v ● Contributors ● Contributors Sandra M. Annesi, RN, MSN Assistant Professor Nursing Program Daytona Beach Community College DeLand, Florida Chapter 25: Respiratory Care Modalities Judith C. Bautch, PhD, RN, CS Professor Department of Nursing Winona State University Winona, Minnesota Chapter 54: Assessment and Management of Patients With Rheumatic Disorders Jo Ann Brooks-Brunn, DNS, RN, FAAN, FCCP Assistant Professor Thoracic Surgery Pulmonary and Critical Care Medicine Indiana University School of Medicine Indianapolis, Indiana Chapter 23: Management of Patients With Chest and Lower Respiratory Tract Disorders Chapter 24: Management of Patients With Chronic Obstructive Pulmonary Disorders Jacqueline Fowler Byers, PhD, RN, CNAA Associate Professor School of Nursing University of Central Florida Orlando, Florida Chapter 21: Assessment of Respiratory Function Kim Cantwell-Gab, BSN, RN, CVN, RVT, RDMS Vascular Surgery Nurse Specialist Department of Surgery, Division of Vascular Surgery University of Washington School of Medicine Seattle, Washington Chapter 31: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation Patricia E. Casey, RN, MSN Director, Regional Cardiovascular Program Kaiser Permanente Mid-Atlantic Region Rockville, Maryland Chapter 27: Management of Patients With Dysrhythmias and Conduction Problems Chapter 28: Management of Patients With Coronary Vascular Disorders Chapter 29: Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders Chapter 30: Management of Patients With Complications From Heart Disease Jill Cash, MSN, APRN, BC Family Nurse Practitioner Southern Illinois OB-GYN Associates, SC Carbondale, Illinois Chapter 59: Assessment and Management of Patients With Hearing and Balance Disorders Linda Carman Copel, PhD, RN, CS, CGP, DAPA Associate Professor Villanova University College of Nursing Villanova, Pennsylvania Chapter 4: Health Education and Health Promotion Chapter 6: Homeostasis, Stress, and Adaptation Chapter 7: Individual and Family Considerations Related to Illness Juliet Corbin, RNC, DNS, FNP Lecturer School of Nursing San Jose State University San Jose, California Chapter 10: Chronic Illness Susanna G. Cunningham, RN, PhD, FAAN, FAHA Professor Department of Biobehavioral Nursing and Health Systems University of Washington School of Nursing Seattle, Washington Chapter 32: Assessment and Management of Patients With Hypertension Lana Currance, RN, BSN, CCRN Chief Nursing Officer National Medical Response System Colorado 2 DMAT/Central U.S. NMRT-Weapons of Mass Destruction Parker, Colorado Chapter 72: Terrorism, Mass Casualty, and Disaster Nursing Margaret A. Degler, RN, MSN, CRNP, CUNP Director, Continence Program West Office of the Center for Urologic Care of Berks County, P.C. West Reading, Pennsylvania Chapter 12: Health Care of the Older Adult Chapter 43: Assessment of Renal and Urinary Tract Function Chapter 44: Management of Patients With Upper or Lower Urinary Tract Dysfunction Chapter 45: Management of Patients With Urinary Disorders Nancy E. Donegan, RN, BS, MPH Director, Infection Control Washington Hospital Center Washington, D.C. Chapter 70: Management of Patients With Infectious Diseases Phyllis Dubendorf, RN, MSN, CS-ACNP Lecturer, Acute Care Nurse Practitioner Program School of Nursing University of Pennsylvania Philadelphia, Pennsylvania Chapter 61: Management of Patients With Neurologic Dysfunction Eleanor Fitzpatrick, RN, MSN, CRNP, CCRN Clinical Nurse Specialist Surgical ICU/Intermediate Surgical ICU Thomas Jefferson University Hospital Philadelphia, Pennsylvania Chapter 39: Assessment and Management of Patients With Hepatic Disorders Chapter 40: Assessment and Management of Patients With Biliary Disorders Mary Beth Flynn, RN, MS CNS/Clinical Educator University of Colorado Hospital Clinical Faculty University of Colorado Health Science Center Denver, Colorado Chapter 15: Shock and Multisystem Failure Kathleen K. Furniss, MSN, APN-C Nurse Practitioner, Women’s Health Women’s Health Initiative University of Medicine and Dentistry of New Jersey and Associates in Women’s Health Care Newark, New Jersey Chapter 46: Assessment and Management of Female Physiologic Processes Chapter 47: Management of Patients With Female Reproductive Disorders Paula Graling, RN, MSN, CNS Clinical Nurse Specialist Perioperative Services Inova Fairfax Hospital Falls Church, Virginia Chapter 18: Preoperative Nursing Management Chapter 19: Intraoperative Nursing Management Chapter 20: Postoperative Nursing Management Randolph E. Gross, RN, MS, CS, AOCN Clinical Nurse Specialist Evelyn H. Louder Breast Center Memorial Sloan-Kettering Cancer Center New York, New York Chapter 48: Assessment and Management of Patients With Breast Disorders Doreen Grzelak, RN, MSN, AOCN Operations Manager Medical Imaging Center Department of Radiology Reston Hospital Center Reston, Virginia Chapter 35: Management of Patients With Oral and Esophageal Disorders Chapter 37: Management of Patients With Gastric and Duodenal Disorders Janice L. Hinkle, PhD, RN, CNRN Assistant Professor Villanova University College of Nursing Villanova, Pennsylvania Chapter 5: Health Assessment Chapter 62: Management of Patients With Cerebrovascular Disorders Chapter 65: Management of Patient With Oncologic and Degenerative Neurologic Disorders Ryan R. Iwamoto, ARNP, MN, AOCN Oncology Clinical Coordinator Genentech BioOncology, Inc. South San Francisco, California Nurse Practitioner Department of Radiation Oncology Virginia Mason Medical Center Clinical Instructor University of Washington and Seattle University Seattle, Washington Chapter 49: Assessment and Management of Problems Related to Male Reproductive Processes Joyce Young Johnson, RN, PhD, CCRN Assistant Chair Department of Nursing Georgia Perimeter College Clarkston, Georgia Chapter 1: Health Care Delivery and Nursing Practice Chapter 2: Community-Based Nursing Practice Chapter 3: Critical Thinking, Ethical Decision Making, and the Nursing Process Chapter 8: Perspectives in Transcultural Nursing Rhonda Kyanko, RN, MS Nursing Education Coordinator National Rehabilitation Hospital Washington, DC