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دانلود کتاب Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems
دانلود کتاب پرستاری پزشکی-جراحی لوئیس: ارزیابی و مدیریت مشکلات بالینی
مشخصات کتاب
Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems
ویرایش: [12 ed.] نویسندگان: Mariann Harding, Jeffrey Kwong, Debra Hagler, سری: ISBN (شابک) : 9780323789615, 9780323792370 ناشر: سال نشر: 2023 تعداد صفحات: [1829] زبان: English فرمت فایل : PDF (درصورت درخواست کاربر به PDF، EPUB یا AZW3 تبدیل می شود) حجم فایل: 154 Mb
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توضیحاتی در مورد کتاب پرستاری پزشکی-جراحی لوئیس: ارزیابی و مدیریت مشکلات بالینی
دانش و مهارت های لازم برای موفقیت در پرستاری پزشکی-جراحی را با این کتاب درسی برجسته به دست آورید! پرستاری پزشکی-جراحی لوئیس، ویرایش دوازدهم، از سبک نوشتاری محاوره‌ای، تمرکز بر مفاهیم پرستاری و روندهای بالینی، محتوای مبتنی بر شواهد و بررسی پاتوفیزیولوژی پایه استفاده می‌کند تا پایه محکم مورد نیاز در یک محیط مراقبت‌های بهداشتی که به سرعت در حال تغییر است را فراهم کند. فصل های جامع موضوعاتی از جمله مدیریت و همکاری پرستاری، ارتقای سلامت، مداخلات حاد و مراقبت های سرپایی را پوشش می دهد. جداول و جعبه‌های خلاصه یافتن اطلاعات ضروری را آسان می‌کنند و یک رویکرد ساختاری حتی پیچیده‌ترین مفاهیم را برای درک آسان می‌کند. علاوه بر سه فصل جدید، این نسخه شامل تمرکز قوی تری بر فرآیند پرستاری، قضاوت بالینی و آمادگی برای آزمون NCLEX® نسل بعدی است.
توضیحاتی درمورد کتاب به خارجی
Gain the knowledge and skills you need to succeed in medical-surgical nursing with this leading textbook! Lewis's Medical-Surgical Nursing, 12th Edition uses a conversational writing style, a focus on nursing concepts and clinical trends, evidence-based content, and basic pathophysiology review to provide the solid foundation needed in a rapidly changing healthcare environment. Comprehensive chapters cover topics including nursing management and collaboration, health promotion, acute interventions, and ambulatory care. Summary tables and boxes make it easy to find essential information, and a building-block approach makes even the most complex concepts simple to grasp. In addition to three new chapters, this edition includes a stronger focus on the nursing process, clinical judgment, and preparation for the Next-Generation NCLEX® Examination.
فهرست مطالب
Front Matter IFC CONTENTS Contents Lewis’s Medical-Surgical Nursing ASSESSMENT AND MANAGEMENT OF CLINICAL PROBLEMS Half Title Lewis’s Medical-Surgical Nursing ASSESSMENT AND MANAGEMENTOF CLINICAL PROBLEMS Copyright ABOUT THE AUTHORS JEFFREY KWONG, RN, DNP, MPH, ANP-BC, FAAN, FAANP DEBRA HAGLER, PHD, RN, ACNS-BC, CNE, CHSE, ANEF, FAAN COURTNEY REINISCH, RN, DNP, FNP-BC CONTRIBUTORS Authors of Teaching and Learning Resources Case Studies (Interactive and Applying Clinical Judgment With Multiple Patients) PowerPoint Presentations TEACH for Nurses NCLEX® Examination Review Questions Study Guide Clinical Companion Evidence-Based Practice Boxes Nursing Care Plans PREFACE SPECIAL FEATURES LEARNING SUPPLEMENTS FOR STUDENTS TEACHING SUPPLEMENTS FOR INSTRUCTORS ACKNOWLEDGMENTS CONTENTS CONCEPT EXEMPLARS SPECIAL FEATURES Lewis’s Medical-Surgical Nursing ASSESSMENT AND MANAGEMENT OF CLINICAL PROBLEMS 1 - Concepts in Nursing Practice 1 - Professional Nursing PROFESSIONAL NURSING PRACTICE Domain of Nursing Practice Definitions of Nursing Nursing’s View of Humanity Scope of Nursing Practice Standards of Professional Nursing Practice INFLUENCES ON PROFESSIONAL NURSING PRACTICE Expanding Knowledge and Technology Diverse Populations Consumerism Health Care Financing Health Policy Professional Nursing Organizations Nursing Core Competencies PATIENT-CENTERED CARE Clinical Judgment Clinical Practice Frameworks Nursing Care Plans Continuum of Patient Care Delivery of Nursing Care Supporting Caregivers INTERPROFESSIONAL PARTNERSHIPS Interprofessional Team Coordinating Care Communication Clinical Pathways Delegation and Assignment SAFETY Serious Reportable Events National Patient Safety Goals QUALITY IMPROVEMENT National Database of Nursing Quality Indicators INFORMATICS Electronic Health Records EVIDENCE-BASED PRACTICE Steps of EBP Process Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Implementing EBP EVOLVE WEBSITE/RESOURCES LIST REFERENCES 2 - Social Determinants of Health SOCIAL DETERMINANTS OF HEALTH Neighborhood Economic Stability Health Care Education Community HEALTH DISPARITIES AND HEALTH EQUITY Factors and Conditions Leading to Health Disparities Ethnicity and Race Gender Age CULTURE CULTURAL COMPETENCE CULTURAL FACTORS AFFECTING HEALTH AND HEALTH CARE Folk Healers and Traditions Spirituality and Religion Cross-Cultural Communication Family Roles and Relationships Personal Space Touch Nutrition Immigrants and Immigration Drugs Psychologic Factors Self-Assessment Assessment Implementation Advocacy Standardized Guidelines Communication EVOLVE WEBSITE/RESOURCES LIST REFERENCES 3 - Health History and Physical Examination DATA COLLECTION Medical Focus Nursing Focus Types of Data Interview Considerations Symptom Investigation Data Organization NURSING HISTORY: SUBJECTIVE DATA Important Health Information Health History Medications Allergies Surgery and Other Treatments Functional Health Patterns Health Perception–Health Management Pattern Nutritional-Metabolic Pattern Elimination Pattern Activity-Exercise Pattern Sleep-Rest Pattern Cognitive-Perceptual Pattern Self-Perception–Self-Concept Pattern Role-Relationship Pattern Sexuality-Reproductive Pattern Coping–Stress Tolerance Pattern Value-Belief Pattern PHYSICAL EXAMINATION: OBJECTIVE DATA General Survey Physical Examination Techniques . Inspection is the visual assessment of a part or region of the body to assess normal conditions or deviations. Inspection is m... . Palpation is the assessment of the body using touch. Using light and deep palpation can yield information about masses, pulsat... . Percussion is a technique that produces a sound and vibration to obtain information about the underlying area (Fig. 3.3). The ... . Auscultation involves listening to sounds produced by the body with a stethoscope to assess normal and abnormal conditions. Th... Equipment Organization of Examination Documentation TYPES OF ASSESSMENT Emergency Assessment Comprehensive Assessment Focused Assessment Using Assessment Approaches 4 - Patient and Caregiver Teaching TEACHING-LEARNING PROCESS Adult Learner Adult Learning Principles Models to Promote Health Nurse as Teacher Required Competencies . Develop confidence as a teacher by becoming knowledgeable about the topic. For example, if you are teaching patients about man... . Patient teaching depends on effective communication between you and the patient or caregiver. Medical jargon can be intimidati... . Teaching patients and caregivers has many challenges, including (1) lack of time, (2) your own feelings as a teacher, (3) nurs... Caregiver Support in the Teaching-Learning Process Regulatory Mandates for Patient Teaching PROCESS OF PATIENT TEACHING Assessment Physical Factors Psychologic Factors Sociocultural Factors . Literacy is the ability to use printed and written information to function in society. Health literacy is the degree to which ... . Cultural traditions influence our health practices, beliefs, and behavior. These traditions, which can affect patient teaching... . Consider a variety of socioeconomic factors when preparing to teach patients. Knowing the patient’s present or past occupatio... Learner Factors . Learning needs are the new knowledge and skills that a person must have to meet a goal. Assess what the patient already knows ... . Motivation and readiness to learn depend on multiple factors, such as perceived need, attitudes, and beliefs. When teaching ad... . Each person has preferred styles of learning. The three general learning styles are (1) visual (reading, pictures), (2) audito... Clinical Problems Planning Setting Goals Choosing Teaching Strategies . Use learning materials in multiple formats. Learn what resources are available in your agency and from support services and pr... . Patients may use the Internet and other digital technology (e.g., smart phones) to obtain information and manage their health.... Implementation Evaluation REFERENCES 5 - Chronic Illness and Older Adults CHRONIC ILLNESS Preventing and Managing a Crisis Carrying Out Prescribed Treatment Plan Controlling Symptoms Reordering Time Adjusting to Changes in the Course of Disease Preventing Social Isolation Attempting to Normalize Interactions With Others Preventing Chronic Illness ATTITUDES TOWARD AGING BIOLOGIC AGING AGE-RELATED PHYSIOLOGIC CHANGES SPECIAL OLDER ADULT POPULATIONS Chronically Ill Older Adults Cognitively Impaired Older Adults Rural Older Adults Homeless Older Adults Frail Older Adults SOCIAL SUPPORT AND OLDER ADULTS Family Caregivers Elder Mistreatment Self-Neglect SOCIAL SERVICES FOR OLDER ADULTS MEDICARE AND MEDICAID CARE ALTERNATIVES FOR OLDER ADULTS Adult Day Care and Adult Day Health Care Home Health Care Long-Term Care Facilities Programs for All-Inclusive Care for the Elderly Age-Friendly Health Systems LEGAL AND ETHICAL ISSUES ?Health Promotion ?Acute and Ambulatory Care . The time of a care transition to another setting (e.g., acute care hospital to rehabilitation) is challenging for many older a... . The goal of rehabilitation is to help older adults adapt to or recover from disability or an acute functional decline. Rehabil... . Consider the use of assistive devices as interventions for older adults. Using assistive devices such as dentures, glasses, he... . Safety is crucial in maintaining an older adult’s health. When compared to younger adults, older adults are at higher risk for... . Medication use in older adults requires thorough and regular assessment, care planning, and evaluation. Nonadherence to medica... . Depression is not a normal part of aging. However, it is often an underrecognized problem in older adults. Around 15% of older... . Physical restraints are devices, materials, and equipment that physically prevent persons from moving freely, such as walking,... . Adequacy of sleep is often a concern for older adults because of altered sleep patterns. Older people have a marked decrease i... ?Evaluation REFERENCES 6 - Caring for Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Gender Diverse Patients LGBTQ+ HEALTH INEQUITIES GERONTOLOGIC CONSIDERATIONS ESTABLISHING INCLUSIVE ENVIRONMENTS Establishing a Welcoming Environment Health History and the Intake Process Social History Sexual and Reproductive Health History PREVENTIVE HEALTH GENDER AFFIRMATION THERAPY Gender Affirming Hormone Therapy Nonsurgical Gender Affirming Interventions Gender Affirming Surgery Chest Masculinization Surgery Feminizing Breast Augmentation ?Assessment Implementation ?Acute Care ?Ambulatory Care Anchor 1015 REFERENCES 2 - Problems Related to Comfort and Coping 7 - Stress Management WHAT IS STRESS? Is Stress Bad or Good? Factors Affecting Response to Stress PHYSIOLOGIC RESPONSE TO STRESS Nervous System Cerebral Cortex Limbic System Reticular Formation Hypothalamus Endocrine System Summary of Stress Response Immune System MIND-BODY-SPIRIT CONNECTION EFFECTS OF STRESS ON HEALTH COPING STRATEGIES RELAXATION STRATEGIES Relaxation Breathing Biofeedback Meditation Imagery Massage Music Prayer ?Nursing Management: Stress ?Assessment ?Clinical Problems ?Planning ?Implementation REFERENCES 8 - Sleep and Sleep Disorders PHYSIOLOGIC SLEEP MECHANISMS Sleep-Wake Cycle Wake Behavior Sleep Behavior Circadian Rhythms Sleep Architecture NREM Sleep REM Sleep INSUFFICIENT SLEEP AND SLEEP DISTURBANCES SLEEP DISTURBANCES IN THE HOSPITAL Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Self-Report Actigraphy Interprofessional Care Cognitive-Behavioral Therapy for Insomnia Drug Therapy . Benzodiazepine-receptor agonists are considered first-line for pharmacologic treatment of insomnia. They act at GABA receptors... . Suvorexant (Belsomra) and lemborexant (Dayvigo) promote sleep by blocking the wake-promoting effects of orexin. They should be... . Ramelteon (Rozerem) is a prescription melatonin-receptor agonist. It has a rapid onset. Ramelteon is recommended for insomnia ... . Certain tricyclic antidepressants (e.g., doxepin, amitriptyline) are used as sleep aids due to their side effect of sedation. ... . Benzodiazepines activate GABA receptors to promote sleep. These drugs are not part of first-line therapy for insomnia. Only 2 ... . Many people self-medicate with OTC sleep aids such as doxylamine (Unisom) and diphenhydramine. Diphenhydramine is in many “nig... Complementary and Alternative Therapy ?Assessment ?Clinical Problems ?Implementation OBSTRUCTIVE SLEEP APNEA Clinical Manifestations Diagnostic Studies ?Behavioral Treatment ?Medical Devices ?Surgical Treatment PERIODIC LIMB MOVEMENT DISORDER CIRCADIAN RHYTHM DISORDERS NARCOLEPSY PARASOMNIAS REFERENCES 9 - Pain EXTENT OF PAIN PROBLEM DEFINITIONS AND DIMENSIONS OF PAIN CLASSIFICATION OF PAIN Nociceptive Pain Neuropathic Pain Acute and Chronic Pain PAIN ASSESSMENT Elements of a Pain Assessment Pain Pattern Location Intensity Quality Associated Symptoms Management Strategies Impact of Pain Patient’s Beliefs, Expectations, and Goals Reassessment PAIN TREATMENT Basic Principles Drug Therapy for Pain Nonopioids Opioids . Opioids are categorized by their physiologic action (e.g., agonist, antagonist) and binding at specific opioid receptors (e.g.... . Some opioid analgesics have 2 distinct actions, or dual mechanisms. Tramadol (Ultram) is a weak mu agonist and inhibits the re... . Some opioids should be avoided for pain relief because of limited efficacy and/or toxicities. The American Pain Society does n... . Common side effects include constipation, nausea and vomiting, sedation, respiratory depression, and pruritus.12 With continue... Adjuvant Analgesic Therapy . Clonidine and tizanidine (Zanaflex) are the most widely used α2-adrenergic agonists. They likely work on the central inhibitor... . TCAs enhance the descending inhibitory system by preventing the cellular reuptake of serotonin and norepinephrine. Higher leve... . Antiseizure drugs affect peripheral nerves and the CNS in several ways. These include sodium channel modulation, central calci... . Baclofen, an agonist at GABA receptors, can interfere with the transmission of nociceptive impulses. It helps manage muscle sp... . Corticosteroids include dexamethasone, prednisone, and methylprednisolone (Medrol). They are used for managing acute and chron... . Local anesthetics, such as bupivacaine and ropivacaine, can be given epidurally by continuous infusion or by intermittent or c... . Cannabinoid-derived medications show promise in treating neuropathic pain, certain pain syndromes, and some symptoms.16 Synthe... Administration . Appropriate analgesic scheduling focuses on preventing or controlling pain, rather than providing analgesics only after the pa... . Analgesic titration is dose adjustment based on assessment of the adequacy of analgesic effect versus the side effects produce... . The term equianalgesic dose refers to a dose of one analgesic that is equivalent in pain-relieving effects to a given dose of ... . We can deliver opioids and other analgesic agents by many routes. This flexibility allows the HCP to (1) target a particular a... . Oral administration is the route of choice for the person with a functioning GI system. Most pain medications are available in... . Although we have historically given morphine sublingually to people with cancer pain who have problems swallowing, little of t... . Intranasal administration allows delivery of medication to highly vascular mucosa and avoids the first-pass effect. Butorphano... . We often overlook the rectal route. It is especially useful when the patient cannot take an analgesic by mouth, such as with s... . Transdermal patches offer systemic or local delivery. Fentanyl (Duragesic) is useful for the patient who cannot tolerate oral ... . Parenteral routes include IV and subcutaneous administration. Single, repeated, or continuous dosing is possible with parenter... . Intraspinal or neuraxial opioid therapy involves inserting a catheter into the subarachnoid space (intrathecal delivery) or th... . Intraspinal catheters can be surgically implanted for long-term pain relief. The surgical placement of an intrathecal catheter... . Patient-controlled analgesia (PCA) (demand analgesia) is a method that allows the patient to self-administer preset doses of a... Interventional Therapy Therapeutic Nerve Blocks . Neuroablative interventions are done for severe pain that is unresponsive to all other therapies. They involve destroying nerv... Neuroaugmentation Nondrug Therapies for Pain Physical Pain Relief Strategies . Massage may be useful to alleviate certain types of acute and chronic pain.17 Many different massage techniques exist. These i... . Exercise is an essential part of the treatment plan for patients with chronic pain, especially those with musculoskeletal pain... . Transcutaneous electrical nerve stimulation (TENS) involves the delivery of an electric current through electrodes applied to ... . Acupuncture is a technique of traditional Chinese medicine in which very thin needles are inserted into the body at designated... . Heat therapy is the application of either moist or dry heat to the skin. Heat therapy can be either superficial or deep. We ca... . Cold therapy involves the application of either moist or dry cold to the skin. Dry cold can be applied by using an ice bag. Mo... Cognitive Therapies . Distraction involves redirection of attention away from the pain and onto something.22 It is a simple but powerful strategy to... . Hypnotherapy is a structured technique that enables a patient to achieve a state of heightened awareness and focused concentra... . Relaxation strategies reduce stress, decrease acute anxiety, distract from pain, ease muscle tension, combat fatigue, promote ... INSTITUTIONALIZING PAIN EDUCATION AND MANAGEMENT MANAGING PAIN IN SPECIAL POPULATIONS Older Adults Patients Unable to Self-Report Pain Patients in the Critical Care Unit Patients With Substance Abuse Problems REFERENCES 10 - Palliative and End-of-Life Care PALLIATIVE CARE HOSPICE CARE DOMAINS OF PALLIATIVE CARE Domain 1: Care Structure and Processes Domain 2: Physical Aspects of Care Domain 3: Psychologic and Psychiatric Aspects Domain 4: Social Aspects of Care Domain 5: Spiritual, Religious, and Existential Aspects of Care Domain 6: Cultural Care Domain 7: Care of the Patient Nearing the End of Life Domain 8: Ethical and Legal Aspects of Care Advance Care Planning and Advance Directives Organ and Tissue Donation Euthanasia and Physician-Assisted Suicide DEATH Physical Manifestations at End of Life Psychosocial Manifestations at End of Life Bereavement and Grief . Patients often show signs of anxiety and depression during the EOL period. Causes of anxiety and depression may include uncont... . Anger is a common and normal response to grief. A grieving person cannot be forced to accept the loss. The surviving family me... . Feelings of hopelessness and powerlessness are common during the EOL period. Encourage realistic hope within the limits of the... . Fear is a typical feeling associated with dying. Specific fears include fear of pain, fear of shortness of breath, fear of lon... ?Physical Care . After a patient is pronounced dead, you will need to prepare or delegate preparing the patient’s body for immediate viewing by... SPECIAL NEEDS OF CAREGIVERS AND NURSES IN END-OF-LIFE CARE Special Needs of Family Caregivers Special Needs of Nurses REFERENCES 11 - Substance Use Disorders in Acute Care DRUGS ASSOCIATED WITH SUBSTANCE USE DISORDER Effects of Use and Complications ?Tobacco Cessation ALCOHOL Effects of Use and Complications ?Alcohol Toxicity ?Alcohol Withdrawal Syndrome ?Toxicity ?Withdrawal DEPRESSANTS Sedative-Hypnotics Opioids ?Toxicity ?Sedative-Hypnotics ?Opioids ?Withdrawal ?Sedative-Hypnotics ?Opioids INHALANTS CANNABIS CAFFEINE ?Assessment ?Clinical Problems ?Planning ?Implementation ?Health Promotion ?Acute Intervention REFERENCES 3 - Problems Related to Homeostasis and Protection 12 - Inflammation and Healing INFLAMMATORY RESPONSE Vascular Response Cellular Response Neutrophils Monocytes Lymphocytes Chemical Mediators Complement System Prostaglandins and Leukotrienes Exudate Formation Types of Inflammation Clinical Manifestations Fever ?Fever ?Drug Therapy ?RICE . Rest, or immobilization, prevents further injury and gives the body time to heal. It decreases the tissues’ metabolic needs an... . Cold application is usually best at the time of the initial trauma. Cold promotes vasoconstriction and decreases swelling, pai... . Compression counters the vasodilation effects and development of edema. Compression by direct pressure over a laceration occlu... . Elevating the injured extremity above the level of the heart reduces edema at the inflammatory site by increasing venous and l... HEALING PROCESS Regeneration Repair Primary Intention . In the initial (inflammatory) phase, the edges of the incision are aligned and sutured (or stapled) in place. The incision are... . The granulation phase is the second step. The components of granulation tissue include proliferating fibroblasts; proliferatin... . The maturation phase, during which scar contraction occurs, overlaps with the granulation phase. It may begin 7 days after the... Secondary Intention Tertiary Intention Wound Classification Complications of Healing ?Clean Wounds ?Contaminated Wounds ?Drug Therapy ?Nutrition Therapy ?Infection Prevention and Control ?Psychologic Implications ?Patient Teaching PRESSURE INJURIES Etiology and Pathophysiology Clinical Manifestations ?Nursing Management: Pressure Injuries REFERENCES 13 - Genetics GENETICS AND GENOMICS Basic Principles of Genetics Chromosomes Genes DNA RNA Protein Synthesis Mitosis Meiosis Genetic Mutations Types of Mutations Inheritance Patterns Human Genome Project GENETIC DISORDERS Classification of Genetic Disorders Single Gene Disorders Multifactorial Inherited Conditions . Epigenetics is the study of inheritable changes in gene expression that do not involve changes in the DNA sequence. There is a... Chromosome Disorders GENETIC SCREENING AND TESTING Interpreting Genetic Test Results Direct-to-Consumer Genetic Tests Genetic Technology DNA Fingerprinting DNA Microarray (DNA Chip) Genome-Wide Association Study (GWAS) PHARMACOGENOMICS AND PHARMACOGENETICS GENE THERAPY STEM CELL THERAPY REFERENCES 14 - Immune Responses and Transplantation NORMAL IMMUNE RESPONSE Antigens Types of Immunity Innate Immunity Acquired Immunity . Active acquired immunity results from the invasion of the body by foreign substances such as microorganisms and the subsequent... . In passive acquired immunity, the host receives antibodies to an antigen rather than making them. This may take place naturall... Lymphoid Organs Cells Involved in Immune Response Mononuclear Phagocytes Lymphocytes . B cells differentiate into plasma cells when activated. Plasma cells make antibodies (immunoglobulins) (Table 14.2) . Cells that migrate from the bone marrow to the thymus differentiate into T lymphocytes (thymus-dependent cells). The thymus se... . T cytotoxic (CD8) cells are involved in attacking antigens on the cell membrane of foreign pathogens and releasing cytolytic s... . T helper (CD4) cells are involved in regulating cell-mediated immunity and the humoral antibody response. T helper cells diffe... . Natural killer (NK) cells are involved in cell-mediated immunity. These cells are not T or B cells but are large lymphocytes w... T Dendritic Cells Cytokines Comparison of Humoral and Cell-Mediated Immunity Humoral Immunity Cell-Mediated Immunity ?Gerontologic Considerations: Effects of Aging on the Immune System ALTERED IMMUNE RESPONSE Hypersensitivity Reactions Type I: IgE-Mediated Reactions . Anaphylaxis can occur when mediators are released systemically (e.g., after injection of a drug, after an insect sting). The r... . Around 20% of the population is atopic. This means they have an inherited tendency to become sensitive to environmental allerg... Type II: Cytotoxic and Cytolytic Reactions . A classic type II reaction occurs when a recipient receives ABO-incompatible blood from a donor. Naturally acquired antibodies... . Goodpasture syndrome is a disorder involving the lungs and kidneys. An antibody-mediated autoimmune reaction occurs involving ... Type III: Immune-Complex Reactions Type IV: Delayed Hypersensitivity Reactions . Allergic contact dermatitis is an example of a delayed hypersensitivity reaction involving the skin. The reaction occurs when ... . The classic example of a microbial cell-mediated immune reaction is the body’s defense against the tubercle bacillus. Tubercul... ALLERGIC DISORDERS Assessment Diagnostic Studies Skin Tests . We can do skin testing by 3 different methods: (1) a scratch or prick test, (2) an intradermal test, or (3) a patch test. The ... . In the scratch and intradermal tests, the reaction occurs in 5 to 10 minutes. In the patch test the patches must be worn for 4... . A highly sensitive person is always at risk for developing an anaphylactic reaction to skin tests. Therefore, never