3: Advanced Clinical Concepts

Respiratory Failure

Acute respiratory distress syndrome (ARDS) is also known as acute lung

injury (ALI), and noncardiac pulmonary edema.

Acute Respiratory Distress Syndrome

ARDS is a serious lung condition that causes hypoxemia in individuals who

are usually ill due to another disease or a major injury. In ARDS, fluid builds
up inside the alveoli causing inflammation and the breakdown of surfactant.
These changes prevent the lungs from filling properly with air and moving
enough oxygen into the bloodstream and throughout the body. The lung
tissue may have decreased pulmonary compliance.

The first symptom of ARDS is usually dyspnea. Other signs and symptoms of
ARDS are hypoxemia, tachypnea, and abnormal breath sounds.

The diagnosis of ARDS is made based on the following criteria: acute onset,
bilateral lung infiltrates on chest radiograph of a non-cardiac origin, and a
PaO/FiO ratio of less than 300 mm Hg. Further, ARDS is sub-classified into
mild (PaO2/FiO2 200 to 300 mm Hg), moderate (PaO2/FiO2 100 to 200 mm
Hg), and severe (PaO2/FiO2 less than 100 mm Hg) subtypes. Mortality and
ventilator days increase with severity. A CT scan of the chest may be
required in pneumothorax cases, pleural effusions, mediastinal
lymphadenopathy, or barotrauma to properly identify infiltrates as pulmonic
in location.

ARDS causes an exchange of oxygen (O2) for carbon dioxide (CO2) in the
lungs that is inadequate for O2 consumption and CO2 production within the
body’s cells. The increased permeability of the alveolar membrane leads to
fluid build-up in the alveoli and interferes with the exchange of CO2 and O2
at the capillary beds. Besides pulmonary infection or aspiration, extra-
pulmonary sources include sepsis, trauma, massive transfusion, drowning,
drug overdose, fat embolism, inhalation of toxic fumes, and pancreatitis.
These extra-thoracic illnesses and/or injuries trigger an inflammatory
cascade culminating in pulmonary injury (Fig. 3.1).

The causes of ARDS can be direct or indirect. Direct injuries include

pneumonia, aspiration of stomach contents, near drowning, lung bruising
from trauma (e.g., auto accident), and smoke inhalation. Indirect injuries
may be associated with other underlying diseases such as inflammation of
pancreas, medication reactions/overdose, sepsis, and blood transfusions.
Regardless of the cause, the overall signs and symptoms of ARDS are the
same and often can be life threatening.

Signs and symptoms for ARDS may include (American Lung Association):

1. Shortness of breath

2. Tachypnea

3. Tachycardia

4. Coughing that produces sputum

5. Cyanosis

6. Fatigue

7. Fever

8. Crackles and wheezes

9. Chest pain, especially when trying to breathe deeply

10. Hypotension

11. Confusion

12. Dense pulmonary infiltrates on radiography

A. Risk factors for ARDS

1. History of smoking

2. Alcohol abuse

3. Recent chemotherapy

4. O2 use for previous lung conditions

5. Recent high-risk surgery

6. Obesity/ Lifestyle habits

7. Environmental

8. COVID-19

B. Complications of ARDS

1. Acid-base imbalance in ARDS: respiratory and metabolic (Tables 3.1–3.3).

2. Atelectasis: a complete or partial collapse of the lung. It may occur as a
result of hospitalization.

3. Complications of treatment in a hospital: may include a hypercoagulable

state, muscle atrophy, infections, stress ulcers, and depression or other
mood disorders. Confusion, memory, and judgment impairment also can
result from the long-term use of sedative medicines.

4. Multisystem organ failure: a condition in which two or more of major

organs of the body begin to fail due to severe inflammation, infection, or
injury.

5. Pulmonary hypertension: a condition may occur when the blood vessel

narrows as a result of damage from inflammation or mechanical ventilation.
ARDS may also cause pulmonary embolism (PE).

HESI Hint

Since ARDS is an unexpected, catastrophic pulmonary complication occurring

in a person with no previous pulmonary problems, it is essential that the
nurse perform a detailed clinical assessment. These critically ill patients are
ventilated and are managed in an intensive care setting. The mortality rate
in this population is 40%. Your assessment knowledge will be tested, and you
will be asked questions about how to prioritize care for these clients on the
examination (Singh, Gladdy, Chandy, & Sen, 2014).

FIG. 3.1 Clinical Manifestations of Disrupted Acid-base Balance. From

Giddens, J. F. [2020]. Concepts for nursing practice [3rd ed.]. St. Louis:
Mosby.

A flowchart for clinical manifestations of disrupted acid-base balance is as

follows: • Acute lung injury (example, pneumonia, aspiration, smoke
inhalation, and sepsis) leads to release of inflammatory cytokines (example, I
L-1, I L-6, T N F).• Released inflammatory cytokines leads to influx of
inflammatory cells (neutrophils, macrophages, and platelets).• Influx of
inflammatory cells is followed by neutrophil aggregation and release of
mediators (R O S, proteolytic enzymes, cytokines, P A F) and complement
activation which results in platelet activation and vasoconstriction with
decreased flow to some lung areas.• Platelet activation results in formation
of microthrombi in pulmonary circulation followed by vasoconstriction with
decreased flow to some lung areas which results in pulmonary hypertension
followed by V over Q mismatching.• Neutrophil aggregation and release of
mediators and complement activation causes damage to alveolar cells and
endothelial cells both of which leads to disrupted alveolocapillary
membrane.• Damage to endothelial cells also leads to platelet activation and
vasoconstriction with decreased flow to some lung areas.• Disrupted
alveolocapillary membrane causes exudation of fluid, protein, and R B C s
into interstitium resulting in decreased surfactant production and impairment
of surfactant function and pulmonary edema and hemorrhage with severe
impairment of alveolar ventilation (Exudative phase) which results in
atelectasis and decreased lung compliance. Atelectasis and decreased lung
compliance leads to V over Q mismatching.• Pulmonary edema and
hemorrhage with severe impairment of alveolar ventilation also leads to
proliferation of type 2 pneumocytes, fibroblasts, and myofibroblasts and
formation of hyaline membranes (Proliferative phase) which leads to
atelectasis and decreased lung compliance and progressive fibrosis and
tissue remodeling (destruction of alveoli and bronchioles) (Fibrotic phase).•
Fibrotic phase results in acute respiratory failure (hypoxemia, hypercapnea,
and acidosis).• Atelectasis and decreased lung compliance along with V over
Q mismatching also results in acute respiratory failure (hypoxemia,
hypercapnea, and acidosis).

HESI Hint

The NGN-NCLEX-RN tests your ability to apply critical thinking skills when
assessing and providing safe and appropriate nursing care for the client.

Example

Which action should the nurse take before drawing a sample for ABGs from
the radial artery?

