Medsurg Notes Nurses Clinical Pocket Guide, 2ND EDITION ppt

Nurses have a duty of care of careful and continuous monitoring of the patient’s status.. health-■Monitor each patient’s vital signs, neurological status, intake and output,status per ph

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Legal Issues in MedSurg Care

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

The nurse practice law of each state defines the scope of nursing practice for that state.

Advanced practice nurses, such as nurse midwives, nurse anesthetists, andclinical nurse specialists, function under a broader scope of practice

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

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

■Keep informed of local, state, and national nursing issues; get involved as

a lobbyist in your state; contact your state representatives regardingissues that affect nursing practice

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

Nurses have a duty of care of careful and continuous monitoring

of the patient’s status.

Nurses assess and directly intervene on patients more than any other care professionals

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

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

Nurses have a duty to communicate the patient’s status to the medical staff, particularly on an immediate/STAT basis when the patient’s status warrants.

The nurse is usually the first team member to detect an urgent care situationand has an obligation to report any changes in patient condition to themedical staff for timely intervention

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

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

(Continued on the following page)

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■The nurse must maintain accurate nursing notes, flow sheets, medicalKardexes, and nursing care plans that record the patient’s symptoms, timesymptoms were present, time physician was notified, and time physicianarrived The medical chart should be a factual record of the patient’smedical treatment, responses thereto, vital signs, and all nursinginterventions.

Nurses have a duty to administer medications safely at all times, including urgent care situations.

Medication errors are the most common source of nursing negligence.Procedural safeguards should be followed to prevent medication errors The

“five rights” of medication administration are minimum practice standards

■Give the right drug in the right dose to the right patient by the right route

at the right time

■Document the five rights—which medication, to whom, in what dose,through which route, and at what time

■Document fully any suspected adverse drug reaction, time and nature

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

■Nurses have a duty to know about all the drugs they administer: drugnames, drug categories, dosage, timing, technique of administration,expected therapeutic response, duration of drug use, and procedures tominimize the incidence or severity of adverse drug effects

Nurses have a duty to maintain safe patient care conditions.

This is akin to the nurse’s duty to advocate for the patient at all times

■Report an unsafe staffing condition to the nursing supervisor as soon as

it is apparent The nurse-patient ratio in intensive care settings should notexceed 1:2; on general floors, 1:6

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

■Know the nurse practice limitations on nurses under your supervision;licensed practical nurses and student nurses cannot perform all theactions of the registered nurse

Nurses have a duty to keep the patient safe from self-harm.

The nurse must be vigilant regarding any changes in the patient’s sensorium/mental status Any patient can experience a psychiatric crisis from a myriad

of causes, including hypoxia, drug reaction, drug withdrawal, ICU psychosis,

or underlying organic disease

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

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

be applied

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

■If restraints are applied, the patient must be monitored closely for changes

in medical condition and mental status, for maintenance of adequate lation, and for prevention of positional asphyxiation Document all assess-ments and frequency of checks (no less frequent than every 15 minutes)

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

Nurses have a duty to carry out physician orders as required by state law, hospital policy and procedure, and nursing practice standards.

Concurrently, as patient advocate, the nurse must question an order he orshe deems problematic, particularly when an urgent care situation is present

or when one could arise from fulfillment of the order

■Contact the physician immediately for any order that is unclear, contrary

to standard drug dosage/route/frequency of administration, or that doesnot address the acuity of the patient’s medical condition; e.g., an order forvital signs every shift for a postoperative patient recently transferred to ageneral surgical floor

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

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

Informed consent is the process of informing the patient, not simply completing the form with the patient’s signature.

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

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

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

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

■If a patient is competent and refuses medical care, even when thecondition is life-threatening, the patient’s choice supersedes the opinion

of the health-care provider

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

Nurses are held to the standard of care of the profession.

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

■Each nurse owes every patient the duty of “reasonable care.” This is

implicit in the standard of care defined by what nursing professionalsgenerally recognize on a national level as correct patient care

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

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

As nursing practice, along with medical technology, continues to become more sophisticated and complex, the standards of nursing care will likewise increase.