leave a pa... Interprofessional and Nursing Management Anaphylaxis Chronic Allergies . You play a key role in helping the patient make lifestyle adjustments so that there is minimal exposure to offending allergens... Drug Therapy . Antihistamines are the best drugs for treating allergic rhinitis, itching, and hives (see Table 29.2). They are less effective... . The major sympathomimetic drug is epinephrine. Epinephrine is made by the adrenal medulla and stimulates α- and β-adrenergic ... . Nasal corticosteroid sprays are effective in relieving the symptoms of allergic rhinitis. Sometimes patients have such severe ... . Antipruritic drugs provide relief from itching and protect the skin. They are most effective when applied topically to intact ... . Cromolyn is a mast cell–stabilizing agent that inhibits the release of histamines, leukotrienes, and other agents from the mas... . Leukotriene receptor antagonists (LTRAs) block leukotriene, a major mediator of the allergic inflammatory process. These medic... Immunotherapy . The IgE level is high in atopic people. When IgE combines with an allergen in a hypersensitive person, a reaction occurs, rele... Method of administration . Subcutaneous immunotherapy (SCIT) involves the subcutaneous injection of titrated amounts of allergen extracts biweekly or we... . Sublingual immunotherapy (SLIT) involves allergen extracts taken under the tongue. Sublingual products include a 5-grass polle... ?Latex Allergies ?Types of Latex Allergies ?Latex-Food Syndrome ?Nursing Management: Latex Allergies ?Multiple Chemical Sensitivity AUTOIMMUNITY Autoimmune Diseases Apheresis Plasmapheresis IMMUNODEFICIENCY DISORDERS Primary Immunodeficiency Disorders Secondary Immunodeficiency Disorders HUMAN LEUKOCYTE ANTIGEN SYSTEM Human Leukocyte Antigen and Disease Associations ORGAN TRANSPLANTATION Tissue Typing HLA Typing Panel of Reactive Antibodies Crossmatch Transplant Rejection Hyperacute Rejection Acute Rejection Chronic Rejection Immunosuppressive Therapy Calcineurin Inhibitors Mycophenolate Mofetil Sirolimus Monoclonal Antibodies Polyclonal Antibodies GRAFT-VERSUS-HOST DISEASE REFERENCES 15 - Infection TYPES OF PATHOGENS SPECIFIC TYPES OF INFECTIONS Emerging Infections Reemerging Infections Antimicrobial-Resistant Infections Health Care–Associated Infections NURSING MANAGEMENT: INFECTION Antimicrobial Therapy Occupational Safety and Health Administration (OSHA) Guidelines Infection Precautions COVID-19 Pathophysiology Clinical Manifestations and Complications Diagnostic Tests Interprofessional and Nursing Management Vaccines HUMAN IMMUNODEFICIENCY VIRUS INFECTION HIV Transmission Sexual Transmission Contact With Blood and Blood Products Perinatal Transmission Pathophysiology Clinical Manifestations and Complications Acute Infection Chronic HIV Infection . The time between initial HIV infection and a diagnosis of AIDS is about 10 years in untreated infection. During the first seve... . As the CD4 cell count declines closer to 200 cells/μL and the viral load increases, HIV advances to a more active stage. Sympt... . A diagnosis of acquired immunodeficiency syndrome (AIDS) is made when a person with HIV meets criteria established by the CDC.... Diagnostic Studies Interprofessional Care Drug Therapy for HIV Infection Drug Therapy for Opportunistic Diseases ?Nursing Management: HIV Infection ?Assessment Biomedical Prevention Behavior Modification . Safe sexual activities eliminate the risk for exposure to HIV in semen and vaginal secretions. Abstaining from all sexual acti... . The major risk for HIV related to using drugs involves sharing equipment or having unsafe sexual experiences while under the i... . The best way to prevent HIV infection in infants is to prevent HIV infection in women. We should ask women with HIV about thei... . The risk for infection from occupational exposure to HIV is small but real. OSHA requires employers to protect workers from ex... . Around 14% of people with HIV in the United States do not know they are infected. They are more likely to transmit the infecti... . Early intervention after detection of HIV infection can promote health and limit disability. Findings from the history, assess... . Reactions to an HIV diagnosis are similar to the reactions of people who are diagnosed with any life-threatening, debilitating... . Nursing care becomes more complex as the patient’s immune system declines and new problems arise to compound existing problems... . As time passes, patients and their loved ones will be confronted with complex treatment decisions; feelings of loss, anger, po... . Physical problems related to HIV or its treatment can interfere with the patient’s ability to maintain a desired lifestyle. Pe... . Despite new developments in the treatment of HIV infection, many patients eventually have disease progression, disability, and... REFERENCES 16 - Cancer BIOLOGY OF CANCER Defect in Cell Proliferation Defect in Cell Differentiation Development of Cancer Initiation . Carcinogens are cancer-causing agents capable of producing cell alterations. Many are detoxified by protective enzymes and har... . Many chemicals are carcinogens (e.g., benzene, arsenic, formaldehyde). People exposed to these chemicals over time have a grea... . Radiation can cause cancer in almost any body tissue. When cells are exposed to a source of radiation, damage occurs to DNA. A... . Certain DNA and ribonucleic acid (RNA) viruses, termed oncogenic, can alter the cells they infect and induce malignant transfo... Promotion Progression Role of the Immune System Escape Mechanisms From Immunologic Surveillance Oncofetal Antigens and Tumor Markers BENIGN VERSUS MALIGNANT NEOPLASMS CLASSIFICATION OF CANCER Anatomic Site Classification Histologic Classification Extent of Disease Classification Clinical Staging TNM Classification System PREVENTION AND DETECTION OF CANCER Diagnosis of Cancer Biopsy Cure Control Palliation PERSONALIZED CANCER MEDICINE SURGICAL THERAPY Prevention Cure or Control Supportive and Palliative Care CHEMOTHERAPY Effect on Cells Classification of Chemotherapy Drugs Chemotherapy Preparation Methods of Administration Regional Chemotherapy Administration Intraarterial Chemotherapy Intraperitoneal Chemotherapy Intrathecal or Intraventricular Chemotherapy Intravesical Bladder Chemotherapy Effects of Chemotherapy on Normal Tissues Treatment Plan RADIATION THERAPY Principles of Radiobiology Simulation and Treatment Planning Treatment External Radiation Internal Radiation . Nausea and vomiting are common effects of chemotherapy and sometimes radiation therapy. Chemotherapy-induced nausea and vomiti... . Diarrhea is a reaction of the bowel mucosa to radiation and some chemotherapy drugs. The patient can have an increase in frequ... . Mucositis is irritation, inflammation, and/or ulceration of the mucosa. Like the bowel mucosa, the mucosal linings of the oral... . Anorexia (loss of appetite) is a common. It is a side effect of cancer and cancer treatment. Anorexia may be related to an inf... ?Skin Reactions . With radiation therapy, skin effects are local, occurring only in the treatment field. Radiation-induced skin changes can be a... . Chemotherapy causes a wide range of skin problems. These can range from mild redness and hyperpigmentation to more serious acr... LATE EFFECTS OF RADIATION AND CHEMOTHERAPY IMMUNOTHERAPY AND TARGETED THERAPY Side Effects of Immunotherapy and Targeted Therapy HORMONE THERAPY HEMATOPOIETIC GROWTH FACTORS HEMATOPOIETIC STEM CELL TRANSPLANTATION Types of Hematopoietic Stem Cell Transplants Procedures Harvest Procedures Preparative Regimens and Stem Cell Infusions Complications GENE THERAPY COMPLICATIONS OF CANCER NUTRITION PROBLEMS Malnutrition Altered Taste (Dysgeusia) Cancer Cachexia INFECTION ONCOLOGIC EMERGENCIES Obstructive Emergencies Metabolic Emergencies Infiltrative Emergencies CANCER PAIN Pain Assessment Pain Management COPING WITH CANCER AND TREATMENT Gerontologic Considerations: Cancer CANCER SURVIVORSHIP REFERENCES 17 - Fluid, Electrolyte, and Acid-Base Imbalances WATER CONTENT OF THE BODY Body Fluid Compartments Calculation of Fluid Gain or Loss ELECTROLYTES Measurement of Electrolytes Electrolyte Composition of Fluid Compartments MECHANISMS CONTROLLING FLUID AND ELECTROLYTE MOVEMENT Diffusion Facilitated Diffusion Active Transport Osmosis Measurement of Osmolality Osmotic Movement of Fluids Hydrostatic Pressure Oncotic Pressure FLUID MOVEMENT IN CAPILLARIES Fluid Shifts Shifts of Plasma to Interstitial Fluid . Increasing the pressure at the venous end of the capillary inhibits fluid movement back into the capillary. This results in ed... . Fluid stays in the interstitial space if the plasma oncotic pressure is too low to draw fluid back into the capillary. Low pla... . Trauma, burns, and inflammation can damage capillary walls and allow plasma proteins to accumulate in the interstitial space. ... . An increase in the plasma osmotic or oncotic pressure draws fluid into the plasma from the interstitial space. This could happ... FLUID SPACING REGULATION OF WATER BALANCE Hypothalamic-Pituitary Regulation Renal Regulation Adrenal Cortical Regulation Cardiac Regulation Gastrointestinal Regulation Interprofessional Care FLUID VOLUME EXCESS Interprofessional Care ?Planning ?Respiratory Care ?Patient Safety ?Skin Care SODIUM IMBALANCES HYPERNATREMIA Clinical Manifestations HYPONATREMIA Clinical Manifestations POTASSIUM IMBALANCES HYPERKALEMIA Clinical Manifestations HYPOKALEMIA Clinical Manifestations CALCIUM IMBALANCES HYPERCALCEMIA HYPOCALCEMIA PHOSPHATE IMBALANCES HYPERPHOSPHATEMIA HYPOPHOSPHATEMIA MAGNESIUM IMBALANCES HYPERMAGNESEMIA HYPOMAGNESEMIA ACID-BASE IMBALANCES PH AND HYDROGEN ION CONCENTRATION ACID-BASE REGULATION Buffer System Respiratory System Renal System ALTERATIONS IN ACID-BASE BALANCE Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis Mixed Acid-Base Disorders CLINICAL MANIFESTATIONS Blood Gas Values ASSESSMENT OF ELECTROLYTE AND ACID-BASE IMBALANCES Subjective Data Important Health Information . Question the patient about any history of problems involving the kidneys, heart, GI system, or lungs that could affect the pre... . Assess the patient’s current and past use of medications. Many drugs, especially over-the-counter drugs, are hidden sources of... . Ask the patient about past or present renal dialysis, kidney surgery, or bowel surgery resulting in a temporary or permanent e... Functional Health Patterns . If the patient currently has a problem related to electrolyte and acid-base balance, obtain a detailed description of the illn... . Ask the patient about their usual diet and any special diet practices. Weight reduction diets, fad diets, or any eating disord... . Make note of the patient’s usual bowel and bladder habits. Carefully document any problems, such as diarrhea, oliguria, polyur... . Ask about the patient’s exercise pattern and any excess perspiration. Determine if the patient is exposed to extremely high te... . Ask about any changes in sensations, such as numbness, tingling, or muscle weakness, which could signal an electrolyte problem... Objective Data Physical Assessment Laboratory Values Clinical Problems Planning Implementation ORAL FLUID AND ELECTROLYTE REPLACEMENT IV FLUID AND ELECTROLYTE REPLACEMENT Solutions Hypotonic Isotonic Hypertonic IV Additives Colloids CENTRAL VENOUS ACCESS DEVICES Centrally Inserted Catheters Peripherally Inserted Central Catheters Implanted Infusion Ports Midline Catheters Complications CVAD Removal REFERENCES 4 - Perioperative and Emergency Care 18 - Preoperative Care SURGICAL SETTINGS PATIENT INTERVIEW ASSESSMENT OF PREOPERATIVE PATIENT Subjective Data Psychosocial Assessment . Most people are anxious when facing surgery because of the unknown. This is a normal survival mechanism. However, a high anxie... . Patients fear surgery for many reasons. The most common fear is the risk of death or permanent disability. Sometimes the fear ... . Hope may be the patient’s strongest method of coping. To deny or minimize hope may negate the positive mental attitude necessa... Health History Medications Allergies Review of Systems . Evaluate cardiovascular (CV) function to determine preexisting disease or problems (e.g., coronary artery disease, prosthetic ... . Ask the patient about any recent or chronic respiratory problems or infections. Elective surgery may be postponed if the perso... . Evaluation of neurologic functioning includes assessing the patient’s ability to respond to questions, follow commands, and ma... . Assess for a history of renal or urinary tract diseases, such as chronic kidney disease or repeated urinary tract infections. ... . The liver is involved in glucose homeostasis, fat metabolism, protein synthesis, drug and hormone metabolism, and bilirubin fo... . Ask about a history of skin problems. Assess the current condition of the skin, especially at the incision site, for rashes, b... . Note any musculoskeletal and mobility problems, especially in the older adult. Identify any joints affected by arthritis. Mobi... . The patient with diabetes is especially at risk for adverse effects of anesthesia and surgery. Hypoglycemia, hyperglycemia, de... . Note if the patient has a history of a compromised immune system or takes immunosuppressive drugs. Corticosteroids used in imm... . Ask the patient about any recent conditions that increase the risk for fluid and electrolyte imbalances, such as vomiting, dia... . Knowing that a patient has a nutrition problem can help the health care team provide more customized care. For example, if the... Objective Data Physical Examination Diagnostic Studies REFERENCES 19 - Intraoperative Care PHYSICAL ENVIRONMENT OF THE OPERATING ROOM Department Layout Preoperative Holding Area Operating Room SURGICAL TEAM Registered Nurse Licensed Practical/Vocational Nurse and Surgical Technologist Surgeon and Assistant Registered Nurse First Assistant Anesthesia Care Provider ANESTHESIA ANESTHESIA TECHNIQUES Moderate to Deep Sedation Monitored Anesthesia Care General Anesthesia IV Agents Inhalation Agents Adjuncts to General Anesthesia Dissociative Anesthesia Local and Regional Anesthesia Spinal and Epidural Anesthesia PERIOPERATIVE CRISIS EVENTS Anaphylactic Reactions Malignant Hyperthermia REFERENCES 20 - Postoperative Care RESPIRATORY PROBLEMS Etiology PACU Clinical Unit CARDIOVASCULAR PROBLEMS Etiology PACU Clinical Unit NEUROLOGIC AND PSYCHOLOGIC PROBLEMS Etiology PACU Clinical Unit PAIN AND DISCOMFORT Etiology TEMPERATURE CHANGES Etiology Hypothermia Fever GASTROINTESTINAL PROBLEMS Etiology URINARY PROBLEMS Etiology SKIN PROBLEMS Etiology ?Implementation DISCHARGE FROM THE PACU Discharge to the Clinical Unit AMBULATORY SURGERY Phase II and Extended Observation Ambulatory Surgery Discharge Planning for Discharge and Follow-Up Care REFERENCES 21 - Emergency and Disaster Nursing CARE OF EMERGENCY PATIENT Triage Primary Survey A = Alertness and Airway B = Breathing C = Circulation and Control of Hemorrhage D = Disability E = Exposure and Environmental Control F = Full Set of Vitals and Family Presence G = Get Monitoring Devices and Give Comfort Secondary Survey H = History and Head-to-Toe Assessment . Check eyes for extraocular movements. A disconjugate gaze is a sign of neurologic damage. Battle’s sign, or bruising directly ... . Inspection and palpation of the chest will help detect heart and lung injuries. These may be life-threatening and need immedia... . Frequent evaluation for subtle changes in the abdomen is essential. Motor vehicle crashes and assaults can cause blunt trauma.... . Inspect and gently palpate the pelvis. Do not rock the pelvis. Pain may indicate a pelvic fracture and the need for imaging. A... . Assess the upper and lower extremities for point tenderness, crepitus, and deformities. If not done prehospital, splint injure... I = Inspect Posterior Surfaces J = Just Keep Reevaluating Cardiac Arrest and Targeted Temperature Management Death in the Emergency Department ?Gerontologic Considerations: Emergency Care ENVIRONMENTAL EMERGENCIES HEAT-RELATED EMERGENCIES Heat Cramps Heat Exhaustion Heatstroke Interprofessional Care COLD-RELATED EMERGENCIES Frostbite Hypothermia Interprofessional Care SUBMERSION INJURIES STINGS AND BITES Hymenopteran Stings Snake Bites Tick Bites Animal and Human Bites Interprofessional Care TOXICOLOGIC EMERGENCIES VIOLENCE AGENTS OF TERRORISM PENETRATING TRAUMA EMERGENCY AND MASS CASUALTY INCIDENT PREPAREDNESS REFERENCES 5 - Problems Related to Altered Sensory Input 22 - Assessment and Management: Visual Problems STRUCTURES AND FUNCTIONS OF VISUAL SYSTEM Periocular Structures Orbit Ocular Adnexa Lacrimal System Eyeball External Ocular Structures Middle Ocular Structures Internal Structures Aqueous Humor Lens Vitreous Humor Retina Optic Nerve VISUAL PATHWAY ASSESSMENT OF VISUAL SYSTEM Subjective Data Important Health Information . Take a health history, including the ocular and nonocular history. The patient’s nonocular history can be significant in asses... . Obtain a complete medication history, including eyedrops. Many drugs effect the eye. For example, many cold preparations conta... . Obtain a history of both ocular and nonocular surgeries. Include laser-based surgery and invasive treatments, such as retinal ... Functional Health Patterns . Patient characteristics, such as gender, ethnicity, and age, are important in assessing eye problems (Box 22.1). Men are more ... . High doses of vitamins containing antioxidant, carotenoids, and omega-3 fatty acids (vitamins C and E, beta-carotene, zinc) ma... . Straining to defecate (Valsalva maneuver) can raise IOP. After eye surgery, many HCPs do not want patients to strain. Assess t... . Reduced vision, symptoms accompanying an eye problem, or activity restrictions after surgery can affect the patient’s usual le... . In the otherwise healthy person, lack of sleep may cause eye irritation, especially if the patient wears contact lenses. Painf... . Assess for other cognitive or perceptual problems. For example, the functional ability of a patient with a visual deficit will... . The loss of independence that can follow a partial or complete loss of vision, even if the condition is temporary, can have de... . Eye problems can negatively affect the patient’s ability to take part in roles and responsibilities in the home, work, and soc... . The patient with severe vision loss may develop such a poor self-image that they lose the ability to be sexually intimate. Ass... . The patient with temporary or permanent vision problems may have emotional stress. Assess the patient’s coping methods and ava... . Be sensitive to each patient’s values and spiritual beliefs as these may guide decisions about eye care. It can be hard to und... Objective Data Physical Assessment . Your initial observation of the patient can provide information that will help focus the assessment. A patient dressed in clot... Assessing functional status . Always record the patient’s visual acuity. When doing your eye assessment, assess the right eye first and then the left eye. N... . Assess the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the ... . Pupil function is determined by inspecting the pupils and their reactions to light. We often abbreviate the normal finding as ... . We assess the visual system structures primarily by inspection. The visual system is unique because we can inspect not only th... . All structures should be present and symmetric, without deformities, redness, or swelling. Eyelashes extend outward from the l... . We can easily assess the conjunctiva and sclera at the same time. Assess the color and smoothness. Look for lesions or foreign... . The cornea should be clear, transparent, and shiny. The iris should appear flat and not bulge toward the cornea. The area betw... . Both irises should be of similar color and shape. However, a color difference between the irises occurs normally in a small nu... . Examine the optic nerve or disc for size, color, and abnormalities. The optic disc is creamy yellow with distinct margins. A c... Special Assessment Techniques . Testing the patient’s ability to distinguish colors is an important part of the assessment. Some occupations require accurate ... . Stereoscopic vision allows a patient to see objects in 3 dimensions. An event that causes a patient to have monocular vision (... DIAGNOSTIC STUDIES OF VISUAL SYSTEM VISION PROBLEMS Refractive Errors Nonsurgical Corrections . The right corrective lenses can enhance vision in those with myopia, hyperopia, presbyopia, and astigmatism. Many people call ... . Contact lenses are another way to correct refractive errors. Contact lenses are made from various plastic and silicone substan... Surgical Therapy . Laser-assisted in situ keratomileusis (LASIK) may be considered for patients with low to moderately high myopia or hyperopia, ... . Refractive intraocular lens (refractive IOL) implantation is an option for patients with a high degree of myopia or hyperopia.... VISUAL IMPAIRMENT . A wide range of technologies are available to help people with low vision. These devices include desktop video magnification/c... . Approach magnification is a simple way to enhance the patient’s residual vision. Recommend that the patient sit closer to the ... . A common problem that can occur in blind people, especially those who are totally blind, is non–24-hour sleep/wake disorder (n... EYE TRAUMA EXTRAOCULAR INFLAMMATION AND INFECTION Conjunctivitis Bacterial Infections Viral Infections Chlamydial Infections Allergic Conjunctivitis Keratitis Bacterial Infections Viral Infections Other Causes of Keratitis Corneal Ulcer DRY EYE DISORDERS STRABISMUS CORNEAL DISORDERS Corneal Scars Keratoconus Corneal Transplant Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies Interprofessional Care Surgical therapy . Because most patients have local anesthesia, they do not need an extensive physical assessment. However, most patients with ca... . The most common form of cataract surgery is phacoemulsification. In this procedure, a very small incision is made in the surfa... . Unless complications occur, the patient is usually ready to go home as soon as the effects of sedative agents have worn off. P... RETINOPATHY RETINAL DETACHMENT Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies Interprofessional Care Surgical Therapy . Retinal tears or holes without accompanying detachment may be treated by sealing the retina to the posterior wall using photoc... . Scleral buckling is an extraocular surgical procedure that involves placing a band around the globe to move the pigment epithe... . Intraocular procedures are used on occasion. Pneumatic retinopexy is the intravitreal injection of a gas to form a temporary b... . Vision prognosis varies. It depends on the extent, length, and area of detachment. After surgery, the patient may be on bed re... AGE-RELATED MACULAR DEGENERATION Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies Interprofessional Care GLAUCOMA Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Chronic Open-Angle Glaucoma Acute Angle-Closure Glaucoma . Because of the chronic nature of glaucoma, teach the patient to follow the treatment plan and follow-up recommendations prescr... INTRAOCULAR INFLAMMATION AND INFECTION OCULAR TUMORS ENUCLEATION REFERENCES 23 - Assessment and Management: Auditory Problems AUDITORY SYSTEM STRUCTURES AND FUNCTIONS OF AUDITORY SYSTEM External Ear Middle Ear Inner Ear Hearing Sound ASSESSMENT OF AUDITORY SYSTEM Subjective Data Important Health Information Medications Functional Health Patterns . Note the onset of hearing loss, whether sudden or gradual, and who noted the onset (e.g., patient, family, significant others)... . Ask the patient about any ear pain (otalgia) or discomfort when chewing or swallowing. These symptoms may occur with middle ea... . Elimination patterns are of interest in the patient with perilymph fistula and after surgery. Frequent constipation or straini... . A review of the patient’s activity-exercise pattern is essential when assessing for balance problems. Ask about the onset, dur... . Ask the patient with chronic tinnitus about sleep problems. Find out if they have tried anything to minimize the tinnitus, suc... . Pain occurs with some ear problems, especially those involving the middle ear and auditory canal. If pain is present, ask the ... . Ask the patient to describe how the ear problem has affected their personal life and feelings about themselves. Hearing loss a... . Ask the patient about the effect that an ear problem or vertigo has had on family life, work responsibilities, and social rela... . Determine whether hearing loss or vertigo has interfered with having a satisfactory sex life. Although intimacy does not depen... . Ask about coping style, stress management strategies, and available support. If the patient seems unable to manage the situati... . Ask the patient about any conflicts produced by the problem or treatment related to values or beliefs. Make every effort to re... Objective Data Physical Assessment . Inspect and palpate the external ear before assessing the external canal and TM. Observe the auricle, preauricular area, and m... . Before inserting an