Chapter 11: Principles and Practices of Rehabilitation Pamela J. LaBorde, MSN, RN Clinical Nurse Specialist, Patient Care Services University of Arkansas Medical Sciences Center Little Rock, Arkansas Formerly, Clinical Nurse Specialist, Burn Unit Orlando Regional Medical Center Orlando, Florida Chapter 57: Management of Patients With Burn Injury Dale Halsey Lea, RN, MPH, CGC, APGN, FAAN Assistant Director Southern Maine Regional Genetics Services Foundations for Blood Research Scarborough, Maine Chapter 9: Genetics Perspectives in Nursing Practice Dorothy B. Liddel, RN, MSN, ONC Associate Professor (Retired) Department of Nursing Columbia Union College Tacoma Park, Maryland Chapter 66: Assessment of Musculoskeletal Function Chapter 67: Musculoskeletal Care Modalities Chapter 68: Management of Patients With Musculoskeletal Disorders Chapter 69: Management of Patients With Musculoskeletal Trauma vi Contributors Martha V. Manning, RN, MSN Nurse Clinician Inova Emergency Care Center at Fairfax Fairfax, Virginia Chapter 34: Assessment of Digestive and Gastrointestinal Function Chapter 38: Management of Patients With Intestinal and Rectal Disorders Barbara J. Maschak-Carey, RN, MSN, CDE Clinical Nurse Specialist Department of Endocrinology, Diabetes and Metabolism University of Pennsylvania Health System Philadelphia, Pennsylvania Chapter 41: Assessment and Management of Patients With Diabetes Mellitus Agnes Masny, RN, MPH, MSN, CRNP Research Associate/Nurse Practitioner Population Science Division, Family Risk Assessment Program Fox Chase Cancer Center Philadelphia, Pennsylvania Chapter 9: Genetics Perspectives in Nursing Lou Ann McGinty, MSN, RN Nurse Science Clinical Specialist Capitol Health System Trenton, New Jersey Chapter 64: Management of Patients With Infectious, Inflammatory, and Autoimmune Neurologic Disorders Nancy A. Morrissey, RN,C, PhD Patient Care Director Mental Health and Behavioral Center Inova Alexandria Hospital Alexandria, Virginia Chapter 36: Gastrointestinal Intubation and Special Nutritional Modalities Martha A. Mulvey, RN, MS, CNS Advanced Practice Nurse Neurosciences University of Medicine and Dentistry of New Jersey, University Hospital Newark, New Jersey Chapter 14: Fluids and Electrolytes: Balance and Distribution Victoria Navarro, RN, MAS, MSN Director of Clinical Services Wilmer Eye Institute The Johns Hopkins Medical Institutions Baltimore, Maryland Chapter 58: Assessment and Management of Patients With Eye and Vision Disorders Donna Nayduch, RN-CS, MSN, CCRN Trauma Regional Director Banner Health Greeley, Colorado Chapter 71: Emergency Nursing Chapter 72: Terrorism, Mass Casualty, and Disaster Nursing Kathleen Nokes, PhD, RN, FAAN Professor Hunter-Bellevue School of Nursing New York, New York Chapter 52: Management of Patients With HIV Infection and AIDS Janet A. Parkosewich, RN, MSN, CCRN Cardiac Clinical Nurse Specialist Department of Patient Services Yale-New Haven Hospital New Haven, Connecticut Chapter 26: Assessment of Cardiovascular Function Anne Gallagher Peach, RN, MSN Chief Operating Officer M.D. Anderson Cancer Center Orlando Orlando, Florida Chapter 22: Management of Patients With Upper Respiratory Tract Disorders JoAnne Reifsnyder, PhD, RN, AOCN Postdoctoral fellow, Psychosocial Oncology School of Nursing University of Pennsylvania Philadelphia, Pennsylvania Chapter 17: End-of-Life Care Susan A. Rokita, RN, MS, CRNP Nurse Coordinator, Cancer Center Oncology Clinical Nurse Specialist Milton S. Hershey Medical Center of Pennsylvania State University Hershey, Pennsylvania Chapter 16: Oncology: Nursing Management in Cancer Care Al Rundio, PhD, RN, ANP Associate Professor Medical College of Pennsylvania/Hahnemann University College of Nursing and Health Professions Philadelphia, Pennsylvania Chapter 50: Assessment of Immune Function Chapter 51: Management of Patients With Immunodeficiency Chapter 53: Assessment and Management of Patients With Allergic Disorders Catherine Sackett, RN, BS, CANP Ophthalmic Research Nurse Practitioner Wilmer Eye Institute Retinal Vascular Center The Johns Hopkins Medical Institutions Baltimore, Maryland Chapter 58: Assessment and Management of Patients With Eye and Vision Disorders Linda Schakenbach, RN, CNS, MSN, CCRN, COCN, CWCN, CS Clinical Nurse Specialist, Critical Care Inova Alexandria Hospital Alexandria, Virginia Chapter 27: Management of Patients With Dysrhythmias and Conduction Problems Chapter 28: Management of Patients With Coronary Vascular Disorders Chapter 29: Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders Contributors vii Margaret A. Spera, NP, APRN Nurse Practitioner Family Medical Associates Ridgefield, Connecticut Assistant Clinical Professor Yale University School of Nursing New Haven, Connecticut Chapter 60: Assessment of Neurologic Function Cindy Stern, RN, MSN Cancer Network Coordinator University of Pennsylvania Cancer Center University of Pennsylvania Health System Philadelphia, Pennsylvania Chapter 16: Oncology: Nursing Management in Cancer Care Christine Tea, RN, MSN, CNA Patient Care Director Main OR Perioperative Services Inova Fairfax Hospital Falls Church, Virginia Chapter 18: Preoperative Nursing Management Chapter 19: Intraoperative Nursing Management Chapter 20: Postoperative Nursing Management Mary Laudon Thomas, RN, MS, AOCN Hematology Clinical Nurse Specialist Veterans’ Administration, Palo Alto Health Care System Palo Alto, California Chapter 33: Assessment and Management of Patients With Hematologic Disorders Dorraine Day Watts, PhD, RN Interim Director of Research and Education Inova Health System Falls Church, Virginia Chapter 63: Management of Patients With Neurologic Trauma Joan Webb, RN, MSN Instructor College of Nursing Widener University Chester, Pennsylvania Chapter 40: Assessment and Management of Patients With Biliary Disorders Chapter 42: Assessment and Management of Patients With Endocrine Disorders Joyce S. Willens, RN, PhD Assistant Professor College of Nursing Villanova University Villanova, Pennsylvania Chapter 13: Pain Management Iris Woodard, RN-CS, BSN, ANP Nurse Practitioner Department of