Perform the Allen test to assess collateral circulation. Make the client’s hand
blanch by obliterating both the radial and the ulnar pulses. Then release the
pressure over the ulnar artery only. If flow through the ulnar artery is good,
flushing will be seen immediately. The Allen test is then positive; therefore,
the radial artery can be used for puncture. If the Allen test is negative,
repeat on the other arm. If that test is also negative, seek another site for
arterial puncture. The Allen test ensures collateral circulation to the hand if
thrombosis of the radial artery should follow the puncture.

TABLE 3.1

Clinical Judgment Measures: Acute Respiratory Distress Syndrome

Clinical Judgment Measure Assessment Characteristics

Recognize Cues

Monitor Lung sounds: Dyspnea, hyperpnea, crackles (or rales), wheezing or

decreased breath sounds

Assess for intercostal retractions or substernal retractions

Note any cyanosis, pallor, mottled skin

Determine if patient is hypoxic: partial pressure of O2(PO 2) <50 mm Hg with

fraction of inspired O2 (FiO 2) >60%

1. Increasing diminished breath sounds

2. Diffuse pulmonary infiltrates seen on chest radiograph as “white-out”

appearance

3. Verbalization of anxiety, restlessness, confusion, and agitation

Analyze Cues

Determine if lung sounds are emergent.

Notify intensivist/physician.

Potential to improve oxygenation with mechanical ventilation

Treat the underlying cause or injury.

Prioritize Cues

Determine if problem is emergent.

Determine impact of problem on patient’s overall health status.

Solutions

Prevent complications of clients on mechanical ventilation.

Elevate head of bed (HOB) to at least 30 degrees.

Assist with daily awakening (“sedation vacation”).

Implement a comprehensive oral hygiene program.

Monitor vital signs note any changes in cardiac function such as peaked T
waves (early sign) as seen in hyperkalemia; as potassium levels become
higher, there is increased Monitor PR intervals.
Metabolic status through routine laboratory work.

1. Arterial blood gases (ABGs) routinely and interpret what ABGs indicate.

2. Monitor fluid and electrolyte balance.

a. Monitor needs to determine whether the client is in a respiratory or

metabolic state.

b. The goal is to get the ABG pH level as close to normal as possible.

Actions

Suction oral cavity

Give antibiotics as ordered

Deep venous thrombosis (DVT) prophylaxis as ordered

Stress ulcer prophylaxis

Observe for barotrauma

Monitor blood chemistry and fluid levels

Nursing judgment measures for ARDS

Intensivist for managing the patient on the ventilator and other ICU-related
issues like pneumonia prevention, Deep vein thrombosis (DVT) prophylaxis,
and gastric stress prevention.

Position the client for maximal lung expansion, proning may be best option if
ordered.

Monitor the client for signs of hypoxemia and O2 toxicity.

Monitor vital organ status: central nervous system (CNS) level of

consciousness, renal system (urinary output), and myocardium (apical pulse
and blood pressure [BP]).

Dietitian and nutritionist for nutritional support

Respiratory therapist to manage the ventilator settings

Pharmacist to manage the medications, which include antibiotics,

anticoagulants, diuretics, among others

Pulmonologist to manage the lung diseases

Social worker to assess the patient financial situation transfer for rehab, and
ensure there is an adequate follow-up

Chaplain for spiritual care

Evaluate Outcomes

The chief treatment strategy is supportive care, along with adequate

nutrition.

Patients are mechanically ventilated, guarded against fluid overload with

diuretics, and given nutritional support until evidence of improvement is
observed.

The mode in which a patient is ventilated affects lung recovery. Evidence

suggests that some ventilatory strategies can exacerbate alveolar damage
and perpetuate lung injury in the context of ARDS. Care is placed in
preventing volutrauma (exposure to large tidal volumes), barotrauma
(exposure to high plateau pressures), and atelectrauma (exposure to
atelectasis).

ARDS, Acute respiratory distress syndrome.

Respiratory Failure in Children

Pediatric respiratory failure develops when the rate of gas exchange between
the atmosphere and the blood is unable to match the body’s metabolic
demands. Acute respiratory failure remains an important cause of morbidity
and mortality in children. Cardiac arrests in children frequently result from
respiratory failure.

TABLE 3.2

Compensation With Blood Gas Values

pH → PaCO 2 → HCO3 → Compensation

Normal Abnormal Abnormal FULLY

Abnormal Abnormal Abnormal PARTIAL

Abnormal Normal Abnormal UNCOMPENSATED

Abnormal Abnormal Normal UNCOMPENSATED

TABLE 3.3
Clinical Manifestations of Disrupted Acid-Base Balance

Types of Problem Too Much Acid Too Little Acid

Too Much Carbonic Acid (Respiratory Acidosis) Too Much Metabolic Acid
(Metabolic Acidosis) Too Little Carbonic Acid (Respiratory Alkalosis) Too
Little Metabolic Acid (Metabolic Alkalosis)

Common clinical findings

Headache

Decreased level of consciousness (LOC)

Hypoventilation (cause of problem)

Cardiac dysrhythmias

If severe: hypotension

Decreased LOC Hyperventilation (compensatory mechanism)

Abdominal pain

Nausea and vomiting

Cardiac dysrhythmias

Excitation and belligerence, lightheadedness, unusual behaviors; followed by

decreased LOC if severe

Perioral and digital paresthesias, carpopedal spasm, tetany

Diaphoresis

Hyperventilation (cause of problem)

Cardiac dysrhythmias

Excitation followed by decreased LOC if severe

Perioral and digital paresthesias, carpopedal spasm

Hypoventilation (compensatory mechanism)

Signs of volume depletion and hypokalemia if present

Blood gas findings Blood gases; pH decreased (or low normal if fully
compensated); PaCO 2 increased; HCO3 - increased from compensation
 Blood gases; pH decreased (or low normal if fully compensated); PaCO
2 decreased from compensation; HCO3 - decreased Blood gases; pH
increased; PaCO 2 decreased; HCO3 - decreased if compensation Blood
gases; pH increased; PaCO 2 increased from compensation; HCO3–increased

From Giddens, J. F. (2017). Concepts for nursing practice (with Pageburst

Digital Book Access on VST) (2nd ed., p. 81). VitalBook file. St. Louis: Mosby.