otoscope, inspect the canal opening for patency, palpate the tragus, and gently move the auricle to check ... DIAGNOSTIC STUDIES OF AUDITORY SYSTEM Audiometry EXTERNAL EAR AND CANAL PROBLEMS CERUMEN AND FOREIGN BODIES IN EXTERNAL EAR CANAL TRAUMA MALIGNANCY OF EXTERNAL EAR Acute Otitis Media Otitis Media With Effusion Chronic Otitis Media and Mastoiditis OTOSCLEROSIS INNER EAR PROBLEMS MÉNIÈRE DISEASE BENIGN PAROXYSMAL POSITIONAL VERTIGO ACOUSTIC NEUROMA HEARING LOSS AND DEAFNESS Types of Hearing Loss Conductive Hearing Loss Sensorineural Hearing Loss Mixed Hearing Loss Central and Functional Hearing Loss Clinical Manifestations Classification of Hearing Loss Tinnitus ?Immunizations ?Ototoxic Substances ?Assistive Devices and Techniques ?Hearing Aids ?Cochlear Implant ?Speech Reading ?Sign Language ?Assistive Listening Devices REFERENCES 24 - Assessment: Integumentary System STRUCTURES AND FUNCTIONS OF SKIN AND APPENDAGES Structures Epidermis Dermis Subcutaneous Tissue Skin Appendages Functions of Integumentary System ASSESSMENT OF INTEGUMENTARY SYSTEM Subjective Data Important Health Information . A health history reveals previous trauma, surgery, or disease that involves the skin. Many diseases have skin manifestations (... . A thorough medication history is important. Ask the patient about skin-related problems that occurred because of taking a medi... . Determine if any surgeries, including cosmetic surgery, were done on the skin. Record any biopsy results. Note any treatments ... Functional Health Patterns . Ask about health practices, such as self-care habits related to daily hygiene. Assess the frequency of use and sun protection ... . Ask about the condition of skin, hair, nails, and mucous membranes. Have there been any changes related to diet? A diet histor... . Ask the patient about skin problems, such as dehydration, edema, and pruritus (itching). These can indicate changes in fluid b... . Obtain information about environmental hazards in relation to hobbies and recreational activities, including exposure to known... . Ask the patient about changes in sleep patterns caused by a skin problem. For example, itching can be distressing and interfer... . Assess the perception of the sensations of heat, cold, pain, and touch. Note any discomfort associated with a skin problem, es... . Assess any feelings related to having a skin problem, such as sadness, anxiety, despair, or altered body image. These feelings... . Determine how the skin problem affects relationships with family members, peers, and work associates. Ask the patient about th... . Assess the effect of the patient’s skin problem on sexual activity. Note the reproductive status of the female patient relativ... . Assess the role that stress may play in creating or worsening a skin problem. Discuss what coping strategies the patient uses ... . Assess cultural or religious beliefs that could influence the patient’s self-image as related to the skin problem. Values and ... Objective Data Physical Assessment . Photographs are an adjunct to documentation and promote communication among the interprofessional team. We use them to assess ... . Inspect the skin for general color and pigmentation, vascularity, bruising, lesions, and discolorations. The critical factor i... . Palpate the skin to obtain information about temperature, turgor, moisture, and texture. Use the back of your hand to gauge sk... Assessment of Dark Skin DIAGNOSTIC STUDIES OF INTEGUMENTARY SYSTEM REFERENCES 25 - Integumentary Problems SKIN CANCER Risk Factors NONMELANOMA SKIN CANCER Actinic Keratosis Basal Cell Carcinoma Squamous Cell Carcinoma MELANOMA Clinical Manifestations Interprofessional Care Atypical or Dysplastic Nevus SKIN INFECTIONS AND INFESTATIONS Bacterial Infections Viral Infections Infestations and Insect Bites Fungal Infections ALLERGIC SKIN PROBLEMS Skin Drug Reactions BENIGN SKIN PROBLEMS INTERPROFESSIONAL CARE: SKIN PROBLEMS Phototherapy Radiation Therapy Laser Technology Drug Therapy Antibiotics Corticosteroids Antihistamines Topical Fluorouracil Immunomodulators Diagnostic and Surgical Therapy Skin Scraping Electrodessication and Electrocoagulation Curettage Punch Biopsy Cryosurgery Excision ?Postprocedure Care COSMETIC PROCEDURES Surgical Therapies Laser Surgery Face-Lift Liposuction SKIN GRAFTS Uses Types REFERENCES 26 - Burns TYPES OF BURN INJURY Thermal Burns Chemical Burns Electrical Burns Cold Thermal Injury CLASSIFICATION OF BURN INJURY Burn Depth Classification Extent of Burn Location of Burn Patient Risk Factors PREHOSPITAL AND EMERGENCY CARE PHASES OF BURN MANAGEMENT EMERGENT PHASE Pathophysiology Fluid and Electrolyte Shifts Inflammation and Healing Immunologic Changes Clinical Manifestations Complications Respiratory Cardiovascular Renal ACUTE PHASE Pathophysiology Clinical Manifestations Fluid and Electrolytes Sodium Potassium Complications Infection Cardiovascular and Respiratory Neurologic Musculoskeletal Gastrointestinal Endocrine REHABILITATION PHASE Pathophysiologic Changes and Clinical Manifestations Complications EMOTIONAL/PSYCHOLOGIC NEEDS OF PATIENTS AND CAREGIVERS SPECIAL NEEDS OF NURSES REFERENCES 6 - Problems of Oxygenation: Ventilation 27 - Assessment: Respiratory System STRUCTURES AND FUNCTIONS OF RESPIRATORY SYSTEM Lower Respiratory Tract Surfactant Blood Supply Chest Wall Physiology of Respiration Oxygenation Ventilation Compliance and Resistance Control of Respiration Chemoreceptors Mechanical Receptors Respiratory Defense Mechanisms Air Filtration Mucociliary Clearance System Cough Reflex Reflex Bronchoconstriction Alveolar Macrophages ASSESSMENT OF RESPIRATORY SYSTEM Subjective Data Important Health Information . It is important to determine the frequency of upper respiratory problems (e.g., colds, sore throats, sinus problems, allergies... . Take a thorough medication history, including the names of prescription and over-the-counter (OTC) medications. Ask about the ... . Find out if the patient has been hospitalized for a respiratory problem. Note the dates, therapy (including surgery), and stat... Functional Health Patterns . Ask the patient if there has been a perceived change in health status within the last several days, months, or years. In COPD,... . Weight loss can be a symptom of respiratory disease. Determine if weight loss was intentional. If not, was food intake changed... . Activity intolerance from dyspnea could result in incontinence, if unable to reach a toilet when needed. Dyspnea can be the ca... . Determine if dyspnea limits activity. Assess whether the patient’s residence (e.g., number of steps, levels) poses any problem... . Determine if the patient wakes up at night because of lung problems. The patient with asthma or COPD may awaken with chest tig... . Because hypoxia can cause neurologic symptoms, ask the patient about apprehension, restlessness, irritability, and memory chan... . Dyspnea limits activity, impairs ability to fulfill normal roles, and often alters self-esteem. A patient may be reluctant to ... . Acute and chronic respiratory problems can seriously affect performance in work or other activities. Discuss the impact of med... . Most patients can continue to have satisfactory sexual relationships despite marked physical limitations. In a tactful manner,... . Dyspnea causes anxiety, and anxiety worsens dyspnea. The result is a vicious cycle—the patient avoids activities that cause dy... . Determine the patient’s adherence to their treatment program. Explore possible reasons for lack of adherence, including confli... Objective Data Physical Assessment . Inspect the nose for patency, inflammation, deformities, symmetry, and discharge. Check each nostril for air patency with resp... . Using a good light source, inspect the interior of the mouth for color, lesions, masses, gum retraction, bleeding, and poor de... . Inspect the neck for symmetry and tender or swollen areas. Palpate the lymph nodes while the patient is sitting erect with the... . Picture imaginary lines on the chest to help identify abnormalities (Fig. 27.2). Describe abnormalities in terms of their loca... . First, observe the patient’s appearance. Note any evidence of respiratory distress, such as tachypnea or use of accessory musc... . Determine tracheal position by gently placing the index fingers on either side of the trachea just above the suprasternal notc... . Percussion is used to assess the density or aeration of the lungs. Percussion sounds are described in Table 27.5 . During chest auscultation, have the patient breathe slowly and a little more deeply than normal through the mouth. Auscultatio... DIAGNOSTIC STUDIES OF RESPIRATORY SYSTEM Oximetry Arterial Venous Arterial Blood Gases CO2 Monitoring Sputum Studies Skin Tests Endoscopy Bronchoscopy Lung Biopsy Thoracentesis Pulmonary Function Tests REFERENCES 28 - Supporting Ventilation RESPIRATORY PHYSIOTHERAPY Breathing Exercises Airway Clearance Techniques Huff Coughing Chest Physical Therapy Postural Drainage Percussion Vibration . Airway clearance devices are available to help mobilize secretions. They are sometimes easier to tolerate than CPT and often t... . High-frequency chest wall oscillation uses an inflatable vest (e.g., Vest System, Smart Vest) with hoses connected to a high-f... O2 THERAPY Methods of O2 Administration Humidification Complications Combustion O2 Toxicity Absorption Atelectasis CO2 Narcosis Infection NURSING MANAGEMENT: O2 THERAPY O2 Therapy at Home ARTIFICIAL AIRWAYS Nasopharyngeal Airway Oropharyngeal Airway Endotracheal Tube Nasotracheal Tube Tracheostomy PROCEDURES TO SUPPORT VENTILATION Chest Tubes and Pleural Drainage Chest Tube Insertion Pleural Drainage System NURSING MANAGEMENT: CHEST DRAINAGE Chest Surgery Thoracotomy Video-Assisted Thoracic Surgery NURSING MANAGEMENT: CHEST SURGERY Preoperative Care Postoperative Care NONINVASIVE VENTILATION Continuous Positive Airway Pressure Bilevel Positive Airway Pressure NURSING MANAGEMENT: NONINVASIVE VENTILATION MECHANICAL VENTILATION Types of Ventilators Negative Pressure Ventilation Positive Pressure Ventilation . With volume ventilation, a predetermined tidal volume (VT) is delivered with each inspiration.11 The amount of pressure needed... . With pressure ventilation, the peak inspiratory pressure (PIP) is predetermined.11 The VT delivered to the patient will vary, ... Endotracheal Intubation Procedure Ventilator Settings Positive End-Expiratory Pressure Modes of Volume Ventilation Full support modes . In assist-control (AC) ventilation (or volume control), the ventilator delivers a preset VT at a preset respiratory rate.12 Wh... . Pressure-control (PC) ventilation provides the patient with a pressure-limited breath.11 In other words, besides a set respira... Partial support modes . In synchronized intermittent mandatory ventilation (SIMV), both the patient and the ventilator do the WOB. The ventilator del... Spontaneous breathing modes . With pressure support ventilation (PSV), positive pressure is applied to the airway only during inspiration. The patient must ... . CPAP refers to a mode of spontaneous ventilation where the ventilated patient controls almost all aspects of the breath.11 Do ... Newer Modes of Mechanical Ventilation . Pressure-regulated volume control (PRVC) is a full support mode of mechanical ventilation. It combines features of both volume... . Airway pressure release ventilation (APRV) can be used in full support or spontaneous mode, depending on the patient. There ar... . Proportional assist ventilation (PAV) is a partial support mode of mechanical ventilation. In this mode, the ventilator genera... NURSING MANAGEMENT: MECHANICALLY VENTILATED PATIENT Artificial Airway Management Maintaining Correct Tube Placement Maintaining Proper Cuff Inflation Maintaining Tube Patency Maintaining Alarm Systems Analgesia and Sedation Hemodynamic Monitoring Oxygenation and Ventilation Oral Care Skin Integrity Nutrition Therapy Venous Thromboembolism and GI Prophylaxis Early Mobility Communication Psychosocial Concerns Preventing Delirium “Rescue” Therapies Inhaled Pulmonary Vasodilators Prone Positioning Extracorporeal Membrane Oxygenation Complications of Mechanical Ventilation Aspiration Sodium and Water Imbalance Adverse Hemodynamic Effects Alveolar Ventilation Changes Barotrauma Volutrauma Auto-Positive End-Expiratory Pressure Alterations in Gastric Motility Ventilator Disconnection and Malfunction Ventilator-Associated Pneumonia Unplanned Extubation Weaning From Positive Pressure Ventilation Extubation TRACHEOSTOMY Preparing the Patient for a Tracheostomy Preprocedure Care During the Procedure Postprocedure Care NURSING MANAGEMENT: PATIENT WITH A TRACHEOSTOMY Accidental Decannulation Decannulation NURSING MANAGEMENT: CARE OF THE PATIENT WITH A LONG-TERM TRACHEOSTOMY Swallowing Problems Speech With a Tracheostomy Tube Tracheostomy and Chronic Mechanical Ventilation in the Home REFERENCES 29 - Upper Respiratory Problems NASAL FRACTURE RHINOPLASTY EPISTAXIS ALLERGIC RHINITIS Clinical Manifestations Clinical Manifestations INFLUENZA Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies SINUSITIS Clinical Manifestations NASAL AND SINUS OBSTRUCTION Nasal Polyps Foreign Bodies Clinical Manifestations PERITONSILLAR ABSCESS ACUTE LARYNGITIS AIRWAY OBSTRUCTION HEAD AND NECK CANCER Clinical Manifestations Diagnostic Studies Staging of Head and Neck Cancer Interprofessional Care Surgical Therapy Radiation Therapy Chemotherapy and Targeted Therapy Nutrition Therapy Physical Therapy Speech Therapy ?Nursing Management: Head and Neck Cancer ?Assessment ?Clinical Problems ?Planning ?Implementation ?Health Promotion ?Acute Care . Before surgery, assess the patient’s physical and psychosocial needs. Physical preparation is the same as for any major surger... . Dry mouth (xerostomia), a frequent and annoying problem, typically occurs within a few weeks of treatment. The patient’s saliv... . Should the patient have a stoma after surgery, teach the patient proper care of the stoma. The patient should wash the area ar... . Psychosocial care of the patient with head and neck cancer is of utmost importance. Issues concerning depression, change in bo... ?Ambulatory Care ?Evaluation REFERENCES 30 - Lower Respiratory Problems LOWER RESPIRATORY TRACT INFECTIONS ACUTE BRONCHITIS PERTUSSIS PNEUMONIA Etiology Classifications of Pneumonia Community-Acquired Pneumonia Hospital-Acquired Pneumonia Types of Pneumonia Aspiration Pneumonia Necrotizing Pneumonia Opportunistic Pneumonia Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Drug Therapy Nutrition Therapy ?Nursing Management: Pneumonia ?Assessment ?Clinical Problems ?Planning ?Implementation ?Health Promotion ?Acute Care ?Ambulatory Care ?Evaluation TUBERCULOSIS Etiology and Pathophysiology Classification Clinical Manifestations Complications Diagnostic Studies Tuberculin Skin Test Interferon-γ Release Assays Chest X-Ray Bacteriologic Studies Interprofessional Care Drug Therapy . The mainstay of TB treatment is drug therapy (Table 30.12). Because of the growing prevalence of MDR-TB, it is important to ma... . In people with LTBI, drug therapy helps prevent a TB infection from developing into active TB disease. Because a person with L... . Bacille Calmette-Guérin (BCG) vaccine is a live, attenuated strain of Mycobacterium bovis. The vaccine is given to infants in ... ?Nursing Management: Tuberculosis ?Assessment ?Clinical Problems ?Planning ?Implementation ?Health Promotion ?Acute Care ?Ambulatory Care ?Evaluation ATYPICAL MYCOBACTERIA PULMONARY FUNGAL INFECTIONS LUNG ABSCESS Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies Interprofessional and Nursing Care RESTRICTIVE RESPIRATORY DISORDERS ATELECTASIS PLEURISY PLEURAL EFFUSION Types of Pleural Effusions Clinical Manifestations Interprofessional and Nursing Care INTERSTITIAL LUNG DISEASES IDIOPATHIC PULMONARY FIBROSIS SARCOIDOSIS CHEST TRAUMA AND THORACIC INJURIES FRACTURED RIBS FLAIL CHEST PNEUMOTHORAX Types of Pneumothoraxes Spontaneous Pneumothorax Iatrogenic Pneumothorax Tension Pneumothorax Hemothorax Chylothorax Interprofessional Care PULMONARY EMBOLISM Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Drug Therapy Surgical Therapy ?Nursing Management: Pulmonary Embolism PULMONARY HYPERTENSION IDIOPATHIC PULMONARY ARTERIAL HYPERTENSION Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies Interprofessional and Nursing Care SECONDARY PULMONARY ARTERIAL HYPERTENSION COR PULMONALE Clinical Manifestations and Diagnostic Studies Interprofessional and Nursing Care ENVIRONMENTAL LUNG DISEASES Clinical Manifestations Interprofessional and Nursing Care LUNG TRANSPLANTATION Preoperative Care Surgical Procedure Postoperative Care LUNG CANCER Etiology Pathophysiology Other Types of Lung Tumors Paraneoplastic Syndrome Clinical Manifestations Diagnostic Studies Staging Screening for Lung Cancer Interprofessional Care Surgical Therapy Radiation Therapy Chemotherapy Targeted Therapy Immunotherapy Other Therapies . Patients with SCLC have early metastases, especially to the CNS. Most chemotherapy does not penetrate the blood-brain barrier.... . Bronchoscopic laser therapy makes it possible to remove obstructing bronchial lesions. The laser’s thermal energy is transmitt... . Photodynamic therapy (PDT) is a form of treatment for early-stage lung cancers that uses a combination of a drug and a specifi... . Stents are used alone or in combination with other techniques for relief of dyspnea, cough, or respiratory insufficiency. The ... ?Nursing Management: Lung Cancer ?Assessment ?Clinical Problems ?Planning ?Implementation ?Health Promotion ?Acute Care ?Ambulatory Care ?Evaluation REFERENCES 31 - Obstructive Pulmonary Diseases BRONCHIECTASIS Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies ?Nursing Management: Bronchiectasis ?Assessment ?Planning ?Implementation ?Health Promotion ?Acute Care ?Evaluation CYSTIC FIBROSIS Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care ?Nursing Management: Cystic Fibrosis ?Assessment ASTHMA Risk Factors and Triggers Nose and Sinus Problems Allergens Cigarette Smoke Air Pollutants Respiratory Tract Infections Immune Response Genetics Gastroesophageal Reflux Disease Drugs and Food Additives Exercise Occupational Factors Psychologic Factors Pathophysiology Clinical Manifestations Asthma Classifications Complications Status Asthmaticus Diagnostic Studies Interprofessional Care Drug Therapy Corticosteroids Bronchodilators . β2-Adrenergic agonists may be SABAs or LABAs. While inhaled SABAs remain effective drugs for relieving acute bronchospasm (as ... . Sustained-release methylxanthine preparations are not a first-line controller medication. They are used only as an alternativ... . Anticholinergic drugs affect the muscles around the bronchi (large airways). When the lungs are irritated, these bands of musc... Leukotriene Modifiers Monoclonal Antibodies . Omalizumab (Xolair) is a monoclonal antibody to IgE that decreases circulating free IgE levels. Omalizumab prevents IgE from ... . Interleukin (IL)-5 is a cytokine involved in the inflammatory response in asthma by promoting eosinophil activity.23 By inhibi... Nonprescription Combination Drugs Inhalation Devices for Drug Delivery . MDIs are small, hand-held, pressurized devices that deliver a measured dose of drug with each activation. The dose is usually ... . DPIs are simpler to use than MDIs. The DPI contains dry, powdered medication and is breath activated (Fig. 31.10). DPIs have s... . Nebulizers are small machines used to convert drug solutions into mists. The mist can be inhaled through a face mask or mouthp... ?Nursing Management: Asthma ?Assessment ?Patient Teaching Related to Drug Therapy CHRONIC OBSTRUCTIVE PULMONARY DISEASE Risk Factors Cigarette Smoking Infection Asthma Air Pollution Occupational Chemicals and Dusts Aging Genetics Alpha-1 Antitrypsin Deficiency Pathophysiology Classification of COPD Clinical Manifestations Complications Pulmonary Hypertension and Cor Pulmonale Acute Exacerbations Acute Respiratory Failure Diagnostic Studies Interprofessional Care Oxygen Therapy Drug Therapy Respiratory Care Nutrition Therapy Surgical Therapy ?Nursing Management: COPD ?Assessment ?Clinical Problems . Pulmonary rehabilitation can be done in an inpatient or outpatient setting or in the home. Components vary. They usually inclu... . The patient with severe COPD typically uses upper thoracic and neck muscles to breathe rather than the diaphragm. Thus, the pa... . Coping is a challenge for the patient and family. As COPD progresses, patients are often confronted with many lifestyle change... . Modifying sexual activity can contribute to well-being. First, assess if the patient has any concerns related to sexuality and... . Adequate sleep is important to maintain quality of life and productivity. Most patients with COPD have sleep problems. Current... . The trajectory of COPD is a gradual decline in health characterized by increasing exacerbations with an increased risk of deat... REFERENCES 32 - Acute Respiratory Failure and Acute Respiratory Distress Syndrome ACUTE RESPIRATORY FAILURE Etiology and Pathophysiology Hypoxemic Respiratory Failure . In normal lungs, the volume of blood perfusing the lungs and the amount of gas reaching the alveoli are almost identical. So, ... . A shunt occurs when blood exits the heart without having taken part in gas exchange. A shunt is an extreme V/Q mismatch. There... . Diffusion impairment occurs when gas exchange across the alveolar-capillary membrane is compromised by a process that damages ... . Alveolar hypoventilation is a decrease in ventilation that increases the PaCO2. Common causes include central nervous system (... . Rarely is acute hypoxemic respiratory failure caused by a single factor. More often, it is a combination of 2 or more factors.... Consequences of Hypoxemia Hypercapnic Respiratory Failure . Several CNS problems can suppress the drive to breathe. An example is an overdose of a respiratory depressant drug (e.g., opio... . Various neuromuscular problems place patients at risk for respiratory failure. For example, patients with Guillain-Barré syndr... . Several conditions can prevent normal chest wall or diaphragm movement and limit lung expansion. With severe obesity, the weig... . Patients with COPD, asthma, and cystic fibrosis are at higher risk for hypercapnic respiratory failure because the underlying ... . The body can tolerate increased CO2 levels better than low O2 levels. This is because with slow changes in PaCO2, the body may... Clinical Manifestations Diagnostic Studies . Position the patient with ARF upright. Elevate the head of the bed at least 30 degrees or use a reclining chair or chair bed. ... . When secretions are present, encourage the patient to cough. Unfortunately, not all patients will have enough strength or forc... . Chest physiotherapy is indicated for all patients producing sputum or have severe atelectasis or pulmonary infiltrates on ches... . Suctioning may be needed if the patient is unable to expectorate secretions. Inserting a soft-tip suction catheter through a n... . Humidification is an adjunct in secretion management. We can thin secretions with aerosols of sterile normal saline or mucolyt... . Thick, viscous secretions are hard to expel. Unless contraindicated, adequate fluid intake (2 to 3 L/day) keeps secretions thi... ?Gerontologic Considerations: Acute Respiratory Failure ACUTE RESPIRATORY DISTRESS SYNDROME Etiology Pathophysiology Injury or Exudative Phase Reparative or Proliferative Phase Fibrotic or Fibroproliferative Phase Clinical Progression Clinical Manifestations and Diagnostic Studies Complications Abnormal Lung Function Ventilator-Associated Pneumonia Barotrauma GI Ulcers Venous Thromboembolism (VTE) Acute Kidney Injury Psychological Issues ?Nursing And Interprofessional Management: ARDS . Patients with ARDS are ventilated with a low VT of 4 to 8 mL/kg.24 Delivering a large VT into stiff lungs can cause volutrauma... . As a result of delivering a lower-than-normal VT to the patient with ARDS, the PaCO2 level will slowly rise above normal limit... . During PPV, it is common to apply PEEP at 5 cm H2O to compensate for the loss of glottic function with an ET. PEEP increases f... ?Analgesia and Sedation REFERENCES 7 - Problems of Oxygenation: Transport 33 - Assessment: Hematologic System STRUCTURES AND FUNCTIONS OF HEMATOLOGIC SYSTEM Bone Marrow Blood Plasma Blood Cells . The main functions of RBCs include transport of gases (both O2 and CO2) and assistance in maintaining acid-base balance. RBCs ... . Leukocytes (WBCs) appear white when separated from blood. Like the RBCs, WBCs originate from stem cells within the bone marrow... . The main function of granulocytes is phagocytosis. This is the process by which WBCs engulf any unwanted organism and then dig... . Lymphocytes make up 20% to 25% of the WBCs in the blood.1 They form the basis of cellular and humoral immune responses. Two ly... . Monocytes, the other type of agranular WBC, make up about 3% to 8% of the total WBCs.1 They are potent phagocytic cells that i... . The main function of thrombocytes, or platelets, is to start the clotting process by producing an initial platelet plug at a s... Normal Iron Metabolism