Dermatology Kaiser Permanente Springfield, Virginia Chapter 55: Assessment of Integumentary Function Chapter 56: Management of Patients With Dermatologic Problems viii Contributors ix ● Contributors ● Consultants and Reviewers Debbie Amason, BSN, MS, RN Assistant Professor Floyd College Rome, Georgia William Ames, MSN, RN, FNP Associate Professor Elizabethtown Community College Elizabethtown, Kentucky Susan Arbogast, MS, RN Faculty Maricopa Community College District Nursing Program, Phoenix College Campus Phoenix, Arizona Gail Armstrong, ND, RN Assistant Professor University of Colorado School of Nursing Denver, Colorado Denise M. Ayers, MSN, RN Assistant Professor, Nursing Kent State University at Tuscarawas New Philadelphia, Ohio Valerie Benedix, BSN, RN Nursing Instructor Clovis Community College Clovis, New Mexico Ilene Borze, MS, CEN, RN Director, Nursing Continuing Education Faculty Gateway Community College Phoenix, Arizona Donna Bowren, RN, MSN, CNOR, CRNFA Interim Chairperson, Division of Nursing and Allied Health University of Arkansas Community College at Batesville Batesville, Arkansas Pat Bradley, RN, MEd MS Nursing Faculty Grossmont College El Cajon, California Lynn Browning, RN, MSN BC Assistant Professor of Nursing Derry Patterson Wingo School of Nursing Charleston Southern University Charleston, South Carolina Elizabeth Bruce, RN, MSN St. Clair Community College Chatham, Ontario Shirley Cantrell, PhD, RN Associate Professor Piedmont College Demorest, Georgia Donna Cartwright, MS, APRN Dean, Professional and Applied Technology Education College of Eastern Utah Price, Utah Pattie Garrett Clark, MSN, RN Associate Professor of Nursing Abraham Baldwin College Tifton, Georgia Terry Cicero, MN, CCRN, RN Instructor, School of Nursing Seattle University Seattle, Washington Tracey D. Cooper, RN, MSN Director, Nursing Learning Resources Lab Instructor, South Plains College Levelland, Texas Dolly I. Daniel, BSN, CDE, RNC Diabetes Nurse Specialist Inova Alexandria Hospital Alexandria, Virginia Toni Doherty, MSN, RN Associate Professor Department Head, Nursing Dutchess Community College Poughkeepsie, New York Sandra Edwards, BScN, RN Instructor Grant MacEwan College Edmonton, Alberta, Canada Mary Elliot, BScN, MEd, RN Professor Humber College of Applied Arts & Technology Etobicoke, Ontario, Canada Cheryl Fenton, BHSc, RN Professor Mohawk College Burlington, Ontario, Canada Kathie Folsom, RN, BSN, MS Department Chair Skagit Valley College Oak Harbor, Washington Donna Funk, MN/E ONC, RN Professor of Nursing Brigham Young University Rexburg, Idaho Vicki Garlock, BSN, MSN, RN Professor, Nursing Department Pensacola Junior College Pensacola, Florida Mary Catherine Gebhart, MSN, CRRN, RN Instructor Georgia State University Atlanta, Georgia Donna Gullette, DNS, RN Associate Professor, Critical Care Chair Mississippi University for Women Columbus, Mississippi Carol Heinrich, PhD, RN Associate Professor Department of Nursing East Stroudsburg University East Stroudsburg, Pennsylvania Sandra Hendelman, MS, RN Adjunct Professor of Nursing Palm Beach Community College Lake Worth, Florida South College Judith Ann Hughes, EdD, RN Associate Degree Nursing Coordinator Southwestern Community College Sylva, North Carolina Sadie Pauline Hutson, MSN, RN, CRNP Cancer Research Training Award PreDoctoral Fellow National Cancer Institute, Clinical Genetics Branch Rockville, MD Jennifer Johnson. MSN, RN C Assistant Professor of Nursing Kent State University, Tuscarawas Campus New Philadelphia, Ohio Susan J. Lamanna, MA, MSN, RN ANP Associate Professor Onondaga Community College Syracuse, New York Joan Ann Leach, MS, ME, RNC Professor of Nursing Capital Community College Hartford, Connecticut Gayle Lee, PhD, RN, CCRN Faculty Brigham Young University Rexburg, Idaho Brenda Lohri-Posey, EdD, RN Assistant Dean of Learning, Nursing & Program Coordination Belmont Technical College St. Clairesville, Ohio Rhonda McLain, MN, RN Assistant Professor of Nursing Clayton College & State University Morrow, Georgia Pat Nashef, MHSc BA (CPMHN)c, RN Professional Practice Clinician, Mental Health Services Halton Healthcare Services Oakville, Ontario Clinical Faculty McMaster University School of Nursing Hamilton, Ontario Lauren O’Hare, MSN, EdD, RN Assistant Professor of Nursing Wagner College Staten Island, New York Caroline Ostand, BC, MSN, RN Clinical Instructor University of Charleston Charleston, West Virginia Thena E. Parrott, PhD, RNCS Director, Associate Degree Nursing Program Blinn College Bryan, Texas Billie Phillips, PhD, RN, CDFS Assistant Professor Tennessee Wesleyan College Fort Sanders Nursing Department Athens, Tennessee Pam Primus, BSN, RN Nurse Educator Casper College Casper, Wyoming Betty E. Richards, RN, MSN Professor of Nursing Middle Georgia College Cochran, Georgia Patsy Ruppert Rider, MSN, CS, RN Clinical Instructor in Nursing University of Texas at Austin School of Nursing Austin, Texas Kathleen L. Russ, MSN, RN Dean of Student Support/Health Careers Gateway Technical College Kenosha, Wisconsin Esther Salinas, MSN, MSEd, RN Associate Professor of Nursing Del Mar College Corpus Christi, Texas Marsha Sharp, MSN, RN Associate Professor Elizabethtown Community College Elizabethtown, Kentucky Kelli Simmons, MS, CS, M-SCNS, RN Cardiothoracic Clinical Nurse Specialist University of Missouri Hospitals and Clinics Columbia, Missouri Terri Small, MSN, RN C Assistant Professor of Nursing Waynesburg College Waynesburg, Pennsylvania Darla R. Ura, MA, ANP-CS, RN Clinical Associate Professor Emory University Atlanta, Georgia Weibin Yang, MD Assistant Professor of Physical Medicine and Rehabilitation Medicine (PM&R) University of Illinois Chicago, Illinois x Consultants and Reviewers xi ● Preface As the 21st century begins, nurses face a future characterized by changes comparable to those of no preceding century: • Science and technology have made the world smaller by making it more accessible. • Mass communication is more widespread, and information is now just an instant away and very easy to obtain. • Economies are more global than regional. • Industrial and