A. Causes of respiratory failure in children

1. Congenital heart disease

2. Respiratory distress syndrome

3. Infection, sepsis

4. Neuromuscular diseases

5. Trauma and burns

6. Aspiration

7. Fluid overload and dehydration

8. Anesthesia and narcotic overdose

9. Structural anomalies resulting in obstruction of the airway

B. Risk factors for respiratory failure in children

1. Choking

2. Cardiac arrest

C. Complications of respiratory failure in children

1. Death

D. Signs and symptoms of respiratory failure in children

1. Signs and symptoms are not always evident and are difficult to recognize.

2. Children may be lethargic, irritable, anxious, or unable to concentrate.

Children with respiratory distress commonly sit up and lean forward to
improve leverage for the accessory muscles and to allow for easy
diaphragmatic movement. Children with epiglottitis sit upright with their
neck extended and head forward while drooling and breathing through their
mouth.
The respiratory rate and quality can provide diagnostic information, as
exemplified by the following:

Bradypnea: most often observed in central control abnormalities

Tachypnea: fast and shallow breathing is most efficient in intrathoracic

airway obstruction; it decreases dynamic compliance of the lung

Clinical Assessment:

• Stridor (an inspiratory sound)

• Wheezing (an expiratory sound)

• Crackles

• Decreased breath sounds (e.g., alveolar consolidation, pleural effusion)

• Paradoxical movement of the chest wall

• Accessory muscle use and nasal flaring (Hammer, 2013)

Refer to Table 3.2. See Pediatric chapter for further respiratory disease
pathologies.

HESI Hint

The NGN-NCLEX-RN tests your ability to assess the child’s condition and then
subsequently apply and implement actions to address acute life-threatening
situations. For example, you need to know Acute respiratory failure describes
any impairment in oxygenation or ventilation in which the arterial oxygen
tension falls below 60 mm Hg (acute hypoxemia), the carbon dioxide tension
rises above 50 mm Hg (acute hypercarbia, hypercapnia) and the pH drops
below 7.35, or both (Hammer, 2013).

HESI Hint

The NGN-NCLEX-RN asks many questions about clinical assessment and

related pathophysiology.

Example

The nurse is assessing an infant who grunts during expiration. Which is the
likely cause of this finding?

Infants and young children grunt during expiration as respiratory distress

begins. Grunting is how the body attempts to create a form of “PEEP”
(positive end-expiratory pressure) to help keep the alveoli open.
Review of Respiratory Failure

The NGN-NCLEX-RN is NOT based on memorization. Nursing school

graduates are expected to assess the elements of a given situation and
subsequently develop a plan of action that meets the client’s needs.

NGN-NCLEX-RN questions are designed for nursing school graduates to

demonstrate their ability to apply critical thinking skills to meet the needs
based on the contents of the questions.

1. What PO 2 value indicates respiratory failure in adults?

2. What blood value indicates hypercapnia?

3. Identify the condition that exists when the PO 2 is less than 60 mm Hg

(acute hypoxemia), the carbon dioxide tension rises above 50 mm Hg (acute
hypercarbia, hypercapnia) and the pH drops below 7.35, or both.

4. List three symptoms of respiratory failure in adults.

5. List four common causes of respiratory failure in children.

6. What percentage of O2 should a child in severe respiratory distress

receive?

See Answer Key at the end of this text for suggested responses.

Shock

Shock is defined as a state of cellular and tissue hypoxia due to either

reduced oxygen delivery, increased oxygen consumption, inadequate oxygen
utilization, or a combination of these processes. The state of shock will
generally present as hypotensive but may also present as hypertensive or
normotensive.

A. Types of shock:

B. Distributive—Distributive shock is characterized by severe peripheral

vasodilatation (vasodilatory shock). Molecules that mediate vasodilatation
vary, such as:

1. Septic shock—Sepsis, defined as a dysregulated host response to infection

resulting in life-threatening organ dysfunction, is the most common cause of
distributive shock. Septic shock is a subset of sepsis associated with
mortality in the 40% to 50% range that can be identified by the use of
vasopressor therapy and the presence of elevated lactate levels (>2 mmol/L)
despite adequate fluid resuscitation.
2. Neurogenic shock—Hypotension and overt shock are common in patients
with severe traumatic brain injury and spinal cord injury. Interruption of
autonomic pathways, causing decreased vascular resistance and altered
vagal tone, is responsible for distributive shock in patients.

3. Anaphylactic shock—Shock from anaphylaxis is most commonly

encountered in patients with severe, immunoglobulin-E (Ig-E) mediated,
allergic reactions to insect stings, food, and drugs.

C. Cardiogenic—Cardiogenic shock is due to intracardiac causes of cardiac

pump failure that result in reduced cardiac output (CO). Causes of cardiac
pump failure are diverse, but can be divided into the following three
categories: Cardiomyopathic, Arrhythmic, and Mechanical.

D. Hypovolemic—Hypovolemic shock is due to reduced intravascular volume

(i.e., reduced preload), which reduces CO. Hypovolemic shock can be divided
into two categories: hemorrhagic and nonhemorrhagic.

Hemorrhagic—Reduced intravascular volume from blood loss including blunt

or penetrating trauma followed by hemorrhage.

Nonhemorrhagic—Reduced intravascular volume from fluid loss other than

blood can cause shock. Volume depletion from loss of sodium and water can
occur from a number of anatomic sites.

E. Obstructive—Obstructive shock is mostly due to extracardiac causes of

cardiac pump failure and often associated with poor right ventricular output.
The causes of obstructive shock can be divided into the following two
categories:

1. Pulmonary vascular—Most cases of obstructive shock are due to right

ventricular failure from hemodynamically significant PE or severe pulmonary
hypertension (PH). Patients with severe stenosis or with acute obstruction of
the pulmonary or tricuspid valve may also fall into this category.

2. Mechanical—Patients in this category present clinically as hypovolemic

shock because their primary physiologic disturbance is decreased preload,
rather than pump failure. Mechanical causes of obstructive shock include the
following:

a. Tension pneumothorax

b. Pericardial tamponade

c. Constrictive pericarditis
d. Restrictive cardiomyopathy

e. Abdominal compartment syndrome (ACS)

3. Refer to Table 3.4 (Box 3.1).

F. Causes of shock

1. Blood loss

2. Trauma

3. Allergic reaction

4. Heatstroke

5. Poisoning

6. Severe burns

TABLE 3.4

Types of Shock

Types of Shock → Cause → End Result

Hypovolemic (most common) Loss of fluid and/or blood → internal or

externally Refer to Table 3.3

CardiogenicDamaged heart → ischemia or impairment of tissue perfusion

Decreased cardiac output

Distributive Anaphylactic Reaction to an allergen Excessive vasodilation

and impaired distribution of blood flow

Neurogenic Spinal cord injury to descending sympathetic pathways

Septic Endotoxins from bacteria

Obstructive Physical obstruction → tamponade, emboli, compartment

syndrome Impeded filling and outflow of blood resulting in decreased
cardiac output

BOX 3.1 Clinical Manifestations of Respiratory Distress

Respiratory Acidosis SEVERE Respiratory Acidosis Respiratory Alkalosis

SEVERE Respiratory Alkalosis

Restlessness Cyanosis Lightheadedness Confusion

Confusion Dilated facial blood vessels Anxiety Syncope

Diaphoresis Dilated conjunctival vessels Circumoral numbness Cardiac

dysrhythmias

Tachypnea Lethargy Paresthesias Seizures

Dyspnea Ventricular dysrhythmias Tetany

Coma

From Potter, P., Perry, A., Stockert, P., Hall, A., & Peterson, V. (2013). Clinical
companion for fundamentals of nursing: Just the facts. In: VitalBook file (8th
ed., p. 218). St. Louis: Mosby; Monahan, F. D. (2006). Phipps’ medical-surgical
nursing: Health and illness perspectives (8th ed., p. 364). St. Louis: Mosby.