Normal Clotting Mechanisms Vascular Injury, Vasoconstriction, and Subendothelial Exposure Adhesion Clotting Cascade Activation Blood Clot Formation Clot Retraction and Dissolution Spleen Lymph System Liver ?Gerontologic Considerations: Effects of Aging on Hematologic System ASSESSMENT OF HEMATOLOGIC SYSTEM Subjective Data Important Health Information . Determine if the patient has had prior hematologic problems. Ask about anemia, bleeding problems, and blood disorders. Are the... . A complete medication history is important. Ask about the use of vitamins, herbal products, or diet supplements. Many medicati... . Obtain a surgical history. This includes splenectomy, tumor removal, prosthetic heart valve placement, and GI surgeries. A par... Functional Health Patterns . Ask the patient to describe the usual and present state of health. Gather demographic data, including age, gender, race, and e... . Determine if the patient has had anorexia, nausea, vomiting, or oral discomfort. A diet history may give clues about the cause... . Ask if there has been blood in the urine or stool or if black, tarry stools have occurred. Ask the patient if they have had a ... . Because fatigue is a prominent symptom in many hematologic problems, ask about feelings of tiredness. Determine any weakness o... . Determine whether the patient feels rested after a night’s sleep. Fatigue from a hematologic problem often does not resolve af... . Assess for any joint pain that may be caused by a hematologic problem. Pain in the joint may occur with an autoimmune disorder... . Determine the effect of the health problem on the patient’s perception of self and personal abilities. Assess the effect of ce... . Ask the patient about any past or present occupational or household exposures to radiation or chemicals. If such exposure has ... . Take a careful menstrual history from women. Include the age at which menarche and menopause began, duration and amount of ble... . The patient with a hematologic problem often needs help with ADLs. Ask the patient if adequate support is available to meet da... . Treatment for some hematologic problems involves blood transfusions or a bone marrow transplant. Determine if these treatments... Objective Data Physical Assessment . Assess lymph nodes symmetrically. Note location, size (in centimeters), degree of fixation (e.g., movable, fixed), tenderness,... . The liver and spleen are normally not detectable by palpating the abdomen. An enlarged liver or spleen may be detectable by pe... . Examine the skin over the entire body in a systematic manner. In patients with RBC disorders, the skin may be pale or pasty. I... DIAGNOSTIC STUDIES OF HEMATOLOGIC SYSTEM Laboratory Studies Complete Blood Count . The total RBC count is reported as RBC × 106/μL. However, the total RBC count is not fully reliable in determining the adequac... . The WBC count gives 2 sets of information. The first is a total count of WBCs in 1 μL of peripheral blood. A WBC count over 10... . The platelet count is the number of platelets per microliter of blood. Normal platelet counts are between 150,000 and 400,000/... Blood Typing and Rh Factor Iron Metabolism Biopsies Bone Marrow Examination Lymph Node Biopsy Molecular Cytogenetics and Gene Analysis REFERENCES 34 - Hematologic Problems ANEMIA Definition and Classification Clinical Manifestations . Skin manifestations include pallor, jaundice, and itching. Pallor results from low Hgb levels and reduced blood flow to the sk... . Cardiopulmonary manifestations of severe anemia result from the heart and lungs trying to provide adequate amounts of O2 to th... ?Implementation ?Gerontologic Considerations: Anemia ANEMIA CAUSED BY DECREASED RBC PRODUCTION IRON DEFICIENCY ANEMIA Etiology Clinical Manifestations Diagnostic Studies Interprofessional and Nursing Management Drug Therapy THALASSEMIA Etiology Clinical Manifestations and Diagnostic Studies Interprofessional Care MEGALOBLASTIC ANEMIAS COBALAMIN DEFICIENCY Etiology Clinical Manifestations Diagnostic Studies FOLIC ACID DEFICIENCY ANEMIA OF CHRONIC DISEASE APLASTIC ANEMIA Etiology Clinical Manifestations Diagnostic Studies ANEMIA CAUSED BY BLOOD LOSS ACUTE BLOOD LOSS Clinical Manifestations Diagnostic Studies CHRONIC BLOOD LOSS ANEMIA CAUSED BY INCREASED RBC DESTRUCTION SICKLE CELL DISEASE Etiology and Pathophysiology Sickling Episodes Clinical Manifestations Complications Diagnostic Studies ACQUIRED HEMOLYTIC ANEMIA POLYCYTHEMIA Etiology and Pathophysiology Primary Polycythemia Secondary Polycythemia Clinical Manifestations and Complications Diagnostic Studies PROBLEMS OF HEMOSTASIS THROMBOCYTOPENIA Etiology and Pathophysiology Immune Thrombocytopenia Thrombotic Thrombocytopenic Purpura Heparin-Induced Thrombocytopenia Clinical Manifestations Diagnostic Studies Interprofessional Care Immune Thrombocytopenic Purpura Thrombotic Thrombocytopenic Purpura Heparin-Induced Thrombocytopenia Thrombocytopenia From Decreased Platelet Production HEMOPHILIA AND VON WILLEBRAND DISEASE Clinical Manifestations and Complications Diagnostic Studies Interprofessional Care DISSEMINATED INTRAVASCULAR COAGULATION Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care NEUTROPENIA Clinical Manifestations Diagnostic Studies MYELODYSPLASTIC SYNDROME Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies LEUKEMIA Etiology and Pathophysiology Classification Acute Myeloid Leukemia Acute Lymphocytic Leukemia Chronic Myelogenous Leukemia Chronic Lymphocytic Leukemia Other Leukemias Overlap Between Leukemia and Lymphoma Clinical Manifestations Diagnostic Studies Interprofessional Care Chemotherapy Stages . The first stage, induction therapy, is the attempt to bring about a remission. Induction is aggressive treatment that seeks to... . Terms used to describe postinduction or postremission chemotherapy include intensification and consolidation. Intensification ... . The goal of maintenance therapy is to keep the body free of leukemic cells. It may also be used for acute leukemia, depending ... Drug Therapy Regimens Other Treatments Hematopoietic Stem Cell Transplantation LYMPHOMAS HODGKIN LYMPHOMA Etiology and Pathophysiology Clinical Manifestations Diagnostic and Staging Studies NON-HODGKIN LYMPHOMA Etiology and Pathophysiology Clinical Manifestations Diagnostic and Staging Studies MULTIPLE MYELOMA Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies DISORDERS OF THE SPLEEN BLOOD COMPONENT THERAPY Administration Procedure Blood Transfusion Reactions Acute Transfusion Reactions Delayed Transfusion Reactions Autotransfusion EVOLVE WEBSITE/RESOURCES LIST REFERENCES 8 - Problems of Oxygenation: Perfusion 35 - Assessment: Cardiovascular System STRUCTURES AND FUNCTIONS OF CARDIOVASCULAR SYSTEM Heart Structure Blood Flow Through Heart . The 4 valves of the heart keep blood flowing in a forward direction. The cusps of the mitral and tricuspid valves are attached... Blood Supply to Myocardium Conduction System . The electrical activity of the heart can be detected using electrodes and recorded on an electrocardiogram (ECG). We use the l... Mechanical System . Many factors can affect either the HR or SV and thus the CO. HR is controlled primarily by the autonomic nervous system. It ca... Cardiac Reserve Vascular System Blood Vessels . The arterial system differs from the venous system by the amount and type of tissue that make up arterial walls (Fig. 35.5). T... . The thin capillary wall made up of endothelial cells has no elastic or muscle tissue (Fig. 35.5). Exchange of cellular nutrien... . Venules are small vessels with a minor amount of muscle and connective tissue. Venules collect blood from the capillary beds a... Regulation of Cardiovascular System Autonomic Nervous System . Stimulation of the sympathetic nervous system increases the HR, speed of impulse conduction through the AV node, and force of ... . The source of neural control of blood vessels is the sympathetic nervous system. Alpha1 (α1)-adrenergic receptors are found in... Baroreceptors Chemoreceptors Blood Pressure Measurement of Arterial Blood Pressure Pulse Pressure and Mean Arterial Pressure ?Gerontologic Considerations: Effects of Aging on the Cardiovascular System ASSESSMENT OF CARDIOVASCULAR SYSTEM Subjective Data Important Health Information . Ask the patient what problem has led to seeking health care. Fully explore all symptoms the patient reports . Many illnesses affect the cardiovascular system directly or indirectly. Ask the patient about a history of angina, diabetes, a... . Assess the patient’s current and past use of medications. Record the dose and time last taken for each. Include over-the-count... . Ask the patient about specific treatments, surgeries, or hospital admissions related to cardiovascular problems. Explore any a... Functional Health Patterns . Ask the patient about the presence of major cardiovascular risk factors. These include abnormal serum lipids, hypertension, se... . Being underweight or overweight may indicate potential cardiovascular problems. Assess the patient’s weight history (e.g., ove... . The patient taking diuretics may report increased voiding and/or nocturia. Ask about incontinence or constipation, including u... . The benefit of exercise for cardiovascular health is clear, with aerobic exercise being most beneficial. Record the types, dur... . Cardiovascular problems often disrupt sleep. Paroxysmal nocturnal dyspnea (attacks of shortness of breath, especially at night... . Ask both the patient and caregiver about cognitive-perceptual problems. Cardiovascular problems such as dysrhythmias, hypert... . Acute cardiovascular events may affect the patient’s self-perception. Invasive diagnostic procedures often lead to body image ... . Gender, race, and age are related to cardiovascular health. The patient’s marital status, role in the household, employment st... . Ask the patient about the effect of the cardiovascular problem on sexual activity. Because some patients fear sudden death dur... . Ask the patient to identify sources of stress and the usual methods of coping with stress. Potentially stressful areas include... . Individual values and beliefs, which are greatly affected by culture, may play a key role in the real or potential conflict th... Objective Data Physical Assessment . Observe the patient’s general appearance and obtain vital signs. Measure BP bilaterally. Readings can vary from 5 to 15 mm Hg ... Peripheral vascular system . Inspect the skin for color, hair distribution, and venous pattern. Check the extremities for edema, dependent rubor, clubbing ... . Palpate the upper and lower extremities for temperature, moisture, pulses, and edema bilaterally to assess for symmetry. Look ... . An artery that is narrowed or has a bulging wall may create turbulent blood flow. This abnormal flow can cause a buzzing or hu... Thorax . Begin examining the thorax with a general inspection and palpation. Next, inspect and palpate the areas where the heart valves... . Normal heart sounds are made by the movement of blood through the heart valves. We can hear these sounds through a stethoscope... HEMODYNAMIC MONITORING Hemodynamic Measurements Cardiac Output and Cardiac Index Preload Afterload Contractility Noninvasive Hemodynamic Monitoring Principles of Invasive Pressure Monitoring Types of Invasive Pressure Monitoring Arterial BP . Use the arterial line to obtain systolic, diastolic, and mean arterial pressure (MAP) (Fig. 35.12). Table 35.7 outlines the st... . Arterial lines carry the risk for hemorrhage, infection, thrombus formation, neurovascular impairment, and loss of limb. Hemor... Arterial Pressure-Based Cardiac Output . Arterial pressure is the force generated by the ejection of blood from the left ventricle into the arterial circulation. The h... Pulmonary Artery Flow-Directed Catheter Central Venous or Right Atrial Pressure Measurement ?Nursing Management: Hemodynamic Monitoring DIAGNOSTIC STUDIES OF CARDIOVASCULAR SYSTEM Blood Studies Cardiac Biomarkers C-Reactive Protein Homocysteine Cardiac Natriuretic Peptide Markers Serum Lipids Diagnostic Studies Electrocardiography Electrocardiogram Event Monitor Functional Studies Exercise or Stress Testing . A general test of cardiac fitness, often used with older adults, is measuring the distance the patient can walk on a flat surf... Imaging Chest X-Ray Echocardiography Cardiac Computed Tomography (CT) Cardiovascular Magnetic Resonance Imaging Nuclear Cardiology Interventional Studies Cardiac Catheterization Intravascular Ultrasound Electrophysiology Study REFERENCES 36 - Hypertension NORMAL REGULATION OF BLOOD PRESSURE Sympathetic Nervous System Baroreceptors Vascular Endothelium Renal System Endocrine System HYPERTENSION Classification of Hypertension Etiology Primary Hypertension Secondary Hypertension Pathophysiology of Primary Hypertension Water and Sodium Retention Altered Renin-Angiotensin-Aldosterone Mechanism Stress and Increased Sympathetic Nervous System Activity Insulin Resistance and Hyperinsulinemia Endothelial Dysfunction Clinical Manifestations Complications Hypertensive Heart Disease . Hypertension is a significant risk factor for coronary artery disease (CAD). The “response-to-injury” theory of atherogenesis ... . Sustained high BP increases the cardiac workload and causes left ventricular hypertrophy (LVH) (Fig. 36.4). Initially, LVH is ... . HF occurs when the heart’s compensatory mechanisms are overwhelmed, and the heart can no longer pump enough blood to meet the ... Cerebrovascular Disease Peripheral Vascular Disease Nephrosclerosis Retinal Damage Diagnostic Studies Ambulatory Blood Pressure Monitoring Interprofessional Care Lifestyle Modifications . Persons who are overweight have an increased incidence of hypertension and increased risk for CVD. Weight loss can have a sign... . Plant-based and Mediterranean diets with increased fruit, nut, vegetable, legumes, and lean proteins from fish and vegetables ... . The average adult sodium intake is around 4200 mg/day in men and 3300 mg/day in women. Healthy adults should restrict sodium i... . Excess alcohol use is strongly associated with hypertension. Drinking 3 or more alcoholic drinks a day is a risk factor for CV... . A physically active lifestyle is essential to promote good health. Adults should perform a minimum of 150 minutes of moderate ... . Nicotine contained in tobacco causes vasoconstriction and increases BP, especially in people with hypertension. Smoking tobacc... . Risk factors can be related to social determinants of health and psychosocial risk factors. These factors can contribute to th... Drug Therapy . Carefully explore all reasons why a patient may not be at goal BP (Table 36.9). Resistant hypertension is the failure to reach... . Hypertension is usually discovered through routine screening for insurance, employment, and military physical examinations. Yo... . Proper size and correct placement of the BP cuff are critical for accurate measurement (Table 36.11). Place the cuff snugly ar... . Screening programs in the community are widely used to identify persons who have a high BP. At the time of the BP measurement,... . Teaching about CVD risk factors is appropriate for all persons. Modifiable CVD risk factors include hypertension, obesity, dia... . Side effects of antihypertensive therapy are common. They may be so severe or undesirable that the patient does not adhere to ... . Most patients with known or suspected hypertension should monitor their BP at home. The readings are often lower than those ta... . A significant problem in the long-term management of the patient with hypertension is poor adherence to the treatment plan (Bo... HYPERTENSIVE CRISIS Clinical Manifestations EVOLVE WEBSITE/RESOURCES LIST REFERENCES 37 - Coronary Artery Disease and Acute Coronary Syndrome CORONARY ARTERY DISEASE Etiology and Pathophysiology Developmental Stages . Fatty streaks, the earliest lesions of atherosclerosis, are lipid-filled smooth muscle cells. As streaks of fat develop within... . The fibrous plaque stage is the beginning of progressive changes in the endothelium of the arterial wall. These changes can ap... . The last stage in the development of the atherosclerotic lesion is the most dangerous. As the fibrous plaque grows, continued ... Collateral Circulation Risk Factors for Coronary Artery Disease Nonmodifiable Risk Factors . The incidence of CAD is highest among middle-aged men (Box 37.1). However, the risk for CAD increases for men over age 45 and ... Major Modifiable Risk Factors . High serum lipid levels are a major risk factor for CAD (see Table 35.9). The increased risk for CAD is associated with a tota... . Hypertension increases the risk for CAD, stroke, peripheral vascular disease, heart failure (HF), and death. In postmenopausal... . Tobacco use is a major CAD risk factor. The risk for developing CAD is much higher in those who smoke tobacco or use smokeless... . Diabetes is a major modifiable risk factor for CAD. The incidence of CAD is 2 to 4 times greater among people who have diabete... . Metabolic syndrome refers to a cluster of risk factors for CAD whose underlying pathophysiology may be related to insulin resi... . Physical inactivity increases risk for CAD. Physical inactivity implies a lack of adequate physical exercise on a regular basi... . The death rate from CAD is higher in obese persons. Obesity is defined as a body mass index (BMI) of greater than 30 kg/m2 and... Contributing Modifiable Risk Factors . Certain behaviors and lifestyles may contribute to the development of CAD. One type of behavior, referred to as type A, includ... . The use of illegal drugs such as cocaine and methamphetamine can produce coronary artery spasm resulting in myocardial ischemi... . Increased levels of CRP, lipoprotein(a), and homocysteine increase the risk of CAD. Folic acid deficiency can cause high homoc... . The statin drugs are the most widely used lipid-lowering drugs (Table 37.6). They inhibit the synthesis of cholesterol in the ... . Niacin, a water-soluble B vitamin, is effective in lowering triglyceride levels and mildly lowering LDL levels (Table 37.6). A... . Fibric acid derivatives (Table 37.6) increase HDL levels. They lower triglyceride levels by reducing the liver’s production of... . Bempedoic acid (Nexletol) helps lower LDL in patients with heterozygous familial hypercholesterolemia or patients with CAD who... . Bile-acid sequestrants increase conversion of cholesterol to bile acids in the liver (Table 37.6). The primary effect is a dec... . PCSK9 inhibitors reduce the number of receptors in the liver that remove LDL cholesterol from the blood (Table 37.6). By block... ?Drugs That Decrease Cholesterol Absorption CHRONIC STABLE ANGINA Prinzmetal’s Angina Microvascular Angina INTERPROFESSIONAL AND NURSING CARE: CHRONIC STABLE ANGINA Acute Care Patient Teaching Drug Therapy Nitrates . SL NTG tablets or translingual spray (Nitrolingual) usually relieve pain in about 5 minutes and last about 30 to 40 minutes. T... Long-Acting Nitrates Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARBs) β-Adrenergic Blockers Calcium Channel Blockers Lipid-Lowering Drugs Sodium Current Inhibitor Diagnostic and Intervention Studies Cardiac Catheterization Surgical Coronary Revascularization Conventional Coronary Artery Bypass Graft Surgery Minimally Invasive Direct Coronary Artery Bypass Off-Pump Coronary Artery Bypass Totally Endoscopic Coronary Artery Bypass Transmyocardial Laser Revascularization Postoperative Care After CABG Surgery Alternative Therapies for Refractory Chronic Stable Angina ACUTE CORONARY SYNDROME UNSTABLE ANGINA ST-ELEVATION AND NON–ST-ELEVATION MYOCARDIAL INFARCTION Clinical Manifestations Pain Sympathetic Nervous System Stimulation Cardiovascular Manifestations Nausea and Vomiting Fever Healing Process Complications of Myocardial Infarction Dysrhythmias Heart Failure Cardiogenic Shock Papillary Muscle Dysfunction or Rupture Left Ventricular Aneurysm Ventricular Septal Wall Rupture and Left Ventricular Free Wall Rupture Pericarditis Dressler Syndrome Diagnostic Studies Electrocardiogram Findings Serum Cardiac Biomarkers Cardiac Catheterization INTERPROFESSIONAL CARE: ACUTE CORONARY SYNDROME Emergent Percutaneous Coronary Intervention Thrombolytic Therapy Indications and Contraindications Procedure Drug Therapy IV Nitroglycerin Morphine β-Adrenergic Blockers Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Antidysrhythmic Drugs Lipid-Lowering Drugs Aldosterone Antagonists Stool Softeners Nutrition Therapy ?Acute Care SUDDEN CARDIAC DEATH Etiology and Pathophysiology Clinical Manifestations REFERENCES 38 - Heart Failure HEART FAILURE 38 Etiology Pathophysiology Left-Sided Heart Failure . HFrEF results from an inability of the heart to pump blood effectively (e.g., MI), increased afterload (e.g., HTN), cardiomyop... Right-Sided Heart Failure Biventricular Failure Compensatory Mechanisms Neurohormonal response . The renin-angiotensin-aldosterone system (RAAS) works to maintain homeostasis. The goal of RAAS activation is increased preloa... . Baroreceptors sense low arterial pressure, stimulating the sympathetic nervous system (SNS) to try to maintain CO. Catecholami... . Endothelin, a vasoconstrictor peptide made by the vascular endothelial cells, is stimulated by hypoxia, ischemia, neurohormone... Ventricular adaptations . Dilation is an enlargement of the heart chambers (Fig. 38.3A). It occurs when pressure in the heart chambers (usually the LV) ... . Hypertrophy is an adaptive increase in the heart muscle thickness as a slow response to overwork and strain (Fig. 38.3B). It t... . Pathologic ventricular remodeling is a change in the structure (dimensions, mass, shape) of the heart. Ventricular remodeling ... Beneficial Counterregulatory Mechanisms Classifications of Heart Failure New York Heart Association Classes of Heart Failure The Stages of Heart Failure Clinical Manifestations: Acute Decompensated Heart Failure Clinical Manifestations: Chronic Heart Failure Fatigue Dyspnea Cough Tachycardia Palpitations Edema Changes in Urine Output Skin Changes Neurologic Manifestations Mental Status and Behavior Changes Sleep Problems Chest Pain Weight Changes Complications of Heart Failure Pleural Effusion Dysrhythmias and Dyssynchronous Contraction Hepatomegaly Cardiorenal Syndrome Anemia Diagnostic Studies Interprofessional Care: Acute Decompensated Heart Failure Nonpharmacologic Therapies Drug Therapy . Diuretics are the first line for treating patients with volume overload. They decrease sodium reabsorption at various sites wi... . Patient with ADHF who are not hypotensive receive vasodilators. IV nitroglycerin (NTG) is a primary venodilator that reduces b... . Morphine dilates pulmonary and systemic blood vessels, reducing preload and afterload. It is often given in small IV boluses t... . Inotropic drugs increase myocardial contractility and are used for patients with low CO despite adequate or high fluid volume.... Interprofessional Care: Chronic Heart Failure Drug Therapy Evidence-based drug therapy for HFrEF . ACE inhibitors are first-line drugs to decrease mortality, hospitalizations, and symptoms in patients with HFrEF.1 ACE inhibit... . For patients who are unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) are recommended.1 They prevent... . Sacubitril/valsartan (Entresto) is a combination of a neprilysin inhibitor (sacubitril) and an ARB (valsartan). This drug pro... . Spironolactone (Aldactone) and eplerenone (Inspra) are potassium-sparing diuretics that inhibit aldosterone activation. They w... . β-Blockers directly block the negative effects of the SNS (e.g., increased HR) on the failing heart. Three β-blockers decrease... . Ivabradine selectively inhibits a particular sodium/potassium current in the SA node, causing a decreased HR. Patients with HF... . This drug is a combination of 2 vasodilators: hydralazine and isosorbide dinitrate. It can significantly reduce mortality and ... . Digitalis (digoxin), a weak positive inotrope, acts mainly as a neurohormonal modulator that reduces the effects of the SNS an... . Dapagliflozin, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, reduces the risk of CV death and hospitalization for patie... Medications for symptom management . Diuretics reduce symptoms of fluid overload in both HFrEF and HFpEF. They reduce edema, pulmonary venous pressure, and preload... Device Therapy Remote Monitoring of Physiologic Data Nutrition Therapy ?Implementation Health Promotion ?End-Stage Heart Failure Therapy MECHANICAL CIRCULATORY SUPPORT DEVICES Intraaortic Balloon Pump Effects of Counterpulsation Complications of IABP Therapy Ventricular Assist Devices Implantable Artificial Heart ?Nursing and Interprofessional Management: Mechanical Circulatory Support HEART TRANSPLANTATION Criteria for Selection Surgical Procedure Post-Transplantation REFERENCES 39 - Dysrhythmias RHYTHM IDENTIFICATION AND TREATMENT Conduction System Nervous Control of the Heart Electrocardiographic Monitoring Telemetry Monitoring Electrophysiologic Mechanisms of Dysrhythmias Evaluating Dysrhythmias Overview of Cardiac Rhythms Normal Cardiac Rhythms . Normal sinus rhythm refers to a rhythm that starts in the SA node at a rate of 60 to 100 