoconcentration or to stress; cul- of insulin, and results in hyperglycemia, ketonuria, tures may be helpful to discern potential cause of metabolic acidosis, and dehydration. Precipitating infection which may be precipitating factor causes include failure to take an adequare amount Arterial blood gases: pH will be less than 7.3, of insulin on a daily basis or failure to increase and bicarbonate levels will be decreased, usually less compensate for acute infection processes, surgery, than 15 mEq/L trauma, pregnancy, or other acute stress events. Early symptoms include polyuria, polydipsia, Electrocardiogram: may show changes associated fatigue, drowsiness, headache, muscle cramps and with electrolyte imbalances, especially nausea/vomiting. Later symptoms, such as hyperkalemia, with peaked T waves Kussmaul breathing, sweet, fruity breath odor, hypotension, and weak and thready pulses will NURSING CARE PLANS precede stupor and coma. Fluid volume deficit Treatment is aimed at correction of the acidotic Related to: hyperglycemic-induced osmotic diure- state, hyperglycemia, hyperosmolality, sis, vomiting, inadequate oral intake hypovolemia, and potassium deficits, in conjunction with treatment of the underlying cause of the Defining characteristics: dry mucous membranes, problem. decreased skin turgor, thirst, hypotension, orthostatic changes, tachycardia, weak and thready MEDICAL CARE pulse, weight loss, intake less than output, increased urinary output, dilute urine Laboratory: serum glucose level is increased above 300 mg/dl and may be greater than 1000 mg/dl; Outcome Criteria serum acetone positive; lipids and cholesterol levels elevated; osmolality increased but normally Patient will have stable vital signs, adequate skin less than 330 mOsm/L; potassium initially normal turgor, intake and output equivalent, and or elevated due to cellular shifting, then later electrolyte levels within acceptable ranges. decreased; sodium may be decreased, normal, or elevated; phosphorus is often decreased; amylase can be elevated if pancreatitis is precipitating INTERVENTIONS RATIONALES cause; serum insulin may be decreased in type I Tachycardia and hypotension are DM or normal to high in type I1 suggesting that Monitor vital signs, especially noting respiratory status changes classic symptoms of hypovolemia. there is improper utilization of insulin or that or alterations in blood pressure. When systolic BP drops more than insulin resistance may have developed secondary to antibody formation; BUN may be elevated if 252 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES 10 rnrnHg when position is vated initially in response to the changed may indicate severity of acidosis, but with diuresis, a hypovolemic state. Kussmauli hypokalemic state will ensue. respirations may be present Sodium may be decreased with depending on degree of hyper- shifting of fluids, and high glycemia, and respiratory changes sodium levels may indicate either may occur as the lungs attempt a severe fluid loss or sodium to remove acids by creating a reabsorption in response to compensatory respiratory alkalo- aldosterone secretion. sis. Fever, in conjunction with Phosphate replacement may help flushed, dry skin, may indicate Administer electrolyte replace- with plasma buffering capacity, dehydration. ments as per hospital policy/ doctor’s orders. but excessive replacement can Monitor intake and output every Facilitates measurement and cause hypocalcemia. Potassium 2-4 hours. effectiveness of volume replace- supplementation is usually done ment and adequate circulating as soon as urinary output is ade- fluid volume. quate to prevent hypokalemic states. As insulin replacement Administer IV fluids per hospital Amounts and solution types may occurs and acidosis is corrected, protocol, usually at least 2-3 vary based upon the degree of hypokalemia usually occurs. L/day, and usually initially, 3+ L. dehydration and patient status. Usual solutions of normal or Assess patient’s mental status and Mental status changes can occur half-normal saline with or with- observe for significant changes in with exceedingly high or low out dextrose are used, as well as status. glucose levels, electrolyte imbal- occasional use of plasma ances, acidotic states, hypoxia, or expanders depending on unsuc- with decreases in cerebral perfu- cessful fluid rehydration. sion pressure.

Weigh every day. Assesses fluid status, Information, Instruction, Observe for complaints of Gastric motility may be affected nausedvomiting, abdominal by fluid deficits, and vomiting or Demonstration bloating, or distention. other gastric losses may potenti- ~~ ate fluid and electrolyte INTERVENTIONS RATIONALES imbalances. Instruct patient/family members Provides information and pro- Auscultate lungs for crackles, and Congestive heart failure or circu- regarding signs/symptoms of motes more timely identification assess patient for presence of latory overload may occur with hyperglycemia. of complications. edema, or bounding pulses. rapid rehydration. Instruct in seeking medical atten- Infection may predispose the Insert catheter per hospital Provides for more accurate assess- tion for infective processes or patient to fever and a hypermeta- policy ment of output, especially if illness that may deplete circulat- bolic state which may increase urinary retention or incontinence ing volume. volume depletion. is present.

Monitor laboratory tests for Hematocrit may be elevated Discharge or Maintenance Evaluation BUN and creatinine, serum because of hemoconcentration osmolality, hematocrit, and following osmotic diuresis. Patient will have vital signs and hernodynamic electrolytes. Dehydration may result in cellu- parameters within acceptable ranges. lar destruction and may result in renal insufficiency. Dehydration Patient will have normal skin turgor with ade- will result in elevated osmolality. Potassium levels are usually ele- quate output. RENAUENDOCRINE SYSTEMS 253-

9 Patient will have electrolytes and glucose levels INTERVENTIONS RATIONALES within normal ranges. may not show normal signs of Alteration in nutrition: less than body hypoglycemia due in part to their diminished response to IOW requirements glucose levels.

Related to: insulin deficiency, excessive amounts Administer regular insulin, either Subcutaneous route may be an of epinephrine, growth hormone, and cortisol, by continuous infusion after an option if the patient’s peripherd increased protein-fat metabolism, decreased oral IV bolus dose has been given, by perfusion is adequate but the intramuscular injections every 1- response will not be as rapid as intake, nausea, vomiting, altered mental status, 2 hours, or by subcutaneous with IV administration. Regular infection injection. insulin is rapid acting and will assist in movement of glucose Defining characteristics: weakness, fatigue, into cells. The continuous IV increased levels of glucose and ketones, weight loss method is normally preferred in spite of polyphagia, lack of adequate food because it oprimizes transition to carbohydrate metabolism, and intake, glycosuria helps to reduce hypoglycemia. Normally, the infusion rate is 5-10 Unidhr until glucose Outcome Criteria levels decrease within a stated parameter. Another goal of IV Patient will be able to have intake of appropriate administration of insulin is to amounts and types of calories and nutrients, and decrease the acidosis. have glucose levels within acceptable range for Monitor serum glucose every Blood glucose levels will decrease patient. hour while on insulin IV with insulin therapy usually in infusion, and notify MD per increments of 75 to 100 parameters of when blood glu- mg/dl/hr. Once the blood sugar __ ~~~ cose has dropped to 250 mgldl. has dropped to 250 mg/dl, and INTERVENTIONS RATIONALES depending upon the degree of acidosis that is present, dextrose Facilitates assessment of nutri- Obtain weight every day. is added to the IV infusion, and tional utilization and fluid shifts. the insulin infusion should be Provide high-nutrient liquids as Provides nutrition and helps stopped to prevent hypoglycemic soon as patient is able to tolerate restore bowel function. episodes. oral intake, with progression to Administer subcutaneous insulin Prevents recurrence of ketosis solid food tolerated. as 1-2 hours before stopping the and rebound hyperglycemia. Auscultate bowel sounds every Elevated glucose levels can cause continuous insulin infusion. 4-8 hours, and observe for altered electrolyte levels and both Administer IV solutions contain- Dextrose solutions are usually abdominal distention or pain. may decrease gastric function. ing dextrose as ordered. added after the blood glucose may also mimic an acute DKA levels have decreased to 250 surgical abdomen. mg/dl in order to avoid hypo- Monitor for changes in level of When carbohydrate metabolism glycemia. begins and blood glucose level consciousness, cool or clammy Administer Reglan IV or PO as May be used to treat symptoms decreases, hypoglycemia can skin, tachycardia, extreme ordered by physician. related to neuropathies that occur. Comatose patients may hunger, anxiety, headache, light- affect the GI tract, and facllitate headedness, tremors, or not exhibit any noticeable oral intake and nutrient irritability. change in mentation status and absorption. should be monitored closely. Long-standing diabetic patients ~ CRITICAL CARE NURSING CARE PLANS

Information, Instruction, Impaired gas exchange Demonstration Related to: accumulation of ketones and acids sec- INTERVENTIONS RATIONALES ondary to insulin deficiencies and excessive production of stress hormones Instruct patientlfamily member Complex carbohydrates decrease in dietary management, with the amounts of insulin needs, Defining characteristics: acid-base imbalances, ideal amounts ofGO% carbohy- reduce serum cholesterol, and drates, 20% fats, and 20% help to satiate patient. Food acetone breath, tachypnea, Kussmaul respirations, proteins to be divided in desig- should be scheduled for peak serum and urine ketones present, decreased pH, nated number of meals and effects with insulin as well as decreased bicarbonate levels, hyperkalernia, snacks. patient preference. Snacks are decreased level of consciousness, confusion important to prevent Somogyi responses and hypoglycemia during sleep. Outcome Criteria Obtain consult with dietician. Assists in facilitating adjustments to diet for patient's special needs, Patient will have normalized acid-base balance and can facilitate development of with stable vital signs and mentation level. workable meal plans.

Instrucr in correct procedure for Monitoring blood glucose levels fingerstick glucose testing, with is more accurate than urine glu- INTERVENTIONS RATIONALES return demonstration as needed. cose testing, and can facilitate identification of alterations in Monitor respiratory status for Acetone breath is due co break- levels of glucose to promote changes in rate, rhythm and down of aceroacetic acids. The tighter control of varying glucose depth, and for presence of ace- lungs remove carbonic acid levelslinsulin usage. tone smell on breath. through respiration process, and may produce a cornpensacory Ensure that at least 50 cc of soh- Promotes saturation of binding respiratory alkalosis for ketoaa- 'tion is flushed through the sites on plastic tubing to decrease dosis. Increased work of tubing prior to connection to incidence of insulin adhering to breathing may indicate that the patient when intravenous insulin tubing rather than staying in patient is losing the ability to drips are utilized. solution. compensate for the severe acidosis or respiratory fatigue. Discharge or Maintenance Evaluation Monitor for changes in neurolog- Acidosis, hypoxia, or decreased Patient will have normalized blood glucose ical status. cerebral perfusion may cause changes in mentation. levels within their own special parameters. Impairment in consciousness may predispose the patient to Patient will be able to ingest oral food of suffi- aspiration and its complications. cient amounts and nutrients to maintain and stabilize weight. Administer IV fluids and insulin Promote correction of acidosis as ordered. with DKA.

Patient will be free of ketosis. Administer sodium bicarbonate, Current recommendations are if ordered, for severe acidosis for use only where pH is 7.1 or Patiendfamily member will be able to verbalize only. below because excessive use of understanding of instructions and able to pro- sodium bicarbonate may induce vide acceptable return demonstration of hypokalernia as well as alcer che procedure. oxygen dissociation curve causing prolongation of the comatose state. ~ RENAL/ENDOCRINE SYSTEMS 255

~~ ~~ ___~ INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Monitor labwork for May occur as acidosis and bronchitis or pneumonia, either hypokalemia. volume deficits are corrected. of which may be the precipitating cause of the DKA. Crackles Administer supplemental oxygen Provides needed oxygen espe- may indicate fluid overload or cially in patients that may not be as necessary per hospital proto- congestive failure as a result from col. able to obtain adequate oxygena- rapid fluid replacement. tion with room air, and helps to improve acidosis. Provide perineal or catheter care Elderly female diabetics are frequently. prone to the development of Discharge or Maintenance Evaluation urinary tract and vaginal infections.

Patient will have pH, bicarbonate, potassium, Reposition patient and provide Facilitates lung expansion, serum and urine ketones within normal limits. skin care every 2 hours. decreases risk of skin irritation and breakdown, and improves Patient will have stable vital signs with respira- peripheral circulation. tory rate within normal limits. Obtain culture specimens as Assists with identification of Patient will be free of acetone on breath. ordered or as per hospital policy. causative organism and appropriate antimicrobial therapy.

Risk for infiction Administer antibiotics as Early intervention may reduce ordered. the risk of sepsis or multi-system Related to: elevated glucose levels, alterations in involvement. circulation, pre-existing infection, especially URI or UTI, decreased leukocyte function Information, Instruction, Demonstration Defining characteristics: increased serum and urine glucose levels, temperature elevation, chills, INTERVENTIONS RATIONALES fever, elevated white blood cell count, differential Ensure proper handwashing Prevenrs cross-contamination with shift to the left techniques are used by staff and and decreases risk of spread of patient. infection. Outcome Criteria Maintain aseptic technique with Elevated glucose levels provide an administration of IV medica- excellent culture medium for tions, insertion of catheters and bacterial growth. Patient will be free of infection and able to verbal- invasive lines, and maintenance ize methods to prevent or reduce risk of infection. care. Restart IVs per hospital protocol.

Instruct patients in perineal care, Promotes compliance, minimizes INTERVENTIONS disposal of secretions and risk of spread of infection, and RATIONALES infected materials. cross-contamination.

Monitor for fever, facial flushing, Patient may have been admitted Instruct in importance of oral Reduces risk of oral or gum drainage from wounds, urine with undiagnosed infection or care. disease. cloudiness, changes in sputum, have developed a nosocomial tachycardia. infection. Discharge or Maintenance Evaluation Auscultate for changes in breath Accumulation of bronchial secre- sounds. tions may be heard as rhonchi Patient will be able to identify actions to reduce and may indicate the presence of or prevent infection and cross-contamination. 256 CRITICAL CARE NURSING CARE PLANS

Patient will be free of infective process. Information, Instruction, Demonstration Patient will be able to adequately demonstrate techniques to prevent or reduce infection risk. INTERVENTIONS RATIONALB

Potential for injury: bypoglycemia Instruct patientlfamily in signs of Promotes knowledge and facili- hypoglycemia and treatment for tates compliance. Assists patient Related to: insulin therapy, decreased insulin- this condition. and family to feel in control. antagonist hormones circulating in body, rebound action Discharge or Maintenance Evaluation Defining characteristics: blood glucose levels Patient will have stable blood glucose level below 70 mg/dl, altered mental state, decreased above 80 mg/dl. level of consciousness, cool and clammy skin, pallor, tremors, tachycardia, irritability, visual dis- Patient/family member will be able to identify turbances, paresthesias, dizziness, hunger, nausea, signs and symptoms of hypoglycemia and inter- fatigue, diaphoresis ventions for treatment. Patient will have no hypoglycemic symptoms. Outcome Criteria Fatigue Patient will have stable blood glucose levels and be Related to: insufficient insulin, increased able to identify methods of treatment and identifi- metabolic demands, decreased metabolic energy cation of hypoglycemic episodes. production, infection Defining characteristics: lack of energy, inability INTERVENTIONS RATIONALES to perform normal routine, decreased Monitor for signs/symptoms of Prompt identification of problem performance, accident prone, lethargy, tiredness, hypoglycemia. will facilitate prompt treatment alterations in consciousness and help prevent further complications. Outcome Criteria Change IV fluid to solution con- Prevents excessive drop in blood taining glucose when blood glucose level and allows time for Patient will have increased energy and be able to glucose level reached 250 mgldl, blood chemistry to normalize. a< well as change inhsion rate on participate adequately in normal activities. insulin drip.

If hypoglycemia occurs, give the Glucagon, 10-50% solutions, patient oral (if able to tolerate may be given IV, or 15 grams of INTERVENTIONS RATIONALES fluids and awake) or parenteral a rapid-acting carbohydrate will glucose solutions, as per policy. be effective in elevating the Observe patient for activity toler- Provides baseline information so blood sugar level. Milk and ance. that identification of problem crackers will assist in protecting and interventions may be patient from recurrences of planned. Elevations in pulse, hypoglycemic episode. blood pressure and respiratory rate may indicate physiologic intolerance of activity.

Provide period of rest or sleep Prevents excessive fatigue. RENAL/ENDOCRINE SYSTEMS 257

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES alternated with periods of activ- Instruct patiendfamily member Provides knowledge base on ity as patient can tolerate. about disease process, normal which further instruction can be ranges for blood glucose, glu- performed. Increase activity and patient par- Provides time to build up toler- cometer use, relationship ticipation gradually. ance, and increases self-esteem. between insulin and glucose levels, type of diabetes the Information, Instruction, patient has, etc. Demonstration Instruct patient/family member Promotes tighter control of dia- in glucometer use and urine test- betes with self-monitoring at INTERVENTIONS RATIONALES ing, with return demonstration least four times per day, and may by patient. help prevent or delay long-term Discuss with patient/family Information may facilitate moti- complications. member the importance of activ- vation to increase activity level ity, planning schedules with knowing that decreased energy Instruct in dietary plan, Dietary control with assist with alternating rest and activity, and will be expended and he will be allowances, caloric intake, meals maintenance of decreased blood methods of conserving energy. able to accomplish more activity. outside the home, etc. glucose levels. Fiber may slow glucose absorption and decrease Discharge or Maintenance Evaluation fluctuations in serum levels. Instruct in medication regime, Promotes understanding of drug with actions, side effects, and use and facilitates compliance 0 Patient will be able to tolerate increased activity contraindications noted. with regimen. Proper techniques with stable vital signs. with administration of insulin Patient/family will be able to verbalize and/or assist with understanding and identification of potential prob- demonstrate techniques to conserve energy lems so that interventions may while performing activities. be found. Knowledge Instruct in activity and other Promotes control of diabetes and &$kit factors that determine diabetic may help reduce incidence of Related to: lack of information, lack of recall, mis- control. ketoacidosis. Aerobic exercises promote effective utilization of interpreted information, unfamiliarity with insulin and strengthens the car- resources diovascular system. Illness management and management of Defining characteristics: requests for information, other stress-type factors facilitates questions, misrepresentation of facts, inaccurate equilibrium with disease process follow-through of instructions, development of during these episodes. preventable complications Instruct in avoidance of Nicotine causes constriction of smoking. blood vessels which restricts insulin absorption up to 30%. Outcome Criteria Instruct in examination and care Identifies potential complications Patient will be able to verbalize understanding of of feet. that may occur because of peripheral neuropathy or circula- diabetes disease process, identify signs and symp- tory impairment, and allows for toms of complications, correctly demonstrate all early intervention.

procedures, and access community resources Instruct in protocols for sick Provides plan for complications adequately. days-to take medications, to that occur, and gives the patient notify MD, to monitor blood the knowledge to enable him to sugar every 2-4 hours, to check adequately care for himself 258 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES urine ketones if blood sugar is during times of illness. >240 mg/dl, and to replace carbohydrates with liquids

Instruct in maintaining medical Vision changes may be gradual maintenance, including vision and may be more pronounced in checks, and follow-up care. poorly-controlled diabetics. Visual acuity may deteriorate to retinopathy and eventual blindness. Follow-up care can assist in preventing exacerbations of diabetic complications and delay development of systemic problems.

Discuss sexual function and Impotence may occur as an ini- questions patientlfamily member tial symptom of diabetes may ask. mellirus. Penile prosthesis and/or counseling may be of help.

Instruct in avoidance of use of May contain increased sugar over-the-counter medications content and may interact with without physician approval. other medications being taken.

Instruct in available community Provides continued support post resources, support groups like the discharge, and assists to support American Diabetic Association, lifestyle changes. smoking and weight loss clinics, etc. Discharge or Maintenance Evaluation

Patient/family member will be able to accurately verbalize knowledge base regarding diabetic disease process. Patientlfamily member will be able to accurately verbalize all information given. Patient/family member will be able to accurately return demonstration for all necessary procedures. ~~ ~ RENAL/ENDOCRINE SYSTEMS 259

DIABETIC KETOACIDOSIS (DKA)

IDeficiency of insulin I s Gluconeogenesis Fat metabolism

Hyperglycemia Free fatty acid metabolism by liver .c dmg'd') Osmotic diuresis I Increased ketones Ketonuria c Acetone breath c Polyuria Dehydration c Hypovolernia Plasma1 hyperosmolality Ketoacidosis 4 I c Hypotension Nauseahomiting Tachycardia Acidosis Flushed face High A-gap Thirst Potassium shift Dry mucus membranes from cells Kussmaul resp. I Decreased CNS I c I W Brain ischernia 4 Coma c DEATH This Page Intentionally Left Blank RENAIJENDOCRINE SYSTEMS 26 1

HHNK has also been associated with usage of thi- Hyperglycemic azide diuretics, glucocorticoids, phenytoin, sympathomimetics, diazoxide, chlorpromazine, sedatives, cimetidine, calcium channel blockers, and immunosuppressive agents because of their effects with glucogenesis and/or insulin. (HHNK) Mortality is approximately 50% due in part to common complications that occur, such as shock, HHNK, or hyperglycemic hyperosmolar nonke- coma, acute tubular necrosis, and vascular throm- totic coma, may also be known as hyperglycemic bosis. Correction of the problem is the main goal nonacidotic diabetic coma, and presents a life- of treatment, with fluid balance the initial threatening emergency. Glucose transportation concern. The lack of insulin may be corrected by across the cell membrane is impaired by enough of supplemental insulin administration and usually an insulin deficiency that causes hyperglycemia requires 100 Units or less in the first 24 hour without inhibiting lipolysis or ketogenesis in the period. Electrolyte imbalances are corrected and liver. The hyperosmolality occurs from the hyper- may require large amounts of potassium supple- natremia and hyperglycemia, and may further mentation. impair the secretion of insulin and prevent fatty acid release from adipose tissues. Extracellular fluid volume deficits occur as a result of osmotic MEDICAL CARE diuresis in the body's attempt to offset increasing Laboratory: blood sugar level elevated, frequently ' plasma osmolality. As fluid volume deficits over 1000 mg/dl; plasma osmolality elevated, fre- increase, glomerular filtration rates decrease and quently as high as 450 mOsm/kg; hematocrit reduces the ability of the kidneys to excrete the elevated due to hemoconcentration; urine and glucose. serum acetone levels negative; BUN and creatinine HHNK occurs when insulin action or secretion is elevated; marked leukocytosis; electrolytes to eval- inadequate, and may occur in patients who have uate deficiency; hypernatremia usually present no previous history of diabetes mellitus. The Arterial blood gases: used to identify acidosis; pH elderly are especially prone to this because of the is usually greater than 7.30, bicarbonate is usually lower body water content and dehydration, and greater than 15 mEq/L; acidosis is mainly due to this may alter their buffering ability to respond to lactic acid or renal dysfunction changes in osmolality. Illnesses, and other stress- provoking episodes, may either cause or hasten the Electrocardiogram: used to identify dysrhythmias development of HHNK by increasing glucose pro- that may result as a consequence of electrolyte and duction in response to excessive stress hormone fluid disturbances production. NURSING CARE PLANS HHNK has almost the same pathophysiologic pattern as DKA, but the difference is that with Fluid volume deficit HHNK, a sufficient amount of insulin is being [See DKA] released to prevent the development of ketosis. 262 CRITICAL CARE NURSING CARE PLANS

Alterution in nutrition: less thun body Information, Instruction, requirements Demonstration [See DKA] INTERVENTIONS RATIONALES Potentiul for injury: hypoglycemiu Instruct patiendfamily member Prevents circulatory impairment [See DKA] to avoid constricting apparel, and risk of complications. crossing legs or ankles, or any Potentiul for ulterution in tissue perjksion: other activity that impedes per+herul circulation.

Related to: dehydration, increased platelet aggre- Notify physician for any Prompt identification can lead to gation, increased viscosity of blood evidence of thrombus formation. timely intervention. Defining characteristics: cool extremities, decreased peripheral pulses, extremity pallor or Discharge or Maintenance Evaluation cyanosis, unequal extremity temperatures Patient will have equal pulses, color, and tem- Outcome Criteria perature to lower extremities bilaterally. Patient will have no evidence of thrombus Patient will have bilaterally equal peripheral . pulses, color and temperature to extremities, with formation. no complications. Patient/family will be compliant with methods to reduce risk of thrombus formation.

INTERVENTIONS RATIONALES Monitor and assess lower extrem- Identifies the status of circulation ities for color, temperature, in the extremities and assists presence of pulses, and equality. with prompt identification of complications.

Test for positive Homan’s sign, May indicate thrombus forma- redness, warmth, tenderness, or tion, but is not always present swelling to legs. with thrombus formation.

Remove TED hose at least every Provides opportunity for thor- 8 hours for 30 minutes to 1 ough assessment and hour. identification of changes, as well as for comfort of pztient.