social changes have made world travel and cultural exchange common. Today’s nurses enter a realm of opportunities and challenges for providing high-quality, evidence-based care in traditional as well as new and innovative health care settings. The rapid changes in health care mandate that nurses be prepared to provide or plan care across the continuum of settings—from hospital or clinic, to home, to community agencies or hospice settings—and during all phases of illness. Recent research has indicated that nurses make significant contributions to the health care outcomes of patients who are hos- pitalized. Therefore, today’s nurses must be prepared to identify patients’ short- and long-term needs quickly and to collaborate ef- fectively with patients and families, other members of the health care team, and community agencies to create a seamless system of care. The continued emphasis on health promotion efforts to keep well people healthy and to promote a higher level of well-being among those with acute and chronic illnesses requires today’s nurses to as- sist patients in adopting healthy lifestyles and strategies. Mapping of the human genome and other advances in genetics have moved the issue of genetics to the bedside and increased the need for nurses to become knowledgeable about genetics-related issues. In preparing for these vast opportunities and responsibilities, today’s nurses must be well informed and up-to-date, not only in nursing knowledge and skills but also in research findings, scien- tific advances, and the ethical dilemmas inherent in many areas of clinical practice. More than ever, today’s nurses need to think crit- ically, creatively, and compassionately. This tenth edition of Brunner & Suddarth’s Textbook of Medical- Surgical Nursing is designed for the 21st century and nurses’ need to be knowledgeable, highly skilled, perceptive, caring, and compas- sionate. A goal of the textbook is to provide balanced attention to the art and science of adult medical-surgical nursing. It addresses nursing care issues from a physiological, pathophysiological, and psychosocial context and assists the reader to identify priorities of care from that context. ABOUT THE TENTH EDITION The tenth edition of Brunner and Suddarth’s Textbook of Medical Surgical Nursing was constructed to provide today’s nursing stu- dents with an understanding of the nurse’s role in health and illness within evolving practice environments and across the spectrum of health and illness. The textbook’s content has been revised and up- dated by experts in the field to reflect current practice and advances in health care and technology. NEW CHAPTERS: GENETICS, END-OF-LIFE CARE, AND BIOTERRORISM Nursing knowledge is constantly expanding. Chapter 9, Genetics Perspectives in Nursing Practice, was written in response to genetics information identified during the last few years. Every nurse needs to be aware of the influence of genetics on health and illness, and every nurse needs to have the knowledge and skill to answer pa- tients’ questions concerning their heredity and health. In addition to Chapter 9, genetics content has been incorporated into each clinical unit of the textbook. Chapter 17, End-of-Life Care, also new to the tenth edition, ad- dresses some of the questions posed by technologies that can pro- long life, often in the face of insurmountable obstacles. The chapter discusses the nurse’s role as it pertains to quality of life, prolonga- tion of dying, pain relief, allocation of resources, ethical issues, communication, healing, spirituality, and patient and family care. It emphasizes the pivotal role of the nurse in providing end-of-life care. A third new chapter—Chapter 72, Terrorism, Mass Casualty, and Disaster Nursing—completes the text by reviewing the nurse’s role in relation to patients affected by terrorism and other disasters. Among the issues addressed are emergency preparedness and plan- ning, triage in cases of mass casualty, radiation, chemical and bio- logic weapons, ethical conflict, stress management, and survival. NANDA, NIC, NOC: LINKS, LANGUAGES, AND CONCEPT MAPS Although Brunner & Suddarth’s Textbook of Medical-Surgical Nursing has long used nursing diagnoses developed by the North American Nursing Diagnosis Association (NANDA), this edition presents the links between the NANDA diagnoses and the Nurs- ing Interventions Classification (NIC) and Nursing-sensitive Out- comes Classification (NOC). The opening page of each unit presents a concept map illustrating these three classification sys- tems and their relationships. Each unit’s concept map is accom- panied by a case study and a chart presenting examples of actual NANDA, NIC, and NOC terminologies related to the case study. This material is included to introduce the reader to the NIC and NOC language and classifications and bring them to life in the clinical realm. Faculty and students alike may use some of the issues presented in the case studies as a springboard for develop- ing their own concept maps. RECENT NURSING RESEARCH AND OTHER FEATURES As before, Nursing Research Profiles included in the chapters identify the implications and applications of recent nursing re- search findings for nursing practice. The chapters also include charts and text detailing special considerations in caring for the elderly patient and for those with disabilities. TEACHING TOOLBOX Each chapter opens with Learning Objectives and a Glossary. Throughout the text the reader will find Nursing Alerts as well as specialized charts focusing on • Physiology/Pathophysiology • Risk Factors • Assessment • Plans of Nursing Care • Pharmacology • Home Care • Patient Education • Health Promotion • Ethics and Related Issues • Guidelines • Gerontological Considerations • Genetics in Nursing Practice Illustrations, photographs, charts, and tables supplement the text and round out the applied-learning experience. Each chapter concludes with Critical Thinking Exercises, References and Selected Readings, and a list of specialized Resources and Websites. MANY MORE OF THE LATEST RESOURCES Additional learning