7. Severe infection

8. Poisoning

B. Risk factors for shock

1. Very young and very old clients

2. Post–myocardial infarction (MI) or with severe dysrhythmia

3. Adrenocortical dysfunction

4. History of recent hemorrhage or blood loss

5. Burns

6. Massive or overwhelming infection (Ismail & Elbaih, 2017)

HESI Hint

You will be tested on your ability to apply your knowledge of shock based on
the information provided in the question or scenario. Remember that early
signs of shock are agitation and restlessness resulting from cerebral hypoxia.

C. Complications of shock

1. Refer to Box 3.2

HESI Hint

The examination may ask you a question about symptoms of a certain type
of shock and then ask you to address the possible complications or impact
described in the question or scenario. Remember that all types of shock can
lead to systemic inflammatory response syndrome (SIRS) and result in
multiple organ dysfunction syndrome (MODS).

D. Signs and symptoms of shock

1. Weak pulse

2. Rapid shallow breathing

3. Cold and clammy skin

4. Pale skin

5. Rapid heart rate

6. Oliguria/anuria

7. Confusion

E. Clinical assessment of shock

1. Refer to Table 3.4.

BOX 3.2 Complications of Shock

Early Severe

TachycardiaOrgan dysfunction

Hypotension Renal failure

Weakened peripheral pulses Pleural effusion

Restlessness, agitation, confusion Respiratory distress

Pale cool, clammy skin Renal failure

Decreased urine output (M30 mL/hr) Death

Data from Giddens, J. F. (2017). Concepts for nursing practice (with Pageburst
Digital Book Access on VST). In: VitalBook file (2nd ed., p. 233). St. Louis:
Mosby; Harkreader, H. (2007). Fundamentals of nursing: caring and clinical
judgment. In: VitalBook file (3rd ed., p. 957). Philadelphia: Saunders.

F. Medical management of shock

1. Refer to Table 3.5.

2. Tissue perfusion

a. Oxygenation and ventilation

1) Optimize O2 delivery and reduce demand on heart.

2) Increase arterial O2 saturation with supplemental oxygenation and

mechanical ventilation.

3) Space activities that decrease O2 consumption.

2. Fluid resuscitation

a. Cause of shock dictates the type of treatment. Based on laboratory data,

lactic acid infusion of volume-expanding fluids is the treatment for
hypovolemic shock and anaphylactic shock.

b. Whole blood, plasma, plasma substitutes (colloid fluids) may be used.

c. Isotonic, (IV) solutions, such as Ringer’s lactate solution and normal saline,
may also be used.

d. If shock is cardiogenic in nature, infusion of volume-expanding fluids may

be contraindicated and may result in pulmonary edema.

3. Drug therapy

a. Restoration of cardiac function should take priority. Drug selection is based

on the effect of the shock on preload, afterload, or contractility.

1) Drugs that increase preload (e.g., blood products, crystalloids) or decrease

preload (e.g., opioids such as morphine, nitrates, diuretics)

2) Drugs that increase afterload (e.g., vasopressors, stimulates alpha and

beta 1 adrenergic and dominergic receptors such as dopamine) or decrease
afterload (e.g., vasodilators/nitrates such as nitroprusside, angiotensin-
converting enzyme inhibitor [ACE-I], angiotensin II receptor blocker [ARB])

3) Drugs that decrease contractility (e.g., beta blockers, calcium channel

blockers) or increase contractility (e.g., antiarrhythmic inhibits sodium-
potassium ATPase such as digoxin, beta 1 stimulator/mild chronotropic
arrhythmogenic and vasodilative effects such as dobutamine, cAMP
phosphodiesterase inhibitors such as milrinone). Milrinone is a
phosphodiesterase 3 inhibitor that increases cardiac inotropy, lusitropy, and
peripheral vasodilatation. In contrast, dobutamine is a synthetic
catecholamine that acts as a β1 and β2-receptor agonist and improves blood
pressure by increasing cardiac output.

G. Monitoring

a. Central monitoring system may be inserted for monitoring shock.

b. Continue to assess pulmonary function (using electrocardiogram [ECG],
pulse oximetry, end-tidal CO2 monitoring, ABGs, and hemodynamic
monitoring urinary output, clinical assessment (i.e., mental status)) with
close monitoring systems

c. Stabilizing and treating the underlying cause of the condition.

H. Clinical nursing judgment measures for shock

1. If cardiogenic shock exists in the presence of pulmonary edema (i.e., from

pump failure), position client to reduce venous return (high Fowler position
with legs down) to decrease further venous return to the left ventricle.

2. If an intra-aortic balloon pump (IABP) is used to decrease myocardial O2

demand and improve myocardial perfusion, the nursing responsibilities are to
monitor and assess the IABP (nurses must be educated on pump dynamics
before being responsible for monitoring a patient with an IABP).

3. The nurse is also responsible for assessing for potential complications of

this device such as limb ischemia, compartment syndrome, aorta dissection,
plaque or emboli dislodgement, migration of the catheter, insertion site
bleeding, rupture of the balloon, signs and symptoms of infection, and skin
breakdown because the client has limited movement.

4. Monitor BP, pulse, respirations, and arrhythmias based on Intensive care

unit (ICU) protocols.

5. Monitor arterial pressure by understanding the concepts related to arterial

pressure (Table 3.6).

6. Assess urine output every hour to maintain at least 30 mL/h (roughly

0.5 mL/kg/h for 70-kg patient) and notify the healthcare provider if urine
output drops below 30 mL/h (reflects decreased renal perfusion and may
result in acute renal failure).

7. Administer fluids as prescribed by provider to improve preload: blood,

colloids, or electrolyte solutions until designated central venous pressure
(CVP) is reached.

(Table 3.7).

8. Remember client’s bed position is dependent on cause of shock.

9. Administer medications IV (not intramuscular [IM] or subcutaneous) until

perfusion improves in muscles and subcutaneous tissue.
10. Maintain warmth; increase heat in room and use warm blankets (not too
hot).

11. Keep side rails up; due to mental confusion and high fall risk.

12. Obtain blood for laboratory work as prescribed. Anticipate: complete

blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine (renal
damage), lactate (sepsis), and blood gases (oxygenation and ventilation).

a. When administering vasopressor, adrenergic stimulants, and or

vasodilators.

b. Administer through volume-controlled pump.

c. Monitor hemodynamic status every 5 to 15 minutes or as ordered.

d. Watch IV site carefully for extravasation and tissue damage.

e. Ensure medications administered are for target MAP.

f. Glucose levels should be sustained based on orders and based on the

shock.