Assist with passive range of Prevents venous stasis. motion/encourage active range of motion exercises. RENAIJENDOCRINE SYSTEMS 263

HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC COMA (HHNK)

Relative lack of insulin but enough to prevent ketosis Gluconeogenesisr 1Glycogenolysis Hyperglycemia (800-2600 mgldl)

Osmotic diuresis 4 lity # k-J'perosmc4 Profound dehydration Polydipsia 4 J, Hypovolemia Increased BUN Hyperthermia Increased sodium Tachycardia Decreased potassium Shock Depressed CNS Gastric stasis 4 4 Cardiac dysrythmias 4 Renal impairment Cardiac dysfunction 4 Increased glucose 1

DEATH + This Page Intentionally Left Blank RENAL/ENDOCRINE SYSTEMS 265

Syndrome of Nursing Care Plans Inappropriate ADH Fluid volume excess Related to: inability to excrete water, inappropri- Secretion (SIADH) ate antidiuretic hormone secretion, failure of negative feedback system SIADH is another dysfunction of the antidiuretic hormone in which there is increased secretion or Defining characteristics: hyponatremia, decreased production of ADH. The increase is not related to plasma osmolality, increased urine osmolality, osmolality, and therefore causes a slight increase in weight gain, neurologic disturbances, seizures body water. Sodium concentration is decreased in the extracellular fluid and plasma. SIADH is usually caused by bronchogenic or pancreatic cancer, INTERVENTIONS RATIONALES but can occasionally result from pituitary tumors. Monitor for changes in level of May be early indication of Other etiologies include central nervous system consciousness, fatigue, weakness, impending water intoxication. injuries, infections and tumors, pulmonary headache or generalized pain. diseases, Addison's disease, hypopituitarism, aneurysms, AIDS, and use of tricyclic drugs, oral Monitor heart rhythm and Fluid shifts and electrolyte dis- hypoglycemics, acetaminophen, chlorpropamide, hemodynamics as ordered. turbances can precipitate cardiac dysrhythmias and changes in thiazide diuretics, cytotoxic agents, and excessive hemodynamic status. vasopressin therapy. Weigh patient every day, and Assists with identification of Unlike diabetes insipidus, SIADH has a failure of maintain accurate I&O. fluid statudbalance. the negative feedback system in which continued Administer IV and PO fluids as Restriction of fluid may be based ADH secretion creates water intoxication because ordered, maintaining fluid partially on urine, nasogastric, or of low plasma osmolality and expanded volume. restriction. other fluid losses. The primary initial goal is to restrict fluid intake Administer hypertonic saline IV These types of infusions are gen- and correct electrolyte imbalances. With severe when ordered. erally reserved for severe hyponatremia or when accornpa- cases, 3% hypertonic saline and IV lasix are used. nied by seizure activity. Fluid overload may worsen and deteriorate into heart failure. There are MEDICAL CARE controversial theories that Laboratory: plasma sodium decreased, plasma sudden increases in serum sodium can result in osmotic osmolality decreased, urine sodium and osmolality demyelination syndrome which increased, elevated plasma ADH levels; renal pro- may have adapted to the lower files used to assess renal status changes from level of sodium. imbalances and from nephrotoxic medications; Administer diuretics as ordered. Assists with decreasing the action thyroid profiles to assess thyroid function; of ADH, but can also cause elec- electrolytes to evaluate concurrent imbalances trolyte losses. Administer other drugs that help Lithium and demeclocycline Electrocardiogram: used to identify cardiac dys- inhibit ADH action, as ordered,' interfere with ADH ac the renal rhythmias that may occur as a result of electrolyte tubular level, but can be nephro- or fluid imbalances toxic. Phenytoin inhibits ADH release. 266 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Constipation Administer supplemental elec- Facilitates replacement of Related to: decreased gastric motility secondary to trolyres as ordered. required electrolytes to maintain hyponatremia, fluid restriction, decreased activity function. Information, Instruction, Defining characteristics: inability to pass stool, Demonstration hard stools, painful, small stools INTERVENTIONS RATIONALES Outcome Criteria Monitor lab studies, especially Some medications are nephro- renal profiles for changes in renal toxic and can worsen renal Patient will be free of constipation. perfusion. function.

Instruct patient/fmily regarding Promotes knowledge, and fluid balance, seizure encourages compliance with INTERVENTIONS RATIONALES precautions, drug therapy, proce- medical regimen. Facilitates dures, lab studies, etc. patient taking active part in his Assess bowel habits of patient; Provides baseline from which to care. normal routines, frequency of plan interventions. stools, use of cathartics, etc.

Discharge or Maintenance Evaluation Administer laxatives or stool Caution must be used in selec- softeners as ordered. Tap water tion of pharmacological agent so Patient will be neurologically stable with enemas should be avoided. as to not further add to fluid approximately equivalent intake and output, volume overload. Water in the and vital signs will be stable. enemas can be absorbed and increase overload. Patient will have normalized weight and be able Discharge or Maintenance Evaluation to maintain weight. Patient will have laboratory values within Patient will have normal bowel function with normal parameters. no complications to fluid status.

Patiendfamily will be able to accurately verbalize understanding of all instructions. Risk for injury [See Status Epilepticus] Related to: impairment of cognitive ability, physical inactivity, seizure activity Defining characteristics: confusion, lethargy, memory impairment, irritability, personality changes, level of consciousness changes, restlessness, fatigue, weakness, seizures, imposed physical inactivity RENAL/ENDOCRINE SYSTEMS 267

SYNDROME OF INAPPROPRIATE ADH SECRETION (SIADH)

Increased ADH (pitressin) c Antidiuretic effect Distal tubules and collecting ducts c Free water retention

J, Plasma dilution I I I Decreased plasma osmolality Activation of Increased urine osmolality volume receptors Increased urine specific gravity Increased urine sodium Hyponatremia I Further decreased hyponatremia e Hypervolemia (sodium and water) c Excretion in proximal tubules

J, Further decrease in plasma osmolality Further increase in urine sodium c Weight gain Weakness Mental confusion Convulsions Coma This Page Intentionally Left Blank RENAL/ENDOCFUNE SYSTEMS 269

greater than 295 mOsm/kg; urine osmolality Diabetes Insipidus (DD decreased, generally less than 500 mOsm/kg and can be low 30 mOsm/kg; urine specific grav- Diabetes insipidus, or DIYis a condition that as as ity low, generally 1.001 to 1.005; plasma ADH results when damage or destruction of the neurons levels decreased in central diabetes insipidus; of the hypothalamus causes decreased levels of serum sodium elevated antidiuretic hormone (ADH) and severe diuresis and dehydration occur. The deficiency results in Water deprivation test: used to demonstrate that the inability to conserve water, and if the patient's in the presence of simple dehydration, kidneys thirst mechanism is not adequate, or if fluids are cannot concentrate urine; used to differentiate not accessible, the fluid balance will be altered. psychogenic polydipsia from diabetes insipidus The two main etiologies of DI are tumors of the Vasopressin test: used in conjunction with water hypothalamus or pituitary and closed head injuries deprivation test to identify that the kidneys can that may have damage to the supraoptic nuclei or concentrate urine with exogenous ADH and dif- hypothalamus. Head injuries, neurosurgery, or ferentiates nephrogenic from central diabetes hypophysectomy may lead to a loss of osmorecep- insipidus tor function and/or damage to the areas that produce antidiuretic hormone. Sometimes, a tran- NURSING CARE PLANS sient type of DI occurs after surgical procedures, histiocyctosis, sarcoidosis, aneurysms, meningitis, Fluid volume encephalititis, or neoplastic conditions. All of the Related to: inability to conserve water, dehydra- above respond to vasopressin. tion, decreased levels of ADH DI that is nephrogenic is usually vasopressin- Defining characteristics: extreme thirst, decreased insensitive, and is seen in polycystic kidney skin turgor, dry mucous membranes, hypotension, disease, pyelonephritis, multiple myeloma, tachycardia, weight loss, dilute urine output, sarcoidosis, sickle cell disease, or any disorder that increased urine output, hemoconcentration, affects the kidneys. Usage of ethanol and pheny- hyperosmolality, increased serum sodium toin inhibit ADH secretion, and drugs such as lithium and demeclocycline inhibit ADH action Outcome Criteria in the kidney. The main goal for treatment is to prevent dehy- Patient will have fluid volume balance restored dration and electrolyte imbalances, while and be able to maintain adequate fluid volume. determination and treatment of the underlying cause is underway. Vasopressin administration will control diabetes insipidus; D-amino-D-arginine INTERVENTIONS RATIONALES vasopressin (DDAW) is a nasal spray that has Assess and monitor vital signs. Tachycardia and hypocension prolonged antidiuretic effects with minimal side may result from hypovolemia.

effects. Measure intake and output every Provides information to identiFy 1-2 hours, and notify physician fluid imbalances and volume for changes. Record specific grav- depletion. I&O should be con- ity measurements per hospital tinued in postoperative patients, protocol. especially neurosurgical pacieno, Laboratory: serum osmolality elevated, usually 270 CRITICAL CARE NURSING CARE PLANS

INTERWNTIONS RATIONALES INTERVENTIONS RATIONALES to ensure that DI has not tran- vasopressin tests by obtaining and that procedure data will be siently resolved and then accurate weights, vital signs, accurate. The water deprivation reappear only to become perma- I&O, lab specimens at proper test is usually terminated if the nent. Urinary output may be as intervals, and maintaining depri- patient has a 3% weight loss. much as 15 Llday, and specific vation for required amount of gravity is usually between 1.001 time. and 1.005. Instruct patient/family member Promotes knowledge and facili- Administer IV fluids as ordered. Helps to restore circulating fluid in methods to prevent tates compliance with medical If able to take oral fluids, encour- volume. dehydration when on long-term regimen. age patient to take in PO. ADH therapy, as well as when hospitalized. Weigh patient daily. Provides identification of fluid balances and water losses. Discharge or Maintenance Evaluation Administer replacement therapy Aqueous pitressin (IV or SQ) is a for central diabetes insipidus. short-acting ADH useful in tran- Patient will have stable vital signs and balanced sient DI. Nasal spray vasopressin intake and output. is also short-acting and may be erratic in patients with respira- Patient will be able to maintain normal hemo- tory infections or nasal problems. dynamic parameters. DDAVP (nasal or SQ) is a synthetic ADH that has a longer Patient will have weight restored and be able to duration and can be given q12- maintain weight. 24 hours. Vasopressin tannate in oil can last 24-72 hours and is Patiendfamily will be able to verbalize not utilized as initial treatment due to inability to titrate dose. accurately any information related to them.

Administer medication therapy Chlorpropamide is used to stim- Knowledge deficit for nephrogenic diabetes ulate ADH release and can insipidus. augment the renal tubular Related to: potential self-care management for response to ADH. Thiazide permanent diabetes insipidus diuretics in conjunction with sodium restriction will reduce Defining characteristics: newly diagnosed DI, solute load and enhance water requests for information, questions, inaccurate reabsorption. follow-through with instructions or medications, Information, Instruction, development of preventable complications, inabil- Demonstration ity to recall information vital to disease process

~ INTERVENTIONS RATIONALES Outcome Criteria Ensure that vasopressin tannate Reduces pain from injection and in oil is warmed and vigorously ensures complete mixture. Patient/family member will be able to accurately agitated prior to injection. verbalize medical regimen to manage diabetes Observe for water intoxication May occur with shifting fluid insipidus. with pharmacologic replacement balances. therapies.

Assist with diagnostic procedures Ensures that correct sequence such as water deprivation and will be maintained for specimens RENAL/ENDOCRINE SYSTEMS 27 1

INTERVENTIONS RATIONALES

~~ ~ ~ Assess for patientlfamily member Provides baseline of knowledge comprehension of disease and and facilitates plan for medications. interventions.

Instruct in all medications, Promotes knowledge and facili- action, side effects, adverse reac- tares compliance. tions, schedule to be taken, method of administration, and importance of adherence to medical regime.

Instruct to notie physician for Prompt identification may facili- excessive water retention or uri- tate timely intervention and nary frequency and increased treatment. amount.

Discuss reasons for non-adher- Explores patient's rationale and ence to medication, if patient has identifies any misconceptions he previously been diagnosed with might have regarding his medical DI. regimen.

Discuss obtaining medical alert Promotes fast recognition of bracelet identifying patient as medical condition in cases where having DI. patient is not able to identify problems. Discharge or Maintenance Evaluation

Patient will be able to accurately verbalize purpose, side effects, and schedule of medications. Patient will adhere to medical therapeutics and take medication as prescribed. Patiendfamily will be able to accurately recall all information related to them. Patient/family will be able to identify fluid balance alterations that should be reported to physician. Patient will be compliant in obtaining medical identification bracelet. 272 CRITICAL CARE NURSING CARE PLANS

DIABETES INSIPIDUS (DI)

Decreased ADH (Pitressin) or low plasma ADH levels 4 Renal tubular unresponsiveness JI Decreased permeability to waters 4 Excess water excreted in urine 4 Decreased urine osmolality Decreased urine specific gravity 4 Plasma volume loss Increased plasma osmolality Increased serum sodium 4 Dehydration

Hypovolemic shock Polydipsia Weakness Fever Confusion RENAIJENDOCRINE SYSTEMS 273

be ruled out. Pheochromocytoma always leads to death if untreated. Pheochromocytoma is a vascular tumor, composed of chromafin cells that secrete catecholamines or MEDICAL CARE their precursors (epinephrine, norephinephrine, or Medications: use of alpha- and beta-blockers dopamine). This, in turn, causes severe persistent (phenoxybenzamine and propranolol, or or intermittent hypertension due to the severe phenoxylbenzamine and metyrosine) to control vasoconstriction in response to the catecholamine catecholamine excess symptoms; IV infusions of excess. trimethaphan camsylate or sodium nitroprusside Usually the tumor is encapsulated and located to control vasopressor effects within the medulla of the adrenal glands, but can Laboratory: fasting serum glucose elevated, occur in the sympathetic paraganglionic areas of increased hematocrit; 24-hour urine for the abdomen, chest, brain, or cervical areas. These catecholamines, vanillymandelic acid and tumors are usually benign, but can be malignant metanephrines to identify elevated levels in up to ten percent of patients. Frequently occurring between the ages of 30 and 50, attacks may Electrocardiogram: used to identify tachycardia, occur paroxysmally if the tumor releases bradycardia, LV enlargement and strain from ele- catecholamines on an intermittent basis. These vated blood pressure, cardiac dysrhythmias episodes may range from once per year to several Radiography: chest and abdominal x-rays used to times per day. Attacks may be spontaneous, or be localize and identify tumor; CT scans, IVP, caused by palpation of the tumor, emotional stress radionuclide imaging and selective venographic or trauma, exposure to cold, beta-blockers, angiography also used to localize tumors; caution postural changes, abdominal compression, anes- must be used due to potential for test to exacer- thesia induction, urination, defecation, or heavy bate hypertensive crisis lifting. Surgery: surgical removal of the pheochromocy- The tumor’s hallmark symptom is high blood toma may be required pressure with fluctuations up to 220/150 or higher. The catecholamine secretion causes symp- NURSING CARE PLANS toms of “flight or fight” reactions, typically beginning with palpitations, headache, pallor, Altered tissue pe&sion: ca rdiop ulm onary, cool, moist hands and feet, flushing, profuse cerebral, gastrointestinal, peripheral, and sweating, and extreme anxiety. renal Pheochromocytoma is also a part of the Multiple Related to: excessive catecholamine secretion Endocrine Neoplasia (MEN) Syndromes and may Defining characteristics: pulse and blood pressure be found in conjunction with neurofibromatoses, changes, changes in cardiac output, changes in hemangiomas, and medullary thyroid cancers. peripheral resistance, impaired myocardial Other diagnoses, such as angina, essential hyperoxygenation, chest pain, cardiac dysrhythmias, tension, hyperthyroidism, acute anxiety reactions, EKG changes, dyspnea, tachypnea, palpitations, transient ischemic attacks, and menopause, must nausea, vomiting, epigastric pain, constipation, 274 CRITICAL CARE NURSING CARE PLANS

slow digestion, weight loss, headaches, visual dis- INTERVENTIONS RATIONALES turbances, paresthesias, oliguria, anuria, electrolyte imbalances, cold and clammy skin, decreased Administer medications as Alpha- and beta-blockers may ordered. stabilize the condition prior to peripheral pulses, flushing, diaphoresis surgical intervention. Metyrosine interrupts the catecholamine synthesis, decreases levels of nor- Outcome Criteria epinephrine production, decreases levels of VMA, and Patient will maintain adequate perfusion to all decreases BI? vital organs and will have adequate peripheral and Titrate IV meds as needed to Reduces risk of complications systemic circulation. keep systolic blood pressure less from severely elevated pressure. than 170 mmHg, and diastolic pressure less than 100 mmHg.

INTERVENTIONS RATIONALES Weigh every day. Weight loss may occur due to increased metabolism, decreased Monitor vital signs, including Provides information about heart appetite, nausea, or vomiting. lying, sitting, and standing BP. rate and perfusion pressure which will affect blood flow and Monitor intake and output, and Decreased renal perfusion may tissue perfusion. Chronic exces- notify physician far urine output lead to decreased urinary output, sive secretion of catecholamines less than 30 cc/hr. renal impairment, and failure. will affect the reflexes that are responsible for maintaining Avoid palpation of abdomen; Prevents possible palpation of upright blood pressure and may post sign near bed to refrain cumor and triggering of acute result in orthostatic hypotension. from palpation during crisis. assessments. Monitor functional abilities in Interrelationships of the body relation to the affected system. systems can cause overlapping Monitor labwork, especially FBS, Catecholarnine release can signs and symptoms associated hematocrit and renal function increase glycolysis and inhibit with tissue perfusion and can levels. insulin release. Excess cause changes in oxygenation, catecholamines can also increase cardiac output, metabolic erythropoierin stimulation and demands, neurologic function, can elevate hematocrit, as well as renal function, and nutrition. decrease blood flow to the kidney resulting in renal impair- Assess for presence and character May indicate decreased perfusion ment. of pulses, capillary refill time, related to the particular body skin color and temperature, urine system. Information, Instruction, output, mentation, gastric distention, presence of bowel Demonstration sounds, and appetite. INTERVENTIONS RATIONALES Position patient in Fowler’s Helps to decrease the blood position. volume returning to the heart by Assist with obtaining 24-hour Elevated levels may be diagnostic pooling blood i,n dependent parts urine specimen for diagnosis. for pheochromocytorna, but of the body. Decreases BP by use coma and increased stress states of orthostatic changes associated must be ruled out. Normal with the chronic catecholamine values for VMA are < 10 mgl24 secretion. hrs, metanephrines < 1.3 mg/24 hrs, free epinephrine and norepi- Avoid any non-essential activi- Ambulation, exercise, and val- nephrine < 100 mcg124 hrs. ties, especially pressure-causing salva-type efforts may provoke an movement. Avoid straining with attack, increasing blood pressure Avoid use of rauwolfia alkaloids, These substances may interfere bowel movements or urination. and decreasing tissue perfusion. tetracycline, quinine, methyl- with the results and hamper RENAL/ENDOCRINE SYSTEMS 275

INTERVENTIONS RATIONALES Organ function will be within patient’s normal dopa, catecholamines, large determination of diagnosis. quantities of vanilla, coffee, Extremities will be warm, with normal color chocolate, nuts, bananas, guaife- and sensation, and have equally palpable pulses. nesin, and salicylates for at least 2 days prior to 24-hour test, if Patient will have adequate urinary output with possible. equivalent intake and output. Instruct parientlfamily in causes Promotes understanding of the of exacerbations or attacks, and condition and risk of decreased Patient will be free of abdominal or epigastric methods to reduce frequency of perfusion to vital organs. pain, and able to ingest adequate nutritional occurrence. intake to maintain weight. Instruct to avoid exposure to Cold may cause vasoconstriction, cold temperatures. decreases circulation, and perfu- Anxiety sion, as well as precipitate an attack. Related to: excessive catecholamine release, threat to health status, changes in health status, life- Instruct in medications, effects, Promotes knowledge and facili- threatening crisis, possibility of surgical side effects, adverse reactions, tates compliance with medical complications, and symptoms to regimen. intervention report to physician. Defining characteristics: apprehension, sense of Instruct in methods to decrease Reduces stress and lessens precip- impending doom, fear of death, restlessness, fear, emotional stress, such as relax- itating factors with intermittent ation techniques. attacks by facilitating vasodila- fear of death, fear of surgery, fear of the unknown, tion. feelings of helplessness, anxiousness, worry, communication of uncertainty, voiced concern over Instruct in having frequent blood Primary indicator of the tumor pressure checks, keeping log of activity is blood pressure changes in life events trends, ranges to report to physi- increases, which cause decreased cian. etc. perfusion to tissues and organs. Increased knowledge will Outcome Criteria decrease fear and increase compliance with treatment, and Patient will have less anxiety or anxiety will be provide opportunity for prompt within an acceptable and manageable level. treatment to prevent serious complications.

Instruct in avoiding rapid Facilitates body’s attempt to cope INTERVENTIONS RATIONALES changes in position. with orthostatic hypotension by ~ allowing time for body and cir- Assess anxiety level, noting ver- Catecholamine increases can culatory system to adjust to balizations of fear or sense of produce marked anxiety which changes. doom. then increases oxygen demand on tissues. Instruct to avoid wearing any May result in an attack by com- clothing that may be tight or pression of abdomen or tumor Provide calm environment for Provides an opportunity to vent constrictive. region. patient to express fears, concerns, feelings and to obtain informa- and feelings. Allow time for tion. Decreases anxiety and patient to ask questions. promotes a caring and trusting Discharge or Maintenance Evaluation atmosphere.

Patient will have normalized vital signs. Encourage visits from family and Provides emotional support and friends who do not increase or relieves anxiety when familiar 276 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Defining characteristics: increase in body temperature greater than normal range, flushed warm provide patient with emotional people are available. s t ress . skin, increased heart rate, increased respiratory rate, diaphoresis, delirium Decrease stimuli in environment. Prevents further stressors.

Administer medications as Assists to allay fear and anxiery ordered. Outcome Criteria Information, Instruction, Patient will have temperature within normal Demonstration range.

INTERVENTIONS RATIONALES

Instruct patientlfamily members Decreases anxiety caused by fear INTERVENTIONS RATIONALES about disease process, what to of the unknown, and promotes Monitor temperature every 1-2 Fluctuations in temperature can expect with procedures, pre- and knowledge and understanding. hours or use continuous moni- occur rapidly and temperature postoperative care. coring. elevations can increase metabo- Instruct on emotional stress and Reduces anxiety and provides lism needs. other precipitating triggers for patient with some measure of Adjust room temperature for Assists patient with comfort and attacks, and methods to reduce control over the situation. patient comfort and maintain at decreases temperature. stress and anxiety. or below 72 degrees. Instruct on medications, effects, Promotes knowledge and Administer antipyretics as Decreases fever. side effects, contraindications, understanding which facilitates ordered. and symptoms to report to compliance with medical physician. regimen. Provide frequent tepid sponge Promotes patient comfort and baths and change linens if reduces temperature by Discharge or Maintenance Evaluation patient is diaphoretic. evaporation. Avoid chilling or shivering of Shivering may increase metabolic Patient will have reduced anxiety and be able to patient. requirements and actually vent feelings and concerns. increase temperature, Patiendfamily will be able to verbalize Place covered ice packs to groin, Decreases temperature by means axillae, andlor behind neck, if of conduction. understanding of disease process, medications, warranted. and treatments, and will be compliant with regimen. Use cooling blanket for tempera- Assists in lowering temperatures tures greater than 103 degrees if by conduction. Blankets should Patient will be able to avoid stressful visitors, warranted. Cool body slowly- be covered ro prevent burns and no faster than 1 degreell5 tissue injury. Cooling that is situations, or other provoking events, and will minutes. Blanket should be cov- done too rapidly can produce be able to perform relaxation exercises when eted and continuous monitoring ventricular ectopy. stressed. of temperature should be performed. Hypertherm ia Administer thorazine IM/IV as Thorazine is an alpha-adrenergic- Related to: increased metabolic rate in response to ordered. blocking agent chat causes peripheral vasodilation which catecholarnines, decreased heat loss due to vaso- helps heat to dissipate and also constriction can assist in decreasing shivering. RENAL/ENDOCRINE SYSTEMS 277

Information, Instruction, cular resistance, altered oxygen-carrying capacity Demonstration of blood, shift of the oxyhemoglobin dissociation curve, hypermetabolic state INTERVENTIONS RATIONALES Defining characteristics: confusion, restlessness, Instruct patiendfamily in proce- Promotes knowledge and reduces hypercapnia, hypoxia, cyanosis, dyspnea, tachyp- dures, what to expect with anxiety. cooling blanket application, etc. nea, changes in ABG values, changes in A-a gradient, changes in vital signs, activity Discharge or Maintenance Evaluation intolerance, changes in mental status

Patient will achieve and maintain normal body Constipation temperature. Related to: inadequate dietary/fluid intake, GI Patient will be compliant with medical regimen. distress, changes in level of activity, decreased blood flow slowing digestion, malabsorption Sensor -perception alteration (visualj thougd t processes, kinesthetic) Defining characteristics: nausea, vomiting, [See CVA] decreased appetite, epigastric pain, hard-formed stool, absence of stool, abdominal pain Related to: altered sensory reception, chemical alterations due to hypoxia, chemical alterations Outcome Criteria due to glucose/insulin and electrolyte imbalances, restrict environment, psychologic stress, vasocon- Patient will have normal elimination pattern striction reestablished and maintained. Defining characteristics: confusion, anxiety, fear, disorientation, change in behavior patterns, hyper- esthesia, restlessness, irritability, impaired INTERVENTIONS RATIONALES decision-making Determine patient’s bowel habits, Assists with identification of an lifestyle, ability to sense urge to effective bowel regime andlor Alteration in nutrition: less than body defecate, painful hemorrhoids, impairment and need for assis- requirements and history of constipation. tance. GI function may be [See Mechanical Ventilation] decreased as a result of decreased digestion.

Related to: hypermetabolic state, nausea, vomit- Auscultate bowel sounds for Presence of abnormal sounds, ing, anorexia, malabsorption presence and quality. such as high-pitched tinkles, suggest complications like ileus. Defining characteristics: inadequate food intake, Monitor diet and fluid intake. Adequate amounts of fiber and weight loss, muscle weakness, fatigue roughage provides bulk and adequate fluid intake (greater than 2 Impaired gas exchange Llday) is importanr in determin- [See Mechanical Ventilation] ing stool consistency.

Related to: increased respiratory workload, Monitor for abdominal pain and Gas, abdominal distention, or impaired oxygen to heart, hypoventilation, altered distention. ileus could be a factor. Lack of peristalsis from impaired diges- oxygen supply, altered blood flow, change in vas- tion can create bowel distention and worsen to the point of ileus. 278 CRITICAL CARE NURSING CARE PLANS

Defining characteristics: increased blood pressure INTERVENTIONS RATIONALES and pulse, cold and clammy skin, jugular vein dis- Provide bulk, stool softeners, May be required to stimulate tention, dyspnea, crackles, edema, cough, frothy laxatives, or suppositories as war- evacuation of stool. blood-tinged sputum, confusion, restlessness, noc- ranted. turia, decreased urinary output, increased mean Provide high-fiber, whole grain Improves stool consistency and arterial pressure, increased systemic vascular resis- cereals, breads and fresh fruits. promotes elimination. tance, decreased cardiac output and cardiac index Information, Instruction, Demonstration Outcome Criteria INTERVENTIONS RATIONALES Patient will have adequate cardiac output to maintain hemodynamic stability and perfusion to all Determine preexisting habits of Laxative dependence can predis- laxativelenema usage. pose patient to constipation. organs.

Instruct patient to avoid frequent Promotes enema dependence and use of enemas. causes fluid loss which results in more difficult elimination. INTERVENTIONS RATIONALES

Provide activity or exercise Promotes peristalsis. Identify other pre-existing condi- Other factors and disease states within limits of disease process. tions and assess cardiac function. may further stress an already compromised heart and place an Discharge or Maintenance Evaluation extra burden of myocardial oxygen supply.