beats/min and follows the normal cond... . In sinus arrhythmia, the conduction pathway is the same as that in sinus rhythm, but the SA node fires irregularly. This often... Types of Dysrhythmias Sinus Bradycardia . Sinus bradycardia may be a normal sinus rhythm in aerobically trained athletes and in some people during sleep. It also occurs... . In sinus bradycardia, the HR is less than 60 beats/min, and rhythm is regular. The P wave precedes each QRS complex and has a ... . The significance of sinus bradycardia depends on how the patient tolerates it. Manifestations of symptomatic bradycardia inclu... . If bradycardia is due to drugs, these may have to be held, stopped, or reduced. For the patient with symptoms, treatment consi... Sinus Tachycardia . Sinus tachycardia is associated with many physiologic and psychologic stressors. Stressors include exercise, fever, pain, hypo... . In sinus tachycardia, the HR is 101 to 180 beats/min, and rhythm is regular. The P wave is normal and precedes each QRS comple... . The clinical significance of sinus tachycardia depends on the patient’s tolerance of the increased HR. The patient may have di... . The underlying cause guides the treatment. For example, if the patient has tachycardia from pain, effective pain management is... Premature Atrial Contraction . In a normal heart, a PAC can result from emotional stress, fatigue, or from caffeine, tobacco, or alcohol use. A PAC can also ... . HR varies with the underlying rate and frequency of the PAC. The rhythm is irregular. The P wave has a different shape from th... . In a person with a healthy heart, isolated PACs are not significant. Patients may report palpitations or a sense that the hear... . Treatment depends on the patient’s symptoms. Sources of stimulation, such as caffeine or sympathomimetic drugs (e.g., epinephr... Paroxysmal Supraventricular Tachycardia . In the normal heart, PSVT may occur with overexertion, emotional stress, deep inspiration, and stimulants, such as caffeine an... . In PSVT, the HR is 151 to 220 beats/min. The rhythm is regular or slightly irregular. The P wave may have an abnormal shape or... . The significance of PSVT depends on the associated symptoms. A prolonged episode and HR greater than 180 beats/min will cause ... . Treatment for PSVT includes vagal stimulation and drug therapy. Common vagal maneuvers include Valsalva and coughing. IV adeno... Atrial Flutter . Atrial flutter rarely occurs in a healthy heart. It is associated with CAD, hypertension, mitral valve disorders, pulmonary em... . Atrial rate is 200 to 350 beats/min. The ventricular rate varies based on the conduction ratio. In 2:1 conduction, the ventric... . The high ventricular rates (greater than 100 beats/min) and loss of the atrial “kick” (atrial contraction coordinated with ven... . The primary goal in treatment of atrial flutter is to slow the ventricular response by increasing AV block. Drugs used to cont... Atrial Fibrillation . Atrial fibrillation usually occurs in a patient with underlying heart disease, such as CAD, valvular heart disease, cardiomyop... . During atrial fibrillation, the atrial rate may be as high as 350 to 600 beats/min. Chaotic, fibrillatory waves replace the P ... . Atrial fibrillation results in a decrease in CO because of ineffective atrial contractions (loss of atrial kick) and/or a rapi... . The goals of atrial fibrillation treatment are to decrease the ventricular response (to less than 100 beats/min), prevent stro... . The left atrial appendage (LAA) is a pouch that extends off the left atrium. The LAA is a common source of blood clots in pati... Junctional Dysrhythmias . Junctional dysrhythmias are often associated with CAD, HF, cardiomyopathy, electrolyte imbalances, inferior MI, and rheumatic ... . In junctional escape rhythm, the HR is 40 to 60 beats/min. HR is 61 to 100 beats/min in accelerated junctional rhythm and 101 ... . Junctional escape rhythms serve as a safety mechanism when the SA node has not been effective. Escape rhythms should not be su... . Treatment varies by the type of junctional dysrhythmia. If a patient has symptoms with a junctional escape rhythm, atropine ca... First-Degree AV Block . First-degree AV block is associated with increasing age, MI, CAD, rheumatic fever, hyperthyroidism, electrolyte imbalances (e.... . In first-degree AV block, the HR is normal. The rhythm is regular. The P wave is normal. The PR interval is prolonged (greater... . First-degree AV block is usually not serious. Patients are asymptomatic . There is no treatment for first-degree AV block. Treatment of associated conditions may be considered. Monitor patients for ch... Second-Degree AV Block, Type I . Type I AV block may result from drugs, such as digoxin or β-blockers. It may be associated with CAD and other diseases that ca... . Atrial rate is regular, but ventricular rate may be slower because of non-conducted or blocked QRS complexes resulting in brad... . Type I AV block is usually a result of myocardial ischemia or inferior MI. It is generally transient and well-tolerated. Howev... . A symptomatic patient may need atropine or a temporary pacemaker to increase HR, especially if the patient has had an MI. If t... Second-Degree AV Block, Type II . Type II AV block is associated with rheumatic heart disease, CAD, anterior MI, and drug toxicity . Atrial rate is usually normal. Ventricular rate depends on the degree of AV block. Atrial rhythm is regular, but ventricular r... . Type II AV block often progresses to third-degree AV block. It is associated with a poor prognosis. The reduced HR often resul... . Transcutaneous pacing or the insertion of a temporary pacemaker may be needed before inserting a permanent pacemaker if the pa... Third-Degree AV Block . Third-degree AV block is associated with severe heart disease, including CAD, MI, myocarditis, cardiomyopathy, and some system... . The atrial rate is usually a sinus rate of 60 to 100 beats/min. The ventricular rate depends on the site of the block. If it i... . Third-degree AV block usually results in reduced CO with subsequent ischemia, HF, and shock. Syncope from third-degree AV bloc... . Symptomatic patients need a TCP until a temporary transvenous pacemaker can be inserted.5,6 Drugs such as dopamine and epineph... Premature Ventricular Contractions . PVCs are associated with stimulants, such as caffeine, alcohol, nicotine, aminophylline, epinephrine, and isoproterenol. They ... . HR varies according to intrinsic rate and number of PVCs. Rhythm is irregular because of premature beats. The P wave is rarely... . PVCs are usually not harmful in a patient with a normal heart. PVCs in CAD or acute MI indicate ventricular irritability. PVCs... . Treatment relates to the cause of the PVCs (e.g., O2 therapy for hypoxia, electrolyte replacement). Assessing the patient’s he... Accelerated Idioventricular Rhythm . It is most often associated with acute MI and reperfusion of the myocardium after thrombolytic therapy or percutaneous coronar... . In the setting of acute MI, AIVR is usually self-limiting and well tolerated, and it needs no treatment. If the patient become... Ventricular Tachycardia . VT is associated with MI, CAD, significant electrolyte imbalances, cardiomyopathy, long QT syndrome, drug toxicity, and centra... . Ventricular rate is 150 to 250 beats/min. Rhythm may be regular or irregular. AV dissociation may be present, with P waves occ... . VT can be stable (patient has a pulse) or unstable (patient is pulseless). Sustained VT causes a severe decrease in CO because... . Precipitating causes (e.g., electrolyte imbalances, ischemia) must be identified and treated. If the VT is monomorphic and the... Ventricular Fibrillation . VF occurs in acute MI, myocardial ischemia, and chronic diseases such as HF and cardiomyopathy. It may occur during cardiac pa... . HR is not measurable. Rhythm is irregular and chaotic. The P wave is not visible. The PR interval and the QRS interval are not... . VF results in an unresponsive, pulseless, and apneic state. If VF is not treated quickly, the patient will not recover . Treatment consists of immediate initiation of CPR and ACLS with the use of defibrillation and definitive drug therapy (e.g., e... Asystole . Asystole is usually a result of advanced heart disease, a severe cardiac conduction system problem, or end-stage HF . Generally, the patient with asystole has end-stage heart disease or had prolonged arrest and cannot be resuscitated . Treatment consists of CPR with ACLS measures. These include definitive drug therapy with epinephrine, intubation, and efforts ... Pulseless Electrical Activity Sudden Cardiac Death ?Interprofessional and Nursing Management: Dysrhythmias ?Antidysrhythmic Drug Therapy ?Defibrillation ?Synchronized Cardioversion ?Implantable Cardioverter-Defibrillator ?Pacemakers ?Permanent Pacemaker ?Cardiac Resynchronization Therapy ?Temporary Pacemaker ?Monitoring of Patients With Pacemakers ?Radiofrequency Catheter Ablation Therapy SYNCOPE REFERENCES 40 - Inflammatory and Structural Heart Disorders INFLAMMATORY HEART DISORDERS Clinical Manifestations Diagnostic Studies Interprofessional Care Prophylactic Treatment Drug Therapy ?Ambulatory Care ACUTE PERICARDITIS Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care CHRONIC CONSTRICTIVE PERICARDITIS Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies MYOCARDITIS Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies and Interprofessional Care RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE Etiology and Pathophysiology Cardiac Lesions and Valve Deformities Extracardiac Lesions Clinical Manifestations Major Criteria Minor Criteria Evidence of Infection Complications Diagnostic Studies and Interprofessional Care ?Nursing Management: Rheumatic Fever and Rheumatic Heart Disease ?Assessment VALVULAR HEART DISEASE MITRAL VALVE STENOSIS Etiology and Pathophysiology Clinical Manifestations MITRAL VALVE REGURGITATION Etiology and Pathophysiology Clinical Manifestations MITRAL VALVE PROLAPSE Etiology and Pathophysiology Clinical Manifestations AORTIC VALVE STENOSIS Etiology and Pathophysiology Clinical Manifestations AORTIC VALVE REGURGITATION Etiology and Pathophysiology Clinical Manifestations TRICUSPID AND PULMONIC VALVE DISEASE Etiology and Pathophysiology DIAGNOSTIC STUDIES: VALVULAR HEART DISEASE INTERPROFESSIONAL CARE: VALVULAR HEART DISEASE Conservative Therapy Percutaneous Transluminal Balloon Valvuloplasty Surgical Therapy Valve Repair Valve Replacement ?Nursing Management: Valvular Disorders ?Assessment ?Evaluation CARDIOMYOPATHY DILATED CARDIOMYOPATHY Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies HYPERTROPHIC CARDIOMYOPATHY Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies RESTRICTIVE CARDIOMYOPATHY Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies EVOLVE WEBSITE/RESOURCES LIST REFERENCES 41 - Vascular Disorders PERIPHERAL ARTERY DISEASE Etiology and Pathophysiology PERIPHERAL ARTERY DISEASE OF THE LOWER EXTREMITIES Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Risk Factor Modification Drug Therapy Exercise Therapy Nutrition Therapy Care of the Patient With Critical Limb Ischemia Interventional Radiology Catheter-Based Procedures Surgical Therapy ?Nursing Management: Lower Extremity Peripheral Artery Disease ?Assessment ACUTE ARTERIAL ISCHEMIC DISORDERS Etiology and Pathophysiology Clinical Manifestations Interprofessional Care THROMBOANGIITIS OBLITERANS RAYNAUD’S PHENOMENON AORTIC ANEURYSMS Etiology and Pathophysiology Classification Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Surgical Therapy . Minimally invasive endovascular aneurysm repair (EVAR) is an alternative to OAR for select patients. EVAR involves the placem... . The most common complication of AAA repair is endoleak, the seepage of blood back into the old aneurysm. This may result from ... ?Nursing Management: Aortic Aneurysms ?Assessment . An adequate BP is important to maintain graft patency. Prolonged low BP may result in graft thrombosis. Give IV fluids and blo... . Myocardial ischemia or infarction may occur in the perioperative period from decreased myocardial O2 supply or increased myoca... . A prosthetic vascular graft infection is a rare but potentially life-threatening complication. Nursing interventions to preven... . After OAR, postoperative ileus may develop because of anesthesia and the handling of the bowel during surgery. The intestines ... . Neurologic complications can occur after aortic surgery. When the ascending aorta and aortic arch are involved, assess the pat... . The location of the aneurysm determines the type of peripheral perfusion assessment. Check and record all peripheral pulses ho... . The patient will have an indwelling urinary catheter after surgery. In the immediate postoperative period, record hourly urine... AORTIC DISSECTION Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Conservative Therapy Endovascular Dissection Repair Surgical Therapy VENOUS THROMBOSIS Etiology Venous Stasis Endothelial Damage Hypercoagulability of Blood Pathophysiology Superficial Vein Thrombosis Clinical Manifestations Interprofessional Care Venous Thromboembolism Clinical Manifestations Complications Diagnostic Studies Interprofessional Care . All health care team members have important roles in VTE prevention. VTE prevention is a core measure of high-quality health c... . Anticoagulants are used routinely for VTE prevention and treatment. The regimen depends on the patient’s VTE risk. The goal of... . The oral anticoagulant for long-term or extended anticoagulation is warfarin, a VKA. Warfarin inhibits activation of the vitam... . There are 2 major classes of indirect thrombin inhibitors: UH and LMWHs. UH (e.g., heparin) affects both the intrinsic and com... . Factor Xa inhibitors inhibit factor Xa directly or indirectly, producing rapid anticoagulation. These include fondaparinux (Ar... . For VTE prevention in the hospitalized medical patient at risk for thrombosis who is not bleeding, low-dose UH, LMWH, or fonda... . Patients with confirmed VTE should receive initial treatment with either LMWH, UH, or an oral factor Xa drug. Oral VKA therapy... . Another treatment option for patients with a thrombus is catheter-directed administration of a thrombolytic drug (e.g., uroki... . A few patients with extensive, acute, proximal VTE who are not candidates for catheter-directed thrombolysis and/or interventi... ?Nursing Management: Venous Thromboembolism ?Assessment ?Clinical Problems ?Nursing Implementation ?Acute Care VARICOSE VEINS Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies and Interprofessional Care Drug Therapy Interventional and Surgical Therapies ?Nursing Management: Varicose Veins CHRONIC VENOUS INSUFFICIENCY AND VENOUS LEG ULCERS Etiology and Pathophysiology Clinical Manifestations and Complications Interprofessional and Nursing Care REFERENCES 42 - Shock, Sepsis, and Multiple Organ Dysfunction Syndrome SHOCK Classification of Shock Cardiogenic Shock Hypovolemic Shock Distributive Shock . Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury and last up to 6 weeks. ... . Anaphylactic shock is an acute, life-threatening hypersensitivity (allergic) reaction to a sensitizing substance (e.g., drug, ... . Sepsis is a life-threatening syndrome in response to infection. It is characterized by a dysregulated patient response along w... Obstructive Shock Stages of Shock Initial Stage Compensatory Stage Progressive Stage Refractory Stage Diagnostic Studies Interprofessional Care Oxygen and Ventilation Fluid Resuscitation Drug Therapy . Drugs that mimic the action of the SNS are called sympathomimetic. Their effects are mediated through their binding to α- or β... . Patients in cardiogenic shock have decreased myocardial contractility. Vasodilators may be needed to decrease afterload. This... Nutrition Therapy Measures Specific to Type of Shock Cardiogenic Shock Hypovolemic Shock Septic Shock Neurogenic Shock Anaphylactic Shock Obstructive Shock ?Nursing Management: Shock ?Assessment . Assess the patient’s neurologic status, including orientation and level of consciousness using a valid tool, at least every 1 ... . We base most of the therapy for shock on information about cardiovascular status. If the patient is unstable, continuously ass... . Frequently assess respiratory status to ensure adequate oxygenation, detect complications, and provide data about acid-base st... . At first, measure urine output every 1 to 2 hours to assess the adequacy of renal perfusion. Inserting an indwelling urinary c... . Monitor temperature every 4 hours if normal. In the presence of a high or subnormal temperature, obtain hourly core temperatur... . Auscultate bowel sounds at least every 4 hours. Monitor for abdominal distention. If a nasogastric tube is present, measure dr... . Hygiene is especially important because impaired tissue perfusion predisposes the patient to skin breakdown and infection. Per... . Do not underestimate the effects of fear and anxiety when the patient and caregiver are faced with a life-threatening situatio... Etiology and Pathophysiology Organ and Metabolic Dysfunction Clinical Manifestations of SIRS and MODS ?Nursing and Interprofessional Management: Sirs and Mods EVOLVE WEBSITE/RESOURCES LIST REFERENCES 9 - Problems of Ingestion, Digestion, Absorption, and Elimination 43 - Assessment: Gastrointestinal System STRUCTURES AND FUNCTIONS OF GASTROINTESTINAL SYSTEM Ingestion Mouth Pharynx Esophagus Digestion and Absorption Stomach Small Intestine Physiology of Digestion Elimination Large Intestine Liver, Biliary Tract, and Pancreas Liver . The liver constantly makes bilirubin, a pigment derived from the breakdown of hemoglobin (Fig. 43.4). When released into the b... Biliary Tract Pancreas ?Gerontologic Considerations: Effects of Aging on GI System ASSESSMENT OF GASTROINTESTINAL SYSTEM Subjective Data Important Health Information . Obtain information from the patient about the history or presence of the problems related to GI functioning and fully explore ... . Assess the patient’s past and current use of medications. Ask about the reason for taking the medication, the dose and frequen... . Obtain information about hospitalizations for any problems related to the GI system. Record any abdominal or rectal surgery, i... Functional Health Patterns . Ask about the patient’s health practices related to the GI system. This includes maintaining normal body weight, proper dental... . A thorough nutrition assessment is essential. Take a diet history and ask about both content and amount or portion size. Food ... . Elicit a detailed account of the patient’s bowel elimination pattern. Note the frequency, time of day, and usual stool consist... . Activity and exercise affect GI motility. Immobility is a risk factor for constipation. Assess ambulatory status to determine ... . GI symptoms can interfere with the quality of sleep. Nausea, vomiting, diarrhea, indigestion, and bloating can produce sleep p... . Sensory changes can result in problems related to acquiring, preparing, and ingesting food. Changes in taste or smell can affe... . Many GI and nutrition problems affect the patient’s self-perception. Overweight and underweight persons may have problems rela... . Problems related to the GI system, such as cirrhosis, hepatitis, ostomies, obesity, and cancer, may affect the patient’s abili... . Changes related to sexuality and reproductive status can result from problems of the GI system. For example, obesity, jaundice... . Determine what is stressful for the patient and what coping mechanisms the patient uses. Factors outside the GI tract can infl... . Assess the patient’s spiritual, religious, and cultural beliefs about food and food preparation. Whenever possible, respect th... Objective Data Physical Assessment . Inspect the mouth for symmetry, color, and size. Observe for abnormalities, such as pallor or cyanosis, cracking, ulcers, or f... . Palpate any suspicious areas in the mouth. Note ulcers, nodules, indurations, and areas of tenderness. The mouth of the older ... . We use 2 systems to anatomically describe the surface of the abdomen. One system divides the abdomen into 4 quadrants by a per... . Assess the abdomen for skin changes (color, texture, scars, striae, dilated veins, rashes, lesions), umbilicus (location and c... . When you examine the abdomen, auscultate before percussion and palpation because these latter procedures may alter the bowel s... . The purpose of percussing the abdomen is to estimate the size of the liver and spleen and determine the presence of fluid, dis... . Use palpation to assess the abdominal organs and detect any tenderness, distention, masses, or fluid. Palpation is important b... . Inspect perianal and anal areas for color, texture, masses, rashes, scars, erythema, fissures, and external hemorrhoids. Palpa... DIAGNOSTIC STUDIES OF GASTROINTESTINAL SYSTEM Radiologic Studies Upper GI Series Lower GI Series Virtual Colonoscopy Endoscopy Liver Function Studies Liver Biopsy EVOLVE WEBSITE/RESOURCES LIST REFERENCES 44 - Nutrition Problems NUTRITION PROBLEMS NORMAL NUTRITION VEGETARIAN DIET MALNUTRITION Etiology Contributing Factors Socioeconomic Factors Physical Illnesses Incomplete Diets Drug-Nutrient Interactions Pathophysiology of Starvation Impact of Inflammation Clinical Manifestations and Diagnostic Studies ?Anthropometric Measurements ?Functional Measurements ?Acute Care ?Refeeding Syndrome ?Ambulatory Care SPECIALIZED NUTRITION SUPPORT Enteral Nutrition Orogastric, Nasogastric, and Nasointestinal Tubes Gastrostomy and Jejunostomy Tubes EN and Safety . Obtain x-ray confirmation of newly inserted nasal or orogastric tubes to confirm proper position before starting feedings or m... . Evaluate all enterally fed patients for risk for aspiration. Before starting feedings, ensure the tube is in the right positio... . Skin care around gastrostomy and jejunostomy tube sites is important because the action of digestive juices irritates the skin... . All enteral feedings require routine flushing. Flush feeding tubes in adults with 30 mL of warm tap water every 4 hours during... . An enteral feeding misconnection is an inadvertent connection between an enteral feeding system and a nonenteral system, such ... Parenteral Nutrition Composition Calories Protein Electrolytes Trace Elements and Vitamins Methods of Administration . Central PN is indicated when long-term support is needed or when the patient has high protein and caloric requirements. We giv... . PPN is given through a peripherally inserted catheter or vascular access device into a large vein. PPN is used when (1) nutrit... EATING DISORDERS ANOREXIA NERVOSA BULIMIA NERVOSA EVOLVE WEBSITE/RESOURCES LIST REFERENCES 45 - Obesity OBESITY Obesity OBESITY Epidemiology of Obesity Etiology and Pathophysiology ?Genetic Link Physiologic Regulatory Mechanisms in Obesity Environmental Factors Psychosocial Factors HEALTH RISKS ASSOCIATED WITH OBESITY Cardiovascular Problems Diabetes Gastrointestinal and Liver Problems Respiratory and Sleep Problems Musculoskeletal Problems Cancer Metabolic Syndrome Psychosocial Problems ?Nursing and Interprofessional Management: Obesity ?Assessment ?Classifications of Body Weight and Obesity ?Body Mass Index ?Waist Circumference ?Waist-to-Hip Ratio ?Body Shape ?Clinical Problems ?Planning ?Implementation ?Nutrition Therapy ?Exercise ?Behavior Therapy ?Support Groups ?Drug Therapy BARIATRIC SURGERY Restrictive Surgeries Adjustable Gastric Banding Sleeve Gastrectomy (Gastric Sleeve) Gastric Plication Intragastric Balloons Combination of Restrictive and Malabsorptive Surgery Roux-en-Y Gastric Bypass Other Bariatric Procedures ?Nursing Management: Perioperative Care of the Patient With Obesity ?Preoperative Care ?Special Considerations for Bariatric Surgery ?Postoperative Care ?Special Considerations for Bariatric Surgery ?Ambulatory and Home Care ?Evaluation ?Gerontologic Considerations: Obesity in Older Adults COSMETIC SURGERY Lipectomy Liposuction METABOLIC SYNDROME Etiology and Pathophysiology Clinical Manifestations ?Nursing and Interprofessional Management: Metabolic Syndrome EVOLVE WEBSITE/RESOURCES LIST REFERENCES 46 - Upper Gastrointestinal Problems NAUSEA AND VOMITING Etiology and Pathophysiology Clinical Manifestations Interprofessional Care Drug Therapy ?Nursing Management: Nausea and Vomiting ?Assessment ?Implementation ?Acute Care ORAL INFLAMMATION AND INFECTIONS ORAL CANCER Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Management: Oral Cancer Surgical Therapy Nonsurgical Therapy Nutrition Therapy ?Nursing Management: Oral Cancer ?Assessment Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies ?Nursing and Interprofessional Management: Gerd HIATAL HERNIA Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies ?NURSING AND INTERPROFESSIONAL MANAGEMENT: HIATAL HERNIA ?Gerontologic Considerations: GERD and Hiatal Hernia ESOPHAGEAL CANCER Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies Interprofessional Management Surgical Therapy Endoscopic Therapy Radiation Therapy Chemotherapy Targeted Therapy Nutrition Therapy ?Nursing Management: Esophageal Cancer ?Assessment . The patient and caregiver usually react with