Documentation Guidelines for Urgent Situations

Documentation is critical in urgent situations It enhances decision makingand helps anyone who reads it understand what happened, how it washandled, and what the outcomes were It is crucial in any legal analysis ofcare Keep the following in mind as you document:

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

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

■Always note at what time, by what route, and how much medication you

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

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

■If you do not get the response from the physician or nurse practitioneryou think is required for the patient’s best interests, call your

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

■If you fail to document something, write another entry called “Addendum”

to the note above, and give the time and date of the first note

Delegation Guidelines

The National Council of State Boards of Nursing defines delegation as

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

Sample of nursing tasks that cannot be delegated:

■Initial assessment or assessments of change in patient condition

■Formulating the nursing diagnosis; creating the nursing plan of care

■Administration of medications by direct IV bolus (IV push)

■Administration of blood products

■Programming a PCA pump

■Changing a tracheotomy tube

Before delegating, determine the following:

■The complexity of the task and the potential for harm posed by the task(what psychomotor skills are required? what harm can occur if the proce-dure is done incorrectly?)

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

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

RN can supply)

Remember the Five Rights of Delegation:

■Right Task—is the task within the caregiver’s scope of practice?

■Right Person—does the assigned caregiver have the knowledge and skillrequired?

■Right Circumstances—is the setting appropriate; are the right resourcesavailable? what is the current health status of the patient?

■Right Direction—clear description of the activity to be performed, relevantpatient conditions, limits, and expectations

■Right Supervision—monitoring performance, maintaining your availability

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

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

account-Critical Thinking GuidelinesIdentifying

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

■Listen and observe Know recent trends in the patient’s status; understandnormal and abnormal findings Recognize differences and similarities

■ Have you noticed or has the patient complained of somethingunexpected?

■ Follow up with questions any new complaint or unusual finding

■ If you have any doubts, do not ignore them; ask a nurse who is senior

to you, or notify the physician/NP

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■Analysis involves breaking the whole into parts and discovering therelationships of the part to the whole Is the problem hypotension? Thinkabout the factors that influence blood pressure: What is the hemoglobinlevel, urinary output, recent blood loss? Can you assess cardiac output?

Is the patient on medications that affect blood pressure?

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

■Consider if the data fit any of the known complications of the patient’scondition Do the data suggest something is worsening? Link the data

to the patient’s physical status Do the data “fit”?

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

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

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

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

Diagnosing

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

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

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

■Implement the plan; document all problems and interventions

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■Evaluation is the step that lets you know if the plan is working

■Assess the status of the problem at appropriate intervals; evaluate if theinterventions are effective

■Determine if further intervention is required

Enhance Your Clinical Reasoning Abilities

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

■Keep current Read journals and other literature

■Learn about other specialty areas such as oncologic nursing, wound care,respiratory or physical therapy

■Know your real strengths, skills, and weaknesses Correct weaknesses

■Be alert in your observations and assessments Realize that everybodymakes assumptions and that assumptions can be wrong Ask yourselfwhat else might be responsible for the signs and symptoms

■Work in other fields to gain experience Challenge yourself

■Ask questions of other experts in medicine, surgery, nursing, and relatedfields All practioners fundamentally are teachers Learn from them

Principles of Pain Management

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

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

■Assess each patient’s pain, and create an individualized treatment plan

■Reassure patients in pain or who expect to have pain that pain can berelieved

■Assess any changes in pain pattern to ensure that new causes are notoverlooked

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

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

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

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

■All can reduce pain and stress and give a greater sense of control

■Do not avoid opioids because of fear the patient will become addicted

■Encourage patients to request pain medication before pain becomessevere

■Suggest administering medication on an around-the-clock schedule tomaintain therapeutic blood levels

■Suggest time-released pain medications to avoid peaks and valleys inpain control

■Consult with a pain management clinical specialist, if available

■Include family in pain control plan

Pain ManagementNumeric Scale

pain

Visual Analog Scale

Wong-Baker FACES Pain Rating Scale Use for children over 3 years (From Hockenberry

MJ, Wilson D, Winkelstein ML: Wong’s Essentials of Pediatric Nursing, ed 7, St Louis,

2005, p 1259 Used with permission Copyright, Mosby.)

0 2 4 6 8

NO HURT HURTS

LITTLE BIT

HURTS LITTLE MORE

HURTS EVEN MORE

HURTS WHOLE LOT

HURTS WORST

10

Text/image rights not available.