Patient will have improved dietary and fluid Monitor blood pressure, heart Cardiac output and blood intake. rate and rhythm, apical and volume is decreased with elevated peripheral pulses, pulse deficits, blood pressure. Afterload Patient will achieve bowel elimination pattern respiratory status, presence of increases, pulse increases, and establishment and be able to maintain elimina- cough or adventitious breath changes in contracriliry and con- sounds, presence and character of duction occur. Respiratory tion of soft-formed stool without cramping or any sputum, and oxygenation. changes may result in decreased straining. oxygen intake and hypoxia. Daily exercise will be maintained within level of Measure cardiac outpurlcardiac Cardiac output < 5 L/min or index and other hemodynamic cardiac index < 2.5 Llminlm’ confinement in ICU. parameters as indicated. indicates severe vasoconstriction and decrease in myocardial oxygenation, leading to myocardial Decreased cardiac output ischemia, cardiac failure, and death.

Related to: altered preload, altered afterload, Monitor EKG for presence of Dysrhythmias decrease the heart’s inotropic changes in the heart from increased dysrhythmias, and treat accord- pumping efficiency which affects blood pressure and TPR, left ventricular enlarge- ing to hospital protocol. the cardiac output. ment and strain, and from accumulation of extra Dysrhythmias may indicate inadequate myocardial perfusion. fluid in the lungs or systemic venous system, Tachydysrhythmias decrease ven- myocardial compromise due to vasoconstriction, tricular filling time and coronary decreased coronary blood flow, increased myocar- blood flow; bradydysrhythmias decrease cardiac output and dial oxygen demands, hyperthermia, increased result in left ventricular failure. catecholamine receptor sensitivity RENAL/ENDOCRINE SYSTEMS 279

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Auscultate heart sounds for pres- Accumulations of extra fluid can decreased, heart rate is slowed, ence of gallops andlor murmurs. be heard as these abnormal heart and oxygen consumption is pre- sounds. served. Blood pressure decreases and coronary perfusion and Monitor for edema to extremi- May indicate decreased venous myocardial oxygen supply is ties, sacral region, or other return to the heart and a decrease increased due to the decrease in dependent areas; assess for jugu- in cardiac output. Fluid retention the heart rate. lar vein distention, cold may result in a decrease in uri- peripheral extremities, decreased nary output as a result of urinary output, and sluggish decreased venous return and Information, Instruction, capillary refill. perfusion. Demonstration Weight gain may indicate fluid Weigh every day. INTERVENTIONS RATIONALES retention. Instruct to elevate legs when Promotes venous return. Monitor intake and output every Intake and output should sitting or lying down. 2 hrs and prn. approximate each other. A fluid deficit between output and Instruct in signs to report: May indicate complications as a intake indicates fluid retention edema, weight gain, chest pain, result of decreased cardiac and a weight gain (500 cc headache, blood pressure or pulse output and facilitate prompt approximately = 1 Ib). rate changes. intervention. Position in semi-Fowler’s or Semi-Fowler‘s positioning pre- high-Fowler’s position. vents blood pooling and Discharge or Maintenance Evaluation facilitates breathing and improved air exchange. High- Fowler’s positioning reduces Patient will have stable vital signs and hemody- preload quickly by pooling blood namics will be within patient’s acceptable but does not decrease stroke parameteirs. volume significantly. Afterload decreases by dilating peripheral Patient will have stable cardiac rhythm with no arteries and decreasing LVEDl? dysrhythmias, and perfusion to organs will be Balance rest with short, planned Prevents increased demand on maintained. periods of activity; provide heart and myocardial oxygen atmosphere that is conducive to supply. Patient will have clear lung fields with no rest. adventitious breath sounds. Monitor for mental status Central nervous system distur- Patient will have palpable peripheral pulses with changes, decreases in orientation, bances can occur with decreased restlessness, agitation, or dizzi- cardiac output due to decreases warm, dry extremities. ness. in perfusion to these areas. Patient will have adequate urinary output, with Administer vasoactive drugs as These agents promote optimum no edema or extra weight gain. ordered, with titration based on cardiac output by changing ordered parameters. blood pressure, and can reduce afterload and preload.

Administer anti-dysrhythmic These agents decrease pacemaker drugs as ordered. activity, modig areas of impaired conduction, and blocks sympathetic effects of the heart: myocardial contractility is 280 CRITICAL CARE NURSING CARE PLANS

PHEOCHROMOCYTOMA

Increased secretion of catecholamines c Increased erythropoietin “Fight or flight” reflex Chronic excess of stimulation Sense of impending doom catecholamines c 4 Increased hemotocrit Impaired reflexes to maintain upright BP 4 4 Vasoconstriction Orthostatic hypotension c .I c c J, Hemodynamic GI Neurologic Renal Metabolic Increased TPR Decreased blood flow Decreased baroreceptor Increased urine Increased metabolism Increased SVR slows digestion sensitivity excretion of in response to Increased CO catecholamines catecholamines 3. c c c Hypertension Nauseahomiting Pounding headaches Increased and epigastric pain Visual disturbances catecholamine Paresthesias by-products (VMA Anxiety & metanephrines) Tremors c c c ImpairedI oxygen Constipation Increased cerebral Angio tension in the heart capillary pressure Aldosterone release I JI JI 4 c LV strain Increased respiratory Cerebral edema Increased renal LV enlargement workload Cerebral hemorrhage blood flow J c c c Cardiac Shortness of breath DEATH Ischemia of renal tissue decompensation on exertion c (decreased cardiac output) Tach ypnea Retention of water. e D yspnea sodium, potassium & chloride c c Chest pain, palpitations Respiratory failure Increased blood pressure with bradycardia c Hypovolemia or tachycardia DEATH c J Kidney failure Decreased peripheral 4 perfusion with cold DEATH clammy skin, pallor

e Inadequate nutrition Increased glycosis Increased heat loss Cardiogenic shock for body’s needs Alpha receptor insulin Increased temperature e Weight loss release inhibited Flushing diaphoresis Impaired immunity Hyperglycemia Seizures

DEATH RENAL/ENDOCRINE SYSTEMS 28 1

ances; thyroid antibodies positive in Graves’ dis- Thyrot oxicosis ease; glucose levels elevated from insulin resistance, increased glycogenolysis, or impaired insulin secretion; serum cortisol decreased due to lower adrenal reserve; alkaline phosphatase Hyperthyroid crisis, also known as thyroid storm increased; serum calcium increased; liver function and thyrotoxicosis, is a life-threatening emergency abnormal, decreased serum catecholamines; urine characterized by greatly exaggerated signs of creatinine increased hyperthyroidism. Mortality is high, and symptoms appear rapidly when triggered by infection, TRH test: used in some cases to identify TSH trauma, surgery, diabetes, or abrupt withdrawal of suppression with administration of TRH thyroid medication. Thyroid storm may be diffi- hormones cult to diagnose because the precipitating illness Electrocardiogram: used to identifjr elevated thy- may mask its detection. roid levels or electrolyte imbalances; atrial Hyperthyroid patients are more susceptible to cat- fibrillation may be present; cardiomegaly in elderly echolamines because of the increased number of with masked hyperthyroidism catecholamine receptors they possess. A triggering Oxygen: used to provide supplemental oxygen due illness creates an outpouring of catecholamines, to increased oxygen consumption and increased and so the elevated levels of thyroid and increased metabolic demands number of receptors create the crisis. A hypermetabolic state then ensues causing increased oxygen Radiography. chest x-rays used to identify cardiac and nutrient consumption, fluid and electrolyte enlargement that may occur in response to imbalances, and a catabolic state. increased circulatory demands, to identify presence of cardiac overload and congestion, respi- Patients in crisis typically have hyperthermia, ratory infiltrates or other precipitating causes tachydysrhythmias, dehydration, nausea, vomiting, weight loss, and neurologic changes. Radioactive iodine uptake test: used to differenti- Treatment is usually begun without waiting for ate types of thyroid problems; usually high in confirmation of lab tests and is aimed at support- Graves’ disease and toxic goiter, but low in ing vital functions. Reversal of excessive thyroid thyroiditis hormone decreases the hypermetabolic state, and Thyroid scan: may be used to aid diagnosis when reduction of the circulating thyroid hormones fur- thyrotoxicosis is caused from cancer or a ther decreases the crisis. Once vital functions are multinodular goiter preserved, treatment of the precipitating cause is begun. If the crisis is untreated, heart failure, Iodine solutions: used to slow the release of thy- exhaustion, and death will ensue. roid hormones; common solutions are Lugol’s solution and sodium iodide MEDICAL CARE Beta-adrenergic blockers: used to reverse periph- Laboratory: serum and serum free T4 and T, are eral effects of excessive thyroid hormones and to increased; TSH levels are decreased; thyroglobulin decrease the hypermetabolic state; commonly used is increased; electrolytes are used to identify imbal- is propranolol; reserpine IN also helps to reduce peripheral effects and may help decrease the tachycardias 282 CRITICAL CARE NURSING CARE PLANS

Corticosteriods: high doses of hydrocortisone help Outcome Criteria support body functions during hypermetabolic state Patient will have normal body temperature Digoxin: may be required for congestive heart fail- restored and be able to maintain temperature ure patients prior to initiating beta-blockade within acceptable range. Diuretics: may be required if congestive heart failure occurs, and may also help decrease calcium level if neuromuscular function is compromised INTERVENTIONS RATIONALES Nutrients: high doses of vitamin B complex are Monitor temperature for eleva- Hyperthermia up to 106 degrees tion andlor pattern of elevation, may result from the acceleration used to provide necessary nutrient support for the chilling, shaking, or diaphoresis. of the metabolic rate caused from catabolism state, as well as to facilitate increased excessive thyroid hormone secre- glucose, protein, and carbohydrate absorption tion. Chills may precede temperature elevation.

Thyroid hormone antagonists: used to block the Monitor other vital signs and Elevated temperatures may result thyroid hormone production and effects; usually heart rhythm for alterations. in elevations of blood pressure, propylthiouracil (PTU) or methimazole (Tapazole) respiration, and pulse. Cardiac are used; lithium carbonate can also inhibit thy- dysrhythmias as a result of heart failure, electrolyte imbalance, or roid hormone synthesis and may be used in fluid overload may be noted patients who cannot tolerate the other drugs promptly to allow timely intervention. Sedatives: may be required to help patient rest and reduce myocardial oxygen consumption and car- If required, use cooling methods Assists in reducing temperature, such as cooling blankets, ice but may cause shivering which diac workload, as well as control of shivering that packs, etc., being careful to not increases metabolic rate and may may increase metabolic rate cause shivering. worsen condition. Surgery: thyroidectomy or subthyroidectomy may Administer antipyretic medica- Assists with reduction of remper- be required tions as ordered by physician, ature. Aspirin should be avoided but avoid the use of aspirin. because it increases free thyroid hormone levels and may worsen NURSING CME PLANS condition. Hyperthemia Administer antithyroid medica- PTU or rnethimazole inhibits tions as ordered. thyroid hormone synthesis, and Related to: accelerated metabolic rate secondary to PTU inhibits conversion ofT, to T, in peripheral tissues. Iodine- excessive thyroid hormone secretion, increased containing agents inhibit the beta-adrenergic responses, increased sodium-potas- release of stored thyroid sium exchange in cells hormones and help to inhibit synthesis. Glucocorticosteroids Defining characteristics: increase in body temper- block conversion of T4 to T3. ature over 100 degrees, flushed warm skin, Administer beta-adrenergic Propranolol and nadolol block diaphoresis, tachypnea, tachycardia, delirium, blockers as ordered. the peripheral effects from exces- lethargy sive thyroid hormone and may block conversion ofT4 to T,.

Administer IV fluids and elec- Replaces fluid losses from fever trolytes as ordered. and diaphoresis. RENAWENDOCRINE SYSTEMS 283

INTERVENTIONS RATIONALES resistance, decreased cardiac output or cardiac index, tachycardia, decreased or absent peripheral Administer antibiotics if ordered. Assist in fighting infection when that is believed to be a precipitat- pulses, EKG changes, hypotension, gallops, ing factor in the crisis. decreased urinary output, diaphoresis, deteriora-

Ensure comfort of patient by Assists in reducing and maintain- tion in mental status, impending cardiovascular frequent repositioning, changing ing temperature. collapse. of linens and clothing, cool clorhs, lowering room temperature, etc. Outcome Criteria

Information, Instruction, Patient will be able to maintain cardiac output at Demonstration an acceptable level for tissue perfusion. INTERVENTIONS RATIONALES Instruct patiendfamily in all Promotes knowledge and facili- INTERVENTIONS RATIONALES medications being utilized. tates compliance with regimen. Monitor vital signs, especially Peripheral vasodilatation and Observe for depression, tremors, Symptoms may indicate adverse blood pressure for widening decreased fluid volume may nausea, vomiting, or increased effects from lithium carbonate. pulse pressures. result from excessive urine output. catecholamine secretion. Instruct in watching for fever, May be indicative of an agranu- Widening of pulse pressure may sore throat, or rashes, and to locytosis caused from indicate compensatory changes notify physician if he develops medication. in stroke volume and decreasing rhese symptoms. systemic vascular resistance. Observe heart rate and respira- Provides accurate assessment of Discharge or Maintenance Evaluation tory rate while patient is tachycardia without increase sleeping. demand of activity. Patient will have stable vital signs and be able to maintain values within normal ranges. Auscultate heart tones for extra Hypermetabolic states create sounds, gallops, and murmurs. prominent S1 sounds and mur- Patient will have no adverse reactions to medica- murs due to the forcefulness of the cardiac ourput, and S3 gallop tions or treatment. development may indicate impending cardiac failure. Patient will be able to accurately recall all instructed information. Monitor cardiac rhythm for Excessive thyroid hormone secre- changes, and treat accordingly tion creates excessive Risk for decreased cardiac output per hospital protocol. catecholamine srimulation to myocardium which can result in Related to: excessive demands on cardiovascular tachycardia and dysrhythmias, system due to hypermetabolic state, increased car- and may worsen condition by decreasing cardiac output. diac workload, hyperthermia, increased sensitivity of catecholamine receptors, changes in venous Assess for weak or thready pulses, May indicate dehydration and decreased capillary refill, reduction in circulating volume return, changes in peripheral and systemic vascular decreased urinary output, and which compromises cardiac resistance, changes in heart rhythm or conduction. deueased blood pressure. output. Defining characteristics: elevated blood pressure, Auscultate lung fields for changes Adventitious breath sounds may elevated mean arterial pressure, elevated systemic in breath sounds. indicate early signs of pulmonary congestion or impending cardiac vascular resistance, elevated peripheral vascular failure. 284 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Administer IV fluids as ordered. Fluid replacement may be'indi- Monitor lab studies, i.e., potas- Hypokalemia may cause cardiac cated to increase circulating sium, calcium, etc. dysrhythmias and hypercalcemia volume, but may result in cardiac may interfere with contractility, failure or overload. both of which decrease cardiac Administer atropine if indicated. Beta-blockers that are given to output and function. control tachycardia and tremors Monitor cultures for infection. Identifies causative organism that during the crisis may decrease may be responsible for thyroid heart rate, and may result in crisis. The most frequent factor symptomatic bradycardia requir- of thyrotoxicosis is respiratory ing treatment. infection. patients may require digi- Administer digoxin if indicated. CHF Assist with hemofiltration, May be used in severe crisis to talization prior to initiating hemodialysis, or plasmapheresis rapidly decrease thyroid beta-blockers. procedures. hormone. Administer sedatives andlor Reduces metabolic demands by Prepare patientlfamily for Subtotal or total thyroidectomy muscle relaxants as ordered. promoting rest, and may be surgery as indicated. may be required once ruthyroid helpful to reduce shivering that state is attained. occurs with fever.

Administer supplemental oxygen Assists to support increased as ordered. metabolic needs and with Discharge or Maintenance Evaluation increased oxygen consumption.

Assist patients by restricting Reduces energy expenditure Patient will have stable vital signs and hemody- activity or assisting with activity which increases oxygen namic parameters will be within normal limits. when required. consumption and contributes to increase metabolic needs. Patient will have stable cardiac rhythm with no dysrh yt hmias . Information, Instruction, Patient will exhibit no signs/symptoms of car- Demonstration diac failure. INTERVENTIONS RATIONALES Patient will be able to tolerate activity without Identify patients who may be at Allows for closer assessment and circulatory compromise. most risk from complications of monitoring of patients who may disease, such as elderly, preexist- develop cardiovascular compro- Patient will be able to accurately verbalize ing coronary disease or cardiac mise from therapeutic measures instructed information. risk, pregnancy, asthma, or bron- designed to relieve thyroid crisis, choconstrictive diseases. and enable appropriate choices of Risk for altered nutrition: less than body beta-blockers or other agents. requirements Once PTU therapy has begun, May result in further thyroid [See DKA] avoid abrupt withdrawal of drug. crisis. PTU may not have rapid effect on thyroid crisis. Related to: hypermetabolic state, excessive thyroid hormone secretion, nausea, vomiting, elevated glu- If oral iodine solution is utilized, Minimizes hormone formation it should be started 1-3 hours from the iodine. Iodine may cose levels after beginning anti-thyroid interfere with radioactive iodine medication. treatment and has been known Defining characteristics: weakness, fatigue, weight to exacerbate the crisis in some loss, lack of inadequate food intake, increased glu- individuals. cose level RENAL/ENDOCRINE SYSTEMS 285

Risk fir injuy Information, Instruction, Related to: cognitive impairment, altered protec- Demonstration tive mechanisms of body, hypermetabolic state INTERVENTIONS RATIONALES

~ ~~~~ Defining characteristics: diminished attention Discuss patient’s feelings regard- Assists patient in verbalizing con- span, agitation, restlessness, impaired judgment, ing alterations in appearance, cerns regarding perceptions of weakness, impaired body functions methods to enhance self-image, unattractiveness and allows for and exercises for eyes. discussion of methods to enhance appearance with Outcome Criteria makeup, shaded glasses, and exercises for extraocular muscles Patient will be free of personal injury with all that can help maintain mobility of eyelids. body systems functioning normally. Discharge or Maintenance Evaluation

Patient will be free of personal injury to any INTERVENTIONS RATIONALES body system. Monitor patient for complaints May result from excessive cate- of eye pain, photophobia, eye cholamine stimulation, and may Patient‘s eyes will remain moist, with decreased irritation, tearing, dificulty clos- require care until crisis is edema, and will have the ability to completely ing eyelids, and presence of resolved. close the eyelids. periorbital edema.

Assess for decreasing visual acuity May be a result of Graves’ disease Patient will be able to freely discuss concerns or blurring of vision. in which increased tissue behind and problems and be able to utilize problem- the orbit causes exophthalmos solving skills. and infiltration of extraocular muscles and weakness. Vision Anxiety may worsen or improve without [See Pheochromocytoma] basis on medical therapy or disease progression. Related to: hypermetabolic state, increased cate- Administer medications as indi- Prevents eyes from drying and cholamine stimulation cated, especidly eye lubricant protects cornea when patient is drops and ointment. unable to close eyelids Defining characteristics: apprehension, loss of completely because of edema. control, panic, shakiness, distorted perception, Ensure interventions to prevent Prevents injury due to physical restlessness, tremors, mental changes, lack of injury to patient are in place, risks in environment. attention such as bed in lowest position, side rails raised, restraints when Fatipe necessary, etc. [See DKA] Assess for changes in mental Assists with identification of Related to: hypermetabolic state, increased status and ability; reorient changes that may occur as a patient as necessary. result of exhaustion, electrolyte thyroid hormone secretion, increased energy or other chemical imbalance, or requirements, changes in body chemistry, central physiological problems and nervous system irritability, increased oxygen con- allows for prompt intervention. sumption and demand 286 CRITICAL CARE NURSING CARE PLANS

Defining characteristics: lack of energy, inability INTERVENTIONS RATIONALES to perform normal activities, inability to concentrate, lethargy, irritability, nervousness, tension, Instruct to avoid taking over-the- Antithyroid medicines can affect counter medications unless andlor be affected by several apathy, depression advised to do so by physician. OTC drugs and may cause dan- Knowledge &fieit gerous interactions. Instruct in diet needs, avoidance Hypermetabolic states require Related to: lack of information, unfamiliarity with of caffeine, artificial preservatives increased nutrients to maintain resources, misinterpretation of information, lack and dyes. well-being and meet demand. of recall Stimulants and additives may result in systemic problems.

Defining characteristics: requests for information, Instruct in needhationale for Compliance with monitoring questions, misrepresentation of facts, inaccurate continued medical follow-up. medical regimen and identifca- follow-through of instructions, development of tion of potential complications can be assessed for timely inter- preventable complications vention.

Outcome Criteria Discharge or Maintenance Evaluation

Patient will be able to accurately recall measures Patient/family members will be able to for managing hyperthyroidism and be able to accurately recall all instructional information decrease risk of complications. provided to them. Patient will be free of preventable complications. INTERVENTIONS RATIONALES Patient will be able to correctly recall all med- Discuss patient's perceptions and Establishes knowledge base of ications and effects. knowledge of disease. patient and helps identify interventions and appropriate plan of Patient will be able to manage hyperthyroidism care. without crisis. Ensure that family members are Patient's physical condition may included in discussions and interfere with his ability to con- allowed to verbalize their concentrate which can hinder the cerns and questions. learning process. Instruction to the family can assist with reinstruction when needed.

Instruct in all medications, Provides knowledge and facili- effects, side effects, complica- tates compliance with regimen. tions. and symptoms to report to Antithyroid therapy will require physician. long-term use in order to inhibit hormone production. Alternate drugs may be chosen if the patient develops symptoms of agranulocytosis from his therapy.

Instruct to notify physician for May be indicative of adverse fever, sore throar, or rashes. reactions to thiourea rherapy and facilitates prompt treatment. RENAL/ENDOCRINE SYSTEMS 287

THYROTOXICOSIS (THYROID STORM)

Underlying hyperthyroidism c Precipitating factor c Thyroid hormone levels increase (T3 and T4)

1 Increased sympathetic 7Unregulated hypermetabolic adrenergic responses responses c JI Increased cardiac output Fever Wide pulse pressures Flushing Increased heart rate Diaphoresis Increased contractility GI irritability Cardiac dysrhythmias Nauseahomiting Heart failure Diarrhea

Increased oxygen consumption 4 Irritability Confision Angina D ysrhythmias Heart failure This Page Intentionally Left Blank MUSCULOS KELETM SYSTEM 289

SYSTEM Fractures Amputation Fat Embolism This Page Intentionally Left Blank .WC"' ' MUSCULOSKELETAL SYSTEM 29 1

occurs to the arm or leg, the fascia surrounding the muscles form compartments with small open- A fracture is a break in a bone that occurs when ings for major arteries, nerves, and tendons, direct or indirect pressure is placed on the bone in Edema can compress these structures and cause a force sufficient to exceed the bone's normal elas- ischemia to muscle tissues. The initial ischemic ticity and causes deformation. There are many changes result in a histamine release that causes types of fractures, but the major classifications dilation of the capillary bed and edema to the include open or compound, closed or simple, area. The edema further compresses the larger complete, incomplete, and pathologic fractures. arteries, which in turn creates further ischemia, further histamine release, and a vicious cycle is In closed fractures, there is no contact of the bone formed. The nerves, veins, arteries, and muscles with the environment. In open fractures, the skin may receive irreversible damage within 6 hours, surrounding the area of the break is open and the and contractures, paralysis, and paresthesia may bone is exposed to the environment. The major occur within 24-48 hours without intervention. goal in these types of fractures involves the preven- Healing begins when the blood around the end of tion of infection in conjunction with achieving proper alignment. Many patients have severe the bone forms a clot and is related to the revascularization process. An inflammatory response bleeding associated with this type of fracture. A complete fracture is one that involves the occurs with blood vessel dilatation, then the complete cross-section of the bone and it is visibly increased permeability of the capillaries allow protein and granulocytes to leak into the tissue. misaligned. In an incomplete fracture, the actual Fibrinogen converts to fibrin that collects proteins break may only involve a part of the cross-section and other types of cells, and the granulation tissue of the bone in which one side of the bone is allows for debris removal. When the pH of the broken and the other part is merely bent. fluid surrounding the bone fragments decreases, Pathologic fractures occur without or with mini- calcium goes into the solution and this begins the mal trauma and are usually seen in diseases such as process that helps to form new bone. After a osteoporosis and cancer. couple of weeks, the pH of the tissues rises, and Fractures not only cause damage to the bone calcium precipitates into the meshwork and a involved, but to the soft tissues, nerves, tendons, callus is formed as a bridge within the fragments and vascular system as well. These structures are in of bone. close proximity to the bones and help to support Frequently, if open fractures are present, fat partic- skeletal weight and to facilitate joint movement. ulate may embolize, and the patient must be When the fracture occurs, this stability is lost, and monitored for this complication. in turn, results in pain, swelling and splinting. [See Fat Embolus] The surrounding muscles are usually flaccid initially after the injury, but within an hour or less, may commence to spasm and this may impair MEDICAL CARE venous circulation and displace the fracture X-rays:used to identify type, location, and sever- further. ity of fractures or traumatic injuries and to Another complication that frequently occurs is evaluate healing process stage called compartmental syndrome. After a fracture Bone scans, CT scans, MRI scans: used to identi$ fractures and/or soft tissue damage 292 CRITICAL CARE NURSING CARE PLANS

Arteriography: may be used to identify presence INTERVENTIONS RATIONALES and severity of vascular damage associated with Administer analgesics as war- Reduces pain, promotes muscle fracture ranted, and especially prior to relaxation, and facilitates patient painful activities. cooperation with medical treat- Laboratory: CBC may identify hemorrhage or ment. hemoconcentration; WBC is usually increased due Provide backrubs, massage, posi- Helps to reduce pressure areas, to the stress response after an injury but may indi- tion changes, and other comfort enhances circulation, and may cate infection; coagulation profiles may be used to measures. decrease pain. identify problems related to blood loss, liver Administer muscle relaxants as Reduces muscle spasms which injuries, or after blood transfusions warranted. can decrease pain. Surgery: may be required to repair and realign bone structure, nerve injury, soft tissue injury, or Information, Instruction, vascular injuries; may be required to stabilize Demonstration skeletal integrity; may be required to relieve com- ~ ____~ partmental syndrome compression INTERVENTIONS RATIONALES Instruct on relaxation Redirects attention from pain Traction: used to realign fractured bones and to techniques, deep breathing exer- and provides patient with feel- facilitate healing in proper alignment cises, visualization, guided ings of control; may assist patient imagery, therapeutic touch, etc. in coping with discomfort. NURSING CARE PLANS Instruct patient in use of PCA as Provides patient with control warranted. over his pain relief and has been Alteration in comfort shown to reduce the amount of narcotic analgesic the patient Related to: pain, muscle spasm, fracture, trauma, requires for pain control. soft tissue injury, nerve injury, vascular injury, Instruct patient to notify nurse May indicate infection, ischemia, tendon injury, traction apparatus or MD of sudden different pain or compartmental syndrome. or pain that is unrelieved with Defining characteristics: communication of pain, analgesics. moaning, facial grimacing, guarding of injured area, inability to be distracted, anxiety Discharge or Maintenance Evaluation

Patient will have no complaints of pain. Outcome Criteria Patient will be able to control pain management Patient will be free of pain or pain will be by use of PCA with satisfaction. controlled to patient’s satisfaction. Patient will be able to recall information accurately and will notify medical personnel for INTERVENTIONS RATIONALES signs/symptoms of complications. Immobilize injured body part. Reduces pain and prevents fur- Patient will be able to demonstrate accurately ther skeletal displacement. and effectively the use of relaxation activity Support injured extremity gently Decreases edema, promotes skills for use with controlling pain. and elevate using pillows as war- venous return, and may help to ranted. decrease pain. MUSCULOSKELETAL SYSTEM 293

Impaired physical mobility INTERVENTIONS RATIONALES Related to: fractures, pain, immobilization, trac- Evaluate integrity of traction Traction provides for a pulling tion, neurovascular impairment apparatus and set-up. force on the long axis of a fractured bone to facilitate proper Defining characteristics: inability to move at will, alignment and healing. limited range of motion, decreased muscle Maintain free hanging weights Ensures that the prescribed strength, decreased muscle control, reluctance to and unobstructed ropes when amount of weight is maintained traction is utilized. on traction and reduces muscle move injured body part spasms and pain.