shock, disbelief, and depression when given the diagnosis of esophageal cancer. P... . During the immediate postoperative period, the patient usually receives care in the ICU for 1 to 2 days. In addition to usual ... ?Evaluation OTHER ESOPHAGEAL DISORDERS Eosinophilic Esophagitis Esophageal Diverticula Esophageal Strictures Achalasia Esophageal Varices STOMACH AND UPPER SMALL INTESTINE PROBLEMS Types Etiology and Pathophysiology Helicobacter pylori Medication-Induced Injury Lifestyle Factors Gastric Ulcers Duodenal Ulcers Clinical Manifestations Diagnostic Studies Interprofessional Management Conservative Care Drug Therapy . Eradicating H. pylori is the most important part of treating PUD in patients positive for H. pylori. Antibiotic therapy is pre... . PPIs are more effective than H2 receptor blockers in reducing gastric acid secretion and promoting ulcer healing. PPIs are use... . Sucralfate is used for short-term ulcer treatment. It provides mucosal protection for the esophagus, stomach, and duodenum. Su... . H2 receptor blockers and antacids may be used as adjunct therapy to promote ulcer healing. Antacids increase gastric pH by neu... Nutrition Therapy Surgical Therapy Complications GI Bleeding Perforation Gastric Outlet Obstruction ?Nursing Management: Peptic Ulcer Disease ?Assessment . Changes in vital signs and an increase in the amount and redness of aspirate often signal massive upper GI bleeding. With blee... . If the patient with an ulcer develops manifestations of a perforation, notify the HCP immediately. Take vital signs promptly a... . Gastric outlet obstruction can happen at any time. It is most likely to occur in the patient whose ulcer is close to the pylor... STOMACH CANCER Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Management Surgical Therapy Chemotherapy and Radiation Therapy Targeted Therapy ?Nursing Management: Stomach Cancer ?Assessment ?Acute Care ?Ambulatory Care GASTROINTESTINAL STROMAL TUMORS GASTRIC SURGERY Postoperative Complications Dumping Syndrome Postprandial Hypoglycemia Bile Reflux Gastritis ?Nursing Management: Gastric Surgery ?Preoperative Care GASTRITIS Etiology and Pathophysiology Risk Factors . Drugs contribute to the development of acute and chronic gastritis. NSAIDs and corticosteroids inhibit the synthesis of prosta... . Diet indiscretions can cause acute gastritis. After binge drinking alcohol, acute damage to the gastric mucosa can range from ... . H. pylori infection causes acute gastritis in most infected persons. Chronic gastritis may develop in some. Prolonged inflamma... . Although not as common as H. pylori, other bacterial, viral, and fungal infections can cause chronic gastritis. Gastritis can ... Autoimmune Gastritis Clinical Manifestations Diagnostic Studies ?Nursing and Interprofessional Management: Gastritis ?Acute Gastritis UPPER GASTROINTESTINAL BLEEDING Etiology and Pathophysiology Stomach and Duodenal Origin Esophageal Origin Diagnostic Studies Interprofessional Management Emergency Assessment and Management Endoscopic Therapy Surgical Therapy Drug Therapy ?Nursing Management: Upper Gastrointestinal Bleeding ?Assessment FOODBORNE ILLNESS EVOLVE WEBSITE/RESOURCES LIST REFERENCES 47 - Lower Gastrointestinal Problems DIARRHEA Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Clostridioides difficile infection ?Nursing Management: Acute Infectious Diarrhea ?Assessment FECAL INCONTINENCE Etiology and Pathophysiology Diagnostic Studies Interprofessional Care ?Nursing Management: Fecal Incontinence ?Assessment CONSTIPATION Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Nutrition Therapy ?Nursing Management: Constipation ?Assessment ACUTE ABDOMINAL PAIN AND LAPAROTOMY Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care ?Nursing Management: Acute Abdominal Pain ?Assessment ?Acute Care . Preoperative care includes the emergency care of the patient described in Table 47.12 and general care of the preoperative pat... . Postoperative care depends on the type of surgery. See eNursing Care Plan 20.1, a general plan for the postoperative patient, ... ABDOMINAL TRAUMA Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies CHRONIC ABDOMINAL PAIN IRRITABLE BOWEL SYNDROME Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies and Interprofessional Care PERITONITIS Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies and Interprofessional Care ?Nursing Management: Peritonitis ?Assessment GASTROENTERITIS INFLAMMATORY BOWEL DISEASE Etiology and Pathophysiology Pattern of Inflammation in Ulcerative Colitis vs. Crohn’s Disease Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Drug Therapy Surgical Therapy . Indications for surgery for UC are outlined in Table 47.19. Surgical procedures used include (1) proctocolectomy with ileal po... . Surgery for Crohn’s disease is usually done for complications such as obstructions or those who do not respond to therapy (Tab... Nutrition Therapy ?Nursing Management: Inflammatory Bowel Disease ?Assessment ?Implementation ?Acute Care ?Ambulatory Care ?Gerontologic Considerations: Inflammatory Bowel Disease BOWEL OBSTRUCTION Types of Bowel Obstruction Mechanical Nonmechanical Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care ?Nursing Management: Bowel Obstruction ?Assessment ?Clinical Problems POLYPS OF LARGE INTESTINE Types of Polyps Diagnostic Studies and Interprofessional Care COLORECTAL CANCER Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Surgical Therapy Chemotherapy and Targeted Therapy Radiation Therapy ?Nursing Management: Colorectal Cancer ?Assessment ?Implementation BOWEL RESECTION AND OSTOMY SURGERY Ostomy . An end stoma is made by dividing the bowel and bringing out the proximal end as a single stoma, making a colostomy or ileostom... . A loop stoma is made by bringing a loop of bowel to the abdominal surface and then opening the anterior wall of the bowel to p... . To create a double-barreled stoma, the HCP divides the bowel, and both the proximal and distal ends are brought through the ab... ?Nursing Management: Bowel Resection and Ostomy Surgery ?Preoperative Care ?Sexual Function DIVERTICULOSIS AND DIVERTICULITIS Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies FISTULAS HERNIAS Types Clinical Manifestations MALABSORPTION SYNDROME CELIAC DISEASE Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional and Nursing Care LACTASE DEFICIENCY SHORT BOWEL SYNDROME Clinical Manifestations Interprofessional Care Etiology and Pathophysiology Clinical Manifestations Interprofessional and Nursing Care ANAL FISSURE ANORECTAL ABSCESS ANAL FISTULA ANAL CANCER PILONIDAL SINUS EVOLVE WEBSITE/RESOURCES LIST REFERENCES 48 - Liver, Biliary Tract, and Pancreas Problems LIVER PROBLEMS Viral Hepatitis Hepatitis A Virus Hepatitis B Virus Hepatitis C Virus Hepatitis D Virus Hepatitis E Virus Pathophysiology Liver Systemic Effects Clinical Manifestations and Complications Acute Hepatitis Chronic Hepatitis Diagnostic Studies Interprofessional Care Drug Therapy . There are no drug therapies for treating acute HAV infection. Treatment of acute HBV may be indicated only in patients with se... . Drug therapy for chronic HBV focuses on decreasing viral load and liver enzymes, and in turn, slowing the rate of disease prog... . Nucleoside and nucleotide analogs inhibit viral DNA replication. HBV reproduces by making copies of its viral DNA nucleosides ... . Interferon is a naturally occurring immune protein made by the body during an infection to recognize and respond to pathogens.... . Treatment of chronic HCV is patient specific. It is based on the genotype of the HCV, severity of liver disease, and presence ... Nutrition Therapy ?Health Promotion . Viral hepatitis outbreaks are usually due to HAV. Preventive measures include personal and environmental hygiene and health ed... . The best way to reduce HBV infection is to identify those at risk, screen them for HBV, and vaccinate those who are not infect... . No vaccine is currently available for HCV. So, it is important to identify those at high risk for contracting HCV and teach th... DRUG- AND CHEMICAL-INDUCED LIVER DISEASES AUTOIMMUNE, GENETIC, AND METABOLIC LIVER DISEASES Autoimmune Hepatitis Wilson Disease Hemochromatosis Primary Biliary Cholangitis Primary Sclerosing Cholangitis Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis CIRRHOSIS Etiology and Pathophysiology Clinical Manifestations Early Manifestations Late Manifestations . Jaundice results from decreased ability to conjugate and excrete bilirubin into the small intestines (Table 48.3). There is an... . Various skin manifestations often occur with cirrhosis. Spider angiomas (telangiectasia or spider nevi) are small, dilated blo... . Hematologic problems include thrombocytopenia, leukopenia, anemia, and coagulation problems. We think thrombocytopenia, leukop... . The liver plays a vital role in the metabolism of hormones, such as estrogen and testosterone. In men with cirrhosis, gynecoma... . Peripheral neuropathy is a common finding in alcoholic cirrhosis. It is probably due to a diet deficiency of thiamine, folic a... Complications Portal Hypertension and Esophageal and Gastric Varices Peripheral Edema and Ascites Hepatic Encephalopathy Hepatorenal Syndrome Diagnostic Studies Interprofessional Care Ascites Esophageal and Gastric Varices . Nonsurgical and surgical methods of shunting blood away from the varices are available. Shunting procedures tend to be done mo... Hepatic Encephalopathy Drug Therapy Nutrition Therapy . If the patient has esophageal or gastric varices, observe for any signs of bleeding from the varices, such as hematemesis and ... . Nursing care focuses on maintaining a safe environment, sustaining life, and assisting with measures to reduce the formation o... ACUTE LIVER FAILURE Clinical Manifestations and Diagnostic Studies LIVER CANCER Clinical Manifestations and Diagnostic Studies LIVER TRANSPLANTATION Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Conservative Therapy Surgical Therapy Drug Therapy Nutrition Therapy ?Ambulatory Care CHRONIC PANCREATITIS Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies PANCREATIC CANCER Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Etiology and Pathophysiology Cholelithiasis Cholecystitis Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Conservative Therapy . The treatment of gallstones depends on the stage of disease. Bile acids (cholesterol solvents), such as ursodiol and chenodiol... . During an acute episode of cholecystitis, treatment focuses on pain control, control of infection with antibiotics, and mainta... Surgical Therapy Transhepatic Biliary Catheter Drug Therapy Nutrition Therapy ?Acute Care . Postoperative nursing care after a laparoscopic cholecystectomy includes monitoring for complications, such as bleeding, makin... ?Ambulatory Care GALLBLADDER CANCER EVOLVE WEBSITE/RESOURCES LIST REFERENCES 10 - Problems of Urinary Function 49 - Assessment: Urinary System STRUCTURES AND FUNCTIONS OF URINARY SYSTEM Kidneys Macrostructure Microstructure Blood Supply Physiology of Urine Formation . Urine formation begins at the glomerulus, where blood is filtered. The glomerulus is a semipermeable membrane that allows fil... . The tubules and collecting ducts are responsible for the reabsorption of essential materials and excretion of nonessential one... Other Functions of Kidneys Ureters Bladder Urethra Urethrovesical Unit ?Gerontologic Considerations: Effects of Aging on Urinary System ASSESSMENT OF URINARY SYSTEM Subjective Data Important Health Information . Ask the patient about the presence or history of kidney disease or other urologic problems. Note specific urinary problems, su... . Assess the patient’s current and past use of medications. Include over-the-counter drugs, prescription drugs, and herbal thera... . Ask the patient about hospitalizations related to renal or urologic problems. Were there any urinary problems during past pre... Functional Health Patterns . Ask about the patient’s general health. Abnormal kidney function may be suspected if the patient reports changes in weight or ... . The usual quantity and types of fluid a patient drinks are important in relation to urinary tract disease. Dehydration may con... . Questions about urine elimination patterns are the cornerstone of the health history in the patient with a lower urinary tract... . Assess the patient’s level of activity. A sedentary person is more likely to have stasis of urine than an active person and, t... . Nocturia is a common and a particularly bothersome symptom that often leads to sleep deprivation, daytime sleepiness, and fati... . Assess the level of mobility, visual acuity, and dexterity. These are important factors to evaluate, especially when urine ret... . Some problems, such as incontinence, urinary diversion procedures, and chronic fatigue (may occur with anemia), can result in ... . Urinary problems can affect many aspects of a person’s life, including the ability to work and relationships with others. Thes... . Assess the effect of renal problems on the patient’s sexual satisfaction. Problems related to personal hygiene and fatigue can... Objective Data Physical Assessment . Assess for changes in the following . The kidneys are posterior organs protected by the abdominal organs, ribs, and heavy back muscles. A landmark useful in locatin... . Tenderness in the flank area may be detected by fist percussion (kidney punch). Perform fist percussion by striking the fist o... . Use the diaphragm of the stethoscope to auscultate bowel sounds, since the bowels can affect the urinary system DIAGNOSTIC STUDIES OF URINARY SYSTEM Urine Studies Urinalysis Creatinine Clearance Urodynamic Studies Radiologic Studies REFERENCES 50 - Renal and Urologic Problems URINARY TRACT INFECTION Classification of Urinary Tract Infection Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care ACUTE PYELONEPHRITIS Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies Interprofessional Care CHRONIC PYELONEPHRITIS URETHRITIS URETHRAL DIVERTICULA INTERSTITIAL CYSTITIS/PAINFUL BLADDER SYNDROME Clinical Manifestations and Diagnostic Studies Interprofessional Care GENITOURINARY TUBERCULOSIS Acute Poststreptococcal Glomerulonephritis ?Chronic Glomerulonephritis ?Anti-Glomerular Basement Membrane Disease ?Rapidly Progressive Glomerulonephritis NEPHROTIC SYNDROME Etiology and Clinical Manifestations OBSTRUCTIVE UROPATHIES URINARY TRACT CALCULI Etiology and Pathophysiology Types of Urinary Stones Clinical Manifestations Diagnostic Studies Interprofessional Care Endourologic Procedures Lithotripsy Surgical Therapy Nutrition Therapy STRICTURES Ureteral Strictures Urethral Strictures RENAL TRAUMA RENAL VASCULAR PROBLEMS NEPHROSCLEROSIS RENAL ARTERY STENOSIS RENAL VEIN THROMBOSIS HEREDITARY KIDNEY DISEASES POLYCYSTIC KIDNEY DISEASE MEDULLARY CYSTIC KIDNEY DISEASE ALPORT SYNDROME Clinical Manifestations and Diagnostic Studies BLADDER CANCER Clinical Manifestations and Diagnostic Studies Etiology and Pathophysiology Diagnostic Studies Interprofessional Care Drug Therapy Surgical Therapy URINARY RETENTION Etiology and Pathophysiology Diagnostic Studies Interprofessional Care Drug Therapy Surgical Therapy CATHETER CONSTRUCTION TYPES OF CATHETERS Urethral Catheterization Ureteral Catheters Suprapubic Catheters Nephrostomy Tubes Intermittent Catheterization Surgical Procedure Laparoscopic Nephrectomy Preoperative Management Postoperative Management Urine Output Respiratory Status Abdominal Distention URINARY DIVERSION Incontinent Urinary Diversion Continent Urinary Diversions Orthotopic Bladder Reconstruction Preoperative Care Postoperative Care REFERENCES EVOLVE WEBSITE/RESOURCES LIST 51 - Acute Kidney Injury and Chronic Kidney Disease ACUTE KIDNEY INJURY Etiology and Pathophysiology Prerenal Intrarenal Postrenal Clinical Manifestations Oliguric Phase . The most common initial manifestation of AKI is oliguria, a reduction in urine output to less than 400 mL/day. It usually occu... . Hypovolemia (volume depletion) has the potential to worsen all forms of AKI. Fluid replacement is often enough to treat many f... . In the normal kidney, excess hydrogen ions are excreted to keep a physiologic balance of the blood pH. Impaired kidneys cannot... . Damaged tubules cannot conserve sodium. Urinary sodium excretion may increase, resulting in normal or below-normal levels of s... . The kidneys normally excrete 80% to 90% of the body’s potassium. In AKI the serum potassium level increases because the kidney... . Several hematologic problems occur in patients with AKI. Hospital-acquired AKI often occurs in patients who have multiorgan fa... . The kidneys are the main excretory organs for urea (an end product of protein metabolism) and creatinine (an end product of en... . Neurologic changes can occur as the nitrogenous waste products accumulate in the brain and other nervous tissue. The manifesta... Diuretic Phase Recovery Phase Diagnostic Studies Interprofessional Care Nutrition Therapy ?Health Promotion CHRONIC KIDNEY DISEASE Clinical Manifestations Urinary System Metabolic Disturbances . As the GFR decreases, the BUN and serum creatinine levels increase. The BUN increase is not only from kidney disease but also ... . Impaired glucose metabolism, from cellular insensitivity to the normal action of insulin, causes defective carbohydrate metabo... . Hyperinsulinemia stimulates hepatic triglyceride production. Many patients develop dyslipidemia, with increased very-low-densi... Electrolyte and Acid-Base Imbalances . Hyperkalemia is a serious electrolyte disorder associated with CKD. Fatal dysrhythmias can occur when the serum potassium leve... . Sodium may be high, normal, or low in kidney disease. Because of impaired sodium excretion, sodium is retained with water. If ... . Calcium and phosphate changes are discussed in the section on the musculoskeletal system . Magnesium is mainly excreted by the kidneys. Hypermagnesemia is often not a problem unless the patient is ingesting magnesium ... . Metabolic acidosis results from the kidneys’ impaired ability to excrete excess acid and from defective reabsorption and regen... Hematologic System . Normocytic, normochromic anemia is associated with CKD. Anemia in CKD is due to decreased erythropoietin production. Erythropo... . The most common cause of bleeding in uremia is a defect in platelet function. This problem is caused by impaired platelet aggr... . Patients with advanced CKD have an increased risk of infection. This is due to changes in WBC function and altered immune resp... Cardiovascular System Respiratory System GI System Neurologic System Musculoskeletal System Skin Reproductive System Psychologic Changes Diagnostic Studies Interprofessional Care Drug Therapy . We use several strategies to manage hyperkalemia (Table 51.5). These include restricting high-potassium foods and drugs. Acute... . For some, the progression of CKD can be delayed by controlling hypertension.16 Treatment of hypertension includes (1) weight l... . Interventions for CKD-MBD include limiting phosphorus intake, giving phosphate binders, supplementing vitamin D, and controlli... . Anemia is caused by the kidneys making less erythropoietin. We give exogenous erythropoietin (EPO) to treat anemia. One option... . Dyslipidemia, a risk factor for CVD, is a common problem in CKD. Statins (HMG-CoA reductase inhibitors), such as atorvastatin ... . The kidneys partially or totally excrete many drugs. CKD causes decreased elimination that leads to an accumulation of drugs a... Nutrition Therapy . The current diet for the person with CKD is designed to maintain good nutrition (Table 51.10). Calorie-protein malnutrition is... . Water and any other fluids are not routinely restricted in patients with CKD stages 1 to 5 who are not receiving HD. To reduce... . Teach patients with CKD to restrict sodium. Sodium-restricted diets may vary from 2 to 4 g/day. Teach the patient to avoid hig... . As kidney function declines, phosphate elimination by the kidneys is decreased. The patient develops high phosphorus levels. B... DIALYSIS General Principles of Dialysis PERITONEAL DIALYSIS Catheter Placement Dialysis Solutions and Cycles Peritoneal Dialysis Systems Automated Peritoneal Dialysis Continuous Ambulatory Peritoneal Dialysis Complications of Peritoneal Dialysis Exit Site Infection Peritonitis Hernias Lower Back Problems Bleeding Pulmonary Complications Protein Loss Effectiveness of Chronic Peritoneal Dialysis HEMODIALYSIS Vascular Access Sites Arteriovenous Fistulas and Grafts Temporary Vascular Access Dialyzers Procedure for Hemodialysis Settings and Schedules for Hemodialysis Complications of Hemodialysis Hypotension Muscle Cramps Loss of Blood Hepatitis Effectiveness of Hemodialysis CONTINUOUS RENAL REPLACEMENT THERAPY WEARABLE ARTIFICIAL KIDNEY KIDNEY TRANSPLANTATION Recipient Selection Histocompatibility Studies Donor Sources Live Donors Deceased Donors Surgical Procedure Live Donor Kidney Transplant Recipient ?Immunosuppressive Therapy ?Complications of Transplantation ?Rejection ?Infection ?Cardiovascular Disease ?Cancers ?Recurrence of Original Kidney Disease ?Corticosteroid-Related Complications EVOLVE WEBSITE/RESOURCES LIST REFERENCES 11 - Problems Related to Regulatory and Reproductive Mechanisms 52 - Assessment: Endocrine System STRUCTURES AND FUNCTIONS OF ENDOCRINE SYSTEM Glands Hormones Hormone Receptors Lipid-Soluble and Water-Soluble Hormones Regulation of Hormonal Secretion . Negative feedback relies on the blood level of a hormone or other chemical compound regulated by the hormone (e.g., glucose). ... . Nervous system activity directly affects some endocrine glands. Pain, fear, sexual excitement, and other stressors can stimula... . A common physiologic rhythm is the circadian rhythm. It is a 24-hour rhythm that is driven by sleep-wake or dark-light 24-hour... Hypothalamus Pituitary Anterior Pituitary Posterior Pituitary Pineal Gland Thyroid Gland Thyroxine and Triiodothyronine Calcitonin Parathyroid Glands Parathyroid Hormone Adrenal Glands Adrenal Medulla Adrenal Cortex . Cortisol, the most abundant and potent glucocorticoid, is necessary to maintain life and protect the body from stress. It is ... . Aldosterone is a potent mineralocorticoid that maintains extracellular fluid volume. It acts on the renal tubule to promote re... . The adrenal cortex secretes small amounts of androgens. They are converted to sex steroids in peripheral tissues: testosterone... Pancreas Glucagon Insulin ?Gerontologic Considerations: Effects of Aging on Endocrine System ASSESSMENT OF ENDOCRINE SYSTEM Subjective Data Important Health Information . Patients with endocrine problems often present with nonspecific complaints. They may report not just one but a group of sympto... . Ask about the use of all medications, herbs, and diet supplements. Ask about the reason for taking the drug, the dosage, and t... . Ask about medical, surgical, and obstetric history. Include the number of pregnancies and live births. Assess growth patterns ... Functional Health Patterns . Heredity plays a key role in the development of endocrine problems (Box 52.1). Ask about first-degree relatives with diabetes,... . Changes in appetite and weight can indicate an endocrine problem. Ask about a history of weight distribution and changes. Weig... . Changes in skin texture and skin that seems thicker or drier may suggest an endocrine problem. A patient with hypothyroidism o... . Because maintaining fluid balance is a key role of the endocrine system, questions related to fluid intake and elimination pat... . Determine if there are any acute or gradual changes in energy level or persistent fatigue. A patient with chronic fatigue from... . Ask the patient how many hours they typically sleep and if they feel rested on awakening. Sleep problems can result from noctu... . Memory deficits may occur with hypothyroidism and changes in sodium levels. Inappropriate secretion of antidiuretic hormone (S... . Many endocrine problems may affect a patient’s self-esteem because of associated changes in physical appearance. For example, ... . Questions related to roles and relationships can highlight depression, chronic fatigue, and sleep problems. With chronic fatig... . The endocrine system regulates GH, prolactin, LH, FSH, testosterone, and estrogen. Therefore, menstrual problems, hirsutism, i... . Because stress worsens some endocrine conditions, ask patients about their stress level and usual coping patterns. Patients wi... . Determining a patient’s ability to make lifestyle changes is an important nursing function. Identify the patient’s value-belie... Objective Data Physical Assessment . Assess the color and texture of the skin, hair, and nails. Note the overall skin color and pigment. Decreased skin pigment can... . Inspect the size and contour of the head. Facial features should be symmetric. Hyperreflexia and facial muscle contraction upo... . The thyroid gland is not usually visible during inspection. A feature that distinguishes the thyroid from other masses in the ... . Inspect the thorax for shape and characteristics of the skin. Note the presence of breast gynecomastia in men. Auscultate lung... . Inspect the contour of the abdomen. Note the symmetry