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Using Pain Scales

■Most patients can use the numerical scale

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

■Ask how distressing the pain is, using a scale of 0–10

■Some patients report a moderate to high numerical score (5 or above)but are not distressed and do not want medication

■Some patients report a lower numerical value but are very distressed

by the pain and may need medication or other intervention

■Always ask the patient directly if he or she would like medication

■Contact a pain care nurse, if available

■For patients who cannot use the numerical scale, use the Wong-BakerFACES Pain Rating Scale Tailor questions accordingly

Mnemonics for Thorough Pain Assessment (PQRST and COLDERRA)

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

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

PQRST

P (provokes/point) What provokes the pain (exertion, spontaneous

onset, stress, postprandial, etc.)Point to where the pain is

Q (quality) Is it dull, achy, sharp, stabbing, pressing, deep,

surface, etc.? Is it similar to pain you have hadbefore?

R (radiation/relief) Does it travel anywhere (to the jaw, back, arms,

etc.)? What makes it better (position, being still)?What makes it worse (deep inspiration,movement)?

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

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

T (time/onset) When did it start? Is it constant or intermittent?

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

Nursing Interventions for Pain Management

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

Comparison of Routes of Analgesic Administration

Route Advantages Disadvantages Oral

IM

Subcutaneous

Easiest, least invasive;

consider oral first

while taking into

account patient status

Quicker onset of action

than oral route

No need for IV access;

changing sites usually

easy; 80% of drug

available

Metabolized in the liver beforereaching bloodstream—lessdrug available (40% to 60%)than with other routes; takeslonger to act Cannot be used

if patient has difficulty takingoral medications

Painful, potential nerve injury;difficulty finding sites inundernourished patientsOnly small volumes of fluid can

be injected each hour Mustuse concentrated medica-tions, which increases risk fordrug error

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Comparison of Routes of Analgesic Administration (continued)

Route Advantages Disadvantages

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

Potential for Stereotyping

Books that list cultural characteristics of various groups have some value but

Immediate effect; can have

a continuous rate and abolus

Much lower doses, fewer

side effectsEasy to use Slow buildup

of drug, fewer sideeffects

Usually used for patients

with cancer pain

Better absorption, quicker

onset than oral route

Good for patients whocannot tolerate POmedications

IV sites are portal forinfection

May not be appropriatefor confused patient.NOTE: Never admin-ister a dose for thepatient—can lead torespiratory depres-sion and death.Inform family also.Potential for infection orother complicationNot suitable for acutepain Drug remainsactive for 14–25 hoursafter removal, whichpresents problems ifpatient overdosed.Used primarily forbreak-through painfor cancer patients

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

Cultural Assessment

Cultural assessment covers many factors, too numerous for this book Keep

in mind that cultural variation is frequently expressed within domainsapplicable to any culture Maintain a respectful and open attitude as youlearn about each patient Common domains of importance related to healthcare include:

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

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

■Language—it is very important to use competent interpreters whenobtaining and receiving health information Do not automatically use

a family member Sensitive information may be embarrassing for thetwo people to discuss Try to get someone of about the same age andgender as the patient Always ask if the patient is willing to use theinterpreter In an emergency, communicate through the oldest familymember present

■Family relationships—families may have a hierarchy that includes aspokesperson, so to speak Show respect for that person’s role As always,

do not reveal confidential information about a person’s health without theexpress consent of the patient

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

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

■Birth and death rituals—End-of-life beliefs can vary significantly withinany culture Suggest meeting with the family if the patient approves ofyou sharing or receiving information about personal preferences Discussissues such as organ donation, autopsy if applicable to the case, specialcare of the body, and what the family will want to do in the immediatetime after death

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Spiritual Care

Providing spiritual care means different things to different people Somenurses may be too intimidated to address this issue Many do not feelcompetent to do so or that it is none of their business You can always askthe patient how he or she feels spiritually The answer will be very revealing

in terms of willingness to discuss the topic Follow the patient’s lead, andnever impose your own beliefs Often, the best spiritual intervention is toask open-ended questions and then listen

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Focused Assessment of the CV System

■A focused assessment of CV status includes:

■ The core cardiovascular system—the heart, its rate and rhythm, the

carotid arteries, blood pressure, and other hemodynamic measures

■ The peripheral vascular system—the extremities, particularly the

lower extremities

■ The lungs—adventitious sounds, cough, and oxygenation status.