Apply antiembolic hose and Prevents venous stasis and Outcome Criteria remove for 1 hour every 8 hours. decreases potential for thrombophlebitis. Patient will achieve and maintain optimal mobility Observe for redness, tenderness, May indicate thrombophlebitis. and function of injured area. pain, or swelling to the calf; assess for positive Homan's or Pratt's signs. INTERVENTIONS RATIONALES Evaluate degree of immobility After trauma, patient's percep- that has resulted from injury tion of limitations may be out of Information, Instruction, and patient's perception of his proportion with their physical Demonstration limitations. levels of activities and may require further information to INTERVENTIONS RATIONALES dispel false concepts. Instruct patient in use of spirom- Prevents atelectasis and facilitates Maintain bedrest and move Decreases potential for further eter and coughing and deep lung expansion. injured limbs gently, supporting injury and impairment in align- breathing exercises to be done areas above and below the frac- ment while stabilizing the every 2 hours. ture. injured area. Do not routinely elevate the Elevation may place pressure on Reposition patient every 2 hours Prevents formation of pressure knees. the lower extremities and and prn. areas and improves circulation. decrease venous return and blood flow. Assist patient with range of Prevents muscle atrophy, motion exercises of all extremi- increases blood flow, improves ties as warranted. joint mobility, and helps prevent Discharge or Maintenance Evaluation reabsorption of calcium due to disuse. Patient will achieve and maintain increased Encourage isometric exercises Helps to contract muscles with- mobility and function of injured area. once bleeding and edema has out bending joints or moving resolved. extremities to facilitate mainte- Patient will be free of complications that may nance of muscle strength. These occur as a result of immobility. exercises can exacerbate bleeding or edema if these problems are Patient will be able to effectively demonstrate not resolved. exercises to increase mobility. Ensure that adequate numbers Casts andlor traction apparatus Patient will be able to recall accurately all infor- of personnel are present for may be cumbersome and heavy repositioning. and may require increased per- mation instructed. sonnel to avoid injury to the patient or the nurses. 294 CRITICAL CARE NURSING CARE PLANS

Risk fir peripheral neurovascuhr INTERVENTIONS RATIONALES dysfinction decreases in muscle movement will require emergency interven- Related to: vascular injury, soft tissue injury, inter- distal to the injury, and notify tion to restore circulation. MD as warranted. Compartmental syndrome can ruption of blood flow, edema, thrombus, result in permanent dysfunction hypovolemia and deformity within 24-48 hours and irreversible damage Defining characteristics: decreased or absent may occur after 6 hours without pulses, cyanosis, mottling, pallor, cold extremities, intervention. mental changes, abnormal vital signs, decreased Assist with monitoring of com- Increases in pressure above 30 urinary output partmental pressures as mmHg requires immediate inter- warranted. vention to prevent permanent damage. Outcome Criteria Assess skin around cast edges for Rough edges of the cast may redness or pressure points, or for produce pressure and result in Patient will be able to maintain adequate tissue complaints of burning under the ischemia or tissue breakdown. perfusion. cast. Cover rough edges of cast Burning pain may indicate pres- with tape. sure areas that are inside cast and not visible.

INTERVENTIONS RATIONALES Monitor cast for presence of flat- May indicate that the cast is tened or dented areas. placing pressure to areas and may Monitor vital signs. Systemic perfusion will be result in tissue necrosis. impaired if circulating blood volume is inadequate. Cutlbivalve cast as needed per Relieves circulatory impairment hospital/MD protocol for circu- that may occur from edema and Palpate peripheral pulses and Decreased or absent pulse may latory impairment. swelling to injured area. identify changes in equality or indicate vascular injury that character of pulses distal to requires immediate intervention. Apply ice packs to fracture site as Reduces edema and hematoma injury. warranted. formation.

Monitor extremity involved for Circulatory impairment may Remove patient’s jewelry from May impair circulation when rapid capillary refill, skin color, result in delayed refill times injured extremity. extremity swells. warmth, and sensation. greater than 5 seconds. Arterial compromise may occur when Perform testing for tendon May indicate superficial tendon skin is cool to cold and white, damage: Immobilize the two damage if the patient cannot and venous compromise may fingers on either side of the wiggle his finger, and deep occur with cyanosis. Sudden patient’s middle finger and ask tendon damage if the patient ischemic signs may be caused him to wiggle the middle finger; cannot flex the finger. with joint dislocation due to immobilize the proximal inter- injury to adjacent arterial struc- phalangeal joint of a tures. laceratedlinjured finger and ask him to flex the finger. Monitor for changes in neurovas- Paresthesias, numbness, tingling, cular integrity every 1-2 hours as or diffused pain may occur when Information, Instruction, warranted. Notify MD for signif- nerves have been damaged or icant changes. when circulation is impaired, and Demonstration may require intervention. INTERVENTIONS RATIONALES Evaluate complaints of pain that Hemorrhage andlor edema are abnormal for the type of within the muscle fascia can Prepare patient for surgery as Surgical intervention may be injury sustained, pain with pas- impair blood flow and cause warranted. required to relieve compartmen- sive muscle stretching, or compartmental syndrome that tal pressure in order to avoid permanent dysfunction. MUSCULOSKELETAL SYSTEM 295

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Instruct patient in signslsymp- Provides knowledge and allows during movement. Positioning toms to notify nurse/MD: for patient involvement in care. helps ro decrease pressure to skin increased pain, decreased sensa- Provides method for prompt areas. tion or movement, or changes in detection of potential complica- temperature or color of injured tions to facilitate prompt Monitor integrity of traction set- Improper set-up or positioning part. intervention. up, pad areas that come in con- of apparatus may result in tissue tact with patient’s skin. injury or skin breakdown. Padding prevents pressure areas Discharge or Maintenance Evaluation from forming on skin and enhances moisture evaporation to Patient will have equally palpable pulses, warm prevent skin excoriation.

and dry skin, and stable vital signs. Cover the ends of any traction Prevents injury to other skin pins or wires with cork or other tissues. Patient will have normal sensation to injured protectors. part. Apply skin traction as ordered. Benzoin provides a protective Patient will be able to recall information accu- Apply traction tape lengthwise layer to prevent skin abrasion rately and will be able to avoid potential on both sides of the injured limb with removal of tapes. Traction after applying tincture of benzoin tape that encircles a limb may complications. and extend the tape beyond the impair circulation. Impaired skin integrz.9 limb. Mark a line on the tapes at the Provides identification marker to Related to: compound fracture, traumatic injury, point when the tape extends assess whether traction tape has surgery, use of traction pins or other devices, use beyond the limb. slipped. of fixation devices, immobilization Using elastic bandage, wrap the Allows prescribed traction with- limb and tape (and padding, if out impairing circulation. Defining characteristics: disruption of skin sur- needed) being careful to avoid face or other tissue layers, open wounds, pain, wrapping too tight. pares thesias Remove skin traction at least May provide evidence of any daily and observe for any red- skin impairment and allows for dened or discolored areas. cleansing of area to remove Outcome Criteria Provide skin care. debris or drainage. Patient will achieve optimal wound healing and If cast is present, cleanse plaster Dry plaster can flake and result have no skin breakdown. off skin while still damp. in skin irritation. Use padding, tape, and/or plastic Prevents skin breakdown and to protect cast near perinea area. helps to prevent contaminants from adhering to cast. INTERVENTIONS RATIONACES Avoid use of lotions or oils These agents can creare a seal Observe skin for open wounds, Changes may indicate problems cast edges. and prevent the casr from redness, discoloration, duskiness, with circulation that may be around “breathing.” Powder should be cyanosis, mottling, or pallor. caused by traction, casts, or splints, or by edema. avoided because of the potential for accumulation inside the cast. Apply eggcrate mattress, flotation Helps prevent formation of pres- mattress, air mattress, sheepskins, sure areas caused by immobility. or use kinetic rype bed.

Encourage patient to use trapeze May minimize potential for abra- bar and reposition frequently. sions to elbows from friction 296 CRITICAL CARE NURSING CARE PLANS

Information, Instruction, INTERVENTIONS RATIONALES Demonstration Observe wounds for redness, May indicate presence of drainage, dehiscence, failure to infection. INTERVENTIONS RATIONALES heal, etc.

Instruct the patient to avoid Objects used for scratching may Perform wound carelpin care Removes drainage and debris purring objects inside cast, such damage tissue. utilizing sterile technique. from wound which may prevent as fly swarters, coat hangers, etc. infection.

Instruct patient in cast care. Provides knowledge for future Obtain cultures as ordered. Identifies causative organism and patient care and involves the allows for specific antimicrobial patient in his medical treatment. therapy to eradicate the infection. Discharge or Maintenance Evaluation Observe prescribed isolation Isolation may be required techniques. depending on type of infective Patient will have no further skin breakdown. organism. Precautions will prevent cross-contamination and Patient will have healed wounds without com- spread of infection. plications. Observe wounds for presence of May indicate the presence of gas crepitus or fruity-smellinglfrothy gangrene infection. Patient will be able to avoid complications of drainage. immobility. Evaluate patient’s complaints of May indicate development of Patient will be able to accurately recall all sudden increase of pain or diffi- comparrmenral syndrome or culty with movement in injured osteomyelitis. instructive information. area.

Risk for infection Observe for hyperreflexia, muscle May indicate development of rigidity, spasticity in facial and tetanus. Related to: broken skin, disrupted tissues, exposed jaw muscles, and decreases in bone structure, traction devices, surgery, invasive ability to speak or swallow. procedures Information, Instruction, Defining characteristics: temperature elevation, Demonstration elevated white blood cell count, shift to the left, purulent drainage, redness, warmth, and tender- INTERVENTIONS RATIONALES ness Instruct patient to avoid touch- Decreases potential for spread of ing wounds or pin sites. infection.

Outcome Criteria Instruct patientlfarnily in kola- Provides knowledge and ensures tion procedures. compliance with procedures and Patient will be free of signs/symptoms of infection decreases chance of cross-conta- and wounds will heal without complications. mination. Prepare patient for surgical pro- Surgical intervention may be cedures as warranted. required to remove necrotic bone INTERVENTIONS RATIONALES or tissue to facilitate healing process and to prevent further Monitor vital signs. Observe for Increased temperature and heart infection. fever, chills, and lethargy. rate may indicate impending or present sepsis. Gas gangrene may result in hypotension and mental changes. MUSCULOSKELETAL SYSTEM 297

Discharge or Maintenance Evaluation INTERVENTIONS RATIONACES Patient will have appropriate wound healing Instruct in signdsymptoms to Provides for prompt identifica- notify MD: pain, elevated tern- tion of problem to ensure with no signdsymptoms of infection. perature, chills, paresrhesias, prompt intervention. paralysis, color changes, edema, Patient will be able to accurately recall all dislodged fixator, cracks in casts, instructions and avoid potential complications. etc. Knowledge deficit Related to: lack of information, misunderstanding of information, inability to recall information Defining characteristics: verbal requests for information, questions, inaccurate statements, lack of Discharge or Maintenance Evaluation compliance with instructions, lack of follow- through, development of preventable Patient will be able to accurately recall all complications instructional information. Patient will be free of preventable Outcome Criteria complications. Patient will be able to accurately verbalize under- Patientlfamily will be able to accurately perform standing of disease process and treatment. demonstration of wound/pin care.

~~ ~ INTERVENTIONS RATIONALES

~~ ~~ Evaluate patient’s understanding Provides baseline of patient’s of disease process, injury, and knowledge and helps identiFy treatment. need for instruction.

Instruct patientlfamily regarding Fractures usually require casts or mobility concerns. splints during healing, and improper use may delay woundlbone healing.

Instruct patient in exercises to Prevents joint stiffness and perform. muscle wasting.

Instruct in wound care/fLuator Enables patient to understand pin care. need for sterile/aseptic wound care to prevent further injury and infection.

Instruct patient to keep all Provides for identification of follow-up appointments. complications and promotes patient compliance with medical regimen. 298 CRITICAL CARE NURSING CARE PLANS

FRACTURES

Trauma

Skeletal Iinstability Soft tissue injury 3 I Loss of weight support Bleeding I Loss of attachments for muscles and ligaments 3 Joint motion disabled I Muscle contractions 4 Inflammatory response Vasodilation Increased capillary permeability I Protein and granulocytes leak into tisssues 3 Edema

LBlood clots at injury site I Granulation tissue invades clot 4 Reticuloendothelial cells remove debris I Calcium goes into solution I New capillaries grown into clot I New bone cells formed I Calcium salts precipitate into cell meshwork I Collagen formed 3 Callus formation MUSCULOSKELETAL SYSTEM 299

Angiography, arteriography: used to assess blood Amputation flow and to identify the optimal amputation level Amputation may be caused by trauma, disease, or CT scans: used to identify neoplasms, congenital problems. It may be required for osteomyelitis, or hematoma formation uncontrolled infection, intractable pain, or Doppler ultrasound or flowmetry: used to assess gangrene due to inadequate tissue perfusion, and blood flow to tissue areas is usually performed as distally as possible to preserve viable tissue and bony structure for use with prosthetics. NURSING CARE PWNS A closed amputation utilizes a flap of skin for clo- Alteration in comfort sure over the residual limb, and an open [See Fractures] amputation requires future revisions and the Related to: injury, trauma, surgical procedure wound heals by granulation. The open amputation is utilized in patients who are poor Defining characteristics: complaints of pain, surgical candidates and with the presence of infec- guarding of area, facial grimacing, moaning, dis- tion. Traumatic amputation is an accidental loss of comfort a body part and is classified as complete when the Alteration in tissue petfksion: peripheral part is totally severed, and partial when there is some connection with soft tissues. Related to: disease, surgical procedure, decreased blood flow, edema, hypovolemia Amputation may be considered as a last option when trying to salvage an extremity, and the sur- Defining characteristics: absent or diminished geon may try revascularization, resection, or pulses, color changes, mottling, blanching, hyperbaric oxygenation in an attempt to save the cyanosis, necrosis, gangrene, temperature changes, limb. A lower extremity amputation is still consid- swelling ered a life-threatening procedure, especially when the patient is elderly or has peripheral vascular dis- Outcome Criteria ease. With the advances in microsurgery, reimplantation of severed digits and limbs have Patient will have adequate peripheral perfusion become more successful. with equal pulses, warm, pink skin, and optimal wound healing. MEDICAL CARE Laboratory. culture and sensitivity of the wound INTERVENTIONS RATIONALES

~ ~~ may be done to identify the infection organism Assess presence of peripheral Changes in equality between and the optimal antimicrobial agent required to pulses, strength, equality, and limbs, diminished strength or eradicate the infection; sedimentation rate usually character. Notify MD for signifi- absence indicates problems with cant changes. perfusion. increased due to inflammatory response; CBC with differential used to identify elevated white blood cell count and presence of a shift to the left representing an infection process 300 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Perform neurovascular checks Circulation may become Monitor vital signs and notify Sepsis may result in temperature every 1-4 hours, noting changes impaired due to edema or tight MD for significant changes. elevation, tachycardia, and in color, temperature, movement, dressings and may result in tachypnea. or sensation. necrosis of tissues. Prompt detection of problems will allow for Observe wound for signs of Prompt recognition of infection prompt intervention. infection: redness, warmth, may result in prompt interven- drainage changes, swelling, or tion and decrease the porential Evaluate non-operative leg for Peripheral vascular disease may d eh is c en ce , for further complications. edema, inflammation, erythema, increase the incidence of post- or positive Homan’s or Pratt’s operative thrombus formation. Culture wound drainage as war- Identifies causative organism and signs. ranted, and as per hospital allows for choice of optimal protocol. antimicrobial agent to eradicate Information, Instruction, infection. Demonstration Change dressing using aseptic or Reduces spread of or introduc- sterile technique as warranted. tion of bacteria to wound.

INTERVENTIONS RATIONALES Ensure that drainage systems are Drainage systems facilitate Instrucr patient to report changes Paresthesias may occur as a result functioning properly, and that removal of drainage from wound in sensarion to operative site or of nerve damage or with measurementlemptying of which can decrease the chance of any swelling. impaired circulation. Swelling drainage is being performed. infection from stagnant body may result from fluid shifting or fluids. Measurement of drainage from continued bleeding which provides a trend to identiG loss would require intervention. of fluid as well as potential healing or deterioration of wounds.

Discharge or Maintenance Evaluation Administer antimicrobials as Drug rherapy may be given pro- ordered. phylactically using a Patient will have strong, equal peripheral pulses, broad-spectrum antibiotic until with no changes in sensation or temperature. specific sensitivity reports are available to identify organism- specific antimicrobials. + Patient will be able to accurately recall signs/symptoms to report to nurse/MD. Information, Instruction, Patient will experience optimal wound healing. Demonstration Risk for infection INTERVENTIONS RATIONALES

Related to: trauma, surgical incisions, open skin, Instruct patient on signslsymp- Allows for prompt recognition of invasive procedures, disease, decreased nutritional toms of infection to report, problems to facilitate prompt intervention. status Instruct on antimicrobial Provides knowledge and facili- Defining characteristics: temperature elevation, effects, side effects, and tates cooperation in the medical elevated white blood cell count, shift to the left, contraindications. regimen. sepsis, purulent drainage, reddened wound site, Instruct patient/family on infec- Provides knowledge and facili- swelling, wound dehiscence tion control procedures, isolation tates compliance with treatment; requirements, etc. involves rhe family in parienr care and reduces the potential for Outcome Criteria spread of infection.

Patient will be free of infection with no threat to wound healing. MUSCULOSKELETAL SYSTEM 301