TABLE 3.5

Clinical Assessment for Shock

A chart for Clinical Manifestations of disrupted acid-base balance shows 4

columns for nursing assessment, cardiogenic, distributive, and obstructive.
Last 2 columns contains 3 sub-columns each with distributive containing sub-
columns including anaphylactic, neurogenic, and septic and obstructive
containing sub-columns including tamponade, emboli, and compartment
syndrome. emboli and compartment syndrome are merged as one column.
The data from left to right is as follows:Blood pressure: S B P less than 90
millimeters of mercury; S B P less than 90 millimeters of mercury; S B P less
than 90 millimeters of mercury; S B P less than 90 millimeters of mercury;
and assessment varies dependent upon the [Link] rate: Greater than
100 B P M; greater than 100 B P M then less than 60 B P M; less than 60 B P
M; greater than 100 B P M; and assessment varies dependent upon the
locale decreased C [Link]: Weak, thready; full, bounding and widen pulse
pressure (septic); J V D and pulse paradoxus; and assessment varies
dependent upon the locale decreased C [Link]: Diminished sounds, chest
pain, dysrhythmias, and decreased C O; chest pain and decreased C O;
decreased C O; increase C O initially, but then contractility fails leading to
decreased C O; decreased C O; and assessment varies dependent upon the
locale decreased C [Link]: R R greater than 24 crackles; throat
tightening, cough, dyspnea, stridor, and wheezing (anaphylactic); greater
than 24 (early) and less than 10 (late) crackles (septic); and assessment
varies dependent upon the locale decreased C [Link]: Cool, pale; warm,
pruritus, redness, and urticaria; warm, dry; pink, warm, and flushed; and
assessment varies dependent upon the locale decreased C [Link] status:
Change in alertness; apprehensive, dizzy, H A, confuse, and syncope
(anaphylactic); change in alertness (septic); and assessment varies
dependent upon the locale decreased C O.G I or G U: N, V, D, and abdominal
cramping incontin (anaphylactic); decreased U.O.; and assessment varies
dependent upon the locale decreased C O.

Table created by Katherine Ralph.

TABLE 3.6

Arterial Pressure

Concept Definition

Mean arterial pressure (MAP)

• Level of pressure in the central arterial bed measured indirectly by blood

pressure (BP) measurement

• MAP = cardiac output × total peripheral resistance = systolic BP + 2

(diastolic BP)/3

• In adults, usually approaches 100 mm Hg

• Can be measured directly through arterial catheter insertion

Cardiac output (CO)

• Volume of blood ejected by the left ventricle per unit of time

• Stroke volume (amount of blood ejected per beat) × heart rate (normal: 4–
6 L/min)
Peripheral resistance (PR)

• Resistance to blood flow offered by the vessels in the peripheral vascular

bed

Central venous pressure (CVP)

• Pressure within the right atrium; normal CVP/RAP ranges from 2 to 6 mm

Hg

TABLE 3.7

Administration of Blood Products

Component therapy has replaced the use of whole blood, which accounts
for <10% of all transfusions.

Blood Products

Description Special Considerations Indications for Use

Packed red blood cells (RBCs) Less danger of fluid overload Acute blood loss

Frozen RBCs: prepared from RBCs using glycerol for protection and then
frozen Must be used within 24 h of thawing Auto transfusion:
infrequently used because filters remove most of white blood cells

Platelets: pooled—300 mL

One unit contains single donor—200 mL

Bag should be agitated periodically. Bleeding caused by thrombocytopenia

Fresh-frozen plasma (FFP): liquid portion of whole blood separated from cells
and frozen The use of FFP is being replaced by albumin plasma expanders.
Bleeding caused by deficiency in clotting factors

Albumin: prepared from plasma and is available in 5% and 25% solutions

Albumin 25 g/100 mL is osmotically equal to 500 mL of plasma.
Hypovolemic shock, hypoalbuminemia

Cryoprecipitates and commercial concentrates: prepared from fresh-frozen

plasma with 10–20 mL/bag Used in treating hemophilia Replacement of
clotting factors, especially factor VIII and fibrinogen

Transfusion Reactions
Reactions/Complications Assessment Nursing Judgment Measures

Acute hemolytic Chills, fever, low back pain, flushing, tachycardia,

hypotension progressing to acute renal failure, shock, and cardiac arrest

Stop transfusion.

Change tubing, then continue saline intravenously (IV).

Treat for shock if present.

Draw blood samples for serologic testing.

Monitor hourly urine output.

Give diuretics as prescribed.

Febrile nonhemolytic (most common) Sudden chills and fever,

headaches, flushing, anxiety, and muscle pain Give antipyretics as
prescribed.

Mild allergic Flushing, itching, urticaria (hives) Give antihistamine as

directed.

Anaphylactic and severe allergic Anxiety, urticaria, wheezing, progressive

cyanosis leading to shock and possible cardiac arrest

Stop transfusion.

Initiate cardiopulmonary resuscitation (CPR).

Circulatory overload Cough, dyspnea, pulmonary congestion, headache,

hypertension Place client in upright position with feet in dependent
position and administer diuretics, O2, morphine; slow IV rate.

Sepsis Rapid onset of chills, high fever, vomiting, marked hypotension,

or shock Ensure a patent airway, obtain blood for culture, administer
prescribed antibiotics, take vital signs every 5 min until stable.

Nursing Skills

• Obtain venous access; use central venous catheter or 19-gauge needle.

• Use only blood administration tubing to infuse blood products.

• Run blood products with saline solutions only. Dextrose solutions and
Ringer’s lactate solution will induce RBC hemolysis.
• Run infusion at prescribed rate and remain with client for the first 15–
30 min of infusion.

• The blood should be administered as soon as it is brought to the client.

• Check vital signs frequently before, during, and immediately after the
infusion; note any increase in temperature.

• Follow agency policy regarding specific timetable for blood infusion.

• Check and double-check the product before infusing to see that it is the:

• Correct product, as prescribed; double-check with a second licensed

person.

• Correct blood type and Rh factor, matched with the client, and note
expiration date.

13. Ensure the pulse oximetry probe is placed appropriately to ensure the
probe is reading correctly and not cause necrosis due to decreased tissue
perfusion.

I. Provide family support.

a. Involve the family in care and facilitate a patient care support person,
social worker, and spiritual support.

b. Keep family updated.

c. Collaborate with the healthcare provider before notifying family of medical

interventions.

Disseminated Intravascular Coagaulation

Description: Disseminated intravascular coagulation (DIC) is a life-

threatening syndrome characterized by disseminated and often uncontrolled
activation of coagulation. This syndrome is associated with a high risk of
macro- and microvascular thrombosis and progressive consumption
coagulopathy, which leads to an increased bleeding risk. Several pathological
conditions may trigger DIC including but not limited to sepsis, cancer,
trauma, and obstetric calamity ranking among the most frequent triggering
factors (Papageorgiou et al., 2018).