■ Mental status—level of alertness, restlessness, confusion, irritability,

or stupor

■Vital signs:

■ Blood pressure, heart rate, respiratory rate, O2saturation

■Mental status, head and neck:

■ Look for restlessness, ↓ LOC, circumoral cyanosis, color of conjunctiva,jugular venous distention

■Inspect the anterior chest:

■ Look for visible pulsations of the chest wall

■Palpate the anterior chest:

■ Locate apical beat, which is the point of maximum impulse (PMI)

■ Assess for heaves—a very forceful PMI

■ Assess for thrills—a palpable murmur; feels like a cat purring

■Auscultate the heart and lungs:

■ Obtain rate and rhythm; assess for rhythm abnormalities

■ Listen for normal heart sounds and possible murmurs

■ Use the diaphragm of stethoscope first, then the bell

■ Listen for carotid abdominal and femoral bruits

■Assess extremities: Check for:

■ Cyanosis, temperature, color, and amount of moisture

■ Capillary refill time in hands and feet

■ Changes in foot color, ulcers, varicose veins

■ Edema of lower extremities (check sacrum if client is bedridden)

■ Presence and equality of pedal pulses If pulses are not palpable,use a Doppler sonogram

■Assess current symptoms:

■RED FLAGsymptoms require immediate attention and intervention.Shortness of breath

Chest pain, possibly with neck, jaw, or left arm pain

Syncope possibly with palpitations and shortness of breath

Palpitations possibly with chest pain and dizziness

Cyanosis of lips, fingers, or nailbeds

Pain, coolness, pallor, or pulse changes in extremities

Sweating, nausea, vomiting, fatigue (especially in women)

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Pulse Strength Absent ⫽ 0 Weak ⫽ ⫹1 Normal ⫽ ⫹2 Full ⫽ ⫹3 Bounding ⫽ ⫹4

Coronary artery disease, angina, MI, heart failure,cardiomyopathy, valve disease, left ventricularhypertrophy, pericarditis, dysrhythmiasCOPD, asthma, pneumothorax, pulmonary embolus(PE), pulmonary edema

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

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

0–1/4 inch; disappears in ⬍5 sec ⫽ ⫹1

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

1/2–1 inch; disappears in 1–2 min ⫽ ⫹3

Possible Causes of Shortness of Breath

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Arterial HematomaCLINICAL PICTURE

The patient may have:

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

■Cannulated artery that has been inadvertently decannulated and ishemorrhaging

■Hematoma, possibly pulsatile, around arterial puncture site

IMMEDIATE INTERVENTIONS

■Notify physician or NP

■Place patient in a supine position with affected limb extended

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

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■Once bleeding is controlled, apply sterile gauze dressing overlayed with

a pressure dressing (Elastoplast) Depending on institution protocol, use

a sandbag or other pressure device over the pressure dressing for addedpressure

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

NP response

FOCUSED ASSESSMENT

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

■Assess VS, noting decrease in BP or increase in HR

■Assess LOC and patient’s ability to maintain extremity in immobile,neutral position

■Assess for pain

STABILIZING AND MONITORING

■Instruct patient to maintain supine position a minimum of 6 hours

■Frequently assess site for rebleeding

■Monitor circulation, mobility, and sensation in affected extremity

■Frequently monitor VS for changes in BP and HR

■Reassess for pain

■Assess for history of preexisting conditions such as clotting abnormalities

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

■Chart patient status, and convey to physician or NP

BE PREPARED TO

■Assist physician or NP with cannulation of an alternate arterial site

■Obtain IV access for the administration of blood, clotting factors, oranticoagulant reversal agents such as protamine sulfate

POSSIBLE ETIOLOGIES

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

Arterial OcclusionCLINICAL PICTURE

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■Pale, mottled, cyanotic, or ashen extremity.