~~ Impaired skin integrity INTERVENTIONS RATIONALES

~~~ ~ Related to: amputation, surgical procedure, inva- Leave wound open to air, or Helps to facilitate healing; a light cover with a light gauze dressing dressing may be required to pre- sive procedures, broken skin as soon as feasible. vent sutures or wound from becoming irritated by linens, Defining characteristics: surgical wounds, punc- clothes, etc. ture sites, abraded skin, disrupted skin or tissues Information, Instruction, Outcome Criteria Demonstration

Patient will have healed wounds with no skin or INTERVENTIONS RATIONALES tissue disruption. Instruct patient to avoid touch- Prevents spread of infection or ing wound. contamination of the wound.

Instruct patient in wound care as Promotes knowledge and pro- INTERVENTIONS RATIONALES warranted. vides for patient involvement in his care. Inspect wound daily to assess for Prompt detection of changes can healing, deterioration, color, facilitate prompt intervention for Instruct in use of abdominal Provides additional support for character and amount of complications. Decreases in binder or supportive device as incisions at risk of dehiscence. drainage, signslsyrnptoms of drainage amounts may indicate warranted. infection, etc. appropriate healing, whereas increasing amounts of drainage, or purulentlodiferous drainage Discharge or Maintenance Evaluation may indicate the presence of fistulas, hemorrhage, or infective Patient will have healed wounds with no process. impairment of skin integrity. If drainage amount is large, Helps reduce skin trauma by apply collection deviceslbags over reducing surface area in contact Patient will be able to accurately perform sites, recording amounts every 8 with drainage, and facilitates wound care utilizing appropriate infection con- hours. more accurate measurement of trol techniques. drainage. Patient will be able to use supportive devices as Cleanse wound per protocol at Helps reduce potential for infec- ordered frequency utilizing sterile tion: removes debris and caustic needed to prevent wound dehiscence. or aseptic technique. (Many drainage from skin surface to facilities use hydrogen peroxide preserve skin integrity and pro- Patient will be able to demonstrate appropriate followed by normal saline rinse.) mote healing. behavior to prevent wound healing complica-

Utilize benzoin or other slun Protects skin from abrasion with tions. barrier products prior to the removal of tape. Use of netting application of tape during dress- or Montgomery straps prevent Risk for fluid volume deficit repeated removal of tape which ing changes, or use Montgomery Related to: nauseahomiting, fever, excessive straps or stretch netting for dress- can further disrupt skin integrity. ings that may require more wound drainage, urine output, changes in vascular frequent changes. integrity, fluid shifts, oral fluid restriction Defining characteristics: imbalance between intake and output, dehydration, poor skin turgor, tenting of skin 702 CRITICAL CARE NURSING CARE PLANS

Outcome Criteria INTERVENTIONS RATIONALES

Patient will achieve and maintain an adequate Concurrent administration with analgesics may potentiare the fluid balance, with stable vital signs and hemody- analgesic in addition to control- namic parameters, and palpable pulses. ling nausea and vomiting related to the pain medication.

~~ ~ Monitor lab values for hemoglo- Hematocrit provides an indicator INTERVENTIONS RATIONALES bin and hernatocrit, and notify of fluid volume status and hydra- MD for significant changes. tion. Blood losses that are not Monitor viral signs every 1-2 Fluid deficit symptoms may be replaced may result in further hours. manifested in low blood pres- fluid deficits. sure, and increases in respiratory and heart rates. Changes in pulse quality or cool and clammy skin may indicate decreased perfusion Information, Instruction, and peripheral circularion and Demonstration

the need for replacement fluids. ~~ ~~~ INTERVENTIONS RATIONALES Monitor intake and output q 1-2 Prompt recognition of imbalance hours, and notify MD of signifi- and fluid loss provides for Instruct patient to report Pressure sensation may result cant fluid imbalances or urine prompt intervention and replen- increases in wound drainage, from retroperitoneal hemorrhage output less than 30 cclhr for 2 ishment of necessary fluids. leakage, or feelings of pressure and should be evaluated immedi- hours. sensation to wound areas. ately. Including the patient in his Evaluate for presence of Immediate postoperative nausea care provides for cooperation with medical regimen and pro- nausedvomiting; medicate as may result due to length of anes- warranted. thesia and predisposition for vides for prompt recognition of nausea. Nausedvomiting lasting potential problems that may lead longer than 3 days may result to circulatory collapse from from adverse reactions to anal- hypovolemia. gesics or other medications. Discharge or Maintenance Evaluation Observe wound sites for Sudden cessation of previously noted wound drainage may indi- increases in drainage, swelling to Patient will be adequately hydrated, normoten- area, or lack of drainage in drain cate an obstruction in the tubes. drainage system, with potential sive, with equal palpable pulses. drainage then routed to tissues and other cavities. Edema to Patient will have a balanced fluid intake with wound sites may indicate the adequate urinary output. formation of a hematoma or hemorrhage from the wound. Patient will have normal skin turgor and moist Lack of swelling does not mean mucous membranes. that hemorrhage is not occurring-retroperitoneal bleeding Patient will be able to accurately recall may not be visually noted until signs/symptoms to notify nurse/MD. long after the patient has shown vital sign changes.

Administer IV fluids, blood and Replaces necessary fluids and Body image disturbance blood products as warranted. increases circulating volume. Related to: loss of body part, disease process, dis- Administer antiemetic drugs as Relieves nausea and vomiting loss warranted; may administer these which can result in the ability to figurement, of function in combination with analgesics. ingest adequate fluid amounts. MUSCULOSKELETAL SYSTEM 303

Defining characteristics: negative feelings about INTERVENTIONS RATIONALES body, preoccupation with missing part, avoidance Encourage family members to Provides opportunity for family of looking at missing part, perceptions of changes assist with care and assess their members to deal with the loss in lifestyle, preoccupation with previous function ability to support patient. and to help in the rehabilitation of missing part, feelings of helplessness phase.

Outcome Criteria Information, Instruction, Patient will be able to adapt and cope with Demonstration changes in body image and demonstrate ability to INTERVENTIONS RATIONALES accept self.

Instruct patientlfamily as to pre- Promotes knowledge and pro-

~~ and postoperative care, rehabili- vides opportuniry for patient to INTERVENTIONS RATIONALES tation, and use of prosthetics. verbalize concerns and questions, May enhance postoperative Evaluate patient’s ability to deal Provides input as to level of recovery and facilitate compli- with amputation and his percep- understanding of patient. ance with medical treatment. tion of need for amputation. Traumatic amputees most often have trouble in dealing with Obtain consultations as May enhance patient’s rehabilita- body image problems, as warranted with counselors or tion and ability to adapt to new opposed to those who have rec- therapists. body image. onciled that amputation may Discuss concerns regarding sexu- Provides knowledge and helps have been a life-saving proce- ality as warranted. with adjustment to body image, dure. as well as provides opportunity Observe for withdrawal, denial, Patients may not be able to deal to dispel any misconceptions. or negativity regarding self. with the trauma initially and may require time to come to terms with their new self. Recognition of stages of grief Discharge or Maintenance Evaluation provides opportunity for interventions. Patient will adapt and accept new situation and Provide time to discuss patient’s Provides opportunity to dispel body image changes. concerns over the change in body false concerns and allows time structure and his perceptions of for problem solving with realistic Patient will be able to identify methods to adapt needs for a new/different goals. to changes and will be able to have positive self- lifestyle. esteem. Encourage patient to help partic- Promotes feelings of indepen- Patient will be able to identify realistic goals and ipate in his care and provide dence and allows time for patient opportunities for patient to to accept his body image. plans for rehabilitation and adapting to modifi- observe stump. Positive reinforcement regarding cation in body image. the progress toward healing may hrther help his self-worth. Anticipatory grieving Discuss the availability of visits Another person who has gone Related to: actual loss of physical well-being by another amputee. through the same experience may facilitate recovery and help the Defining characteristics: expressions of anger or patient to recognize how he may attain a normal lifestyle. 304 CRITICAL CARE NURSING CARE PLANS

distress at loss, crying, sadness, guilt, alterations in INTERVENTIONS RATIONALES sleep patterns, activity, eating or libido Assist patient to focus on needs Reduces frustration of facing an Outcome Criteria he has now before changing uncertain future, and allows the focus to long-term goals. patient some control in dealing Patient will be able to express feelings Encourage patient to take con- with current problems. appropriately and work through the stages of grief trol in decisions regarding his care whenever possible. and grieving. Provide acceptance of anger, Acceptance of the patient‘s feel- hopelessness, and depression, but ings acknowledges him as being set limits on unacceptable behav- worthwhile and a non-judgmen- INTERVENTIONS RATIONALES ior when warranted. ral attitude is important in establishing trust and care. Evaluate emotional status. Anxiety, depression, and anger Limits may be needed to protecr are normal reactions to loss of the patient and others from vio- body parts. The patient may lent behavior while allowing the progress through the various patient to express his negative stages of grief at their own rate feelings. and changes may be related to their physical condition as well. Provide consultation with thera- Physical and spiritual distress will pists, social workers, or minister be faced by the patient and hls Identify patient‘s stage in the Shock may be the initial response as warranted. family and they will require long- grieving process. associated with the amputation, term assistance and counseling in especially if it was traumatic. The order to cope with the changes patient may be so acutely ill that required by this injury. he is unable to express his feelings and concerns. Denial may initially be useful for patient’s ability to cope with the injury, Discharge or Maintenance Evaluation but continued denial may impair the patient’s ability to effectively Patient will be able to progress through the vari- deal with the problem. Anger ous stages of grief and grieving effectively. may be expressed either verbally, non-verbally, or physically, and Patient will be able to express his feelings and the patient may displace his concerns appropriately without unacceptable anger by placing blame. Depression may last from weeks violent be havior. to years and acceptance and support for these feelings will Patient will be able to access community facilitate recovery. resources for long-term counseling and

Provide factual information to Family may be where the initial assistance to deal with his injury. patientlfamily in regard to the instruction is directed if the Patient and family will be able to gain adequate diagnosis/prognosis. Do not give patient’s awareness is diminished false reassurance. due to his injury. The final out- support throughout the grieving process. come of a patient’s injuries may not be initially known and so information should be kept simple. MUSCULOSKELETAL SYSTEM 305

AMPUTATION

Trauma or end result of disease process 4 Loss of body part I I I I I Hemorrhage Edema Decreased mobility Infection J 4 4 Decreased fluid Decreased venous Pain volume return 4

Decreased perfusion Respiratory insufficiency

LHypoxia I 4 Inability for wound to heal 4 Cellular ischemia/death

Systematic infection 4 4 Sepsis 4 DEATH This Page Intentionally Left Blank ~ MUSCULOSKELETAL SYSTEM 307

Fat Dextran: low molecular weight dextran may be Embolism used to alter platelets and decrease intimal adhe- A fat embolism usually occurs in patients with sions multiple fractures or fractures that involve the X-rays: serial chest x-rays are used to evaluate pul- long bones or pelvis, when particles of bone monary improvement or deterioration; x-rays of marrow, tissue fat droplets, or combinations of the bones involved in injury are used to evaluate platelets and free fatty acids are released and healing process or alignment problems migrate to the lungs or brain. Embolization can occur within the first 24 hours up to 72 hours after injury. NURSING CARE PLANS Impaired exchange The first signs/symptoms are usually changes in gas the mental status, with apprehension, confusion Related to: altered blood flow due to embolism, and restlessness noted. Petechiae to the chest, shunting anterior axillae, shoulders, conjunctiva and buccal Defining characteristics: abnormal acid-base bal- membranes occur due to capillary occlusion and ance, hypoxemia, hypoxia, tachypnea, tachycardia, are usually seen later. Respiratory distress with air hunger, dyspnea, cyanosis, decreased oxygen hypoxemia and hypoxia, pulmonary edema, and saturation interstitial pneumonitis occur. The pulse rate increases, temperature elevates above 100 degrees and PaO, decreases. Outcome Criteria Patient will be able to achieve and maintain ade- MEDICAL CARE quate respiratory function with arterial blood gases Laboratory: serum lipase is elevated, sedimenta- within normal ranges and with no evidence of res- tion rate is increased; urine tests used to evaluate piratory distress. presence of free fat

Arterial blood gases: used to evaluate acid-base INTERVENTIONS RATIONALES balance, presence of adequate oxygenation, and ~~ Monitor vital signs, especially Dyspnea and tachypnea may be response to oxygen therapy respiratory status; assess for dysp- early signs of respiratory insufficiency. Other signs usually result Electrocardiogram: used to evaluate changes in nea, use of accessory muscles, retractions. nasal flaring, or stri- from advanced respiratory dis- heart rate as well as cardiac changes, such as inver- dor. tress, and all require prompt sion of T waves and prominence of S wave in lead intervention. I showing myocardial and right ventricular failure Observe for changes in mental Changes in mental status often status, irritability, apprehension, are the very first signs in respira- Corticosteroids: use is controversial, but may or confusion. tory insufficiency.As hypoxernia decrease inflammation and swelling and acidosis worsen, the level of consciousness may deteriorate to Heparin: use is controversial, but low dose the point of lethargy or stupor. heparin may be used to clear lipemic plasma and Monitor pulse oxirnetry for Oximetry may provide early stimulate lipase activity oxygen saturation and notify warning of decreasing oxygena- MD for levels below 90%. tion and allow for prompt and timely intervention. In patients 308 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

who have decreased peripheral Monitor lab studies. Patients with far emboli circulation however, the accuracy frequenrly have anemia, elevated of pulse oximetry will be com- sedimentation rates, elevated promised and cannot be relied lipase levels, fat in body fluids, on totally. hypocalcemia, and thrombocytopenia. Administer oxygen via nasal can- Provides supplemental oxygcn nula or mask as warranted. and increases available supply of Administer corticosteroids as Some physicians use steroids to oxygen to ensure optimal tissue ordered. prevent and treat fat emboli. oxygenation.

Obtain ABGs as warranted. Decreased PaO, and increased PaCO, indicate impending respi- Discharge or Maintenance Evaluation ratory failure and impaired gas exchange. Patient will have no respiratory dysfunction or distress. Auscultate breath sounds for Adventitious breath sounds may changes in equality and for pres- indicate progression of respira- Patient will have arterial blood gases within his ence of crackles (rales), rhonchi, tory insufficiency. Inspiratory wheezing, inspiratory stridor or crowing may indicate upper normal range. crowing, or hyperresonant airway edema frequently seen sounds. with fat emboli.

Observe for presence of blood in May indicate hemoptysis that spurum. occurs with pulmonary embolism.

Observe for petechiae CO chest, Petechiae to these areas are fre- axillae, buccal mucosa, and con- quently seen with fat emboli, junctiva. and may occur 2-5 days after injury.

Encourage coughing, deep Improves alveolar ventilation/ breathing exercises, and use of oxygenation and helps to mini- incentive spirometer. mize atelectasis.

Information, Instruction, Demonstration

INTERVENTIONS RATIONALES

Prepare for placement on ventila- Deteriorating respiratory status tor as warranted. may require mechanical ventilation to facilitate oxygenation. [See Mechanical Ventilation Care Plan.]

Use great care in repositioning Gentle handling of injured bones patient especially dxing the first and tissues may prevent the days post-injury. development of a fat embolism. MUSCULOS KELETm SYSTEM 309

FAT EMBOLISM

Fractures 4 Trauma

Increased catecholamine Increased pressure in long and steroid release bones with high fat content 4 4 Causes serum lipids to Fat forced into blood stream mobilize tissue stores of fat into circulation I I I I Marrow embolus Tissue fat globules Platelets & free fatty acids I c I Embolize to pulmonary capillaries 4 Obstruction of pulmonary blood flow 4 Decreased tissue perfusion 4 Increased pulmonary vascular resistance and back-up pressures 4 Pulmonary hypertension 4 Ventilation/perfusion mismatching Right to left shunting 4 Pulmonary constriction 4 Decreased Pa02 Hypoxemia 4 Respiratory distress 4 Cardiovascular collapse 4 DEATH This Page Intentionally Left Blank INTEGUMENTARY SYSTEM 31 1

Frost bite/Hypothermia Malignant Hyperthermia BurndTherrnal Injuries This Page Intentionally Left Blank INTEGUMENTARY SYSTEM 313

The core temperature may be as low as 80" FrostbiteAiyuotherrnia Fahrenheit and below 900, the body loses its self- Injuries from overexposure to cold, either air or warming mechanisms. water, occur in two types-localized injuries, such Hypothermia may also preclude successful resusci- as frostbite, and systemic injuries, such as tation. Cardiac arrest is difficult to overcome if the hypothermia. Untreated, both may be fatal. core temperature is less than 85" Fahrenheit due to Frostbite occurs after exposure to cold the increased ventricular fibrillation threshold. temperatures, usually below freezing. The severity Treatment is aimed at rewarming the body to of the injury is dependent on the,amount of body increase the core temperature to adequate ranges, heat lost, age and exacerbating factors such as and to preserve organ and tissue viability. wind chill, presence of wet clothing, and impairment of the circulatory status. MEDICAL CARE In frostbite, ice crystals form in the tissue fluids in Laboratory: CBC may indicate infection with and between the cells, causing injury to the red shift to left; electrolytes will be required to restore blood cells, which then develop sludging, and vas- balance from fluid shifts cular damage. Blood is shunted to the heart and the brain. Skin is cold, hard, ashen white and IV fluids: used to restore circulating volume and numb, and with rewarming, becomes splotchy red prevent dehydration, and may be used to assist or grayish in color, edematous, and very painful. with rewarming Frostbite can be either superficial, affecting skin Dextran: low molecular weight dextran may be and subcutaneous tissues, or deep, extending used to improve microcirculation to tissues below subcutaneous tissues. With deep frostbite, Reserpine: may be used to decrease sludging from the skin becomes white until thawed and then it injured cells and tissues becomes purplish-blue, with painful skin blisters, tissue necrosis, and development of gangrene Antibiotics: may be necessary to treat infection if when the tissue dies. At this point, amputation of patient has open wounds or systemic infection the extremity may be required. Analgesics: morphine and other drugs may be The most frequently seen sites that are involved used to relieve severe pain from cold injuries; with frostbite are the nose, ears, hands, and lower aspirin may be used to decrease platelet aggrega- extremities. The goal of treatment is to restore tion and sludging body temperature to normal and prevent vascular Surgery: fasciotomy may be required to reduce damage to tissues. Supportive care is also impor- tissue pressure caused from edema; amputation tant in restoring electrolyte imbalances and may be necessary for gangrenous injuries, or preventing hypovolemia. debridement may be required for necrotic tissues Hypothermia occurs when the body's core temper- Dialysis: peritonea1 or hemodialysis may be used ature drops below 95" Farenheit and is noted by depending on severity of injury, in order to lethargy, mental dullness, decreasing level of con- rewarm body sciousness, visual and auditory hallucinations, decreases in respirations and heart rate, and coma. 314 CRITICAL CARE NURSING CARE PLANS

Rewarming techniques: warming blankets, INTERVENTIONS RATIONALES warmed solutions for chest lavage or bladder irrigation, and warmed IV solutions may be utilized Observe for mental changes and Shivering is suppressed at tem- to increase temperature return of shivering response. peratures below 90 degrees F and is che body's normal response to facilitate self-warming. Patients NURSING CARE PLANS have decreased mental abilities and levels of consciousness Inefective thermorepltion dependent on severity of hypothermidinjury, with Related to: exposure to cold, suppressed shivering hypoxia and hypoxemia occur- response ring due to decreased perfusion. Defining characteristics: temperature below 95" Fahrenheit, cold skin, mottling, cyanosis, pallor, Information, Instruction, poor judgment, apathy, decreased mental ability, Demonstration level of consciousness changes, coma, lack of shiv- INTERVENTIONS RATIONALES ering, cardiopulmonary arrest, anuria, oliguria, ~ decreased peripheral perfusion Instruct patient/family on appro- Provides knowledge and reduces priate procedures for rewarming. anxiety.

Outcome Criteria Discharge or Maintenance Evaluation Patient will achieve and maintain an acceptable Patient will be normothermic, with stable vital temperature with no complications. signs. Patient will be awake, alert, and oriented, with INTERVENTIONS RATIONALES no alterations in abilities. Patient will be able to maintain thermoregula- Obtain baseline temperature, and Temperatures below 90 degrees monitor every 15 minutes until result in suppression of normal tion. stable. body mechanisms to self-warming. Rewarming that is done too Patient will exhibit no complications from rapidly may cause peripheral hypothermia. vasodilation and may actually impede rewarming efforts. Alteration in tissue pe@sion: peripheral, cerebral, curdiopulmonuy, renal, gastroin- Rewarm patient per hospital Early rewarming decreases tissue protocol. (Whole body or partial damage from ice crystal forma- testinul immersion into water that is 99- tion, and helps to decrease 105 degrees, hypothermia cardiac instability and predisposi- Related to: exposure to cold temperatures, frozen blankets, gastric lavage with tion to ventricular fibrillation. body parts, hypothermia, tissue necrosis, sludging warmed solutions, peritonea1 or of red blood cells, tissue ischemia hemodialysis, and IV infusions that are warmed are some meth- Defining characteristics: skin mottling, grayish ods currently used.) skin color, purplish-blue color, cold skin, burning, tingling, numbness, pain, skin blisters, gangrene, diminished or absent pulses, decreased capillary INTEGUMENTARY SYSTEM 315

refill, cardiac dysrhythmias, cardiac standstill, INTERVENTIONS RATIONALES apnea, dyspnea, mental changes, unconsciousness, changes in consciousness level, coma, gangrene, Move and handle patient and Excessive movement may trigger oliguria, anuria, absent bowel sounds, ileus handle him gently when lethal dysrhythmias or may cause required. tissue damage.

Administer warmed IV solutions Restores circulating volume, as ordered. helps to maintain hydration and output, assists with rewarming Outcome Criteria efforts, and assists with treatment of hypotension. Patient will achieve and maintain normal body temperature with no lasting complications of Monitor hourly intake and Anuria or oliguria may indicate output, and notify MD for sig- decreased perfusion CO renal ves- decreased perfusion. nificant changes or sels or dehydration. abnormalities.

Evaluate patient's level of con- Patients may have weakness, INTERVENTIONS RATIONALES sciousness and mental status, and incoordination, apathy, drowsi- notify MD for significant ness, and confusion with Monitor EKG for rhythm Hypothermia affects heart rate changes. hypothermia. When body tem- changes, dysrhythmias, and car- and rhythm and may cause heart perature is below 90 degrees diac standstill, and treat irregularities due to hypoxemia F, stupor and coma are common. according to hospital policy. and conduction problems. Heart rhythm may be difficult to Observe for muscle tremors, Neurologic symptoms may occur restore to sinus when body tem- decreased reflexes, seizures, and due to hypothermic influences. perature is less than 85" F Parkinson-like muscle tone. because of the increased ventricular fibrillation threshold. A Remove constricting clothing Constriction especially in the 12-lead EKG may show an early and jewelry from patient. presence of edema may impair J wave in the left ventricular circulation and perfusion. leads. Rewarm involved extremity in Prompt rewarming teverses ice Monitor vital signs every 15 During initial period after tepid water (37-40" Centigrade) crystal formation in tissues. minutes until stable, then every exposure, pulses and blood until the tips of the injured part Warmer water is not indicated 1-2 hours. pressure may be too weak to be flush. due to the potential for burns. detectable. Rewarming too The appearance of skin flushing rapidly may result in heart indicates that circulatory flow irregularities. has been reestablished.

Administer oxygen as ordered, PaOz should be maintained Avoid rubbing the injured Helps to prevent further tissue with warmed humidification. above normal levels to treat extremity, and handle the area damage. hypoxia and hypoxemia that gently. occurs with acidosis as a result of Encourage patient to take warm Assists with rewarming. the injury and exposure. liquids if possible. Monitor pulse oximetry levels Facilitates prompt identification Monitor vital signs; palpate for When extremity has rewarmed, and notif) MD if level drops of acid-base imbalances and presence and character of pulses pulse should be able to be pal- below 90%. Monitor ABGs for changes in ventilation/ to extremities. Notify MD if pated. Absence of pulse may changes. oxygenation. pulse is absent after rewarming is indicate decreased or absent Monitor peripheral pulses for Decreased or absent pulses may accomplished. circulation. presence, character, quality, and indicate impairment in circula- changes. tion to extremities and may preclude tissue ischemia and necrosis. 316 CRITICAL CARE NURSING CARE PLANS

Information, Instruction, INTERVENTIONS RATIONALES Demonstration Evaluate pain level, and medicate Rewarming process is extremely INTERVENTIONS RATIONALES with analgesics as ordered. painful.

Prepare patient for fasciotorny or Ederna may impair circulation Elevate injured extremity on Decreases edema which can amputation as warranted. requiring a fasciotomy to relieve pillows as warranted. result in pressure to tissues and pressure. If gangrene is present, pain. amputation of the involved area will be necessary. Provide backrubs, repositioning, Helps to refocus attention and deep breathing exercises, visual- enhances relaxation and ability to Instruct patient regarding long- Provides knowledge and identi- ization, guided imagery, etc. cope with pain. term effects: increased sensitivity fies symptoms that patient may to cold, tingling, burning, be faced with during his lifetime. increased sweating, etc. Discharge or Maintenance Evaluation Instruct patient to avoid Smoking causes vasoconstriction smoking. and may inhibit healing process. Patient will be. pain free. Patient will be able to utilize comfort measures Discharge or Maintenance Evaluation and techniques effectively to reduce or alleviate pain. Patient will achieve optimal circulation and Risk infection peripheral perfusion with equal palpable pulses. for Patient will be able to recall and adhere to Related to: frozen tissue, open wounds, decreased tissue perfusion, edema ’instructions and avoid preventable complications. Defining characteristics: elevated temperature, Patient will be able to recall instructions accu- elevated white blood cell count, shift to left on differential, tachycardia, drainage, gangrene, rately. edema Alteration in comfirt Related to: tissue damage, surgical procedures, Outcome Criteria rewarming Patient will be free of open wounds and infection Defining characteristics: communication of pain, process, and/or wounds will heal in a timely facial grimacing, moaning, guarding, abnormal manner. focus on pain, anxiety

Outcome Criteria INTERVENTIONS RATIONALES When extremity has been Dressings between digits reduce Patient will be free of pain, or pain will be rewarmed, apply a bulky sterile moisture and help prevent tissue controlled to patient’s satisfaction. dressing to the area. Place gauze damage. Dressings help protect between toes or fingers. the area to reduce further injury. If blisters are present, avoid rup- Reduces the risk of infection. turing them. INTEGUMENTARY SYSTEM 317

INTERVENTIONS RATIONALES

Use sterile or strict aseptic tech- Frostbite makes the patient sus- nique for all dressing changes. ceptible to infection.

Assist with whirlpool treatments Treatments help CO improve cir- for the injured extremity. culation, remove dead tissue, and help prevent infection.

Monitor vital signs and patient Fever, tachycardia, and tachypnea for presence of fever and chills. may indicate presence of infection.

Administer antimicrobials as Eradicates infective organism and ordered. may be given prophyiacticdly.

Administer tetanus toxoid as Concurrent trauma may necessi- ordered. tate administration to prevent onset of tetanus.

Discharge or Maintenance Evaluation

Patient will be free of drainage from injury. Patient will be afebrile, with normal vital signs, and no symptoms of infection. Patient will have no systemic infection, or preventable complication. 318 CRITICAL CARE NURSING CARE PLANS

FROSTBITE/HYPOTHERMIA

Exposure to cold JI Vasoconstriction 4 Failure of autoregulatory warming mechanisms 4 Shunting of blood to vital organs 4 Ice crystals form in and between cells c RBCs form sludge c Capillary ihrombosis 4 Tissue ischemia I I Decreased Axygenation Tissue necrosis 4 4 Gangrene '7 Hypoxia