DIC destroys the clotting factors, platelets, and red blood cells (RBCs).

A. DIC is a complication or an effect of the progression of other illnesses, is

always secondary to an underlying disorder, and is associated with a number
of clinical conditions, generally involving activation of systemic inflammation,
such as sepsis and severe infection (including COVID-19), trauma
(neurotrauma), organ destruction, malignancy, severe transfusion reactions.

B. DIC is most commonly observed in severe sepsis and septic shock. Indeed,
the development and severity of DIC correlate with mortality in severe
sepsis. Bacteremia, both gram-positive and gram-negative organisms, is
most commonly associated with DIC. Other organisms (e.g., viruses, fungi,
and parasites) may also cause DIC (Box 3.3).

C. The first phase involves abnormal clotting in the microcirculation, which

uses up clotting factors and results in the inability to form clots, so
hemorrhage occurs (Fig. 3.2).

D. The diagnosis is based on laboratory findings.

1. Prothrombin time (PT): prolonged

2. Partial thromboplastin time (PTT): prolonged

3. Fibrinogen: decreased

4. Platelet count: decreased

5. Fibrin degradation (split) products (FSP or FDP): increased

Clinical Assessment

A. Petechiae, purpura, hematomas

B. Respiratory distress, tachypnea, dyspnea

C. Oozing from IV sites, drains, gums, and wounds

D. Gastrointestinal and genitourinary bleeding

E. Hemoptysis

F. Mental status change

G. Hypotension, tachycardia

H. Pain

I. ABGs and saturation

Clinical Nursing Judgment Measures

A. Treatment should primarily focus on addressing the underlying disorder

B. Monitor for bleeding.

BOX 3.3 Comparison of HELLP Syndrome and Disseminated Intravascular

Coagulation

HELPP Syndrome DIC

Signs and Symptoms

Nausea with or without vomiting

Epigastric pain or pain in right upper abdominal quadrant

Hypertension varying from mild to severe

Malaise

Obvious signs of bleeding, such as hematuria or hematoma development at

venipuncture sites, hemorrhage in the conjunctiva, and petechiae

Laboratory

Blood

Values

Increased aminotransferase, bilirubin, hemoglobin levels, and increased

hematocrit

Decreased platelet count

Elevated levels of fibrin degradation products, prothrombin time, and

stimulated partial thromboplastin time

Treatment

Delivery of the fetus if the outcome of the mother or fetus is endangered

Platelet administration if the cell count is < 20,000/mm3

Monitoring of liver function

Observation for organ systems dysfunction

Volume blood and clotting factor replacement

Removal of the underlying precipitating factor to reverse the DIC

Support for organ systems dysfunction

DIC, Disseminated intravascular coagulation. From Bridges, E. J., Womble, S.,
Wallace, M., & McCartney, J. (2003). Hemodynamic monitoring in high-risk
obstetrics patients, I. Expected hemodynamic changes during pregnancy.
Critical Care Nurse 23, 53–62; Pourrat, O., Pierre, F., & Magnin, G. (2009). Le
syndrome HELLP: les dix commandements. La Revue de Médecine Interne
30(1), 58–64; Beucher, G., Simonet, T., & Dreyfus, M. (2008). Point de vue
d’expert Prise en charge du HELLP syndrome Management of HELLP
syndrome. Gynecologie Obstetrique Fertilite 36, 1175–1190; Alspach, A. A. C.
N. (2006). Core curriculum for critical care nursing. In: VitalBook file (6th ed.).
St. Louis: Saunders.

FIG. 3.2 Pathophysiology of Disseminated Intravascular Coagulation. From

Urden, L. D., Stacy, K. M., & Lough, M. E. [2020]. Priorities in critical care
nursing [8th ed.]. St. Louis: Mosby.

A flowchart for pathophysiology of disseminated intravascular coagulation is

as follows:• Massive tissue destruction along with sepsis and endothelial
injury results in release of tissue factor. Endothelial injury causes platelet
aggregation.• Release of tissue factor and platelet aggregation leads to
widespread microvascular thrombosis which results in activation of plasmin,
vascular occlusion, and consumption of clotting factors and platelets.•
Activation of plasmin leads to fibrinolysis and proteolysis of clotting factors.
Proteolysis of clotting factors results in bleeding.• Vascular occlusion results
in microangiopathic hemolytic anemia and ischemic tissue damage.•
Consumption of clotting factors and platelets results in bleeding.• Fibrinolysis
leads to fibrin split products that leads to inhibition of thrombin, platelet
aggregation, and fibrin polymerization which results in bleeding.

C. Monitor vital signs.

D. Monitor PT/international normalized ratio (INR).

E. Protect from injury and bleeding.

1. Provide gentle oral care with mouth swabs.

2. Minimize needle sticks; use smallest gauge needle possible.

3. Turn frequently to eliminate pressure points.

4. Minimize number of BP measurements taken by cuff.

5. Use gentle suction to prevent trauma to mucosa.

6. Apply pressure to any oozing site(s).

F. Provide emotional support to decrease anxiety.

HESI Hint

The nurse is caring for a patient who sustained several fractures and internal
injuries in a motor vehicle crash. The patient underwent exploratory
laparotomy to control the bleeding. Several hours later, the nurse’s
assessment of the client reveals bleeding from the incision site; dyspnea;
weak, thready pulse; cold, clammy skin; and hematuria.

The NGN-NCLEX-RN asks questions that begin with a detailed clinical

scenario. To address this scenario, you must be able to address the typical
signs and symptoms of DIC crisis. The nurse should immediately advise the
surgeon for evaluation for further surgical intervention. Care would include
administration of clotting factors, along with interventions to stop the
hemorrhage (Papageorgiou et al., 2018).

Review of Shock and DIC

1. Define shock.

2. What is the most common cause of shock?

3. What causes septic shock?

4. What is the goal of treatment for hypovolemic shock?

5. What intervention is used to restore cardiac output when hypovolemic

shock exists? In this answer include the word warm: Rapid infusion of warm
volume-expanding fluids.

6. It is important to differentiate between hypovolemic and cardiogenic

shock. How might the nurse determine the existence of cardiogenic shock?

7. If a client is in cardiogenic shock, what might result from administration of

volume-expanding fluids, and what intervention can the nurse expect to
perform in the event of such an occurrence?

8. List five assessment findings that occur in most shock victims.

9. Once circulating volume is restored, vasopressors may be prescribed to

increase venous return. List the main drugs that are used. Include milrinone
in the answer to #9.

10. What is the established minimum renal output per hour?

11. List four measurable criteria that are the major expected outcomes of a
shock crisis.

12. Define DIC.

13. What is the effect of DIC on PT, PTT, platelets, and FSPs.

14. What medication is used in the treatment of DIC?

15. Name four nursing judgment measures to prevent injury in clients with
DIC.

See Answer Key at the end of this text for suggested responses.