tools accompany the tenth edition and offer visual, tactile, and auditory reinforcement of the text. These re- sources include: • CD-ROM to help students test their knowledge and enhance their understanding of medical-surgical nursing. This CD in- cludes 500 self-study questions organized by unit; 3000 bonus NCLEX-style cross-disciplinary questions; 3-D animated il- lustrations that explain common disease processes; and in- teractive clinical simulations. • Student Study Guide to further enhance the learning ex- perience (available at student bookstores) • Instructor’s Resource CD-ROM to help facilitate class- room preparation, with an instructor’s manual, test gener- ator, and searchable image collection, among other features • Supplemental cartridges for Blackboard and WebCT • Connection Website—Get connected at connection.LWW. com/go/smeltzer. The tenth edition of Brunner and Suddarth’s Textbook of Medical-Surgical Nursing continues the tradition of presenting up-to-date content that addresses the art and science of nursing practice. The updating of the material and use of a variety of teaching methods to convey that content are intended to provide the nursing student and other users of the textbook with infor- mation needed to provide quality care to patients and families across health care settings and in the home. Suzanne C. O’Connell Smeltzer, RN, EDD, FAAN Brenda G. Bare, RN, MSN xii Preface ▼ Plans of Nursing Care— illustrate applications of the nursing process to diseases and disorders. ▲ Home Care Checklists—include guidelines on goals and management of home-based patients. Risk for Ineffective Airway Clearance Risk for Thrombophlebitis Acute Pain Impaired Physical Mobility Respiratory Monitoring Respiratory Status: Gas Exchange Pain Level Immobility Consequences: Physiologic Mobility Level Cough Enhancement Embolus Precautions Pain Management Anxiety Control The patient recovering from abdominal surgery with reluctance to move and a history of smoking Risk for Impaired Gas Exchange receives the nursing diagnoses and and secondary to and Teaching: Prescribed Activity/Exercise and and and and and and and and improves outcomes in improves outcomes in limits improves helps to prevent helps to prevent leads to improved reduces risk for requires nursing interventions outcomes should show improvement in requires may be reduced by may be reduced by may be lessened by may be lessened by requires requires requires Concept Maps—with NANDA, NIC, and NOC illustrate reality- based clinical scenarios for the visual learner. ▲ How to use Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 10th edition Plan of Nursing Care Care of the Patient With COPD (Continued) Nursing Interventions Rationale Expected Outcomes 1. Teach patient diaphragmatic and pursed- lip breathing. 2. Encourage alternating activity with rest periods. Allow patient to make some de- cisions (bath, shaving) about care based on tolerance level. 3. Encourage use of an inspiratory muscle trainer if prescribed. 1. Helps patient prolong expiration time and decreases air trapping. With these techniques, patient will breathe more efficiently and effectively. 2. Pacing activities permits patient to per- form activities without excessive distress. 3. Strengthens and conditions the respira- tory muscles. • Practices pursed-lip and diaphragmatic breathing and uses them when short of breath and with activity • Shows signs of decreased respiratory effort and paces activities • Uses inspiratory muscle trainer as pre- scribed Nursing Diagnosis: Self-care deficits related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation Goal: Independence in self-care activities 1. Teach patient to coordinate diaphragmatic breathing with activity (eg, walking, bending). 2. Encourage patient to begin to bathe self, dress self, walk, and drink fluids. Discuss energy conservation measures. 3. Teach postural drainage if appropriate. 1. This will allow the patient to be more ac- tive and to avoid excessive fatigue or dys- pnea during activity. 2. As condition resolves, patient will be able to do more but needs to be encouraged to avoid increasing dependence. 3. Encourages patient to become involved in own care. Prepares patient to manage at home. • Uses controlled breathing while bathing, bending, and walking • Paces activities of daily living to alternate with rest periods to reduce fatigue and dyspnea • Describes energy conservation strategies • Performs same self-care activities as before • Performs postural drainage correctly (continued) Nursing Diagnosis: Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, and airway irritants Goal: Improvement in breathing pattern Nursing Diagnosis: Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns Goal: Improvement in activity tolerance 1. Support patient in establishing a regular regimen of exercise using treadmill and exercycle, walking, or other appropriate exercises, such as mall walking. a. Assess the patient’s current level of functioning and develop exercise plan based on baseline functional status. b. Suggest consultation with a physical therapist or pulmonary rehabilitation program to determine an exercise pro- gram specific to the patient’s capability. Have portable oxygen unit available if oxygen is prescribed for exercise. 1. Muscles that are deconditioned consume more oxygen and place an additional bur- den on the lungs. Through regular, graded exercise, these muscle groups become more conditioned, and the patient can do more without getting as short of breath. Graded exercise breaks the cycle of debilitation. • Performs activities with less shortness of breath • Verbalizes need to exercise daily and demonstrates an exercise plan to be carried out at home • Walks and gradually increases walking time and distance to improve physical condition • Exercises both upper and lower body muscle groups Nursing Diagnosis: Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, and the inability to work Goal: Attainment of an optimal level of coping 1. Help the patient develop realistic goals. 2. Encourage activity to level of symptom tolerance. 