1 I I 1 I Acidosis Lethargy Decreased Cardiac c respiratory dysrhythmias effort 4 1 4 Sepsis Confusion Bradypnea Cardiac arrest 4 4 Hallucinations Apnea 4 4

DEATH INTEGUMENTARY SYSTEM 319

Hypothermic treatment: cooling blankets, iced Malignant Hmerthermia lavages and enemas, infusions of cooled IV solu- Malignant hyperthermia is a condition occurring tions may be required to reduce temperature from surgical procedures in which inhalation agents or muscle relaxants, such as NURSING CARE PLANS succinylcholine, enflurane, fluroxene, ether, or Hypertbermiu halothane, are used. Although it occurs only about once in every 20,000 patients, the consequences Related to: reaction to anesthetic agents; hyper- may be lethal. Malignant hyperthermia results metabolic state from excessive stores of calcium in the intracellular Defining characteristics: elevated temperature, spaces that causes a hypermetabolic state with tachycardia, tachypnea, muscle rigidity, tetany, increased muscle contractions. cyanosis, presence of heart failure, acidosis, The inherited trait for this condition can be iden- dysrhythmias, shock tified by increased creatine phosphokinase levels and/or muscle biopsy for histiochemistry and in Outcome Criteria vitro exposure to halothane. When this condition trait is identified in a patient who requires surgery, Patient will be free of fever, with stable vital signs, the preferred option is for local anesthesia. and will exhibit no evidence of muscle tetany. The patient will notably have muscle rigidity, followed by tachycardia, dysrhythmias, rapidly INTERVENTIONS RATIONALES increasing temperature, acidosis and shock. If left untreated, it has a mortality rate of 70%. Monitor vital signs frequently; if Provides for prompt identifica- able, continuously monitor tem- tion of worsening condition and Treatment is aimed at recognition of the perature for changes. allows for observation for effec- condition, with discontinuation of all anesthetic tiveness of therapy. agents, and administration of dantrolene Monitor EKG for changes and Dysrhythmias may occur as a intravenously to slow down rate of metabolism. treat dysrhythmias per hospital result of the marked protocol. hyperkalemia that may occur, or Supportive therapy to correct acidosis and fever with electrolyte imbalances from should also be performed. fluid overload.

Administer dantrolene as Normally given from 2-4 mg/kg MEDICAL CARE ordered. IV rapidly through fast-running IV line; repeated every 15 min- Electrocardiogram: used to identify conduction utes until a total of 10 mg/kg has problems or dysrhythmias that may occur been given, or symptoms subside. Dantrolene inhibits calcium Oxygen: used to supplement oxygen supply due release. to increased metabolic state Monitor ABGs for changes. May indicate metabolic or respiratory acidosis, and patients Dantrium: drug used to reverse effects of excessive frequently have noted base excess calcium in intracellular areas; usually given until -10 mmol. symptoms abate Administer cooled IV solutions Methods may be required to as ordered, utilize iced solutions decrease remperature to prevenr Sodium bicarbonate: may be used to treat severe acidosis 320 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Related to: hypermetabolic state, fluid shifting Defining characteristics: increased blood pressure for gastric lavage or enema, further complication and body and/or place patient on cooling exhaustion. and pulse, dyspnea, edema, confusion, restlessness, blanket. decreased urinary output, increased systemic vascular resistance, decreased cardiac output and Observe for shivering and Shivering is a normal reaction to administer Thorazine as ordered. applications of cold, but is coun- cardiac index terproductive because it increases metabolism to try to compensate Risk for altered nutrition: less than body for temperature changes. requirements Thorazine is given to decrease [See Pheochromocytoma] shivering and reduce metabolic workload. Related to: hypermetabolic state, anorexia Defining characteristics: inadequate food intake, Information, Instruction, weight loss, muscle weakness, fatigue Demonstration Risk for impaired gas exchange INTERVENTIONS RATIONALES [See Pheochromocytoma] Instruct patientlfamily in need May identify potential for anes- Related to: increased respiratory workload, of testing other members of the thetic complications and avoid family for autorecessive trait. potentially life-threatening impaired oxygen to the heart, hypoventilation, condition. altered oxygen supply, altered blood flow, change in vascular resistance Instruct in utilization of Assists with understanding and hypothermic therapy methods. facilitates compliance with Defining characteristics: confusion, restlessness, discomfort. hypercapnia, hypoxia, cyanosis, dyspnea, tachyp- Discharge or Maintenance Evaluation nea, changes in ABG values, metabolic acidosis, respiratory acidosis, activity intolerance Patient will be normothermic with stable vital signs. Patient will have EKG with no rhythm aberrancies or conduction problems. Patient will exhibit no abnormal muscle contractions or tetany. Patient will be able to verbalize understanding of treatment and comply with regimen. Patient’s family will comply and be tested for presence of trait that predisposes them to complications from anesthetic. Risk for decreased cardiac output [See Pheochromocytoma] ~ INTEGUMENTARY SYSTEM 321

MALIGNANT HYPERTHERMIA

Inherited autosomal dominant PLUS Muscle relaxants and/or general inhalation agents used for surgical procedures 4 Excessive intracelldar accumulations of calcium 4

Increased metabolism rate Hyperkalemia 4 4 Increased muscle rigidity Cardiac dysrhythmias 4 4 Increased muscle contractions Cardiac insufficiency 4 Muscle tissue breakdown with increased CPK and myoglobin c Increased workload on renal system

Impaired oxygenation of tissues - 4 - Metabolic acidosis 4 Cardiovascular and renal compromise J, Organ failure J, DEATH This Page Intentionally Left Blank INTEGUMENTARY SYSTEM 323

body surface area is involved. The burn injury causes dilation of the capillaries and small vessels Burns/Thermal Injuries which leads to increased capillary permeability and Burns may be caused from thermal, chemical, increased plasma loss. As edema increases, the electrical, or radioactive sources and may involve destruction of the epidermis becomes a breeding complex forms of trauma to multiple body ground for bacterial invasion and dead tissue systems. The depth of the injury is partially deter- sloughs off. mined by the duration and intensity of exposure to the burning agent. The initial treatment of a burn patient is to stop Laboratory: CBC will initially show elevated the burning process. This may be accomplished by hematocrit due to hernoconcentration, and later cooling the skin, removal of contact with chemi- decreased hematocrit may mean vascular damage cals, removal from electrical current, or removal to endothelium; white blood cell count may from radioactive environment. Often, inhalation increase due to inflammatory response to the injury also occurs because of inspiration of heated trauma and wound infection; electrolytes may soot particles, chemicals and corrosives, or toxic show initially hyperkalemia due to injury, later fumes. changing to hypokalemia when diuretic phase begins; sodium initially decreased with fluid loss A severe burn, one in which the patient has 30% and later changes to hypernatremia when renal of his body involved, may take months to years to system attempts to conserve water; alkaline phos- heal, and mortality is very high. Full-thickness, or phatase elevated, glucose elevated due to stress third degree, burns involve all the layers of the reaction; albumin decreased; BUN and creatinine skin and sometimes underlying tissues. Partial- elevated due to renal dysfunction; carboxyhemo- thickness burns involve the epidermis and upper globin may be done to identify carbon monoxide portions of the dermis. Fourth degree burns poisoning with inhalation injury involve not only the epithelium, but fat, musculature, and bones, requiring extensive debridement Radiography: chest-x-rays used to identify compli- and skin grafting. cations that may occur as a result of inhalation injury or with fluid shifting from rapid There are several methods available for determina- replacement tion of the percentage of body burn involvement, but the “rule of nines” is frequently utilized. The Arterial blood gases: used to identify hypoxia or body is sectioned off with each arm and head/neck acid-base imbalances; acidosis may be noted area equaling 3%, front, back, and each leg equal- because of decreased renal perhsion; hypercapnia ing 18%, and the perineum equaling 1%. Extent and hypoxia may occur with carbon monoxide of thickness, age, and other factors also play a sig- poisoning nificant role with treatment options. For acutely Lung scans: may be used to identify magnitude of severe burns, transport to a burn center is recom- lung damage from inhalation injury mended. Electrocardiogram: used to identify myocardial Shock may occur in adults who have burns cover- ischemia or dysrhythmias that may occur with ing greater than 15% of their body surface area, burns or electrolyte imbalances and with children when greater than 10% of their 324 CRITICAL CARE NURSING CARE PLANS

Analgesics: required to reduce pain associated INTERVENTIONS RATIONALES with tissue damage and nerve injury Measure hemodynamics if pul- CW, or right atrial pressure, Tetanus toxoid: required to provide immunity monary artery catheter has been gives estimate of fluid volume against infective organism placed. Notify MD for abnormal status. Dehydration may be parameters. reflected by CVP of less than 5, Antimicrobials: may be required to treat infection while overhydration may be reflected at levels over 18 cm Surgery: may be required for skin grafting, H20. Hemodynamic values may fasciotomy, debridement, or repair of other help to evaluate the body’s response to the circulating vol- injuries umes. lV fluids: massive amounts of IV fluids may be Observe for restlessness, anxiery, Changes may reflect the severity required for fluid resuscitation immediately post- mental changes, changes in level of fluid loss. burn, and will be required for maintenance of of consciousness, or weakness. fluid balance as shifting occurs Observe for bleeding from all May indicate impaired coagula- orifices and puncture sites, and tion, impending or present DIC, for presenceldevelopment of or inadequate replacement of NURSING CARE PLIINS ecchymoses, hematomas, or clotting factors. petechiae. Risk for fluid volume &ficit Monitor intake and output May indicate fluid volume Related to: burn injury, loss of fluid through hourly and notify MD for signif- deficit, and establishes a guide injured surfaces, hemorrhage, increased metabolic icant imbalances. for fluid and blood product state, fluid shifts, third spacing, shock, increased replacement. Fluid replacement is titrated to ensure urinary cellular membrane permeability output of at least 30-40 cdhr. Myoglobin may discolor the Defining characteristics: tachycardia, urine red to black, and if present, hypotension, changes in mental status, restlessness, urinary output should be at leas decreased urine output, prolonged capillary refill, 75-100 cc/hr to reduce potential pallor, mottling, diaphoresis, poor turgor for renal tubular necrosis. Administer IV fluids as ordered. Replaces fluid loss, allows for Two IV sites should be main- administration of vasoactive Outcome Criteria tained. drugs, plasma extenders, and emergency medications, as well Patient will achieve and maintain fluid balance as the administration. Two sites with adequate urinary output. are recommended to facilitate simultaneous fluid and blood resuscitation in critical settings. Crystalloids, such as Ringer’s INTERVENTIONS RATIONALES lactate, are used during the first 24 hours, then colloids are used Monitor vital signs, and notify Hypotension may indicate that because colloids help to mobilize MD of significant changes or the circulating fluid volume is extravascular fluids. Dextrose is trends. decreased. Changes in vital signs usually not given during the first may indicate the amount of 24 hours after injury because blood loss but may not change dextrose does not remain in the until loss is greater than 1000 cc. vascular space where it is needed. Hypovolemic shock may occur due to hemorrhage, third spacing, or coagulopathy. INTEGUMENTARY SYSTEM 325

INTERVENTIONS RATIONALES apnea, cough with or without productivity, cyanosis, fever, anxiety] restlessness Administer blood andlor blood Whole blood may be required products as ordered. for acute bleeding episodes with shock due to the lack of clotting Outcome Criteria factors in packed red blood cells. Fresh frozen plasma andlor Patient will have clear breath sounds with stable platelets may be required to replace clotting factors and to respiratory status. promote platelet function.

INTERVENTIONS RATIONALES Identify causative agent of burn. May reflect type of exposure to toxic substances and potential for Information, Instruction, inhalation injury. Demonstration Monitor respiratory status for May indicate the presence or changes in rate, character, or impending respiratory insuffi- INTERVENTIONS RATIONALES depth; note tissue color changes ciency and distress. Cherry red ~~ ____~ ~~ ~ ~~ with cyanosis, pallor, or cherry color may indicate carbon Prepare patient for placement of Provides knowledge to the red color. monoxide poisoning. pulmonary artery catheter. patient, and catheter is invalu- able for identifying changes in Auscultate lung fields for adven- Obstruction of aimay and respi- fluid status and hemodynamic titious breath sounds. ratory distress may happen responses to those changes. quickly, but may be delayed up to 48 hours post injury. Identification of abnormal crack- Discharge or Maintenance Evaluation les, wheezing, or stridor may indicate impending airway compromise and require immediate Patient will have stable vital signs and urinary intervention. output. Observe for presence of cough, Inhalation injury may result in Patient will have balanced intake and output. reflexes, drooling, or dysphagia. patient’s inability to handle salivary or pulmonary secretions as a Patient will have good turgor, moist result of pulmonary edema. membranes, and adequate capillary refill times. Elevate head of bed 30-45 Promotes lung expansion and degrees. improves respiratory function. Patient will be free of hemorrhage or abnormal coagulation. Administer supplemental oxygen May be required to correct as warranted. hypoxemia and acidosis; humidi- Patient will have no transfusion reactions. fication of oxygen prevents drying out mucous membranes Risk for ineffective airway clearance and keeps secretions less viscous. Related to: airway obstruction, edema, burns to Monitor ABGs and observe for May facilitate timely identifica- trends or deterioration. tion of respiratory insufticiency the neck and chest, trauma to upper airway, pul- and hypoxemia that requires monary edema, decreased lung compliance intervention. Defining characteristics: adventitious breath Monitor oximetry continuously. Decreases in oxygen saturation may indicate impending hypox- sounds, dyspnea, tachypnea, shallow respirations, emia or hypoxia. 326 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Alteration in comfort [See Snakebite] Monitor EKG continuously and Cardiac dysrhythmias may occur treat dysrhythmias per protocol. as a result of hypoxia or Related to: burn injury, tissue destruction, electrolyte imbalances, and some wounds, debridement, surgery, invasive lines conduction problems may occur in response to rapid fluid resusci- Defining characteristics: communication of pain, tation. moaning, crying, facial grimacing, inability to concentrate, tension, anxiety Information, Instruction, Demonstration Impaired skin integn'ty [See Snakebite] INTERVENTIONS RATIONALES Related to: burn injury, surgical procedures, inva- Instruct on coughing and deep Increases lung expansion and sive lines breathing exercises. helps to mobilize secretions.

Prepare patient/family for poten- May be required for respiratory Defining characteristics: disruption of skin tial placement on mechanical embarrassment and distress. tissues, incisions, open wounds, drainage, edema ventilation. FeadAnxiety Discharge or Maintenance Evaluation [See Snakebite] Related to: burn injury, threat of death, fear of Patient will be able to breathe spontaneously on disfigurement or scarring, hospitalization, his own with no adventitious breath sounds and mechanical ventilation adequate oxygen saturation. Defining characteristics: expressions of apprehen- Patient will have arterial blood gases within sion, tension, restlessness, insomnia, expressions of normal limits. concern, fear of unknown, tachypnea, tachycardia, Patient will be able to comply with coughing inability to concentrate or focus and deep breathing exercises to help clear Alteration in nutrition: less than body mucous secretions. requirements Patient will not develop complications from [See Pheochromocytoma] injury. Related to: burn injury, increased metabolic rate, Risk for impairedgm exchange intubation [See Mechanical Ventilation] Defining characteristics: intake less than output, Related to: carbon monoxide poisoning, smoke weight loss, abnormal electrolytes, weakness, inhalation, upper airway obstruction, burn lethargy, catabolic state Defining characteristics: increased work of breath- Impaired physical mobility ing, dyspnea, abnormal arterial blood gases, [See Fractures] hypoxemia, hypoxia, decreased oxygen saturation, Related to: burn injury, dressings, imposed physi- inability to effectively cough or clear secretions, cal inactivity viscous secretions, confusion, lethargy, restlessness, anxiety INTEGUMENTARY SYSTEM 327

Defining characteristics: inability to move at will, imposed inactivity, contractures, wounds, pain Risk for infiction [See Frostbite] Related to: burn injury, tissue destruction, open wounds, impaired skin integrity, ARDS Defining characteristics: elevated white blood cell count, differential shift to the left, fever, tachycardia, tachypnea, wound drainage, necrosis, presence of systemic infection 328 CRITICAL CARE NURSING CARE PLANS

BURNS/THERMAL INJURIES

(thermal, electrical, chemical)

Contact with agent Electrical injury Inhalation injury s s s Dialation of capillaries and Physiological function Irritation to small blood vessels altered respiratory mucosa s s s Platelets and leukocytes Muscle stimulation Inflammation adhere to endothelium s s .s Increased capillary permeability Loss of reflex control Mucosal sloughing s s s Fluid shifts to interstitial spaces Ventricular fibrillation Pharngeal and laryngeal swelling/edema

s s J, Edema Respiratory paralysis Upper airway obstruction Is s Fluid lost in Hypovolemia Seizures Pulmonary edema burned tissue s s s s

4 s Bacterial invasion Hypoxemia

J, Increased metabolic rates I Multiple Organ Dysfunction Syndrome (MODS) Acute Poisoning/Drug Overdose Snakebite Transplants Cardiogenic Shock This Page Intentionally Left Blank OTHER 331

body systems are affected with decreased Multiole Orflan Dysfunction perfusion, hypoxia, and anaerobic mechanisms that the body tries to use to maintain metabolic Syndrome (MODS) function.

Sepsis denotes the presence of microorganisms or The goal of treatment is to support their by-products in the bloodstream that create a cardiopulmonary function and to identify and fulminating infection with resultant systemic eradicate the organisms responsible for the infec- involvement and shock. The hemodynamic tion in the first place. With two organ systems changes that occur during septic shock may result involved, mortality is 50-60% despite treatment, in inadequate perfusion and the development of with the percentage increasing to 90-100% mor- multiple organ dysfunction syndrome (MODS). tality with four or more systems involved. Another syndrome which may lead to MODS is systemic inflammatory response syndrome (SIRS). The most frequent precipitating factor is usually a Both sepsis and SIRS utilize the same inflamma- temporary episode of a shock state that results in tory cascade with differing sources of infectious body cell ischemia. The typical pattern of MODS versus non-infectious causes, and can both poten- includes a hypotensive episode that is apparently tially lead to MODS. successfully resuscitated, with elevation of heart rate and progressive respiratory failure. The As the bacterial infection progresses, the immune patient is then intubated and appears to be doing system attempts to destroy the causative microor- better, but is in a hypermetabolic and ganism, and the endotoxins within the cell hyperdynamic state that produces progressive membrane are released into the vascular system. changes in labwork. Inotropic support is required, The endotoxins then trigger systemic then pseudomonas, yeast, or viral organisms inflammation, activation of the complement cas- progress, causing renal failure and involvement of cade, and histamine release. This results in all systems, with death ensuing approximately one vasodilation, increased capillary permeability, and month after the initial event. leakage of the protein-rich plasma into the interstitial tissues. MEDICAL CARE As the plasma seeps into the alveoli, and platelets Laboratory: CBC used to identi5 hemorrhage, and white blood cells embolize in the microcircula- platelet dysfunction, infection, shifts to the left on tion, resulting in release of more vasoactive differential; electrolytes with sodium decreased; materials, the lung's compliance decreases and renal profiles used to evaluate renal dysfunction ARDS develops. The liver is unable to detoxify the and therapeutic response to treatment; hepatic circulating endotoxins because of microemboliza- profiles to evaluate hepatic dysfunction; coagulation in the liver itself as well as sludge in the tion profiles to identifjr clotting dysfunction and hepatic system. As fluid volume decreases, the DIC; fibrinogen elevated with DIC; cultures done heart rate increases and cardiac output is raised. As to identify causative organism and determine the abdominal organs are constricted from emboli appropriate antimicrobial therapy; glucose in the microcirculation, myocardial toxic factor elevated due to metabolic state; lactate level (MTF) is released and blocks the calcium ion increased with metabolic acidosis, shock, or action and contractility decreases. As more and hepatic dysfunction more endotoxins are circulating, more and more 332 CRITICAL CARE NURSING CARE PLANS

Electrocardiogram: used to identify conduction Defining characteristics: increased temperature, disturbances or cardiac dysrhythmias; may have fever, flushed, warm skin, tachypnea, tachycardia ST and T wave changes mimicking MI Risk for alteration in tissue pefiion: cere- Arterial b1,ood gases: used to identify hypoxia, bral, gaseointestinal, cardiopulmonary, hypoxemia, acid-base imbalances and evaluate renal, andperip heral effectiveness of therapy; initially may have respiratory alkalosis and hypoxemia, and in later stages, Related to: vasoconstriction, microembolism, vas- metabolic and respiratory acidosis with compen- cular occlusion, hypovolemia, increased oxygen satory mechanism failure consumption, inadequate oxygen delivery, alter- Radiography: chest x-rays used to identify ation in utilization of oxygen by tissues pulmonary or cardiac changes in vasculature, Defining characteristics: decreased peripheral edema, complications; abdominal x-rays used to pulses, prolonged capillary refill time, pallor, identifi potential sources of infection, i.e., free air cyanosis, erythema, paresthesias, pain, tissue in abdomen edema, lethargy, confusion, oliguria, anuria, Antibiotics: may be used to treat infectious cause abnormal ABGs of sepsis Narcan: has been used to counteract some of the Outcome Criteria endotoxins that are circulating in system Patient will have adequate perfusion to all body Corticosteroids: have been used to decrease systems. inflammatory response to toxins

NURSING CARE PLANS INTERVENTIONS RATIONALES

Risk for in$iction Moniror vital signs, noting Hypotension occurs when [See Renal Failure] trends. microorganisms enter the bloodstream and activate chemical Related to: progression of sepsis to septic shock, substances that result in vasodila- secondary infections, compromised immune tion, decreased systemic vascular system, invasive lines, malnutrition, debilitation resistance, and hypovolemia. Tachypnea may be the first Defining characteristics: increased white blood symptom of sepsis as the body responds to endotoxins and cell count, shift to the left, fever, chills, cough developing hypoxia. with or without sputum production, wound Monitor hernodynamic pressures When shock progresses to cold drainage, hypo tension, tachycardia, impaired skin if available, at least every 1-2 stage, cardiac output decreases in integrity, wounds, positive blood, urine or sputum hours and pm. response to decreased contractil- cultures, cloudy concentrated urine ity and alterations in afterload and preload. Fluid shifting may Hypertbermia cause third spacing and fluid [See Pheochromocytoma] overload, and monitoring hemodynamics can facilitate early Related to: circulating endotoxins, dehydration, identification of changes in trends. hypermetabolic state OTHER 333

INTERVENTIONS RATIONALES Information, Instruction, Demonstration Monitor EKG for changes and Tachycardia occurs in response to treat according to hospital proto- hypovolemia and circulating INTERVENTIONS RATIONALES col. endotoxins. Dysrhythrnias may occur from hypoxia, acid-base Observe for oozing at puncture May indicate presence or imbalances, electrolyte imbal- sites, petechiae, ecchymoses, or impending DIC or coagulation ances, or shock. bleeding from any area. problem.

Monitor mental status and level May indicate impending or pre- Monitor for drug toxicicy signs Decreased perfusion may of consciousness for changes. sent hypoxia or acidosis leading and symptoms. increase half-life and decrease to decreased cerebral perhsion. metabolism of therapeutic drugs and cause toxic reactions. Auscultate lung fields for adven- May indicate fluid overload in titious breath sounds. response to fluid resuscitation or presence of congestive failure. Discharge or Maintenance Evaluation Observe for changes in periph- Vasodilation may occur in the eral skin color and temperature. early phase of shock with warm, Patient will have stable vital signs and hemody- pink, dry skin, but as shock pro- namic parameters. gresses, vasoconstriction occurs and reduces peripheral blood Patient will have warm skin, with palpable flow resulting in mottling, or pale to dusky skin that is cold peripheral pulses that are equal bilaterally. and clammy. Patient will be neurologically stable, and have Monitor intake and output every As renal perfusion is compro- adequate perfusion to all body systems. hour. mised by vasoconstriction or microemboli, oliguria or anuria Risk for impziredgas excbunge may develop. [See Mechanical Ventilation] Palpate abdomen and auscultate Absence of bowel sounds may for bowel sounds. indicate decreased perfusion to Related to: endotoxins in circulation, hyperventi- the mesentery from vasoconstric- lation, hypoventilation, respiratory alkalosis, tion that may result in paralytic increased capillary permeability, alterations in ileus. blood flow due to microembolism, capillary Administer IV fluids as ordered. Large volumes may be required damage to maintain circulating volume from hypovolemic state, but Defining characteristics: dyspnea, tachypnea, must be monitored to identify hypoxia, hypoxemia, hypercapnia, confusion, rest- and treat fluid overloading. lessness, cyanosis, inability to move secretions, Administer oxygen as ordered. Provides supplemental oxygen tachycardia, dysrhythmias, abnormal ABGs, necessary for cellular perfusion decreased oxygen saturation and to relieve hypoxia.

Administer vasoactive drugs as May be required to maintain Risk for fluid volume &$kit ordered. pressure and hemodynamics at [See GI Bleeding] adequate levels to maintain perhion to body systems. Related to: vasodilation, third spacing, fluid shifting, increased capillary permeability 334 CRITICAL CARE NURSING CARE PLANS

Defining characteristics: weight loss, output greater than intake, hypotension, tachycardia, decreased central venous pressure, decreased hernodynamic pressures, increased temperature, dilute urine with low specific gravity, oliguria with high specific gravity, weakness, stupor, lethargy OTHER 335

MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

I I

Increased capillary permeability Coagulation J, 4

Fluid shiftinglthird spacing Capillary occlusion

Release of vasoactive peptides and toxins for complement activation LDecreased tissue perfusion I J, Tissue ischemia Organ' failure Lysis of clotted blood

J, I Decreadd cardiac Vasobotor Rkal Decreased DIC output center ischemia GI blood depression flow

J, J, 4 4 MDF released Decreased Decreased Decreased Depressed sympathetic blood flow antibacterial stimulation defenses J, J, J, 4 Decreased Decreased Relld Endotoxins calcium ion function venous return insufficiency released

J, J, J, J, Cardiac Failure Lethargy Renal Vascular Coma failure dilation This Page Intentionally Left Blank Acute PoisoninaDrug MEDICdL CARE Laboratory: drug screens may be used to identify Overdose agent used for suicide attempt; alcohol level to Attempts to end one's life by use of excessive assess concurrent use or toxicity; electrolytes may amounts of medication may be executed for many be abnormal due to trauma or interaction with reasons. Active self-destructive behavior usually medication; hematocrit may be decreased with results from the patient's perception of an hypovolemia; drug levels, such as phenobarbital or overwhelming catastrophic event in his life, in acetaminophen, may be elevated due to toxicity; conjunction with the lack of appropriate coping renal profile may show renal insufficiency; liver strategies, and is visualized as a means of escape profile may show hepatic dysfunction, especially from the sensed threat to himself. with acetaminophen overdose; coagulation profiles may be abnormal; urinalysis may show low Suicidal patients are frequently ambivalent about specific gravity, increased protein, hematuria, wanting to die, and may have visions of last- oxalate crystals, or metabolic by-products from minute rescue. The suicidal person may feel drug overdose despair, guilt, shame, hopelessness, boredom, depression, weariness, or dependency, and when Radiography: chest x-rays may show aspiration the point is reached when the person perceives pneumonia or pulmonary edema complications that life no longer has meaning and despair is Electrocardiogram: used to identify conduction overwhelming, the patient acts on those emotions. problems or dysrhythmias that may occur from Suicide may be considered the last logical step drug overdosage, electrolyte disturbances, or with when the person perceives that others do not want congestive failure them around or that the problem can never be reconciled. Dialysis: hemodialysis or hemoperfusion may be performed to remove some drugs when levels are Usually, an attempt at causing death is the culmi- severely elevated nation of a process in which the person had ideations about killing himself, verbal or nonver- Diuretics: may be required to force osmotic diure- bal threats of his intention, and gestures in which sis with agents such as mannitol, to manage attempts of causing self-injury without actual certain forms of overdose intentions to cause death. Acetylcysteine: Mucomyst is treatment of choice Suicide is the eighth leading cause of death in this with acetaminophen overdose country today, and the second leading cause of Charcoal: used to bind poisons, toxins, or other death in young people. Drug ingestion is the most irritants, increases absorption in the GI tract, and frequent method utilized with suicide attempts, helps to inactivate toxins until excreted partially because of the availability of medications, and partially to avoid more violent means of NURSING CARE PWNS death, such as with weapons or by hanging. Risk for inefective breathing pattern [See Mechanical Ventilation] 338 CRITICAL CARE NURSING CARE PLANS