■Edematous, tight, shiny skin over affected extremity

■Capillary refill ⬎3 sec or absent

■Assess for pallor, pain, paresthesias, paralysis, and pulselessness (5 Ps)

by assessing circulation (skin color, capillary refill, pulses), movement(flexion, extension, rotation), and sensation (response to pinprick or lighttouch; pain level) of affected extremity

■Assess pulses with Doppler amplification

■Assess bandages or cast proximal to diminished pulses

■Continue to monitor condition of extremity

■Keep extremity at heart level to promote arterial flow without diminishingvenous return

■Remove or do not use ice on the extremity

■Control and manage pain

BE PREPARED TO

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

■Prepare the patient for surgery

■Initiate large-bore IV access

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

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BradycardiaCLINICAL PICTURE

■HR⬍60 bpm

■Nausea and vomiting, dizziness or lightheadedness

■Signs of unstable bradycardia:

■ Altered LOC

■ Chest pain, shortness of breath (SOB)

■ Hypotension, pulmonary congestion, and/or cyanosis

■Obtain a 12-lead ECG

■Check for patent IV access

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

or NP response

■Assess LOC and orientation

■Assess BP and HR

■Assess respirations for rate and effort; assess SaO2if readily available

■Assess skin for color, moistness, and temperature Assess for associatedsymptoms (chest pain, SOB, hypotension)

■If patient on telemetry or cardiac monitor, assess ECG

■Monitor VS

■Set up cardiac monitoring, and monitor rate and rhythm

■Assess recent laboratory results

BE PREPARED TO

■Administer oral or IV medications as ordered

■Obtain or order laboratory tests

■Titrate O2to SaO2⬎90%

■Obtain IV access if none available

■Assist with external pacing

■

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■Medication toxicity, vasovagal response, hyperkalemia, hypothermia,hypothyroidism, sepsis, severe infection, hypoglycemia, hypothermia,excellent physical condition (athletes), myocardial infarction, shock

Chest PainCLINICAL PICTURE

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

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

■Cool, pale, and/or diaphoretic skin

■Nausea, vomiting

■SOB, tachypnea

■Dizziness, fatigue, fainting

■Marked anxiety, expression of “impending doom.”

■Elevate head of bed (HOB) to facilitate breathing

■Administer high-flow O2by nonrebreather mask (10–15 L/min) or by nasalcannula (4–6 L/min)

■Assess VS, character and quality of pain (PQRST), skin color

■Check for standing orders of nitrogylcerine (NTG) sublingual 0.4 mg q

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

■Check for IV access Prepare to initiate saline lock IV access

or NP response

■Assess HR, rhythm, BP, respiratory rate (RR), and effort

■Inspect skin for color, temperature, and moistness

■Assess SaO2with pulse oximetry

■Assess rhythm strip

■Auscultate lung fields

■Administer medications STAT for cardiac symptoms, if ordered: NTG 0.4

mg SL (hold for BP ⬍90 mm Hg); morphine (MS) 2 mg IV (hold for RR ⬍8,

BP⬍90 mm Hg); aspirin (ASA) 162–325 mg PO

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■Assess response to medications.

■Identify underlying rhythm

■Obtain cardiac enzymes/troponin levels

BE PREPARED TO

■Assess need and eligibility for thrombolytic therapy

■Set up cardiac monitoring

■Set up or change the O2delivery system

■Administer oral or IV medications

■Call for a STAT 12-lead ECG

■Obtain laboratory tests (electrolytes, PT, PTT, cardiac markers)

■Transfer patient to ICU

■Call a code; perform CPR

■Angina, anxiety, MI, pulmonary embolism, pulmonary edema, chesttrauma, endocarditis, pericarditis, indigestion, gastroesophageal refluxdisorder, pleurisy, bronchitis

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Gradual or suddenonset.

No provocation

Sudden

Pressure,tightness

Rest or sl NTGprovides reliefAche with sharp,stabbing pain

No relief

Dull, aching butmay also havesharp pain

No relief

arm, backSame as MI

Anterior chest,shoulder, neck

Variable

Mild to moderate,lasting⬍2 min

Moderate, lastinghours

None, mild, ormoderate ofvariableduration

Trang 29

Provocation Quality Location and Severity and Etiology and Onset and Relief Radiation Time (Duration) Pericarditis

Gradual or suddenonset

Gradual or sudden

Sharp

Sharp, burningwhen patient

in uprightposition,antacidsprovide relief

Dull ache;

possible sharppain

Rest and mildanalgesics orNSAIDsprovide relief

Substernalanterior chest

Chest, throat,RUQ, LUQ, back

Arm, shoulder,neck, back,sternum, ribs,abdomen

Moderate tosevere, enduresfor hours todays

Moderate, ing minutes orhours

last-Mild to moderate,lasting minutes

Trang 30

Heart FailureCLINICAL PICTURE

■Fatigue, weakness, anxiety

■SOB, orthopnea, dyspnea, adventitious breath sounds (rales or crackles),cyanosis