1. Developing realistic goals will promote a sense of hope and accomplishment rather than defeat and hopelessness. 2. Activity reduces tension and decreases degree of dyspnea as patient becomes conditioned. • Expresses interest in the future • Participates in the discharge plan • Discusses activities or methods that can be performed to ease shortness of breath • Uses relaxation techniques appropriately • Expresses interest in a pulmonary rehabili- tation program Chart 16-5 Home Care Checklist • Chemotherapy Administration At the completion of the home care instruction, the patient or caregiver will be able to: • Demonstrate how to administer the chemotherapy agent in the home. ✓ ✓ • Demonstrate safe disposal of needles, syringes, IV supplies, or unused chemotherapy medications. ✓ ✓ • List possible side effects of chemotherapeutic agents. ✓ ✓ • List complications of medications necessitating a call to the nurse or physician. ✓ ✓ • List complications of medications necessitating a visit to the emergency department. ✓ ✓ • List names and telephone numbers of resource personnel involved in care (ie, home care nurse, infusion services, IV vendor, equipment company). ✓ ✓ • Explain treatment plan (protocol) and importance of upcoming visits to physician. ✓ ✓ Patient Caregiver FIGURE 22-1 Pathophysiologic processes in rhinitis and sinusitis. Although pathophysiologic processes are similar in rhinitis and sinusitis, they affect dif- ferent structures. In rhinitis (A), the mucous membranes lining the nasal pas- sages become inflamed, congested, and edematous. The swollen nasal conchae block the sinus openings, and mucus is discharged from the nostrils. Sinusitis (B) is also marked by inflammation and congestion, with thickened mucous secretions filling the sinus cavities and occluding the openings. Physiology/Pathophysiology Discharging mucus Occluded sinus openings Edematous conchae; polyps may develop A. Rhinitis B. Sinusitis Thick mucus occludes sinus cavity and prevents drainage Enlarged nasal mucosa General Instructions • Breathe slowly and rhythmically to exhale completely and empty the lungs completely. • Inhale through the nose to filter, humidify, and warm the air before it enters the lungs. • If you feel out of breath, breathe more slowly by prolonging the exhalation time. • Keep the air moist with a humidifier. Diaphragmatic Breathing Goal: To use and strengthen the diaphragm during breathing • Place one hand on the abdomen (just below the ribs) and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing. • Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. • Breathe out through pursed lips while tightening (contract- ing) the abdominal muscles. • Press firmly inward and upward on the abdomen while breathing out. • Repeat for 1 minute; follow with a rest period of 2 minutes. • Gradually increase duration up to 5 minutes, several times a day (before meals and at bedtime). Pursed-Lip Breathing Goal: To prolong exhalation and increase airway pressure during ex- piration, thus reducing the amount of trapped air and the amount of airway resistance. • Inhale through the nose while counting to 3—the amount of time needed to say “Smell a rose.” • Exhale slowly and evenly against pursed lips while tighten- ing the abdominal muscles. (Pursing the lips increases intra- tracheal pressure; exhaling through the mouth offers less resistance to expired air.) • Count to 7 while prolonging expiration through pursed lips—the length of time to say “Blow out the candle.” • While sitting in a chair: Fold arms over the abdomen. Inhale through the nose while counting to 3. Bend forward and exhale slowly through pursed lips while counting to 7. • While walking: Inhale while walking two steps. Exhale through pursed lips while walking four or five steps. Chart 25-3 • PATIENT EDUCATION Breathing Exercises Chart 17-6 • ASSESSMENT Nursing Assessment of Symptoms Associated With Terminal Illness • How is this symptom affecting the patient’s life? • What is the meaning of the symptom to the patient? To the family? • How does the symptom affect physical functioning, mobility, comfort, sleep, nutritional status, elimination, activity level, and relationships with others? • What makes the symptom better? • What makes it worse? • Is it worse at any particular time of the day? • What are the patient’s expectations and goals for managing the symptom? The family’s? • How is the patient coping with the symptom? • What is the economic effect of the symptom and its management? Adapted from Jacox, A., Carr, D. B., & Payne, R. (1994). Management of cancer pain. Rockville, MD: AHCPR. Chart 16-4 • PHARMACOLOGY Investigational Antineoplastic Therapies and Clinical Trials Evaluation of the effectiveness and toxic potential of promising new modalities for preventing, diagnosing, and treating cancer is accom- plished through clinical trials. Before new chemotherapy agents are approved for clinical use, they are subjected to rigorous and lengthy evaluations to identify beneficial effects, adverse effects, and safety. • Phase I clinical trials determine optimal dosing, scheduling, and toxicity. • Phase II trials determine effectiveness with specific tumor types and further define toxicities. Participants in these early trials are most often those who have not responded to stan- dard forms of treatment. Because phase I and II trials may be viewed as last-chance efforts, patients and families are fully informed about the experimental nature of the trial therapies. Although it is hoped that investigational therapy will effectively treat the disease, the purpose of early phase trials is to gather information concerning maximal tolerated doses, adverse effects, and effects of the antineoplastic agents on tumor growth. • Phase III clinical trials establish the effectiveness of new medications or procedures as compared with conventional approaches. Nurses may assist in the recruitment, consent, and education processes for patients who participate. In many cases, nurses are instrumental in monitoring adher- ence, assisting patients to adhere to the parameters of the trial, and documenting