Related to: respiratory depression from drug, INTERVENTIONS RATIONALES obstruction, pulmonary edema, pneumonia striction or obstruction leading Defining characteristics: apnea, dyspnea, lethargy, to respiratory arrest and death. stupor, coma, abnormal arterial blood gases, Supplemental oxygen may be decreased oxygen saturation, shallow respirations, required to offset acid-base imbalances that result from tachypnea, stridor, adventitious breath sounds overdosage. Risk for injury Auscultate lung fields for breath Pulmonary edema may result sounds and presence of adventi- from overdoses of barbiturates, Related to: toxic effects of ingested drugs tious sounds. sedatives, hypnotics, and tran- quilizers. Changes in breath Defining characteristics: respiratory arrest, sounds may identify impending pulmonary edema, shock, cardiac dysrhythmias, edema or heart failure. conduction changes, encephalopathy, amblyopia, Auscultate heart for tones and Gallops, murmurs, and rubs may edema, bronchoconstriction, blindness, blurring of presence of abnormal sounds. indicate the presence or impend- vision, hypotension, hypothermia, seizures, hyper- ing presence of complications tension, rhabdomyolysis, oliguria, anuria, heart such as pulmonary edema or heart failure. failure Administer IV fluids as ordered. Crystalloid solutions are normally used to treat hypovolemia Outcome Criteria which may occur due to compromised circulatory status.

Patient will achieve and maintain function of all Administer naloxone as ordered. Reverses effects of narcotic agents organ and body systems and be able to eliminate and may be required to manage ingested drug. CNS depression or respiratory depression.

Monitor intake and output every Assists with estimation of fluid INTERWNTIONS RATIONALES 2 hours; compare 24-hour totals, balance within body. Myoglobin and observe for changes in urine may be present if rhabdomyolysis Monitor vital signs every 1-2 Facilitates early identification of character and color. occurs as a result of overdose. hours and prn. changes and prompt interventions. Drug overdose may cause Insert nasogastric tube, aspirate Lavage is done to remove any CNS depression with hypother- fluid for analysis, lavage stomach, drugs that may be left in stom- mia, cardiac dysfunction from and administer activated charcoal ach to p.revent further absorption toxic drug levels, and pressure as ordered. of the drug. Aspirate may be sent changes with volume imbalances. to lab for analysis of drugs ingested to provide identification Monitor EKG for changes in Overdoses of tricyclic antidepres- for appropriate treatment. rhythm, dysrhythmias, or con- sants may cause prolongation of Charcoal is given to absorb drugs duction problems, and treat PR, QT, and QRS complex; ST from gastric contents to prevent according to hospital protocol. segment and T wave abnormali- systemic absorption. ties, intraventricular conduction defects, bundle branch blocks, Administer osmotic diuretics as May be required to manage over- and dysrhythrnias that may lead ordered. doses of ethanol, methanol, to cardiac arrest. ethylene glycol, and isoniazid, but must be done using caution Maintain airway and provide Patients with overdoses may be to avoid fluid overload and elec- supplemental oxygen as unable to protect their own trolyte imbalances. warranted. airway and have bronchocon- OTHER 339

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Administer sodium bicarbonate May be required for manage- Patient will have stable vital signs and neurolog- as ordered. ment of salicylate poisoning to alkalinize urine. ical status.

Administer ascorbic acid or May be required for manage- Patient will have stable function of all body ammonium chloride as ordered. ment of amphetamine or PCP sys terns. overdoses to acidify urine. Patient will have absorption of drugs minimized Administer Mucomyst as May be required for manage- ordered. ment of acetaminophen overdose and maximal elimination of absorbed drugs. to decrease absorption and limit hepatic dysfunction. Patient will remain free of other injury.

Administer physostigmine as May be required for manage- Risk for violence directed at self ordered. ment of tricyclic antidepressant overdoses to reverse the Related to: drug overdose, psychological status anticholinergic effects, but should be given cautiously to Defining characteristics: feelings of loneliness, prevent cholinergic toxicity. hopelessness, helplessness, perceived or real loss of significant person, job, health status, or control, Information, Instruction, unpredictable behavior, threats, low self-esteem, Demonstration dependence on drugs or alcohol, withdrawal from substances, communication of suicidal ideations, INTERVENTIONS RATIONALES depression, hostility

Prepare patientlfamily for dialysis Hemodialysis or hemoperfusion procedures. may be required for removal of Outcome Criteria drugs from system in severe intoxication when levels are Patient will achieve and maintain psychologic sta- potentially lethal or the toxin may be metabolized to a more bility and seek assistance with mental health lethal substance. providers.

Ensure suicide precautions are Maintenance of precautions facil- exercised-removal of all poten- itate a safe environment and tially dangerous items from room allows for identification of INTERVENTIONS RATIONALES and reach, close observation at all potential problems. A patient Ensure environment is calming, Facilitates decreased fear and times, keeping exiting windows who has made one attempt at darkened, with enough light for anxiety which may result with and doors impenetrable, provid- suicide may attempt to complete observation of patient. violent behavior. ing all medications in liquid the job and may be quite form, accompanying the patient resourceful with items to per- Approach patient in a nonjudg- May have a calming effect on to other ancillary areas, and form the deed. Medications mental, nonthreatening manner. patient. avoidance of secret pacts with should be given in liquid form to patient. ensure that the patient has swal- Listen to patient and what he has Allows patient to verbalize prob- lowed the medication rather than to say about his current situation lems. Emotional responses from saving it to use as suicide attempt without reacting emotionally. caregivers may exacerbate hostile later. reactions from patient.

Provide padded side rails, with Provides safe environment and Confirm understanding of Fosters communication and facil- rails elevated at all times. reduces risk of injury, especially patient’s problem, but do not itates realistic feelings and if patient has a seizure. reinforce denial. methods for coping. 340 CRITICAL CARE NURSING CARE PLANS

INTERVENTIONS RATIONALES Patient and family will be able to access available resources. Assist patient to verbalize emo- Provides safe outlets for patient tions, anger, and other stressors, to express feelings and helps to Risk for ineffective individual coping and to develop a plan for dealing work out realistic solutions for with them. solving problems. [See Mechanical Ventilation] Related to: crisis, drug overdose, loss of control, Information, Instruction, depression Demonstration Defining characteristics: verbal manipulation, INTERVENTIONS RATIONALES inability to meet basic needs, inability to Instruct patiendfamily on com- Provides knowledge and assis- effectively deal with crisis, ineffective defense munity resources, hot lines, crisis tance of resources available once mechanisms, irritability, hostility centers, ministerial counselors, patient is discharged. etc.

Consult mental health provider/ Allows for effective therapeutic professional as warranted. psychological treatment to discern appropriate methods of coping with crisis.

Encourage family members to Validates their feelings and discuss their feelings and meth- responses and may assist them in ods of coping. finding more appropriate methods to cope with crisis.

Discuss actions to take if patient Patient may be more likely to try expresses suicidal ideations or suicidal attempt again if situa- attempts. tions or coping strategies are not changed. Understanding that if the patient has a definite plan for suicide, the more likely it is that he will be successful at ending his life, and that immediate intervention will be required.

Discharge or Maintenance Evaluation

Patient will achieve psychological equilibrium and have no further suicidal attemptdgestures. Patient will be able to cope with crises in an appropriate manner, and will be able to effectively search out community resources for assistance. Patient and family will be able to verbalize feelings and effectively achieve therapeutic communication. OTHER 34 1

ACUTE POISONING/DRUG OVERDOSE

Severe personal loss Psychiatric illness Substaice abuse Memory aberrations I I I 1 I Accidental or purposeful ingestion of substance toxic to body J, Toxin identified

I I I Appropriate treatment to Antidote available Appropriate treatment to enhance . reduce absorption of drug removal of substance to body

c J, Lavage Forced diuresis Induction of emesis, if warranted Hemoperfusion Charcoal Hemodialysis Cathartics Repeated charcoal dosages

SYMPTOMS WILL BE DIFFERENT BASED ON ACTUAL SUBSTANCE INGESTED System involved

CNS Cardiac Resp Kidney Liver

Decreased perfusion Increased demand on tissues

Cerebral edema Dysrhythmias Metabolic acidosis Coagulation Seizures Ischemia Respiratory failure problems 4 Cardiac failure Kidney failure J, Coma Hemorrhage

I W DEATH- This Page Intentionally Left Blank OTHER 343

as presence of envenomation. Designation of severity of the bite is commonly rated as minor, moderate, or severe, and depends on the presence In the United States, there are actually two types of poisonous snakes-coral snakes and pit vipers, of symptoms, depth of envenomation, and labora- which include rattlesnakes, water moccasins, and tory findings. copperheads. Coral snakes are usually nocturnal Treatment of snakebite involves administration of creatures and less active than pit vipers, but tend antivenin after a test dose for horse serum sensitiv- to bite with a chewing motion and cause signifi- ity is performed. If this sensitivity is present, cant tissue damage. diphenhydramine may be given prior to the Snakebites may occur on any portion of the body, antivenin. Swelling may necessitate surgical intervention to relieve the pressure and to prevent but usually are noted on the extremities. Pit viper further vascular damage, and ensuing bites with envenomation result in immediate pain complications are usually related to secondary and edema within 10-20 minutes. Other infection, renal failure, disseminated intravascular symptoms include fever, ecchymoses, blisters, and coagulation, or gangrene. local necrosis, as well as nausea, vomiting, diarrhea, metallic or rubbery taste, tachycardia, hypotension, and shock. Neurotoxins may cause MEDICAL CARE numbness, tingling, fasciculations, twitching, con- Laboratory: CBC used to identify blood loss and vulsions, dysphasia, occasional paralysis, hemoconcentration; fibrinogen level, platelets, PT, respiratory distress, coma, and death. Pit viper PTT, and APTT to evaluate clotting; blood type bites may also impair coagulation and cause inter- and cross-matching to provide blood products as nal bleeding. warranted; renal and liver studies to identify dys- Coral snake bites usually have a delayed reaction function, elevated BUN, creatinine, bilirubin, or up to several hours, and may result in very little or creatine kinase no tissue pain, edema, or necrosis. The neurotoxic Electrocardiogram: used to establish a baseline for venom produces paresthesias, weakness, nausea, identification of problems that may occur with vomiting, dysphagia, excessive salivation, blurred hernodynamic changes and to identify dysrhyth- vision, respiratory distress and failure, loss of mias and conduction problems muscle coordination, paralysis, abnormal reflexes, shock, cardiovascular collapse, and death. Coral Surgery: fasciotomy may be required to relieve snake bites may also result in coagulopathy prob- pressure caused from swelling or compartmental lems. syndrome; amputation may be required for gangrene or necrosis The snake venom is a mixture of several proteins, enzymes, and polypeptides, and may produce sev- Analgesics: used to alleviate and/or control the eral toxic reactions in patients who have been pain related to envenomation and swelling; mor- bitten. Correct diagnosis is imperative to treat the phine is usually not given due to its vasodilator specific envenomation accurately and in a timely action manner. Snakebites are critical emergencies and Antivenin: required as the antidote for snakebite; require precise identification of the snake as well amount of antivenin is dependent on the severity of the reaction rather than patient weight, and ranges from 3 to 15 or more vials; children usually 344 CRITICAL CARE NURSING CARE PLANS

require more antivenin because of the ratio of INTERVENTIONS RATIONALES venom to body size until loss is greater than 1000 cc. Sedation: may be required to alleviate anxiety and Hypovolemic shock may occur to facilitate compliance with treatments due to hemorrhage, third spacing, as well as the release of Tetanus toxoid: given to prevent complication vasoactive substances and coagulopathy from the snakebite. that may be induced with infection from snakebite Measure hernodynamics if pul- CW, or right atrial pressure, monary artery catheter has been gives estimate of fluid volume Corticosteroids: usually are not recommended in placed. Notify MD for abnormal status. Dehydration may be the initial phase after snakebite because of the parameters. reflected by CVP of less than 5, while overhydration may be enhancement of the venom action and blocking of reflected at levels over 18 cm antivenin; may be warranted to treat shock or H,O. Hemodynamic values may allergic reactions help to evaluate the body’s response to the circulating Diphenhydramine: used when the patient has a volume and bleeding status. reaction to the horse serum used for antivenin, or Observe for restlessness, anxiety, Changes may reflect the severity for other anaphylactic reactions mental changes, changes in level of fluid loss. of consciousness, or weakness. NURSING CARE PLANS Observe for bleeding from all May indicate impaired coagula- orifices and puncture sites, and tion, impending or present DIC, Risk forfluid volume deficit for presenceldevelopment of or inadequate replacement of ecchymoses, hematomas, or clotting factors. Related to: hemorrhage, third spacing, altered petechiae. coagulation, increased cellular membrane perme- Monitor intake and output May indicate fluid volume ability, shock hourly and notify MD for signif- deficit, and establishes a guide icant imbalances or urinary for fluid and blood product Defining characteristics: tachycardia, output less than 30 cclhr for two replacemenr. hypotension, changes in mental status, restlessness, hours. decreased urine output, prolonged capillary refill, Administer IV fluids as ordered. Replaces fluid loss, allows for pallor, mottling, diaphoresis, poor turgor Two IV sites should be administration of vasoacrive maintained. drugs, plasma extenders, and emergency medications, as well Outcome Criteria as the administration of antivenin. Two sites are recom- Patient will achieve and maintain fluid balance mended to facilitate with adequate urinary output. simultaneous fluid and blood resuscitation in critical settings. Crystalloids do not work as well

~~ as colloids because of the INTERVENTIONS RATIONALES increased capillary permeability. Monitor vital signs, and notify Hypotension may indicate that Administer blood andlor blood Whole blood may be required MD of significant changes or the circulating fluid volume is products as ordered. for acute bleeding episodes with trends. decreased. Changes in vital signs shock due to the lack of clotting may indicate the amount of factors in packed red blood cells. blood loss but may not change Fresh frozen plasma andlor platelets may be required to replace clotting factors and CO promote platelet function. OTHER 345

Information, Instruction, Outcome Criteria Demonstration Patient will have adequate tissue perfusion to all INTERVENTIONS RATIONALES organ systems.

Instruct on use of antivenin, Provides knowledge and effects, side effects. Test dose for decreases anxiety. Skin test is horse serum. required to identify hypersensi- INTERVENTIONS RATIONALES tivities to the antivenin and Observe puncture wound for Skin normally changes after a frequently is repeated to ensure bleeding, color, temperature, and snakebite from inflamed to a that the results are not false. If a note changes from baseline. dark, cyanotic color. Changes in reaction is noted, the antivenin is the wound and local tissues may still given but is preceded by reflect the action of the venom diphenhydramine. and potential complications. Prepare patient for placement of Provides knowledge to the Measure the circumference of the Monitors for swelling and pulmonary artery catheter. patient, and catheter is invalu- extremity involved initially and inflammation, and helps to iden- able for identifying changes in then every 2-4 hours. tify the need for fasciotomy. fluid status and hemodynamic responses to those changes. Palpate, or use doppler, to dis- Edema may result in compart- cern peripheral pulses distal to mental syndrome and obstruct the snakebite, and notify MD for circulation to the extremity caus- Discharge or Maintenance Evaluation absence or decrease. ing ischemia, necrosis, and gangrene. Patient will have stable vital signs and urinary Assist with fasciotomy or inser- Reduces tissue pressure and pre- output. tion of catheter into the tissues vents tissue dehiscence and other Patient will have balanced intake and output. of the edematous extremity. complications. Administer oxygen as warranted. Provides supplemental oxygen Patient will have good turgor, moist which may be decreased due to membranes, and adequate capillary refill times. hemorrhage or oxygen-carrying capabiliry. Patient will be free of hemorrhage or abnormal Evaluate extremity and site of Venom effects may jeopardize coagulation. snakebite for pain, ecchymoses, tissue perfusion. Swelling and Patient will have no transfusion reactions. blisters, or blebs. discoloration usually begin to dissipate after 48 hours, and con- Risk alteration in tissue petfhsion: tinued problems may indicate for the presence of other complica- peripheral, cardiopulmonary, renal, tions. cerebral Apply ice packs over dressings as May reduce swelling. Ice packs Related to: envenomation, edema, compartmental warranted. DO NOT apply ice may increase damage to skin directly over snakebite and sur- tissues and cause necrosis. syndrome, coagulopathy, hemorrhage, rounding tissues. hypovolemia, neurotoxins Monitor for complaints of pares- May indicate advancement of Defining characteristics: hypotension, tachycar- thesias, weakness, muscle neurotoxic venom. dia, edema, decreased or absent pulses, incoordination, or fasciculations. inflammation, reddened or cyanotic skin, necrosis, Observe for increases in saliva- May indicate advancement of gangrene, mental changes, restlessness, anxiety, tion, dysphasia, dysphagia, or venom and further complications lethargy. that will require life-saving abnormal hemodynamic parameters, abnormal treatment. arterial blood gases INTERVENTIONS RATIONALES Alteration in comfort [See Fractures] Observe for changes in respira- May indicate impending respirations, increased work of tory distress and may lead to Related to: snakebite, swelling, edema, surgical breathing, nasal flaring, retrac- cardiovascular failure and death. procedures, decreased tissue perfusion, anxiety, tions, dyspnea. envenomation Information, Instruction, Defining characteristics: communication of pain, Demonstration moaning, crying, facial grimacing, inability to concentrate INTERVENTIONS RATIONALES Impaired skin integr.9 Prepare patient for fasciotomy. Provides knowledge and reduces anxiety. Incision may be required Related to: snakebite, envenomation, surgical pro- to prevent skin dehiscence from edema. cedures, invasive lines, necrosis, gangrene

Instruct patient in signs to notify Provides for prompt identifica- Defining characteristics: disruption of skin MD or nurse: swelling, paresthe- tion of problem and prompt tissues, incisions, open wounds, drainage, edema sias, color changes, temperature intervention to prevent further changes, etc. complications.

Prepare patient for amputation. Provides knowledge and facili- Outcome Criteria tates understanding of need for procedure, risks, and benefits, Patient will have wound healing occurring in a and allows the patient to make timely manner. an informed choice. Amputation may be required for gangrendnecrosis. INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation Assess wound and surrounding Provides baseline fof comparison Patient will achieve and maintain adequate per- tissues for appearance, drainage, and for identification of deterio- swelling, healing, deterioration, ration. fusion to all body systems. etc.

Patient will have palpable, equal peripheral Cleanse wound with soap and Removes debris and drainage pulses, with no paresthesias or evidence of water, or other agents per hospi- from skin surfaces and helps to tal protocol, warranted. prevent infection. ischemia. as Apply gauze dressing as Dressing may help to control Patient will have adequate urine output and bal- warranted and change every day bleeding, absorbs drainage, and anced intake/output. utilizing sterile technique. provides barrier for wound. Using proper technique for Patient will have adequate cerebral perfusion wound care prevents potential with no mental status changes. complications. Elevate extremity as warranted. Reduces swelling and pain, and Patient will be able to accurately recall all infor- helps to keep skin tissues free of mation. pressure that might cause ischemia or necrosis. Patient will be able to make an informed con- sent for procedures and will comply with Monitor extremity and wound Swelling and discoloration for changes. should begin to subside by 48 treatment modalities. hours. If swelling increases, or tissue perfusion is impaired, sur- Patient will not exhibit any preventable compli- gical intervention may be cations. required. OTHER 347

Information, Instruction, INTERVENTIONS RATIONALES Demonstration Obtain ABGs as warranted for Will identify acid-base imbal- signs of respiratory distress. ances well as hypoxemia, INTERVENTIONS RATIONALES as hypercarbia, and orher ventila- Prepare patient for fasciotomy or Provides knowledge to patient to tory problems. amputation, as warranted. facilitate an informed choice, and Prepare for intubation and Hypoxemia that is not able to be reduces anxiety. mechanical ventilation, as war- corrected will require mechanical ranted. ventilation to facilitate adequate Discharge or Maintenance Evaluation oxygenation Patient will have healed wounds with no circu- Discharge or Maintenance Evaluation latory impairment. Patient will be free of respiratory distress and Patient will be able to circumvent preventable able to maintain own airway and oxygenation complications. on room air. Impaired gas exchange Patient will have no respiratory complications. Related to: envenomation, ARDS, neurotoxins, Fea r/Anxiety cardiotoxins, hematotoxins, lactic acidosis, edema, snakebite, anaphylactic reactions, bronchospasm [See Mechanical Ventilation] Defining characteristics: dyspnea, tachypnea, air Related to: snakebite, threat of death, fear of dis- hunger, abnormal arterial blood gases, altered figurement or scarring, hospitalization, mechanical acid-base balances, cyanosis, inadequate oxygen ventilation, envenomation saturation levels Defining characteristics: expressions of apprehension, tension, restlessness, insomnia, expressions of Outcome Criteria concern, fear of unknown, tachypnea, tachycardia, inability to concentrate or focus Patient will maintain own airway and have optimal ventilation and perfusion.

INTERVENTIONS RATIONALES

Monitor respiratory status for May indicate hypoxemia and changes: dyspnea, tachypnea, hypoxia. decreased oxygen saturation levels, cyanosis, decreases in mentation, restlessness, etc.

Administer oxygen as ordered. Provides supplementd oxygen to increase availability, and to satu- rate red blood cells with oxygen.

Observe for laryngeal spasm, May indicate worsening respira- bronchospasm, or excessive sali- tory status which may require vation. mechanical ventilation. 348 CRITICAL CARE NURSING CARE PLANS

SNAKEBITE

Envenomation e

Release of enzymes Release of toxic substance Local tissue damage I I I I I I Cardiovascular Hemhytic Neuron-hscular Renal EdLma 4 c c c 4 Toxins alter Blood cell Nerve transmission Nephrotoxins Necrosis vascular dynamics changes impairment alter perfusion 4 c c c Hypotension Hemolysis Nerve conduction Decreased GFR decreased

4 c e c Decreased perfusion Coagulation Muscle Myoglobin and circulating disturbances fasciculations volumes

4 4 c J, Hypoxemia Hemorrhage Paralysis Renal insufficiency c c c e Shock Respiratory distress+ Cardiovascular collapse Arrest Renal failure DEATH 1 OTHER 349

graft heart is implanted. Frequently, a combined heart-lung transplant is performed due to the Transplants increased success rate as a result of fewer vascular anastomoses being required. Transplantation of living tissues, cells, or organs Renal transplants are performed to restore kidney from one individual to another is one method of function in end-stage renal disease. Allografts are treatment for several end-stage organ diseases. usually obtained from living relatives or cadavers. Often, transplantation is the last resort for a vari- The kidney is usually implanted in a ety of disorders after conventional medical or retroperitoneal position against the psoas muscle surgical therapies have failed to provide adequate in the iliac fossa. When cadaver kidneys are used functioning. Recent advances in technique and approximately half of the recipients may require treatment have improved the rate of success, and dialysis because of the presence of acute tubular transplantation has improved the quality of life for necrosis. many patients who otherwise would either die or be resigned to lives of dialysis or suffering. Liver transplants are performed to restore function in patients with chronic active hepatitis, hepatitis Transplants are categorized by the relationship B antigen-negative postnecrotic cirrhosis, primary between the donor and the recipient. An autograft hepatocellular tumor, or congenital anomalies of relates to the transplantation of tissue from one the bile duct or inborn errors of metabolism in location to another in the same person. An children. The liver is implanted into the right isograft is a graft between identical twins, and an upper abdominal quadrant and the vasculature is allograft, or homograft, is a graft between mem- anastomosed. Biliary drainage anastomosis prob- bers of the same species. A xenograft, or lems often result in bacteremia. heterografi, is a graft between members of different species. Pancreas transplants are performed on patients with insulin-dependent diabetes mellitus to pro- Bone marrow transplants are performed in order vide insulin-producing tissue. The pancreas, either to restore immunologic and hematologic function total with a small amount of duodenum, or partial to patients who have aplastic anemia, leukemia, or segment of the distal pancreas, is transplanted. severe combined immunodeficiency disorder. This type of transplant is performed as a life- Multiple aspirations of bone marrow are obtained enhancing procedure and is most successful prior and then infused intravenously with red blood to the development of severe secondary diabetic cells. complications. Heart transplants are performed to attempt to The goal in transplantation is to maintain optimal restore function in end-stage cardiac failure that functioning of the organ and to prevent rejection. has been unresponsive to other medical therapeu- This goal is facilitated by antigen matching, tissue tics, and usually involve patients who have typing for histocompatibility, tests for prior sensi- cardiomyopathy, rheumatic heart disease, congeni- tization, transfusions of whole blood, and tal heart disease, or coronary artery disease. After immunosuppressive therapy. the patient is placed on cardiopulmonary bypass and the diseased heart is removed, the donor allo- Despite a small increase in the available donor 350 CRITICAL CARE NURSING CARE PLANS organs, the number of candidates for transplant symptoms of increased glucose levels, polyuria, far exceeds the organs available, and many patients polydipsia, polyphagia, weight loss, low grade die prior to undergoing transplantation. fever, and tender or enlarged pancreas. Bone Complications of infection, rejection, and marrow transplantation rejection is usually immunosuppressive drugs are a very real part of evidenced by severe diarrhea, jaundice and skin the process. changes. Transplantation of almost any tissue is feasible but Rejection can be classified as being acute, hypera- rejection is the most frequent complication when cute, or chronic depending on the mechanisms of the body tries to destroy the graft tissue. Rejection rejection and the duration of time prior to the occurs when the immune system recognizes the appearance of symptoms. Acute reactions may graft as being foreign to the body and begins a occur anywhere from 7 days to several weeks after responsive action to the antigens of the graft. Thus transplant. A cell-mediated acute reaction occurs begins a cell-mediated immune response in the when the graft develops interstitial edema, lymph tissues. Antibody-mediated immune ischemia, and necrosis, but high dose steroid ther- responses, inflammatory responses, and comple- apy may reverse the reaction. Antibody-mediated ment activation also play a significant role in the acute reactions occur when fibrin, platelets, and rejection process. polymorphonuclear cells adhere to the graft cells, resulting from recipient antibody-donor antigen Rejection may occur immediately after transplan- responses. This aggregation produces ischemia and tation or up to years later, and most transplant eventually necrosis. Hyperacute reactions develop patients experience at least one rejection episode immediately after the transplant up to a few days during their lives. Signs/symptoms of rejection after. Immediate hyperacute reactions happen vary depending on the type of graft. Cornea1 when the recipient has preformed antibodies transplant rejection is evidenced by corneal cloud- against the donor antigens and is usually caused ing, corneal edema, or conjunctival hyperemia. by previous blood transfusions, previous Cardiac transplant rejection is evidenced by transplants, or from pregnancy. An accelerated decreased QRS, right axis shift, atrial hyperacute reaction happens when the recipient dysrhythmias, conduction defects, S, gallop, jugu- lymphocytes and neutrophils infiltrate the graft lar vein distention, decreased exercise tolerance, and may be prevented with the use of antisera to low grade fever, malaise, weight gain, dyspnea, T lymphocytes. Chronic reactions occur over right ventricular failure, and peripheral edema. many months and eventually leads to loss of graft Liver transplant rejection may be manifested with function. This occurs when the vascular endothe- changes in urine or stool color, jaundice, hum becomes inflamed, and the arterial lumen hepatomegaly, ascites, pain in the center of the decreases. Fibrin and platelets aggregate and over back, right flank, or right upper quadrant of the time, result in decreased blood flow to the organ abdomen, low grade fever, malaise, or anorexia. and ischemia and dysfunction prevail. Renal transplant rejection may involve low grade fever, decreased urine output, pain, swelling The principal mechanism of rejection is GVH and/or tenderness in the kidney, increased blood (graft versus host) disease. This occurs when an pressure, malaise, weight gain, or peripheral immunocompetent donor graft is transplanted edema. Pancreas transplant rejection may show into an immune-impaired recipient. If the donor OTHER 35 1 and the recipient are not histocompatible, foreign NURSING CARE PLANS cells will initiate an attack against the host cells, which are then unable to reject them. This usually Risk fir infection occurs with bone marrow or liver transplants. Related to: immunosuppression, effects of transplantation, invasive procedures, invasive MEDICAL CARE linedcatheters, trauma, surgery Laboratory: renal profiles used to assess kidney Defining characteristics: increased immature function; hepatic profiles used to assess liver func- white blood cells, differential with a shift to the tion; CBC used to evaluate anemia, infection, and left, fever, chills, cough, hypotension, tachycardia, blood loss; glucose levels used to monitor pancre- presence of wounds, positive blood, urine, or atic function; AB0 blood grouping; Lewis sputum cultures, cloudy urine, purulent drainage antigens used to evaluate compatibility for kidney transplants; microtoxicity assays for evaluation of Outcome Criteria bone marrow; tissue typing for histocompatibility; lymphocyte antibody screen to evaluate preformed Patient will have no signs/symptoms of infection antibodies; lymphocyte cross-matching used after after transplant surgery. a suitable donor is found; serology, HIV, hepatitis screens to evaluate suitability for transplantation ~ ~~ INTERVENTIONS RATIONALES Surgery: required for transplantation of Patient should be in private Decreases potential of infection tissueslorgans room, with appropriate isolation when patient is already immuno- techniques in use. Visitors with compromised. Biopsy: tissue biopsies used as the most accurate illness must be restricted from diagnostic tool to determine the extent of lympho- visiting. cyte infiltration and potential tissue damage; serial Observe for signslsymptoms of Provides for prompt identifica- biopsies can be used to monitor course of infection to all body systems. tion of complication and treatment facilitates timely intervention.