and color. Cushing syndrome (hypercortisolism) causes the skin to be fra... . Assess the size, shape, symmetry, and general proportion of hands and feet. Patients with acromegaly from pituitary tumors may... . Assessment abnormalities related to the endocrine system are outlined in Table 52.5. A focused assessment of the endocrine sys... DIAGNOSTIC STUDIES OF ENDOCRINE SYSTEM EVOLVE WEBSITE/RESOURCES LIST REFERENCES 53 - Diabetes DIABETES Etiology and Pathophysiology Normal Glucose and Insulin Metabolism Type 1 Diabetes . Type 1 DM is an autoimmune disorder in which the body develops antibodies against insulin and/or the pancreatic β cells that m... . In type 1 DM, the islet cell autoantibodies responsible for β-cell destruction are present for months to years before the onse... Type 2 Diabetes . Type 2 DM is characterized by a combination of inadequate insulin secretion and insulin resistance. The pancreas usually makes... Onset of disease. The disease onset in type 2 DM is usually gradual. The person may go for many years with undetected hyperglyce... Prediabetes Gestational Diabetes Other Specific Types of Diabetes Clinical Manifestations Type 1 Diabetes Type 2 Diabetes Diagnostic Studies Interprofessional Care Drug Therapy: Insulin Types of Insulin Insulin Plans Mealtime Insulin (Bolus) Long- or Intermediate-Acting (Basal) Background Insulin Combination Insulin Therapy Insulin Storage Insulin Administration . The steps in giving a subcutaneous insulin injection are outlined in Table 53.6. Teach this technique to new insulin users and... . An insulin pump delivers a continuous subcutaneous insulin infusion through a small device worn on the belt, in a pocket, or u... Problems With Insulin Therapy . Local inflammatory reactions to insulin may occur. These include itching, redness, and burning around the injection site. Loca... . Lipodystrophy (changes in subcutaneous fatty tissue) may occur if the same injection sites are used frequently. Atrophy, which... . Hyperglycemia in the morning may be due to the Somogyi effect. A high dose of insulin causes a decline in glucose levels durin... Inhaled Insulin Drug Therapy: Oral and Noninsulin Injectable Agents Biguanides Sulfonylureas Meglitinides α-Glucosidase Inhibitors Thiazolidinediones Dipeptidyl Peptidase-4 Inhibitors Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors Dopamine Receptor Agonist Combination Oral Therapy Glucagon-Like Peptide-1 Receptor Agonists Amylin Analogs Other Drugs Affecting Glucose Levels Nutrition Therapy Type 1 Diabetes Type 2 Diabetes Food Composition . Carbohydrates are an important source of energy, fiber, vitamins, and minerals. They are needed by all people, including those... . Fat provides energy, transports fat-soluble vitamins, and provides essential fatty acids. The ADA recommends 20% to 35% of tot... . The amount of daily protein in the diet for people with DM and normal kidney function is the same as the general population. T... . Alcohol inhibits gluconeogenesis by the liver. This can cause severe hypoglycemia in people who take insulin or OAs that incre... Patient Teaching Related to Nutrition Therapy Exercise Blood Glucose Monitoring Pancreas Transplantation . Emotional and physical stress can increase the glucose level and cause hyperglycemia. Because stress is unavoidable, certain s... . Nursing responsibilities for the patient receiving insulin include proper administration, assessing the patient’s response to ... . Your responsibilities for the patient taking OAs and noninsulin injectable agents are similar to those for the patient taking ... . The potential for infection requires diligent skin and dental hygiene practices. Because of the susceptibility to periodontal ... . Teach the patient to always carry medical identification indicating that they have DM. Police, paramedics, and many private ci... ACUTE COMPLICATIONS OF DIABETES DIABETES-RELATED KETOACIDOSIS (DKA) Etiology and Pathophysiology Clinical Manifestations Interprofessional Care HYPEROSMOLAR HYPERGLYCEMIA SYNDROME Interprofessional Care HYPOGLYCEMIA CHRONIC COMPLICATIONS ASSOCIATED WITH DIABETES Macrovascular Complications Microvascular Complications RETINOPATHY Etiology and Pathophysiology Interprofessional Care NEPHROPATHY NEUROPATHY Etiology and Pathophysiology Classification Sensory Neuropathy Autonomic Neuropathy COMPLICATIONS OF FEET AND LOWER EXTREMITIES SKIN COMPLICATIONS INFECTION PSYCHOLOGIC CONSIDERATIONS REFERENCES EVOLVE WEBSITE/RESOURCES LIST 54 - Endocrine Problems ANTERIOR PITUITARY GLAND PROBLEMS ACROMEGALY Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies EXCESSES OF OTHER TROPIC HORMONES PITUITARY GLAND HYPOFUNCTION Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies PITUITARY SURGERY POSTERIOR PITUITARY GLAND PROBLEMS SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies DIABETES INSIPIDUS Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies THYROID GLAND PROBLEMS GOITER THYROIDITIS HYPERTHYROIDISM Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Drug Therapy . Iodine is available as saturated solution of potassium iodine (SSKI) and Lugol solution. Iodine is used with other antithyroid... . β-Adrenergic blockers are used for symptomatic relief of thyrotoxicosis. They block the effects of sympathetic nervous stimula... Radioactive Iodine Therapy Surgical Therapy Nutrition Therapy HYPOTHYROIDISM Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care THYROID NODULES AND CANCER Types of Thyroid Cancer Clinical Manifestations and Diagnostic Studies MULTIPLE ENDOCRINE NEOPLASIA Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies Interprofessional Care Surgical Therapy Nonsurgical Therapy HYPOPARATHYROIDISM ADRENAL CORTEX PROBLEMS CUSHING SYNDROME Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care ADRENOCORTICAL INSUFFICIENCY Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies CORTICOSTEROID THERAPY HYPERALDOSTERONISM EVOLVE WEBSITE/RESOURCES LIST REFERENCES 55 - Assessment: Reproductive System STRUCTURES AND FUNCTIONS OF MALE AND FEMALE REPRODUCTIVE SYSTEMS Male Reproductive System Testes Ducts Glands External Genitalia Female Reproductive System Pelvic Organs . The ovaries are found on either side of the uterus, just behind and below the fallopian tubes (Fig. 55.3). The almond-shaped o... . The fallopian tubes transport the ovum toward the uterus, facilitating fertilization or implantation. The tubes are uterine ap... . The uterus is a pear-shaped, hollow, muscular organ found between the bladder and rectum (Fig. 55.3). In the mature nulliparou... . The vagina is a tubular structure 3 to 4 in (7.6 to 10 cm) long. The anterior vaginal wall lies along the urethra and bladder.... External Genitalia Breasts Neuroendocrine Regulation of Reproductive System Menarche Menstrual Cycle Menopause Phases of Sexual Response Male Sexual Response Female Sexual Response ASSESSMENT OF MALE AND FEMALE REPRODUCTIVE SYSTEMS Subjective Data Important Health Information . The health history should include information about major illnesses, hospitalizations, immunizations, and surgeries. Ask about... . Obtain a complete medication history. Include the reason for use, dosage, and length of time that the drug has been taken. Ask... . Note any surgical procedures. Common surgeries involving the female reproductive system are listed in Table 58.7. Record any t... Functional Health Patterns . Discuss the patient’s perception of their own health and measures that they take to maintain health. Ask about self-examinatio... . Anemia is a common problem in women in their reproductive years, especially during pregnancy and the postpartum period. Evalua... . Many gynecologic problems can result in GU problems. Urinary incontinence is common in older women. Factors associated with in... . Record the amount, type, and intensity of activity and exercise. Lack of weight-bearing exercise is an important factor in the... . Sleep patterns may be affected during the postpartum period and while raising young children. Hot flashes and sweating during ... . Pelvic pain can occur with various gynecologic disorders, such as pelvic inflammatory disease, ovarian cysts, and endometriosi... . Changes that occur with aging, such as pendulous breasts and vaginal dryness in women and decreased penis size in men, may lea... . Obtain information about the family structure and occupation. Ask about recent changes in work-related relationships or family... . For women, obtain a menstrual and a chronologic obstetric history. The menstrual history includes the first day of the LMP, de... . The stress related to situations such as pregnancy or menopause increases dependence on support systems. Determine whom the su... . Sexual and reproductive functioning is closely related to cultural, religious, moral, and ethical values. Be aware of your own... Objective Data Physical Assessment: Male . Assess for hair distribution and presence of body lice. Normally, the hair is in a diamond-shaped pattern and coarser than sca... . Inspect the penis for any lesions, bleeding, or swelling. Note the location of the urethral meatus and the presence of a fores... . Note if the buttocks have any lesions, swelling, or inflammation. Spread the buttocks apart with both hands to expose the anus... Physical Assessment: Female . To perform a breast examination, first examine the breasts by visual inspection. With the patient seated, inspect the breasts ... . The assessment of the external female genitalia includes inspection and palpation of the mons pubis, vulva, and anus. Use glov... . HCPs with advanced or specialized training usually do this part of the examination. During the speculum examination, the HCP i... DIAGNOSTIC STUDIES OF REPRODUCTIVE SYSTEMS EVOLVE WEBSITE/RESOURCES LIST REFERENCES 56 - Breast Problems ASSESSMENT OF BREAST PROBLEMS Breast Cancer Screening Guidelines Diagnostic Studies Radiologic Studies Biopsies BREAST INFECTIONS Mastitis Lactational Breast Abscess FIBROCYSTIC CHANGES FIBROADENOMA NIPPLE DISCHARGE ATYPICAL HYPERPLASIA INTRADUCTAL PAPILLOMA DUCTAL ECTASIA MALE GYNECOMASTIA Senescent Gynecomastia BREAST CANCER Etiology and Risk Factors Risk Factors for Women Risk Factors for Men Prophylactic Oophorectomy and Mastectomy Pathophysiology Types of Breast Cancer Noninvasive Breast Cancer Invasive Ductal Carcinoma Invasive Lobular Carcinoma Other Types of Breast Cancer . Inflammatory breast cancer is an aggressive and fast-growing breast cancer with a high risk for metastasis. It accounts for ab... . Paget disease is a rare breast cancer that starts in the breast ducts and spreads to the nipple and areola. It causes about 1%... . A phyllodes tumor is a very rare tumor that develops in the connective tissue (stroma) of the breast. The tumors tend to grow ... Triple-Negative Breast Cancer Clinical Manifestations Complications Diagnostic Studies Axillary Lymph Node Analysis Tumor Size Estrogen and Progesterone Receptor Status Genomic Assay Cell-Proliferative Indices Interprofessional Care Breast Cancer Staging Surgical Therapy . Breast-conserving surgery, or lumpectomy, involves removing the entire tumor along with a margin of normal surrounding tissue ... . A total or simple mastectomy removes the entire breast. A modified radical mastectomy includes removal of the breast and axill... Radiation Therapy . When radiation therapy is a primary treatment, it is usually done after surgery. The decision to use radiation after mastectom... . Brachytherapy (internal radiation) is used for partial-breast radiation. It is an alternative to traditional external radiatio... . Reducing the primary tumor mass with radiation often results in a decrease in pain. Radiation is a treatment option for sympto... Drug Therapy . Chemotherapy is the use of cytotoxic drugs to destroy cancer cells. A combination of drugs is usually better than using a sing... . Estrogen can promote the growth of breast cancer cells if the cells are ER positive. Hormone therapy promotes tumor regression... . ER blockers include tamoxifen, toremifene (Fareston), and fulvestrant (Faslodex). Tamoxifen has been the hormone therapy of ch... . Aromatase inhibitors lower estrogen levels by stopping aromatase, an enzyme in fat tissue, from changing other hormones into e... . Raloxifene (Evista) is a selective ER modulator that has both estrogen-agonistic effects on bone and estrogen-antagonistic eff... Targeted Therapy Immunotherapy . Lymphedema is an accumulation of lymph in soft tissue. It can occur because of the lymph node sampling procedure or radiation ... . Post–breast therapy pain syndrome (PBTPS) occurs in some people who have had procedures for breast cancer. It is often caused ... . Phantom breast pain is feeling pain in the breast after the breast was removed with mastectomy. It occurs for the same reasons... . Throughout history, the female breast has been a symbol of beauty, femininity, sexuality, and motherhood. The potential loss o... . Almost 3 million breast cancer survivors are alive in the United States, making this population the largest group of cancer su... MAMMOPLASTY Breast Reconstruction Indications Types of Reconstruction . Implants have a silicone shell filled with either silicone gel or saline.24 Some newer types use a cohesive gel, which is a th... . We can use autologous (person’s own) tissue to recreate a breast mound. In autologous reconstruction, tissue from the abdomen,... . Many patients undergoing breast reconstruction also have nipple-areolar reconstruction. Nipple reconstruction gives the recons... Breast Augmentation Breast Reduction Breast Lift EVOLVE WEBSITE/RESOURCES LIST REFERENCES 57 - Sexually Transmitted Infections STIS CHARACTERIZED BY DISCHARGE, CERVICITIS, OR URETHRITIS Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care GONOCOCCAL INFECTIONS Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care TRICHOMONIASIS Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care STIS CHARACTERIZED BY GENITAL LESIONS OR ULCERS Etiology and Pathophysiology Clinical Manifestations Primary Episode Recurrent Episodes Complications Diagnostic Studies Interprofessional Care GENITAL WARTS Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Complications Interprofessional Care HPV Vaccine Drug Therapy SYPHILIS Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Drug Therapy . Help patients to be aware of specific signs and symptoms of infection. Encourage patients to take notice of a sexual partner’s... . Screening programs are a way to identify, treat, prevent, and control the spread of STIs. At present, there are CDC-recommende... . Interviewing and case finding are other methods used to control the spread of STIs. These activities are directed toward findi... . Actively encourage your community to provide better education about STIs for its citizens. High-risk populations (e.g., young ... ?Acute Care . The diagnosis of an STI may be met with a variety of emotions, such as embarrassment, shame, guilt, anger, or even a desire fo... . If you work in public health facilities, clinics, or other outpatient settings, you are more likely to care for a patient with... . Emphasize the importance of certain hygiene measures, such as frequent hand washing. Tell the patient not to scratch infection... . Sexual abstinence is needed during the communicable phase of any STI. Long-term precautions must be taken with those STIs that... EVOLVE WEBSITE/RESOURCES LIST REFERENCES 58 - Female Reproductive Problems INFERTILITY Etiology and Pathophysiology Diagnostic Studies ?Interprofessional and Nursing Management PREGNANCY LOSS Spontaneous Abortion Induced Abortion ECTOPIC PREGNANCY Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies ?Interprofessional and Nursing Management PROBLEMS RELATED TO MENSTRUATION PREMENSTRUAL DISORDERS Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care and Nursing Management DYSMENORRHEA Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies ABNORMAL UTERINE BLEEDING Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Polycystic Ovary Syndrome Clinical Manifestations Diagnostic Studies Interprofessional Care MENOPAUSE Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care ?Nursing Management: Menopause LOWER GENITAL TRACT INFECTIONS Etiology and Pathophysiology Clinical Manifestations ?Interprofessional and Nursing Management PELVIC INFLAMMATORY DISEASE Etiology and Pathophysiology Clinical Manifestations Complications Interprofessional Care ?Interprofessional and Nursing Management BENIGN GYNECOLOGIC PROBLEMS Cervical Problems Uterine Problems Adnexal Masses Pelvic Organ Prolapse FISTULA ?Interprofessional and Nursing Management FEMALE REPRODUCTIVE SYSTEM CANCERS CERVICAL CANCER OVARIAN CANCER UTERINE CANCER VAGINAL AND VULVAR CANCER ?Nursing management: Female Reproductive System Cancers SEXUAL ASSAULT EVOLVE WEBSITE/RESOURCES LIST REFERENCES 59 - Male Reproductive Problems Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care Drug Therapy . 5α-Reductase inhibitors work by reducing the size of the prostate gland. They block the 5α-reductase type 1 and 2 isoenzymes, ... . α-Adrenergic receptor blockers are another drug treatment option for BPH. These drugs selectively block α1-adrenergic receptor... . Tadalafil (Cialis) can be used in men who have symptoms of BPH alone or in combination with ED. It can be effective in reducin... . Some patients take plant extracts, such as saw palmetto (Serenoa repens). However, research shows that saw palmetto has no ben... Minimally Invasive Therapy . Photoselective vaporization of the prostate (PVP) uses a high-power green laser light to vaporize prostate tissue. Laser thera... . Laser enucleation also involves delivering a laser beam transurethrally through a fiber instrument. It is used for rapid coagu... . Prostatic urethral lift (PUL) is a relatively new minimally invasive treatment. PUL involves permanent transprostatic implants... . Transurethral microwave thermotherapy (TUMT) involves the delivery of microwaves directly to the prostate through a transureth... . Transurethral needle ablation (TUNA) is another procedure that increases the temperature of prostate tissue, thus causing loca... . Transurethral vaporization of the prostate (TUVP) is an electrosurgical modification of the standard TURP. Vaporization and de... . Water vapor thermal therapy uses heated water vapor/steam to destroy obstructive prostate tissue. The steam is delivered trans... Surgical Therapy . Transurethral incision of the prostate (TUIP) is a surgical procedure done under local anesthesia for men with moderate to sev... . Transurethral resection of the prostate (TURP) involves the removal of prostate tissue using a resectoscope inserted through t... ?Clinical Problems . Antibiotics are usually given before any invasive genitourinary (GU) procedure. UTI must be treated before surgery. Restoring ... . The main complications after surgery are bleeding, bladder spasms, urinary incontinence, and infection. Adjust the plan of car... PROSTATE CANCER Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies Interprofessional Care Active Surveillance Surgical Therapy . With radical prostatectomy, the entire prostate gland, seminal vesicles, and part of the bladder neck (ampulla) are removed. T... . Near the prostate gland are neurovascular bundles that maintain erectile function. The preservation of these bundles during a ... . Cryotherapy (cryoablation) is a surgical technique that destroys cancer cells by freezing the tissue. It has been used both as... Radiation Therapy . External beam radiation is the most widely used method of delivering radiation treatments for prostate cancer. This therapy ca... . Brachytherapy involves placing radioactive seed implants into the prostate gland. This delivers high doses of radiation direct... Drug Therapy . Prostate cancer growth is largely dependent on the presence of androgens. Androgen deprivation therapy (ADT) reduces the level... . The hypothalamus produces luteinizing hormone–releasing hormone (LHRH), which stimulates the anterior pituitary to produce lut... . Androgen receptor blockers are another classification of antiandrogen drugs that compete with circulating androgens at the rec... . Chemotherapy is limited to treatment for those with hormone-refractory prostate cancer (HRPC) in late-stage disease. In HRPC t... . Radium-223 dichloride (Xofigo) can be used in the treatment of patients with castration-resistant prostate cancer, symptomatic... . A bilateral orchiectomy is the surgical removal of the testes. It may be done alone or after prostatectomy. It is the gold sta... PROSTATITIS Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies PROBLEMS OF THE PENIS CONGENITAL PROBLEMS PROBLEMS OF PREPUCE PROBLEMS OF ERECTILE MECHANISM CANCER OF PENIS PROBLEMS OF SCROTUM AND TESTES INFLAMMATORY AND INFECTIOUS PROBLEMS Skin Problems Epididymitis Orchitis CONGENITAL PROBLEMS ACQUIRED PROBLEMS Hydrocele Spermatocele Varicocele Testicular Torsion TESTICULAR CANCER Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies ERECTILE DYSFUNCTION Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies Erectogenic Drugs Vacuum Erection Devices Intraurethral Devices and Intracavernosal Injections Penile Implants Sexual Counseling HYPOGONADISM INFERTILITY EVOLVE WEBSITE/RESOURCES LIST REFERENCES 12 - Problems Related to Movement and Coordination 60 - Assessment: Nervous System STRUCTURES AND FUNCTIONS OF NERVOUS SYSTEM Cells of Nervous System Neurons Glial Cells Nerve Regeneration Nerve Impulse Synapse Neurotransmitters Central Nervous System Spinal Cord . In general, the ascending tracts carry specific sensory information to higher levels of the CNS. This information comes from s... . Descending tracts carry impulses that are responsible for muscle movement. Important descending tracts are the corticobulbar a... . A reflex is an involuntary response to stimuli. In the spinal cord, reflex arcs play an important role in maintaining muscle t... . Upper motor neurons (UMNs) originate in the cerebral cortex and project downward. The corticobulbar tract ends in the brainste... Brain . The cerebrum is composed of the right and left cerebral hemispheres. It is divided into 4 lobes: frontal, temporal, parietal, ... . The brainstem includes the midbrain, pons, and medulla (Fig. 60.5). Ascending and descending fibers to and from the cerebrum a... . The cerebellum is in the posterior cranial fossa below the occipital lobe. It coordinates voluntary movement and maintains tru... . The ventricles are 4 interconnected fluid-filled cavities. The lower part of the 4th ventricle becomes the central canal in th... Peripheral Nervous System Spinal Nerves Cranial Nerves Autonomic Nervous System Cerebral Circulation Blood-Brain Barrier Protective Structures Meninges Skull Vertebral Column ASSESSMENT OF NERVOUS SYSTEM Subjective Data Important Health Information . When performing a neurologic assessment, first determine if an emergency exists. For example, does the patient have decreasing... . Obtain a medication history. Include the use of sedatives, opioids, tranquilizers, and mood-elevating drugs. Many drugs have n... . Ask about any surgery involving any part of the nervous system, such as head, spine, or sensory organs. If a patient had surge... Functional Health Patterns . Ask about the patient’s health practices that affect the nervous system. Include substance use, smoking, adequate nutrition, B... . Neurologic problems can result in poor nutrition. Problems related to chewing, swallowing, facial nerve paralysis, and muscle ... . Bowel and bladder problems often occur with neurologic problems, such as stroke, head injury, spinal cord injury, MS, and deme... . Many neurologic disorders can cause problems with mobility, strength, and coordination. These problems can affect the patient’... . Sleep pattern changes can be both a cause and a response to neurologic problems. Pain and reduced ability to change position b... . Because the nervous system controls cognition and sensory integration, many neurologic problems affect these functions. Consid... . Neurologic problems can drastically change a patient’s control over life and create dependency on others for meeting daily nee... . Physical impairments, such as weakness and paralysis, can alter or limit participation in usual roles and activities. Cognitiv... . Assess the person’s ability to take part in sexual activity. Many neurologic problems can affect sexual response. Cerebral les... . The physical sequelae of a neurologic problem can strain a patient’s coping ability. Often the problem is chronic, and the pat... . Many neurologic problems have serious, long-term, life-changing effects. Determine what these effects are because they can str... Objective Data Physical Assessment . Assessing mental status (cerebral function) gives a general impression of how the patient is functioning. It involves determin... . Testing each CN is an essential part of the neurologic assessment (Table 60.4) . Chronic rhinitis, sinusitis, and heavy smoking may decrease the sense of smell. Problems with smell may occur with a tumor inv... . Visual field defects may arise from lesions of the optic nerve, optic chiasm, or tracts that extend through the