data describing patients’ responses. The physical and emotional needs of patients in clinical tri- als are addressed in much the same way as those of patients who receive standard forms of cancer treatment. • Phase IV testing further investigates medications in terms of new uses, dosing schedule, and toxicities. Chart 21-8 Risk Factors for Hypoventilation • Limited neurologic impulses transmitted from the brain to the respiratory muscles, as in spinal cord trauma, cerebrovascular accidents, tumors, myasthenia gravis, Guillain-Barré syndrome, polio, and drug overdose • Depressed respiratory centers in the medulla, as with anesthesia and drug overdose • Limited thoracic movement (kyphoscoliosis), limited lung movement (pleural effusion, pneumothorax), or reduced functional lung tissue (chronic pulmonary diseases, severe pulmonary edema) Gerontologic Considerations Factors Contributing to Urinary Tract Infection in Older Adults • High incidence of chronic illness • Frequent use of antimicrobial agents • Presence of infected pressure ulcers • Immobility and incomplete emptying of bladder • Use of a bedpan rather than a commode or toilet ▲ Pathophysiology Displays— utilize illustrations and algorithms to demonstrate processes. ▲ Assessment Displays— provide clinical features of diseases and disorders and include guidelines for assessing health history and exam findings. Pharmacology Charts—review recent or common drug therapies with discussion of clinical trials where appropriate. Patient Education Boxes—provide suggestions on such topics as self-care, or how to cope with health challenges. Risk Factor Charts—outline factors that may impair health (eg, carcinogens, environmental factors), and offer preventive measures to sidestep them. Gerontologic Considerations— provide specific information relevant to the older population. ▲ ▲ ▲ ▲ xvi Unit 5 GAS EXCHANGE AND RESPIRATORY FUNCTION NURSING ALERT It is the responsibility of all nurses, and partic- ularly perianesthesia and perioperative nurses, to be aware of latex allergies, necessary precautions, and products that are latex-free (Meeker & Rothrock, 1999). Hospital staff are also at risk for de- veloping a latex allergy secondary to repeated exposure to latex products. ! ▲ Nursing Alerts—offer brief tips for clinical practice and red-flag warnings to help students avoid common mistakes. How to use continued Nursing Research Profiles—contain research samples with purpose of research, study sample, and design and findings, and implications for use in evidence-based nursing. ▲ Glossary adaptation: a change or alteration designed to assist in adapting to a new situation or environment adrenocorticotropic hormone (ACTH): a hormone produced by the anterior lobe of the pituitary gland that stimulates the se- cretion of cortisone and other hormones by the adrenal cortex antidiuretic hormone (ADH): a hormone secreted by the posterior lobe of the pitu- itary gland that constricts blood vessels, elevates blood pressure, and reduces the excretion of urine catecholamines: any of the group of amines (such as epinephrine, norepinephrine, or dopamine) that serve as neurotransmitters coping: the cognitive and behavioral strate- gies used to manage the stressors that tax a person’s resources dysplasia: a change in the appearance of a cell after exposure to chronic irritation glucocorticoids: the group of steroid hor- mones, such as cortisol, that are produced by the adrenal cortex; they are involved in carbohydrate, protein, and fat metabolism and have anti-inflammatory properties gluconeogenesis: the formation of glucose, especially by the liver from noncarbohy- drate sources such as amino acids and the glycerol portion of fats guided imagery: use of the imagination to achieve relaxation or direct attention away from uncomfortable sensations or situations homeostasis: a steady state within the body; the stability of the internal environment hyperplasia: an increase in the number of new cells hypoxia: inadequate supply of oxygen to the cell infectious agents: biologic agents, such as viruses, bacteria, rickettsiae, mycoplasmas, fungi, protozoa, and nematodes, that cause disease in people inflammation: a localized, protective reac- tion of tissue to injury, irritation, or infec- tion, manifested by pain, redness, heat, swelling, and sometimes loss of function metabolic rate: the speed at which some substances are broken down to yield en- ergy for bodily processes and other sub- stances are synthesized metaplasia: a cell transformation in which a highly specialized cell changes to a less specialized cell negative feedback: feedback that decreases the output of a system positive feedback: feedback that increases the output of a system steady state: a stable condition that does not change over time, or when change in one direction is balanced by change in an op- posite direction stress: a disruptive condition that occurs in response to adverse influences from the internal or external environments vasoconstriction: the narrowing of a blood vessel ▲ Glossary—at the beginning of every chapter, helps students learn vocabulary. Identification of Agitation in Patients with Alzheimer’s Disease Whall, A. L., Black, M. E. A., Yankou, D. J., et al. (1999). Nurse aides’ identification of onset and level of agitation in late stage dementia patients. American Journal of Alzheimer’s Disease, 14, 202–206. Purpose Nursing assistants provide the majority of care to patients in nursing homes. They are vital links in the early identification, and therefore in the treatment, of agitation in patients with Alzheimer’s disease. Nurses’ aides (NAs) are sometimes characterized as unwilling or un- able to manage patients’ agitation. This study examines the process by which nurses’ aides can successfully identify this agitation. Design NAs from five different nursing homes owned by the same cor- porate entity were asked to participate in the study. Criteria to par- ticipate included being employed for at least 1 year. (Research demonstrates that NAs who remain at a facility longer than 1 year usually have a commitment to those