Resuscitation

Cardiopulmonary Arrest

Occurs when the heart malfunctions and stops beating unexpectedly. Cardiac
arrest is an “ELECTRICAL” problem.

Myocardial infarction (MI) occurs when blood flow to the heart is blocked. A
heart attack is a “CIRCULATION” problem.

A. MI is the irreversible death/necrosis of heart muscle secondary to

ischemia. Approximately 1.5 million cases of MI occur annually in the United
States.

B. Patients with typical MI may have the following symptoms in the days or
even weeks preceding the event (although typical STEMI may occur
suddenly, without warning):

1. Fatigue

2. Chest discomfort

3. Malaise

C. Typical chest pain in acute MI has the following characteristics:

1. Intense and unremitting for 30 to 60 minutes

2. Substernal, and often radiates up to the neck, shoulder, and jaw, and
down the left arm

3. Usually described as a substernal pressure sensation that also may be

characterized as squeezing, aching, burning, or even sharp
4. In some patients, the symptom is epigastric, with a feeling of indigestion
or of fullness and gas

5. Chest pain in a client with known coronary heart disease that is unrelieved
by rest or nitroglycerin

D. Prehospital care

1. For patients with chest pain, prehospital care includes the following:

2. Intravenous (IV) access, supplemental oxygen if SaO2 is less than 90%,

pulse oximetry

3. Immediate administration of nonenteric-coated chewable aspirin

4. Nitroglycerin for active chest pain, given sublingually or by spray

E. Telemetry and prehospital ECG

The ECG is the most important tool in the initial evaluation and triage of
patients in whom an acute coronary syndrome (ACS), such as MI, is
suspected. It is confirmatory of the diagnosis in approximately 80% of cases.
The information in this section is according to the 2020 ESC Guidelines for
the Management of ACSs (Collet et al., 2020).

HESI Hint

NGN-NCLEX-RN questions on cardiopulmonary resuscitation (CPR) often use

critical thinking skills to determine prioritization of actions.

Question: What actions are required for each of the following situations?

• 24-year-old motorcycle accident victim with a ruptured artery of the leg

who is pulseless and apneic

• 36-year-old first-time pregnant woman who arrests during labor

• 17-year-old with no pulse or respirations who is trapped in an overturned

car that is starting to burn

• 40-year-old businessman who arrests 2 days after a cervical laminectomy

A. Chest pain in MI:

1. Typical chest pain in acute MI has the following characteristics:

a. Intense and unremitting for 30 to 60 minutes

b. Substernal, and often radiates up to the neck, shoulder, and jaw, and
down the left arm

2. Usually described as a substernal pressure sensation that also may be

characterized as squeezing, aching, burning, or even sharp

3. In some patients, the symptom is epigastric, with a feeling of indigestion

or of fullness and gas

Cardiopulmonary Resuscitation

The six links in the adult out-of-hospital Chain of Survival are:

• Recognition of cardiac arrest and activation of the emergency response

system (calling 9-1-1 in the US)

• Early cardiopulmonary resuscitation (CPR) with an emphasis on chest

compressions

• Rapid defibrillation

• Advanced resuscitation by Emergency Medical Services and other

healthcare providers

• Post-cardiac arrest care

• Recovery (including additional treatment, observation, rehabilitation, and

psychological support)

A strong Chain of Survival can improve chances of survival and recovery for
victims of cardiac arrest.

Family presence during CPR benefits outweigh the risks. (Merchant et al.,
2020)

HESI Hint

The nurse must stay current with the AHA guidelines for basic life support
(BLS) by being certified every 2 years, as required. See the AHA website for
current CPR guidelines and locate a CPR class.

Major components of BLS consist of immediate recognition of cardiac arrest

and activation of the emergency response system, CPR with emphasis on
chest compression, and rapid defibrillation if indicated. There are several
options for CPR known as Hands-Only CPR, High-Quality CPR, and In-Hospital
CPR (Box 3.4).

HESI Hint
Initiate CPR with basic life support (BLS) guidelines immediately; then move
on to advanced cardiac life support.

Pediatric Resuscitation

See “Maternity Nursing” (see Chapter 6) for Newborn Resuscitation.

• Rapid recognition of cardiac arrest, immediate initiation of high-quality

chest compressions, and delivery of effective ventilations are critical to
improve outcomes from cardiac arrest.

• Lay rescuers should not delay starting cardiopulmonary resuscitation (CPR)

in a child with no “signs of life.”

• Healthcare providers may consider assessing the presence of a pulse as

long as the initiation of CPR is not delayed more than 10 s.

• Palpation for the presence or absence of a pulse is not reliable as the sole
determinant of cardiac arrest and the need for chest compressions.

• In infants and children, asphyxia cardiac arrest is more common than

cardiac arrest from a primary cardiac event; therefore, effective ventilation is
important during resuscitation of children.

• When CPR is initiated, the sequence is compressions-airway-breathing.

• High-quality CPR generates blood flow to vital organs and increases the
likelihood of return of spontaneous circulation (ROSC).

• The five main components of high-quality CPR:

1. adequate chest compression depth,

2. optimal chest compression rate,

3. minimizing interruptions in CPR (i.e., maximizing chest compression

fraction or the proportion of time that chest compressions are provided for
cardiac arrest)

4. allowing full chest recoil between compressions,

5. avoiding excessive ventilation.

• Compressions of inadequate depth and rate, incomplete chest recoil, and

high ventilation rates are common during pediatric resuscitation.

From Topjian, A. A., Raymond, T. T., Atkins, D., Chan, M., Duff, J. P., Joyner,
et al. (2021). Part 4: Pediatric Basic and Advanced Life Support 2020
American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Pediatrics, 147(Suppl 1),
e2020038505D. [Link]

For infants, single rescuers (whether lay rescuers or healthcare providers)

should compress the sternum with two fingers or two thumbs placed just
below the intermammary line.

For infants, the two-thumb–encircling hands technique is recommended

when CPR is provided by two rescuers.

If the rescuer cannot physically encircle the victim’s chest, compress the
chest with two fingers.

For children, it may be reasonable to use either a one- or two-hand technique

to perform chest compressions.

For infants, if the rescuer is unable to achieve guideline-recommended

depths (at least one-third the anterior-posterior diameter of the chest), it
may be reasonable to use the heel of one hand (Topjian et al., 2021).

The American Heart Association algorithms for CPR for adult and pediatric
resuscitation can be downloaded from: [Link]
science/cpr-and-ecc-guidelines/algorithms

HESI Hint

The pediatric cardiac arrest algorithm known as the reversible causes include
the four “H’s”: hypoxia, hypovolemia, hyperkalemia, hypokalemia, other
electrolyte disturbances, and the four “Ts”: Tension pneumothorax, cardiac
tamponade, drug toxicity and therapeutics, thromboembolism, and other
outflow obstructions.