temporal, pari... . Because the oculomotor (CN III), trochlear (CN IV), and abducens (CN VI) nerves help move the eye, we test them together (Tabl... . The motor system assessment includes strength, tone, coordination, and symmetry of the major muscle groups. Test muscle streng... . We evaluate several modalities in the somatic sensory assessment. Each modality is carried by a specific ascending pathway in ... . Light touch is usually tested first using a cotton wisp or light pinprick. Gently touch each extremity. Ask the patient to ind... . Assess vibration sense by applying a vibrating tuning fork to the fingernails and bony prominences of the hands, legs, and fee... . Assess position sense (proprioception) by placing your thumb and forefinger on either side of the patient’s forefinger or grea... . Several tests assess cortical integration of sensory perceptions (which occurs in the parietal lobes). Explain these tests to ... . Tendons have receptors that are sensitive to stretch. A reflex contraction of the skeletal muscle occurs when the tendon is st... DIAGNOSTIC STUDIES OF NERVOUS SYSTEM EVOLVE WEBSITE/RESOURCES LIST REFERENCES 61 - Acute Intracranial Problems INTRACRANIAL REGULATION Normal Intracranial Pressure Normal Compensatory Adaptations Cerebral Blood Flow Autoregulation of Cerebral Blood Flow Factors Affecting Cerebral Blood Flow INCREASED INTRACRANIAL PRESSURE Mechanisms of Increased Intracranial Pressure Cerebral Edema Vasogenic Cerebral Edema Cytotoxic Cerebral Edema Interstitial Cerebral Edema Clinical Manifestations Change in Level of Consciousness Changes in Vital Signs Ocular Signs Decrease in Motor Function Headache Vomiting Complications Diagnostic Studies Monitoring ICP and Cerebral Oxygenation Indications for Intracranial Pressure Monitoring Methods of Measuring ICP Cerebrospinal Fluid Drainage Cerebral Oxygenation Monitoring Interprofessional Care Drug Therapy Nutrition Therapy . Maintaining a patent airway is critical in the patient with increased ICP. It is a major nursing responsibility. As the LOC de... . Pain, anxiety, and fear related to the primary injury, therapeutic procedures, or noxious stimuli can increase ICP and BP, thu... . Fluid and electrolyte problems can have an adverse effect on ICP. Closely monitor IV fluids with the use of an accurate IV inf... . ICP monitoring is used with other parameters to guide the care of the patient and assess their response to treatment. Suctioni... . Proper head positioning is important. Maintain the patient in the head-up position. Keep the head in a midline position, avoid... . The patient with increased ICP and decreased LOC needs protection from self-injury. Confusion, agitation, and the possibility ... . Be aware of the psychologic well-being of patients and their families. There is a need for support, information, and teaching ... HEAD INJURY Types of Head Injuries Scalp Lacerations Skull Fractures Head Trauma . A concussion is a sudden transient mechanical head injury with disruption of neural activity and a change in the LOC. It is a ... . Diffuse axonal injury (DAI) is widespread axonal damage occurring after a mild, moderate, or severe TBI. The damage occurs pri... . Focal injury can be minor to severe and localized to an area of injury. Focal injury consists of lacerations, contusions, hema... Complications Epidural Hematoma Subdural Hematoma Intracerebral Hematoma Diagnostic Studies Interprofessional Care BRAIN TUMORS Types Clinical Manifestations and Complications Diagnostic Studies Interprofessional Care Surgical Therapy Ventricular Shunts Radiation Therapy and Stereotactic Radiosurgery Chemotherapy and Targeted Therapy Other Therapies CRANIAL SURGERY Types Craniotomy Stereotactic Radiosurgery INFLAMMATORY CONDITIONS OF THE BRAIN BACTERIAL MENINGITIS Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Interprofessional Care VIRAL MENINGITIS BRAIN ABSCESS ENCEPHALITIS Clinical Manifestations and Diagnostic Studies EVOLVE WEBSITE/RESOURCES LIST REFERENCES 62 - Stroke PATHOPHYSIOLOGY OF STROKE Anatomy of Cerebral Circulation Regulation of Cerebral Blood Flow RISK FACTORS FOR STROKE Nonmodifiable Risk Factors Modifiable Risk Factors Transient Ischemic Attack TYPES OF STROKE Ischemic Stroke Thrombotic Stroke Embolic Stroke Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage CLINICAL MANIFESTATIONS Motor Function Communication Affect Intellectual Function Spatial-Perceptual Problems Elimination DIAGNOSTIC STUDIES INTERPROFESSIONAL CARE Preventive Therapy Preventive Drug Therapy Left Atrial Appendage Occlusion Patent Foramen Ovale Surgical/Endovascular Therapy for TIA and Stroke Prevention Acute Care for Ischemic Stroke Drug Therapy for Ischemic Stroke Endovascular Therapy for Ischemic Stroke Acute Care for Hemorrhagic Stroke Drug Therapy for Hemorrhagic Stroke Surgical Therapy for Hemorrhagic Stroke Rehabilitation Care . During the acute phase after a stroke, management of the respiratory system is a nursing priority. Stroke patients are vulnera... . Perform ongoing neurologic assessments, including the NIHSS, mental status, pupillary response, and extremity movement and str... . Nursing goals for the cardiovascular system are aimed at maintaining homeostasis. Many patients with stroke have decreased car... . The nursing goal for the musculoskeletal system is to maintain optimal function by preventing joint contractures and muscular ... . The skin of the patient with stroke is susceptible to breakdown related to loss of sensation, decreased circulation, and immob... . The most common bowel problem after stroke is constipation. Fluid and fiber intake goals are determined with the stroke team b... . In the acute stage of stroke, the primary urinary problem is poor bladder control, resulting in incontinence. Take steps to pr... . The patient’s nutrition needs require quick assessment and treatment. The patient may initially receive IV infusions to mainta... . During the acute stage of stroke, your role in meeting the patient’s psychologic needs is primarily supportive. Speech, compre... . Patients who had a stroke often have perceptual deficits. Patients with a stroke on the right side of the brain usually have d... . A stroke is usually a sudden, very stressful event. Stroke is often a family disease, affecting the family emotionally, social... . The patient is usually discharged from the acute care setting to home, an intermediate- or long-term care facility, or a rehab... . Rehabilitation is the process of maximizing the patient’s capabilities and resources to promote optimal functioning related to... . The initial assessment consists of determining the stage of recovery of muscle function. If the muscles are still flaccid seve... . The patient may have many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social... . A patient who had a stroke may be concerned about the loss of sexual function. Many patients are comfortable talking about the... . Traditionally, successful community integration after stroke is hard for the patient because of persistent problems with cogni... EVOLVE WEBSITE/RESOURCES LIST REFERENCES 63 - Chronic Neurologic Problems HEADACHES TENSION-TYPE HEADACHE Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies MIGRAINE HEADACHE Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies CLUSTER HEADACHE Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies OTHER TYPES OF HEADACHES INTERPROFESSIONAL CARE: HEADACHES Drug Therapy Tension-Type Headache Migraine Headache Cluster Headache Other Headaches CHRONIC NEUROLOGIC DISORDERS Seizure Disorder Etiology and Pathophysiology Clinical Manifestations Generalized-Onset Seizures . Tonic-clonic seizure (formerly called grand mal) is the most common generalized-onset motor seizure. During a tonic-clonic sei... . Other types of generalized-onset motor seizures include tonic and clonic. A tonic seizure involves a sudden onset of increased... . Absence seizure most often occurs in children. They rarely occur beyond adolescence. This type of seizure occurs more often in... Focal-Onset Seizures Psychogenic Nonepileptic Seizures Complications Physical Psychosocial Diagnostic Studies Interprofessional Care Drug Therapy Surgical Therapy Other Therapies RESTLESS LEGS SYNDROME Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Drug Therapy Other Therapies ?Nursing Management: Multiple Sclerosis ?Assessment PARKINSON DISEASE Etiology and Pathophysiology Clinical Manifestations Tremor Rigidity Bradykinesia Postural Instability Complications Diagnostic Studies Interprofessional Care Drug Therapy Surgical Therapy ?Nursing Management: Parkinson Disease ?Assessment MYASTHENIA GRAVIS Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies Interprofessional Care Drug Therapy Surgical Therapy Other Therapies ?Nursing Management: Myasthenia Gravis ?Assessment AMYOTROPHIC LATERAL SCLEROSIS HUNTINGTON DISEASE EVOLVE WEBSITE/RESOURCES LIST REFERENCES 64 - Dementia and Delirium DEMENTIA Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies ALZHEIMER DISEASE Etiology Aging Family History Cardiovascular Factors Head Trauma Pathophysiology Clinical Manifestations Retrogenesis Diagnostic Criteria Preclinical Stage Mild Cognitive Impairment Diagnostic Studies Interprofessional Care Drug Therapy . Behavior problems occur in about 90% of patients with AD. These problems include repetitiveness or asking the same question re... . The patient is at risk for problems related to personal safety. Hazards include falling, ingesting dangerous substances, wande... . Because of difficulties with oral and written language, patients may have a hard time expressing physical problems, including ... . Undernutrition is a problem in the moderate and severe stages of AD. Loss of interest in food and decreased ability to self-fe... . In the late stages, the patient is unable to perform oral self-care. With decreased tooth brushing and flossing, dental proble... . Urinary tract infection and pneumonia are the most common infections in patients with AD. Such infections are the cause of dea... . It is important to monitor the patient’s skin over time. Note and treat rashes, areas of redness, and skin breakdown. In the l... . During the moderate and severe stages of AD, urinary and fecal incontinence lead to an increased need for nursing care. Schedu... . More than 16 million Americans provide unpaid care for people with AD or other dementias.3 Most of these are family members pr... DELIRIUM Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies EVOLVE WEBSITE/RESOURCES LIST REFERENCES 65 - Spinal Cord and Peripheral Nerve Problems Etiology and Pathophysiology Types of Injury . Primary injury results from direct physical trauma to the spinal cord due to blunt or penetrating trauma. Trauma can cause spi... . Secondary injury refers to the ongoing, progressive damage that occurs after the primary injury. Secondary injury causes furth... Spinal and Neurogenic Shock Classification of SCI . The major mechanisms of injury include flexion, flexion-rotation, hyperextension, vertical compression, extension-rotation, an... . Skeletal level of injury is the vertebral level with the most damage to vertebra and related ligaments. Neurologic level is th... . The degree of spinal cord involvement may be complete or incomplete (partial). Complete cord involvement results in total loss... Clinical Manifestations Motor and Sensory Effects Respiratory System Cardiovascular System Urinary System Gastrointestinal System Skin Thermoregulation Metabolic Needs Peripheral Vascular Problems Pain Diagnostic Studies Interprofessional Care Prehospital Acute Care . Nonoperative treatments involve stabilization of the injured spinal segment and decompression, either through traction or real... . Surgical treatment after acute SCI is used to manage instability and decompress the spinal cord. It may reduce secondary injur... Drug Therapy . To restrict spinal motion, maintain the neck in a neutral position. For cervical injuries, closed reduction with skeletal trac... . Respiratory complications are the leading cause of morbidity and mortality in SCI.6 Respiratory dysfunction is present in up t... . Heart rate is slowed, often to less than 60 beats/min, because of unopposed vagal response. Any increase in vagal stimulation,... . During the first 48 to 72 hours after the injury, the GI tract may stop functioning (paralytic ileus). We may insert a nasogas... . Immediately after the injury, urine retention occurs because of the loss of autonomic and reflex control of the bladder and sp... . Monitor the environment closely to maintain an appropriate temperature. Regularly assess the patient’s temperature. Do not use... . Stress ulcers can occur because of the physiologic response to severe trauma and psychologic stress. Peak incidence of stress ... . To prevent sensory deprivation, compensate for absent sensations by stimulating the patient above the level of injury. Convers... . Musculoskeletal nociceptive pain can develop from injuries to bones, muscles, and ligaments. The pain is worse with movement o... . The most common long-term complication in SCI is a pressure injury (PI). Healthy skin requires adequate blood circulation. Con... . Once spinal cord shock is resolved, return of reflexes may complicate rehabilitation. Lacking control from the higher brain ce... . The return of reflexes after the resolution of spinal shock means patients with injury at T6 or higher may develop autonomic d... . The patient with mechanical ventilation will need around-the-clock caregivers to provide respiratory hygiene and tracheostomy ... . Types of neurogenic bladder are described in Table 65.8. The type of bladder dysfunction determines management options. After ... . Management of bowel evacuation is necessary for the patient with SCI because voluntary control may be lost. Usual measures for... . Spasticity can be both beneficial and undesirable. It aids with mobility, especially for the patient with incomplete SCI. Spas... . Prevention of PI is part of the lifelong treatment plan after SCI. Nurses in rehabilitation are responsible for teaching the p... . The acute pain of the initial injury may persist during the first few weeks of rehabilitation. Chronic pain can result from ov... . Sexuality is an important issue regardless of the patient’s age or gender. Open discussion with the patient about sexual rehab... . Depression after SCI is common and disabling. Patients with SCI may feel an overwhelming sense of loss. They may temporarily l... SPINAL CORD TUMORS Etiology and Pathophysiology Clinical Manifestations CRANIAL NERVE DISORDERS TRIGEMINAL NEURALGIA Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care BELL’S PALSY Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY Etiology and Pathophysiology Clinical Manifestations and Diagnostic Studies TETANUS EVOLVE WEBSITE/RESOURCES LIST REFERENCES 66 - Assessment: Musculoskeletal System STRUCTURES AND FUNCTIONS OF MUSCULOSKELETAL SYSTEM Bone Function Microscopic Structure Gross Structure Types Joints Cartilage Muscle Types Structure Contractions Neuromuscular Junction Energy Source Ligaments and Tendons Fascia Bursae ASSESSMENT OF MUSCULOSKELETAL SYSTEM Subjective Data Important Health Information . The most common manifestations of musculoskeletal impairment include pain, weakness, deformity, limitation of movement, stiff... . Obtain a complete medication history. Ask about the use of skeletal muscle relaxants, opioids, nonsteroidal antiinflammatory d... . Ask about any hospitalizations due to a musculoskeletal problem. Document the reason for hospitalization; the date and duratio... Functional Health Patterns . Ask about health practices related to the musculoskeletal system. This includes maintaining normal body weight, avoiding exces... . The patient’s description of a typical day’s diet gives clues to areas of nutrition concern that can affect the musculoskeleta... . Questions about the patient’s mobility may reveal problems with ambulating to the toilet. Ask the patient if an assistive devi... . Many musculoskeletal problems can affect the patient’s activity-exercise pattern. Get a detailed account of the type, duration... . Discomfort from a musculoskeletal problem can interfere with sleep and lead to fatigue. Ask the patient about any changes in s... . Fully discuss any reports of pain reported from a musculoskeletal problem. To give a baseline for later reassessment, ask the ... . Many chronic musculoskeletal problems lead to deformities and a reduction in activities. This can have a serious negative imp... . Impaired mobility and chronic pain from musculoskeletal problems can negatively affect the patient’s ability to perform in rol... . Ask women about their menstrual history. Premenopausal amenorrhea can contribute to osteoporosis. Pain from musculoskeletal pr... . Mobility limitations and pain are serious potential stressors that challenge the patient’s coping resources. Recognize the pot... . Ask about cultural or religious beliefs that may influence acceptance of treatment for the musculoskeletal problem. These may ... Objective Data Physical Assessment . Perform a systematic inspection. Start at the head and neck then moving to the upper extremities, lower extremities, and trunk... . Palpation usually proceeds head to toe. Examine the neck, shoulders, elbows, wrists, hands, back, hips, knees, ankles, and fee... . When assessing the patient’s joint mobility, evaluate active and passive range of motion (ROM). ROM is the full movement poten... . Grade the strength of individual muscles or groups of muscles during contraction on a 5-point scale (Table 66.4). Grade normal... . When you note limb length discrepancies or subjective problems, measure limb length and circumferential muscle mass. For examp... . Note the use of an assistive device such as a walker or cane. Assess the patient for proper fit while reviewing the safe and c... DIAGNOSTIC STUDIES OF MUSCULOSKELETAL SYSTEM EVOLVE WEBSITE/RESOURCES LIST REFERENCES 67 - Musculoskeletal Trauma and Orthopedic Surgery HEALTH PROMOTION SOFT TISSUE INJURIES SPRAINS AND STRAINS DISLOCATIONS REPETITIVE STRAIN INJURY CARPAL TUNNEL SYNDROME ROTATOR CUFF INJURY MENISCUS INJURY ANTERIOR CRUCIATE LIGAMENT INJURY BURSITIS FRACTURES Classification Manifestations Fracture Healing Interprofessional Care Fracture Reduction . Closed reduction is the nonsurgical, manual realignment of bone fragments to their anatomic position. Traction and countertrac... . Open reduction is the correction of bone alignment through surgery. It usually includes internal fixation of the fracture with... . Traction is the application of a pulling force to an injured or diseased body part or extremity. Traction is used to (1) preve... Fracture Immobilization . A cast is a temporary immobilization device often applied after closed reduction. A cast usually immobilizes the joints above ... . An acute fracture or soft tissue injury of the upper extremity can be immobilized by using a (1) sugar-tong splint, (2) poster... . The body jacket brace is used for immobilization and support for stable spine injuries of the thoracic or lumbar spine. The br... . Injuries to the lower extremity can be immobilized with a long leg cast, short leg cast, cylinder cast, or prefabricated splin... . An external fixator is composed of metal pins and wires that are inserted into the bone and attached to external rods to stabi... . Internal fixation devices (pins, plates, intramedullary rods, metal and bioabsorbable screws) are surgically inserted to reali... Electrical Bone Growth Stimulation Drug Therapy Nutrition Therapy . If surgery is needed to treat a fracture, patients must be prepared. In addition to the usual preoperative nursing care (see C... . In general, nursing care after surgery involves monitoring vital signs and applying general principles of postoperative nursin... . Patients often have reduced mobility because of a fracture. Plan care to decrease risk for the many possible complications of ... . When slings are used with traction, regularly inspect exposed skin areas. Pressure over a bony prominence created by wrinkled ... ?Ambulatory Care . Most uncomplicated fractures are treated in an outpatient setting. Whatever the type of cast material, a cast can interfere wi... . Know the overall goals of PT in relation to the patient’s abilities, needs, and tolerance. The physical therapist is responsib... . Devices for ambulation range from a cane (can relieve up to 40% of the weight normally borne by a lower limb) to a walker or c... . Short-term rehabilitative goals address the transition from dependence to independence in performing simple ADLs. They are dir... COMPLICATIONS OF FRACTURES Infection Compartment Syndrome Clinical Manifestations Interprofessional Care Venous Thromboembolism Fat Embolism Syndrome Clinical Manifestations . Management of FES is supportive and related to managing symptoms. The patient needs appropriate respiratory support (see Chapt... Rhabdomyolysis HUMERAL SHAFT FRACTURE CLAVICULAR FRACTURE PELVIC FRACTURE HIP FRACTURE Clinical Manifestations Interprofessional Care FEMORAL SHAFT FRACTURE TIBIAL FRACTURE STABLE VERTEBRAL FRACTURE FACIAL FRACTURE MANDIBULAR FRACTURE AMPUTATION Diagnostic Studies Interprofessional Care . Reinforce information that the patient and caregiver have received about reasons for the amputation, proposed prosthesis, and ... . General care for the patient who had an amputation depends largely on the patient’s age, general state of health, and reason f... ?Ambulatory Care ?Prostheses ?Phantom Limb Sensations ?Upper Limb Amputation COMMON JOINT SURGERIES TYPES OF JOINT SURGERIES Synovectomy Osteotomy Debridement Arthroplasty Total Hip Arthroplasty Hip Resurfacing Arthroplasty Knee Arthroplasty Finger Joint Arthroplasty Elbow and Shoulder Arthroplasty Ankle Arthroplasty Arthrodesis Complications of Joint Surgery ?Preoperative Care ?Postoperative Management EVOLVE WEBSITE/RESOURCES LIST REFERENCES 68 - Musculoskeletal Problems OSTEOMYELITIS Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies Interprofessional Care BONE TUMORS BENIGN BONE TUMORS Osteochondroma MALIGNANT BONE TUMORS Osteosarcoma Metastatic Bone Cancer MUSCULAR DYSTROPHY LOW BACK PAIN ACUTE LOW BACK PAIN CHRONIC LOW BACK PAIN Spinal Stenosis INTERVERTEBRAL DISC DISEASE Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies Interprofessional Care Surgical Therapy ?Nursing Management: Spine Surgery NECK PAIN FOOT PROBLEMS METABOLIC BONE DISEASES OSTEOMALACIA OSTEOPOROSIS Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies PAGET DISEASE EVOLVE WEBSITE/RESOURCES LIST REFERENCES 69 - Arthritis and Connective Tissue Diseases ARTHRITIS OSTEOARTHRITIS Etiology and Pathophysiology Clinical Manifestations Joints Deformity Systemic Diagnostic Studies Interprofessional Care Drug Therapy Surgical Therapy Complementary and Alternative Therapies ?Heat and Cold Applications ?Nutrition Therapy ?Exercise ?Rest and Joint Protection ?Role Performance RHEUMATOID ARTHRITIS Etiology and Pathophysiology Clinical Manifestations Joints Extraarticular Manifestations Diagnostic Studies Interprofessional Care Drug Therapy . Drugs are the cornerstone of RA treatment (Table 69.9). Because irreversible joint changes can occur as early as the first yea... . Biologic response modifiers (also called biologics or immunotherapy) are used to slow disease progression. They can be used al... . The antibiotics doxycycline (Vibramycin) and minocycline (Minocin) continue to be researched. Any current use of these drugs f... Surgical Therapy ?Rest ?Joint Protection ?Cold and Heat Therapy ?Exercise ?Nutrition ?Psychologic Support GOUT Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies LYME DISEASE SEPTIC ARTHRITIS SPONDYLOARTHROPATHIES ANKYLOSING SPONDYLITIS Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies PSORIATIC ARTHRITIS REACTIVE ARTHRITIS SYSTEMIC LUPUS ERYTHEMATOSUS Etiology and Pathophysiology Clinical Manifestations and Complications Skin Problems Musculoskeletal Problems Cardiopulmonary Problems Renal Problems Nervous System Problems Hematologic Problems Infection Diagnostic Studies Interprofessional Care Drug Therapy ?Role Performance ?SLE and Pregnancy SCLERODERMA Etiology and Pathophysiology Clinical Manifestations Raynaud Phenomenon Skin and Joint Changes Internal Organ Involvement Diagnostic Studies Interprofessional Care Drug Therapy AUTOIMMUNE MYOSITIS Etiology and Pathophysiology Clinical Manifestations and Complications Muscular Skin Other Manifestations Diagnostic Studies MIXED CONNECTIVE TISSUE DISEASE SJÖGREN SYNDROME MYOFASCIAL PAIN SYNDROME FIBROMYALGIA Etiology and Pathophysiology Clinical Manifestations and Complications Diagnostic Studies SYSTEMIC EXERTION INTOLERANCE DISEASE Etiology and Pathophysiology Clinical Manifestations Diagnostic Studies EVOLVE WEBSITE/RESOURCES LIST REFERENCES A - Basic Life Support for Health Care Providers CARDIOPULMONARY RESUSCITATION Chest Compressions Defibrillation Airway and Breathing HANDS-ONLY CPR B - Clinical Problems With Definitions c - Laboratory Reference Intervals INDEX A B C D E F G H I J K L M N O P Q R S T U V W X Y Z ABBREVIATIONS IBC
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