■Change in mental status anxiety, restlessness, confusion

■Edema, jugular vein distention, increased CVP, positive fluid balance

■Assess VS; note if hypotensive

■Elevate HOB, and lower legs if possible

■Administer supplemental O2(100% nonrebreather mask)

■Restrict fluids

■Assess for patent IV

■Assess airway, RR and effort, BP, and HR

■Auscultate lung fields for pulmonary congestion (crackles, wheezes)

■Assess SaO2via pulse oximetry

■Assess LOC and orientation

■Assess cardiac rhythm

■Restrict fluids, and administer diuretics as ordered

■Closely monitor I&O

■Assess for improvement of LOC and oxygenation status

BE PREPARED TO

■Titrate O2to keep SaO2⬎90%

■Obtain IV access

■Set up cardiac monitoring

■Administer oral or IV diuretics, NTG, morphine, and electrolytes asordered

■Order a chest x-ray and ECG

■Order or obtain laboratory tests (BUN, creatinine, CBC, electrolytes)

■Transfer patient to ICU or telemetry unit

■Atrial fibrillation, marked bradycardia, systemic infection, septic shock,pulmonary embolism; physical, environmental, and emotional excesses;

Trang 31

stress; cardiac infection and inflammation; excessive intake of waterand/or sodium administration of cardiac depressants or drugs causesalt retention; cardiomyopathy, hypertension, severe aortic stenosis,ischemic myocardial disease, coronary artery disease, acute mitral

or aortic regurgitation, infective endocarditis with acute valve petence, MI, anemia, hyperthyroidism, pregnancy, glomerulonephritis,cor pulmonale, polycythemia vera, carcinoid syndrome, obesity

incom-Hemorrhage/Wound Hemorrhage

CLINICAL PICTURE

■Saturated postoperative dressings

■Excessive amounts of blood in wound drainage system

■Peri-incisional swelling and hematoma

■Subtle changes in LOC, anxiety, irritability, restlessness, decreasedalertness (early CNS signs of blood loss)

■Confusion, combativeness, lethargy, coma (later CNS signs)

■Increased HR to severe tachycardia

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

■Slightly elevated RR to severe tachypnea

■Get help, and notify surgeon

■Discontinue thrombolytics or anticoagulants

■Control external bleeding with direct pressure

■Do not remove saturated dressings, as this may also remove any clotformation

■Instead, reinforce with additional dressing and pressure

■Administer supplemental O2; maintain patent airway

■If IV not in place, obtain large gauge (#18) IV access, and have IVF ready

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■Assess LOC, orientation, and VS (HR, RR, BP)

■Assess for orthostatic hypotension if possible

■Assess SaO2via pulse oximetry if available (Note: may be unreliable due

to decreased peripheral perfusion)

■Assess skin for color, temperature, moistness, turgor, capillary refill

■Monitor VS and oxygenation status

■If patient previously typed and cross-matched, call blood bank to see ifany blood available

■Monitor output from Hemovac, JP drains, NGT, and urinary catheter

■Check laboratory values

■Provide emotional support to patient/family

BE PREPARED TO

■Assist with insertion of a central line

■Obtain laboratory tests STAT (Hgb/Hct, ABGs, electrolytes, blood type andcrossmatch)

■Prepare the patient for surgery

■Administer colloidal infusions

■Insert Foley catheter

Hypertensive Urgency/Emergency

Hypertensive urgency: systolic BP ⬎200 mm Hg or a diastolic BP ⬎120 mm

Hg Hypertensive emergency: diastolic BP ⬎140 mm Hg with evidence ofacute end-organ damage

CLINICAL PICTURE

■Fatigue, headache, restlessness, confusion, visual disturbances, seizure

■Dyspnea, tachycardia, bradycardia, pedal edema, chest pain

■Lightheadedness, dizziness

■Nausea, vomiting

Trang 33

■Assess LOC and orientation.