Immunosuppressive drugs: used to decrease or Provide diet with appropriate Proper nutrition facilitates anti- nutrients and fluids. Restrict body formation and prevents to eliminate the body's ability reject new fresh fruits and vegetables. dehydration. Fresh fruidvegeta- transplanted tissues; can increase the risk for bles may harbor parasitic spores opportunistic organisms; usually a combination of or bacteria that may result in an drugs are used rather than just one infection. Monitor CBC, especially WBC Sudden decreases in mature Blood transfusions: used to improve graft survival count for abrupt changes in neu- WBCs may result from of certain organisms trophils. chemotherapy and further compromise the immune response. Radiation therapy: used in some instances for pretransplantation immunosuppression Use sterile/aseptic technique with Immunosuppressive drugs or dressing changes, IV site changes, effects of the patient's disease Thoracic duct drainage: used in some instances or other invasive care. process may slow wound healing. Drainage is a potential medium for pretransplantation imrnunosuppression for bacterial growth.

Observe mouth and oral cavity Steroid and antibiotic adminis- for presence of lesions or thrush. tration may result in an Use nystatin as warranted. overgrowth of fungal coloniza- tion resulting in candidiasis. 352 CRITICAL CARE NURSING CARE PLANS

Discharge or Maintenance Evaluation INTERVENTIONS RATIONALES Patient will exhibit no signs of infection post- response. Imuran suppresses DNA and RNA synthesis; transplant. cyclosporine block the release of interleukin- 1 and gamma-inter- Patient will have stable vital signs and hemody- ferons and block activated T namics. lymphocytes; prednisone and other corticosteroids inhibit T- 0 Patient will not develop any complication. cell proliferation, decreases production of interleukin-2 and Risk for injury gamma-interferons, and decreases IgG synthesis; muromonab Related to: rejection of transplanted organ, tissue, blocks T cells that foster renal or bone marrow, allergic reaction to transplant rejection. Defining characteristics: fever, chills, diaphoresis, Administer blood products as Anemia and blood dyscrasias peripheral edema, weight gain, decreased urine warranted. may be present after bone marrow transplants and require output, hypertension, urticaria, enlargement of the supplementation of blood prod- graft, oliguria, anuria, hypotension, right-sided ucts until transplantation is heart failure, right flank pain, light-colored stools, successful and may occur up to 2 week after infusion. Granulocyte anorexia infusion may be deemed necessary if antibiotic therapy is not Outcome Criteria effective to treat bacterial infections. Patient will not have rejection of new transplant. Monitor lab studies for signifi- Provides data that may be indica- cant changes. tive of impending or present rejection. INTERVENTIONS RATIONALES Information, Instruction, Monitor patient for fever, chills, May indicate impending rejec- Demonstration hypotension, flushing, inflammation of transplant, or adverse tion, thrush, cough, urinary reaction to immunosuppressants. changes. Acute rejection is common and INTERVENTIONS RATIONALES usually occurs during the first Prepare patient for biopsies as Cardiac transplants require peri- weeks or months following the warranted. odic endomyocardial biopsies to transplant. identify cellular rejection.

Monitor for increased bilirubin May indicate complication as a Instruct patient/family on Promotes knowledge, facilitates levels, hepatomegaly, result of bone marrow transplant signslsymptoms of rejection of compliance, and allows for encephalopathy, or heart failure. and is usually seen in 25% of particular transplanted prompt notification to decrease patients. organ/tissue. severity of complications or rejection episode. Observe for rash or skin May indicate presence of grafi- ulcerations. versus-host (GW)disease and Prepare patient for surgery as If excessive immunosuppression may occur up to 2 weeks post- warranted. is required or if rejection is transplant. inevitable, kidney transplants may require removal and patient Administer immunosuppressive Drugs interfere with some step will need placement back of therapy as ordered. in the body’s response against the dialysis. graft to decrease the immune OTHER 353

INTERVENTIONS RATIONALES Defining characteristics: feelings of loneliness, ~~ feelings of rejection, absence of family Instruct patient on all medica- Decreases risk of self-medication, tions taken, side effeccs, adverse and provides for prompt notifi- membedfriends, sad, dull affect, inappropriate effects, contraindications, and cation of adverse reactions that behaviors potential drug interactions. may require further intervention. Outcome Criteria Discharge or Maintenance Evaluation Patient will be able to participate in activities as Patient will have minimal rejection of tolerated and be able to have effective interaction transplanted organ/tissue. with people within confines of medical disease Patient will be able to comply with drug regi- process. men to prevent rejection.

Patient will be able to verbalize understanding INTERVENTIONS RATIONALES of signslsymptoms to report to physician, and Determine patient’s comprehen- Identifies potential misconcep- will be able to seek prompt medical care. sion of medical situation and tions and allows for realistic Patient will be cognizant of all medications rationales. input to facilitate understanding. being taken, purposes, and potential side effects, Utilize appropriate isolation Facilitates providing safe environ- and will have no adverse reactions. techniques based on patient’s ment for patient yet providing condition, and when possible, social interaction to decrease Patient will avoid further surgery. limit use of protective feelings of social isolation. equipment. Appropriate use of gcwns, mask;, Alteration in tissue perfision: and gloves may be required due to patient’s suppressed immune curdiopulmonary, cerebra4 renai system. gastrointestinal, peripheral [See Renal Failure] Encourage visitation of family as Transplantation costs are high much as possible. Provide a tele- and done in major hospital set- Related to: transplant rejection, allergic reactions, phone so that patient may tings, so that family members contact family and friends. may not be able to travel great infection, pulmonary edema, DIC distances for the length of time the patient may be hospitalized. Defining characteristics: oliguria, anuria, Methods of communication are polyuria, fever, chills, increased white blood cell important to promote feelings of count, differential shift to the left, bleeding, inclusion in family matters. ecchymoses, hematuria, guaiac positive stools, Identify significant family mem- Support systems decrease sense of DIC, blood dyscrasias, decreased platelet count, bers or friends who are isolation and loneliness and helps headache, mental status changes, adventitious important to patient and involve to reestablish communication. them in care. breath sounds, gallops, abnormal heart tones, dysrhythmias, rashes, ulcerations, nausea, vomiting Assist patient to develop strate- Promotes feelings of self-control gies for coping with isolation. while developing goals for Social isolation achievement. Related to: changes in health status, changes in Contact social services, coun- May be helpful to continue care selors, organizations, ministers, once patient is discharged, and physical status, imposed physical isolation, inade- or other resources. may be able to facilitate support- quate support system ive encounters. 354 CRITICAL CARE NURSING CARE PLANS

Discharge or Maintenance Evaluation

Patient will be able to verbalize understanding of necessity for isolation procedures and will comply. Patient will have fewer feelings of loneliness and isolation. Patient will be able to meet sensory demands by family and friends. Patient will be able to effectively access community resources for referrals. Alteration in comfort [See Cardiac Surgery] Related to: transplant operation, invasive lines and catheters, immobility Defining characteristics: communication of pain, facial grimacing, increased blood pressure, increased heart rate, diaphoresis, moaning, splinting Alteration in skin integity [See Cardiac Surgery]

Related to: transplant operation, invasive lines and catheters, biopsies, wounds Defining characteristics: surgical incisions, disruption of skin surfaces, abrasions, redness, warmth, drainage Knowledge deficit [See Renal Failure]

Related to: transplant operation, changes in health status, anxiety Defining characteristics: lack of knowledge, presence of preventable complications, verbalized questions OTHER 355

TRANSPLANTS

Organ dysfunction and failure 4 Transplant of organ I I I Humoral immunity Cellular immunity 4 4 Antigdantibody reaction T-lymphocytes activated I 4 Hyperacute+ Accelerated Antibody formation rejection rejection

I I Antibody formation B-lymphocyte activation

Chronic rejection Signs of rejection will vary depending on particular organ that is transplanted. This Page Intentionally Left Blank OTHER 357

blood pressure may be masked by the nervous Cardiogenic Shock system and compensatory mechanisms from the Cardiogenic shock is a severe form of pump fail- baroreceptors, which attempt to compensate for the increases in the body’s cardiac workload and ure that occurs when damage to the heart muscle is sufficient enough to impair contractility and myocardial oxygen demand. Unless the cycle is interrupted, the scenario is always death. reduce stroke volume and cardiac output. Usually the patient must necrotize 40% or more of the left ventricular myocardium to result in shock. In this type of shock, blood volume is adequate and fluid Oxygen: to increase available oxygen supply challenges will not improve cardiac output because the problem is that the heart fails to pump effec- Alpha-adrenergic agonists: p henylep hrine (Neo- tively. This decreases the stroke volume, and Synephrine) used to improve blood pressure eventually tissue ischemia and hypoxia occurs. through vasoconstriction without inotropic effect Cardiac output is decreased and hypotension Beta-adrenergic agonists: isoproterenol (Isuprel) ensures. Because of inadequate tissue perfusion, and dobutamine (Dobutrex) used to act directly anaerobic metabolism produces lactic acid, leading on the myocardium to improve contractility, and to an acidotic state in the body. Despite treatment, to lower preload and afterload 80% of patients who suffer this shock state will die. Alpha-beta adrenergic agonists: norepinephrine (Levophed), epinephrine (Adrenalin), and Cardiogenic shock may result from mechanical dopamine (Intropin) used to improve contractility interference with ventricular filling, from interfer- through vasoconstriction and direct action on ence with ventricular emptying, from disturbances myocardium in heart rate or rhythm, or from inadequate myocardial contraction. Other causes that may Vasodilators: nitroglycerin (Tridil) and nitroprus- predispose the patient to cardiogenic shock side (Nipride) used to reduce venous return to the include acute dysrhythmias, severe congestive heart by promoting peripheral pooling of blood, heart failure, cardiac tamponade, papillary muscle reduces preload, afterload, and myocardial oxygen rupture, rupture of the interventricular septum or consumption wall of the ventricle, ventricular aneurysm, mural Diuretics: furosemide (Lasix) used to reduce car- throm bi, cardiomyopathy, pulmonary embolism, diac congestion and pulmonary edema tension pneumothorax, or damage to the myocardial valves. Enzyme inhibitors: amrinone (Inocor) used to inhibit the enzyme phosphodiesterase, increase Patients with cardiogenic shock usually have available calcium, and increases cyclic adenosine increased CVP with jugular vein distention, car- monophosphate, or CAME levels to strengthen diac index less than 2.0 Llmin/m2, systolic blood con tractions pressure less than 80 mmHg, mean arterial pressure less than 60 mmHg, PCWP greater than 18 Cardiac catheterization: used to assess pathophysi- mmHg, increased systemic vascular resistance, ology of the patient’s cardiovascular disorder, to oliguria less than 20 cc/hr, peripheral edema, and provide left ventricular function information, to pulmonary congestion. In the early stages of this shock, the initial decrease in cardiac output and 358 CRITICAL CARE NURSING CARE PLANS

allow for measurement of heart pressures and car- INTERVENTIONS RATIONALES diac output, and to measure mixed venous blood gas content tive drugs. Maintain MAP at >GO sure, increased respiratory rate, mmHg. and can increase heart rate. Intra-aortic balloon pump: used to decrease Compensatory mechanisms in the body can easily fail within a workload on the heart by decreasing preload and short time. MAP < 60 is inade- afterload, and to improve coronary artery perfu- quate to perfuse coronary or sion cerebral vessels. Ventricular assist devices: used when other mea- Monitor hemodynamic pressures Evaluates effectiveness of treat- and calculate CI, SVR, TPR, left ment and allows for efficient sures have failed; VADs allow blood to bypass the and right stroke work and stroke titration of vasoactive drugs. ventricle(s) which allows the heart to rest and work index. Measure CO. Determines actual cardiac output lowers myocardial oxygen demands by measurement. In cardiogenic shock, CVP will be elevated >10 Arterial blood gases: used to evaluate hypoxia and mmHg, CO will be <2.2 L/min, hypoxemia, metabolic acidosis, and other imbal- SVR will be increased, PVR and TPR will be increased, and stroke ances volume will be decreased. A good predictor of mortality is the LVSWI, with 95% death rate if NURSING CARE PLANS <25 gm m/m2.

Decreased cardiac output Administer oxygen as ordered. Provides supplemental oxygen to Monitor oxygenation by use of increase available oxygen to us- Related to: circulatory failure, bradycardia, tachy- pulse oximetry or ABGs. sues and reduce hypoxia. cardia, congestive failure Monitor for mental changes and Decreased cardiac output may Defining characteristics: SBP < 80 mmHg, olig- changes in level of consciousness. decrease perfusion to cerebral tissues. uria, cold clammy skin, weak thready pulses, dyspnea, tachypnea, cyanosis, confusion, restless- Monitor urine output every Decreased cardiac output results ness, mental lethargy, dysrhythmias, chest pain hour and notify MD if <30 in decreased renal perfusion and cclhr. may lead to oliguria or renal failure.

Outcome Criteria Monitor for weadthready pulses, Decreased cardiac output results capillary refill >5 seconds, cool in decreased peripheral perfusion Patient will have adequate cardiac output to main- clammy skin, pallor or cyanosis. and tissue compromise. tain perfusion to all systems. body Auscultate lungs for crackles May indicate increasing fluid to (rales) or wheezes, and heart lungs and impending congestive tones for S3 gallop. heart failure.

INTERVENTIONS RATIONALES Observe for cough and pink May indicate pulmonary edema. frothy sputum. Monitor EKG for dysrhythmias Decreased cardiac output will and changes in heart rhythm. decrease perfusion to the heart Auscultate heart tones for systolic May indicate ventricular septal and dysrhythmias may occur. murmur. rupture or mitral insuGciency which may cause cardiogenic Monitor vital signs every 15 Bradycardia may result in shock. minutes, or every 5 minutes decreased cardiac output, which during active titration of vasoac- leads to lowering of blood pres- OTHER 359

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Observe for abnormal precordial May indicate cardiogenic shock. Patient will have cardiac output/cardiac index movement at 3-5 intercostal space. and hemodynamic pressures within normal limits. Place head of bed no higher than Elevation of the head of the bed 30 degrees if blood pressure is may promote lung expansion and Urine output will be adequate. within acceptable parameters. facilitate easier breathing. Blood Avoid trendelenburg position. pressure may be too low to have Vital signs will be normal and without overt HOB elevated and patient signs of impaired perfusion to any body system. should be supine to maintain blood pressure and perfusion to Lung fields will be clear with adequate oxygena- vital organs. Placement in trendelenburg position may increase tion. preload, increase the workload on the heart, inhibit lung expansion, Patient will be alert and oriented, with no and prevent baroreceptors from mental changes. sensing decreases in cardiac output. Anxiety [See MI] Administer vasoactive drugs and Through a variety of actions, titrate to maintain vital signs and these drugs allow alteration of Related to: change in health status, fear of death, hemodynamic pressures within hemodynamic status to achieve MD ordered parameters. and maintain optimal perfusion. threat to body image, threat to role functioning, pain Administer morphine IV as Relieves pain and helps to ordered. improve blood pressure and car- Defining characteristics: restlessness, insomnia, diac output by decreasing anorexia, increased respirations, increased heart preload. rate, increased blood pressure, difficulty concen- Administer atropine as ordered. May be used to reverse bradycar- trating, dry mouth, poor eye contact, decreased dia and help prevent some of the vagal effects from morphine. energy, irritability, crying, feelings of helplessness

Avoid using isoproterenol with Isuprel increases myocardial KnowZedge &$kit MI patients except for temporary oxygen consumption and work- [See MI] use prior to transvenous pacing, load of the heart while it and only if shock is associated increases heart rate. Related to: lack of understanding, lack of under- with severe bradycardia. standing of medical condition, lack of recall Provides knowledge and Prepare patient for placement on Defining characteristics: questions regarding IABP or for VAD usage. decreases fear. problems, inadequate follow-up on instructions given, misconceptions, lack of improvement of Information, Instruction, Demonstration previous regimen, development of preventable complications INTERVENTIONS RATIONALES

Instruct on equipment, proce- Provides knowledge and dures, medications. decreases fear. 360 CRITICAL CARE NURSING CARE PLANS

CARDIOGENIC SHOCK

Left ventricular dysfunction Loss of critical muscle mass * Decreased pumping ability of the heart 4 Decreased stroke volume Decreased cardiac output Decreased blood pressure Decreased perfusion pressure to coronary arteries Increased myocardial ischemia

Cell necrosis Impaired contractility / +\ Metabolic acid release Humoral toxins released

SYMPATHETIC NERVOUS SYSTEM STIMULATION I NEURAL SYSTEM STIMULATED CHEMICAL SYSTEM ACTIVATED - Skin Decreased cardiac output Increased rate Vasoconstriction Decreased blood to lungs Increased depth Cool clammy skin Increased capillary permeability Decreased oxygen diffusion Sweat glands Cardiac Increased physiological dead space Increased sweat production Vasodilates arteries VentiIation/perfusion mismatch Increased coronary artery blood flow Decreased Pa02 GU Increased heart rate Respiratory insuffciency Vasoconstriction Increased strength of contractions Respiratory alkalosis Decreased peristalis Increased cardiac output Vasoconstriction to cerebral arteries Decreased perfusion to liver Increased blood pressure Cerebral ischemia Ischemia to pancreas Changes in level of consciousness GI Vasoconstriction Decreased peristalsis Decreased perfusion to liver Ischemia to pancreas Myocardial depressant factor (MDF) released

HORMONAL SYSTEM ACTIVATED

Decreased renal blood flow Increased renin Increased sodiumlwater retention Adrenal medulla Increased epinephrine Increased norepinephrine Sustained stress response Increased gluconeogenesis Acute tubular necrosis Increased blood glucose ~ ~~ INDEX OF NURSING DIAGNOSES 361 This Page Intentionally Left Blank INDEX OF NURSING DIAGNOSES 363

cerebral 26 Anticipatory grieving 303 Activity intolerance 92, 203, 235 Anxiety 10, 27, 36, 42, 63, 74, 86, 92, 128, 196, 248, 275, 285,359 Alteration in comfort 15, 26, 50, 63, 70, 79, 107, 163, 170, 182, 196,208,214,292,299,316,326,346, 354 Anxiety, fear 173 Alteration in nutrition: less than body requirements 204, Body image disturbance 302 208,214,218,235,244,253,326 Bowel incontinence 164 Alteration in skin integrity 62, 73, 190, 354 Constipation 277 Alteration in temperature regulation 161 Decreased cardiac output 6, 18, 27, 34, 86, 278, 358 Alteration in thought processes 152, 218 Disturbance in body image 221 Alteration in tissue perfusion: cardiopulmonary, cerebral GO Disturbance in self-esteem 177 Alteration in tissue perfusion: cardiopulmonary, cerebral, gastrointestinal, peripheral, renal 78 Disturbance of body image 64,75 Alteration in tissue perfusion: cardiopulmonary, cerebral, Dyshnctional ventilatory wean response 133 renal, gastrointestinal, peripheral 353 Fatigue 256 Alteration in tissue perfusion: cardiopulmonary, renal, cere- FearJAnxiety 326, 347 bral, gastrointestinal, peripheral 233 Fluid volume deficit 194, 208, 219, 251, 261,269 Alteration in tissue perfusion: cerebral 140, 149, 181, 186, 189 Fluid volume excess 4, 240, 265 Alteration in tissue perfusion: peripheral 47, 299 Grieving 178 Alteration in tissue perfusion: peripheral, cerebral, cardiopul- Hyperthermia 34, 176, 182, 282, 319, 332 monary, renal, gastrointestinal 314 Impaired gas exchange 8, 86, 92, 101, 107, 123,254, 277, Alteration in tissue perfusion: renal, cardiopulmonary, cere- 307,347 bral, gastrointestinal, peripheral 242 Impaired physical mobility 64,74, 141, 154, 162, 169, 293, Alteration in nutrition: less than body requirements 262, 326 277 Impaired skin integrity 219, 295, 301, 326, 346 Altered nutrition: less than body requirements 94, 131, 196 Impaired verbal communication 127, 141, 170 Altered oral mucous membrane 131, 247 Ineffective airway clearance 86, 92, 106, 118, 122 Altered tissue perfusion: cardiopulmonary, cerebral, gastroin- Ineffective breathing pattern 8692, 100, 112, 124, 160, 220 testinal, peripheral, and renal 273 Ineffective individual/family coping 93, 129 Altered tissue perfusion: cardiopulmonary) cerebral, gastrointestinal, renal, peripheral 54 Ineffective thermoregulation 3 14 Altered tissue perfusion: cardiopulmonary, cerebral, periph- Inneffective in breathing pattern 1GO eral 17 Knowledge deficit 10,23,28,36,43, 50,65,74, 81,86, Altered tissue perfusion: cardiopulmonary, renal, peripheral, 94, 107, 135, 197,205,235,257,270,286,297,354,359 364 CRITICAL CARE NURSING CARE PLANS

Knowledge deficit 10, 23, 28, 36, 43, 50, 65, 74, 81, 86, Risk for impaired swallowing 142 94, 107, 135, 197,205,235,257,270,286,297,354,359 Risk for ineffective airway clearance 175, 325 Potential for alteration in tissue perfusion: peripheral 262 Risk for ineffective breathing pattern 15 1, 169, 337 Potential for infection 130 Risk for ineffective breathing pattedimpaired gas exchange Potential for injury 63, 74, 208 71 Potential for injury: hypoglycemia 256, 262 Risk for ineffective individual coping 200, 340

Risk for alteration in nutrition: less than body requirements Risk for infection 35, 56, 94, 153, 188, 204, 212, 245, 255, 155, 170 296,300,316, 327,332,351 Risk for alteration in tissue perfusion: cardiopulmonary, Risk for injury 176, 181, 189, 200, 212, 220, 226, 230, peripheral, renal 170 247,266,284,338,352 Risk for alteration in tissue perfusion: cerebral, cardiopul- Risk for peripheral neurovascular dysfunction 294 monary, gastrointestinal, renal, and peripheral 200 Risk for urinary retention 171 Risk for alteration in tissue perfusion: cerebral, gastrointestinal, cardiopulmonary, renal, and peripheral 332 Risk for violence directed at self 339 Risk for alteration in tissue perfusion: peripheral, cardiopul- Self-care deficit: bathing, dressing, feeding, toileting 143 monary, renal, cerebral 345 Sensory-perception alteration (visual, thought processes, Risk for altered nutrition: less than body requirements 284, kinesthetic) 277 320 Sensory-perceptual alteration 163 Risk for altered tissue perfusion: cardiopulmonary, cerebral, Sensory-perceptual alterations: visual, kinesthetic, gustatory, renal, gastrointestinal, and peripheral 32, 41 tactile 170 Risk for altered tissue perfusion: cardiopulmonary, periph- Sensory-perceptual alterations: visual, kinesthetic, gustatory, eral, cerebral 101 tactile, olfactory 142 Risk for altered tissue perfusion: gastrointestinal, cerebral, Social isolation 353 cardiopulmonary, renal, peripheral 196 Urinary retention 164 Risk for altered nutrition: less than body requirements 107 Risk for constipation 172 Risk for decreased cardiac output 40, 68, 101, 160, 189, 200,283, 320 Risk for dysreflexia 165 Risk for fluid volume deficit 57, 87,107, 176, 214, 226, 230,234,242, 301,324,333,344 Risk for fluid volume excess 20, 87,107 Risk for impaired gas exchange 175, 208, 226, 229, 320, 326,333 Risk for impaired skin integrity 9,49, 81, 163, 204, 246 REFERENCES 365

REFERENCES This Page Intentionally Left Blank REFERENCES 367

Books

Berkow, Robert, Editor. The Merck Manual, 16th Ed., Merck, Sharp, & Dohme Inc., Rahway, NJ, 1993.

Guyton, Arthur. Human Physiolow and Mechanisms of Disease, 6th Ed., W. B. Saunders Co., Philadelphia, PA, 1997.

Guyton, Arthur. Textbook of Medical Physioloc, 9th Ed., W. B. Saunders Co., Philadelphia, PA, 1995.

Minssen, Beth. Critical Care Core Curriculum, 6th Ed., Panhandle Education For Nurses, Lubbock, TX, 1995.

Minssen, Beth. Multi& Orvan Failure Syndrome, 2nd ed., Panhandle Education For Nurses, Lubbock, TX, 1995.

Skidmore-Roth, Linda. Mosbv’s 1997 Nursinc Druc Reference, Mosby Year-Book Inc., St. Louis, MO, 1997.

Suddarth, Doris Smith. The Lippincott Manual of Nursin? Practice, 6th Ed., J. B. Lippincott, Philadelphia, PA, 1996.

Swearington, Pamela and Keen, Janet. Manual of Critical Care, 3rd Ed., Mosby, St. Louis, MO, 1995.

Tierney, Lawrence M., et al., Current Medical Diamosis and Treatment, 35th ed., Appleton and Lange, Stamford, CT,1996. Periodicals

Ahrens, Susan G. “Managing Heart Failure: A Blueprint for Success,” Nursing 95, 25 (12): 26-31, 1995.

Blanford, Nickie. “Renal Transplantation: A Case Study of the Ideal,” Critical Care Nurse, 13 (1): 46-55, 1993.

Bright, Linda D. “Deep Vein Thrombosis,” American Journal of Nursing, 95 (6): 48-49, 1995. 368 CRITICAL CARE NURSING CARE PLANS

Huston, C. J. and Boelman, R. “Autonomic Dysreflexia,” American Journal of Nursing, 95 (6):55, 1995.

Mee, Cheryl L. “Ventilator Alarms-How to Respond with Confidence,” Nursing 95, 25 (7): 61-64, 1995.

Meissner, Judith E. “Caring for Patients with Meningitis,” Nursing 95, 25 (7): 50-5 1, 1995.

Merkley, Kathleen. “Assessing Chest Pain,” RN, 57 (6):58-62, 1994.

Teplitz, Linda. “Hypertensive Crisis: Review and Update,” Critical Care Nurse, 13 (6):20-35, 1993.

Weinman, Steven A. “Emergency Management of Drug Overdose,” Critical Care Nurse, 13 (6):45-5 1, 1993. Career CollegesKomrnunity Colleges and Post Secondary Vo-Techs For desk or review copies call: 1-800-477-3692 or fax 1-518-464-0301 For orders call: 1-800-347-7707 or fax 1-606-647-5023 Mail to: ITP Career Education Attn: Order Fulfillment P.O. Box 6904 Florence, KY 41022 Email: [email protected]

Four-Year CollegeKJniversity For desk or review copies call: 1-800-423-0563 or fax 1-606-647-5020 For orders call: 1-800-354-9706 or fax 1-800-487-8488 Mail to: ITP Higher Education Attn: Order Fulfillment P.O. Box 6904 Florence, KY 41022

Business, Industry and Government For orders call: 1-800-347-7707, ext. 4 or fax 1-606-647-5963 Mail to: ITP Business, Industry, Government Attn: Order Fulfillment P.O. Box 6904 Florence, KY 41022 All other orders and inquiries 1-800-347-7707, ext. 4

Retail Mail to: International Thomson Publishing Attn: Professional/TechnicalOrder Fulfillment P.O. Box 6904 Florence, KY 41022 Phone: 1-800-842-3636 or fax 1-606-647-5963

High Schools and Secondary Vo-techs For desk or review copies call: 1-800-824-5179 or fax 1-800-453-7882 For orders call: 1-800-354-9706 or fax 1-800-487-8488 Mail to: ITP School Attn: Order Fulfillment P.O. Box 6904 Florence, KY 41022

Canada Mail to: Nelson ITP Canada 1120 Birchmount Road Scarborough, Ontario M1K 5G4 Canada Telephone Number: 1-416-752-9448 or 1-800-268-2222 Fax Number: 1-416-752-8101 or 1-800-430-4445 E-mail: [email protected]

International Ordering Mail to: International Thomson Learning P.O. Box 6904 Florence, KY 41022 Phone: 1-606-282-5786 Fax: 1-606-282-5700