they serve.) The NAs did not receive any additional wages and were only promised a letter to in- dicate that they had participated in the study. Each NA received ap- proximately 1 hour of training via audio tapes and conversation with nurse experts. Each NA was then paired with a nurse expert to as- sess his or her skill at appropriately identifying levels of agitation in patients with late-stage Alzheimer’s disease. Conclusions This study demonstrated that NAs with a minimum of 1 year of employment did an excellent job in acquiring new observation skills with only 1 hour of training and positive reinforcement via a letter noting their participation in this study. The NAs’ assessment of signs of agitation agreed with that of the nurse expert more than 90% of the time. All the NAs involved reported gaining helpful in- sights in managing agitated behavior as a result of participation in the study. Implications for Practice The results of this study support the ability of NAs to accurately observe and report agitated behavior as a result of a brief training session using adult learning principles that stressed the importance of their input into the training and learning objectives. Early ob- servation and reporting of agitated behavior is important to prevent agitation from increasing to the level of physical aggression. NURSING RESEARCH PROFILE 12-2 NURSING INTERVENTIONS RATIONALE 1. Careful assessment of multiple weaning indices helps to deter- mine readiness for weaning. When the criteria have been met, the patient’s likelihood of successful weaning increases. 2. Reestablishing independent spontaneous ventilation can be physi- cally exhausting. It is crucial that the patient have enough energy reserves to succeed. Providing periods of rest and recommended nutritional intake can increase the likelihood of successful weaning. 3. The weaning process can be psychologically tiring; emotional support can help promote a sense of security. Explaining that weaning will be attempted again later helps reduce the sense of failure if the first attempts are unsuccessful. 4. The prescribed weaning method should reflect the patient’s indi- vidualized criteria for weaning and weaning history. By having different methods to choose from, the physician can select the one that best fits the patient. 5. Monitoring the patient closely provides ongoing indications of success or failure. 6. These values can be compared to baseline measurements to evalu- ate weaning. Suctioning helps to reduce the risk of aspiration and maintain the airway. 7. These signs and symptoms indicate an unstable patient at risk for hypoxia and ventricular dysrhythmias. Continuing the weaning process can lead to cardiopulmonary arrest. 8. These values help to determine if weaning is successful and should be continued. 9. Psychological dependence is a common problem after mechanical ventilation. Possible causes include fear of dying and depression from chronic illness. It is important to address this issue before the next weaning attempt. 1. Assess patient for weaning criteria: Vital capacity—10 to 15 mL/kg Maximum inspiratory pressure (MIP) at least –20 cm H2O Tidal volume—7 to 9 mL/kg Minute ventilation—6 L/min Rapid/shallow breathing index—below 100 breaths/minute/L PaO2 greater than 60 mm Hg with FiO2 less than 40% 2. Monitor activity level, assess dietary intake, and monitor results of laboratory tests of nutritional status. 3. Assess the patient’s and family’s understanding of the weaning process and address any concerns about the process. Explain that the patient may feel short of breath initially and provide encour- agement as needed. Reassure the patient that he or she will be at- tended closely and that if the weaning attempt is not successful, it can be tried again later. 4. Implement the weaning method prescribed: A/C, IMV, SIMV, PSV, PAV, CPAP, or T-piece. 5. Monitor vital signs, pulse oximetry, ECG, and respiratory pattern constantly for the first 20 to 30 minutes and every 5 minutes after that until weaning is complete. 6. Maintain a patent airway; monitor arterial blood gas levels and pulmonary function tests. Suction the airway as needed. 7. In collaboration with the physician, terminate the weaning process if adverse reactions occur. These include a heart rate increase of 20 beats/min, systolic blood pressure increase of 20 mm Hg, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breaths/minute, ventricular dys- rhythmias, fatigue, panic, cyanosis, erratic or labored breathing, paradoxical chest movement. 8. If the weaning process continues, measure tidal volume and minute ventilation every 20 to 30 minutes; compare with the patient’s desired values, which have been determined in collaboration with the physician. 9. Assess for psychological dependence if the physiologic parameters indicate weaning is feasible and the patient still resists. Chart 25-15 GUIDELINES FOR Care of the Patient Being Weaned From Mechanical Ventilation ▲ Procedure Guidelines Charts—offer nursing activities and rationales for important skills. Situation A 68-year-old attorney was diagnosed with cancer of the larynx 8 years ago. He was treated successfully with radiation therapy, re- sulting in an altered voice quality. Recently, he has complained of shortness of breath and difficulty swallowing. In the past few months, he also has noticed a marked change in his voice and phys- ical condition, which he attributed to “winter colds.” After a complete physical exam and an extensive diagnostic workup and biopsy, it is determined that the cancer has recurred at a new primary site. His health care provider recommends surgery (a total laryngectomy) and chemotherapy as the best options. The patient states that he is not willing to “lose my voice and my liveli- hood” but instead will “take my chances.” He has also expressed concern about his quality of life after surgery. His family has ap- proached you about trying to convince him to have surgery. Dilemma The patient’s right to refuse treatment conflicts with the family’s wishes and recommendation from his health care provider. Discussion 1...