■Assess respiratory status

■Assess for neurological deficits (hemiparesis, slurred speech)

■Assess baseline VS (temperature, HR, RR, BP)

■Assess SaO2via pulse oximetry, if available

■Assess for associated symptoms: visual disturbances, chest pain,peripheral edema, hematuria

■Maintain continuous monitoring of BP and HR

■Assess for changes in cardiac rhythm if patient is on a monitor

■Monitor I&O

BE PREPARED TO

■Titrate O2to SaO2⬎90%

■Obtain a saline lock IV access

■Administer ordered antihypertensive medications (oral or IV)

■Obtain or order laboratory tests (BUN, creatinine, electrolytes, UA)

■Assist with arterial line placement

■Transfer patient to ICU

■Atherosclerosis, primary hypertension, stress, anxiety, anger, medication,stroke, toxemia of pregnancy, diabetes, cardiac or renal disease, drugs(amphetamine, cocaine, corticosteroids, oral contraceptives)

HypotensionCLINICAL PICTURE

■A systolic BP of ⬍90 mm Hg or systolic BP 40 mm Hg less than baseline

■Altered LOC or orientation

■

Trang 34

if the airway is compromised; to maintain airway patency, place patient

in supine or low Fowler’s position (HOB slightly elevated)

■If respiratory effort inadequate (RR ⬍8, cyanosis, SaO2⬍90%), administerhigh-flow O2via mask (10–15 L/min), or manually assist ventilations with

an Ambu bag (mask-valve device)

■Control bleeding, if any, with direct pressure

■Check for patent IV access Note: IVF is not routinely administered untilreason for hypotension is determined Hypotension could be due tocardiac compromise, in which case fluids might be contraindicated

■Assess respiratory effort and airway patency

■Assess skin for color, temperature, moistness, turgor, and capillary refill

■Assess for associated symptoms (chest pain, dyspnea, nausea)

■Assess I&O; ask patient about recent history of vomiting, diarrhea, orurinary symptoms (burning, frequency, flank pain, hematuria)

■Assess MAR for medications that can affect blood pressure

■Assess for cause

■Continue to monitor VS

■Review laboratory data (Hgb/Hct; BUN; urine specific gravity, electrolytes)

■Evaluate previous 24-hr I&O

■Check MAR for possible medication-induced hypotension

BE PREPARED TO

■Titrate O2to SaO2of 90%

■Obtain IV access, and administer ordered IVF

■Administer ordered vasoactive medications

■Order specific laboratory tests to be drawn STAT

■Transfer patient to a critical care unit

Trang 35

■Medication; dehydration; hemorrhage; vasovagal response to anxiety;sepsis; shock; GI bleed or other internal bleeding; aneurysm; congestiveheart failure; cardiac dyrsrhythmias; myxedema; adrenal crisis;

hypoglycemia; completed stroke

PalpitationsCLINICAL PICTURE

The patient may have or be:

■Sensation of fluttering in chest, heart racing, or dizziness

■Tachycardia, bradycardia, irregular rate

■Cold and clammy skin, hypotensive (drop in BP ⱖ20 mm Hg frombaseline)

■SOB, dyspnea, nausea

■Place patient supine in bed Apply O2if available at bedside

■Stay with patient, and provide reassurance

■Take BP, and assess apical HR and rhythm Compare apical rate to radialrate as one measure of perfusion

■Check for patent IV access

■Quickly assess perfusion by assessing mental status, peripheral pulses

■Observe cardiac monitor if patient is being monitored Obtain rhythm strip

■Assess LOC, VS, and pulse quality and rhythm

■Assess precipitating event, pain level, anxiety, hyperventilation

■Assess breath sounds, O2saturation

■Assess peripheral pulses, skin temperature and color, edema

■Assess trends in pertinent laboratory data, e.g., Hg, Hct, electrolytes

■Obtain and assess laboratory data such as ABG, cardiac enzymes,

if appropriate

■Document assessment thoroughly

■Continue to monitor rhythm; obtain and analyze rhythm strip every

4 hours and when rate or rhythm changes

Trang 36

■Keep IV line patent, and infuse IVF.

■Review laboratory data such as Hgb/Hct; BUN and creatinine; electrolytes,other chemistries, blood glucose, liver and cardiac enzymes

■Check MAR for possible drug side effect or interactions

BE PREPARED TO

■Obtain a 12- or 15-lead ECG

■Administer antiarrhythmic medication (e.g.: procainamide, quinidine,amiodarone)

■Obtain IV access, administer ordered IVF and medications

■Transfer patient to a unit with cardiac monitoring

■Assist with placement of temporary transvenous or external pacemaker

or cardioversion

■Premature atrial or ventricular contractions (PACs or PVCs) or othercardiac dyrsrhythmia, mitral valve prolapse; stress, anxiety; medications;hyperthyroidism; dehydration; hemorrhage; heart failure; adrenal crisis;hypoglycemia

Possible Causes of Palpitations

Heart failure, cardiomyopathy, pericarditis

Congenital heart disease

Vasovagal or postural hypotension

Transient ischemic attack, stroke

Hyperventilation, hypoxia, fever, hypoglycemia, thyrotoxicosis,anemia

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SyncopeCLINICAL PICTURE

The patient may have or be:

■Lightheadedness, feeling faint

■Assist patient to chair or bed, or floor (if necessary)

■Administer supplemental O2via nasal cannula

■Assess rate, ease of breathing

■Assess BP

■Assess HR, rhythm, and quality

■If patient is hypotensive, keep supine, and elevate lower legs above heartlevel, using pillows

or NP response

■Assess patency of airway and patient’s breathing

■Assess LOC and mental status; determine if patient had a sensation

of spinning or movement

■Assess for associated neurological signs (slurred speech, numbness,weakness)

■Assess skin for color, temperature, turgor, and moistness

■Ask if patient feels nauseated or is experiencing chest pain

■Check recent chemistry and hematology laboratory results

■Check if new medications have been administered

■Review I&O records from preceding days

■Assess orthostatic VS: take HR and BP in supine, sitting, and standingpositions, each 2 min apart Note if pulse increases by 20 or more bpmand the systolic BP drops by 20 mm Hg or more, which suggestshypovolemia or dehydration

■Assess mucous membranes and skin turgor for signs of dehydration

■Continue to assess VS as frequently as indicated

■Review history and all current medications

Trang 38

■Test stool for occult blood.

■Chart patient status and convey to physician or NP

BE PREPARED TO

■Obtain IV access

■Administer IVF or a fluid challenge

■Obtain a chemstick blood sugar level

■Administer 50% dextrose IV

■Order specific laboratory tests to be drawn STAT

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

Possible Causes of Syncope

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

HR⬎150 bpm (supraventricular tachycardia)

■Palpitations, dizziness or lightheadedness

■Chest discomfort, SOB

Seizure, head trauma

Vasovagal or postural hypotension

Transient ischemic attack, stroke

Hyperventilation, hypoxia

Trang 39

■Signs of unstable tachycardia:

■Have patient sit or lie in bed

■Assess blood pressure and respirations

■Assess LOC, orientation, and VS (temperature, HR, RR, BP)

■Assess SaO2via pulse oximetry, if available

■Assess heart rhythm

■Assess skin for color, turgor, moistness, and temperature

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

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

■Assess HR, BP, and SaO2

■Assess 12-lead ECG (see ECG in Tools tab)

■Assess recent history of emotional upset, medication use, infectiousdisease, diarrhea, vomiting, blood loss from menses, GI pain or nausea,melanotic stool

■Assess MAR for medications with potential to cause tachycardia

■Assess blood glucose level

■Assess recent I&O

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■Administer oral or IV medications as ordered.

■Order laboratory tests to be drawn STAT

■Assist with cardioversion

■Transfer patient to the cardiac care or telemetry unit

■Hypoxia, exercise, caffeine, fever, medications, pain, anxiety, stress, atrialfibrillation, infection, hypoglycemia, hemorrhage, hypovolemia,dehydration, electrolyte imbalance

A & P Snapshot

Cardiac structure and blood flow

Brachiocephalic artery

Superior vena cava

Left common carotid arteryLeft subclavian arteryAortic archRight pulmonary

ApexChordae

Rightventricle Papillarymuscles

Tiêu đề	Medsurg Notes Nurse’s Clinical Pocket Guide
Tác giả	Tracey Hopkins, BSN, RN, Ehren Myers, RN
Trường học	F. A. Davis Company
Chuyên ngành	Nursing / Medical-Surgical Nursing
Thể loại	Notes Book
Năm xuất bản	2008
Thành phố	Philadelphia

Định dạng
Số trang	242
Dung lượng	2,17 MB