HESI Hint

• For infants and children provide chest compressions that depress the chest

compression rate of ∼100 to 120/min for infants and children.

at least 1/3 of the anterior posterior diameter of the chest, use chest

• Single rescuers compression to ventilation rate 30:2; two rescuers 15:2

Management of Foreign Body Airway Obstruction

Adults and Children

Foreign-body airway obstruction (FBAO), or choking, is an alarming and
dramatic emergency.

To confirm a complete FBAO, ask the victim “Are you choking?” If the victim
cannot speak or can only make weak, high-pitched sounds, perform
abdominal thrust until the object is expelled or the victim becomes
unresponsive.

A. Stand behind the victim

B. Make a fist with one hand

C. Place your fist on the victim’s abdomen, slightly above the navel and well
below the breastbone

D. Grasp your fist with your other hand

E. Deliver quick upward thrusts into the victim’s abdomen (Heimlich

maneuver)

BOX 3.4 Hands-Only CPR, High-Quality CPR, and In-Hospital CPR

Hands-Only CPR

Consists of two easy steps:

1. Call 9-1-1 (or send someone to do that)

2. Push hard and fast in the center of the chest

The focus is on early, high-quality chest compressions. The healthcare

provider includes chest compressions before rescue breaths. “C-A-B” (Chest
Compression, Airway, and Breathing) is now used for adults and children,
whereas steps for the newborns remain “A-B-C” (Airway, Breathing, and
Circulation).

Automated external defibrillators (AEDs) can greatly increase a cardiac arrest

victim's chances of survival. To minimize the time to defibrillation for cardiac
arrest victims, deployment of AEDs should not be limited to only trained
people (although training is still recommended).

High-Quality CPR

High-quality CPR should be performed by anyone—including bystanders.

There are five critical components:

1. Minimize interruptions in chest compressions

2. Provide compressions of adequate rate and depth

3. Avoid leaning on the victim between compressions

4. Ensure proper hand placement

5. Avoid excessive ventilation

In-Hospital Cardiac Arrest

1. For healthcare providers and those trained: conventional CPR using chest
compressions and mouth-to-mouth breathing at a ratio of 30:2
compressions-to-breaths. In adult victims of cardiac arrest, it is reasonable
for rescuers to perform chest compressions at a rate of 100 to 120/min and
to a depth of at least 2 inches (5 cm) for an average adult, while avoiding
excessive chest compression depths (greater than 2.4 inches [6 cm]).

CPR, Cardiopulmonary resuscitation. Modified from What Is CPR. American

Heart Association. Available at: [Link]

F. Deliver thrusts until the object is expelled or the victim becomes

unresponsive. If a choking adult becomes unresponsive while you are doing
abdominal thrust, you should ease the victim to the floor and send someone
to activate the emergency response system.

G. When a choking victim becomes unresponsive, you begin the steps of

CPR, starting with compressions.

H. The only difference is that each time you open the airway, look for the
obstructing object before giving each breath.

I. Remove the object if you see it.

J. Chest thrust should be used in obese or pregnant patients.

Infants and Children

A. FBAO develops when an object becomes lodged in the airway and blocks
the movement of air into and out of the lungs.

B. If the blockage is severe or complete, the victim will be unable to breathe

and oxygenate blood supplying the brain, heart, and other vital organs with
adequate oxygen to function normally.

C. If the blockage is not relieved, the victim will become unresponsive and
can die.
D. Signs of severe or complete FBAO in infants and children include sudden
onset of respiratory distress associated with weak or silent cough/cry,
inability to speak, stridor or increasing respiratory difficulty.

E. These signs and symptoms of airway obstruction may also be caused by

infections and croup.

F. Typically with FBAO these signs and symptoms will develop suddenly with
no other signs of illness or infection.

G. If you suspect a severe (victim not passing air or ineffective cough/cry) or

complete FBAO, follow these steps:

H. For a Responsive Infant

1. Pick the infant up from a supine (lying face up) position by lifting the legs
with one hand and sliding the other hand all the way to the infant’s head.
Once this is done, “sandwich” the infant by placing the opposite arm and
hand on the infant’s stomach and face, grasping the infant’s facial cheeks.

2. Supporting the infant–place them face down on your thigh–make sure the
head is lower than the body.

3. Deliver five back slaps with the heel of your free hand between the
shoulder blades. “Sandwich” the infant between your arms once again and
turn the infant over so that the infant is lying on their back along your arm
which should be placed on your thigh for support.

4. Deliver five chest thrusts in the same location used for CPR compressions.
Alternate five back slaps and five chest thrusts until the object is expelled or
the infant becomes unresponsive.

5. If unresponsive, begin the steps of CPR–in this sequence–every time

before you administer a breath–check the airway for foreign objects.

6. For a Responsive Child–The steps for FBAO in a child are exactly the same,
as you would use with an adult FBAO victim.

7. Please review previous information.

Review of Resuscitation

1. What is the first priority when an adult with an unwitnessed cardiac arrest
is found?

2. Define myocardial infarction.

3. What criteria should alert a client with known angina who takes
nitroglycerin tablets sublingually to call EMS? Delete

4. After calling out for help and asking someone to dial for emergency
services, what is the next action in CPR?

5. True or false? In feeling for presence of a carotid pulse, no more than 5

seconds should be used.

6. During one-rescuer CPR, what is the ratio of compressions to ventilations

for an adult? During one-rescuer CPR, what is the ratio of compressions to
ventilations for a child?

7. What is the first drug most likely to be used for an in-hospital cardiac
arrest?

8. A client in cardiac arrest is noted on bedside monitor to be in pulseless

ventricular tachycardia. What is the first action that should be taken?

9. How would the nurse assess the adequacy of compressions during CPR?
How would the nurse assess the adequacy of ventilations during CPR?

10. If a person is choking, when should the rescuer intervene?

11. One should never make blind sweeps into the mouth of a choking child or
infant. Why?

See Answer Key at the end of this text for suggested responses.

Fluid and Electrolyte Balance

Electrolytes play a vital role in maintaining homeostasis within the body.

• Electrolytes help to regulate myocardial and neurological functions, fluid

balance, oxygen delivery, acid–base balance, and much more.

• The most serious electrolyte disturbances involve abnormalities in the

levels of sodium, potassium, and/or calcium.

• Kidneys work to keep the electrolyte concentrations in the blood constant

despite changes in the body.

• Homeostasis: The ability of a system or living organism to adjust its

internal environment to maintain a stable equilibrium, such as the ability of
warm-blooded animals to maintain a constant temperature.
• Electrolyte: Any of the various ions (such as sodium or chloride) that
regulate the electric charge on cells and the flow of water across their
membranes.

• Sodium: A chemical element with symbol Na (from Latin: natrium) and

atomic number 11. It is a soft, silvery white, highly reactive metal and is a
member of the alkali metals.

Importance of Electrolyte Balance

Electrolytes maintain voltages across their cell membranes, especially those

of the nerves, heart, and muscle and to carry electrical impulses across
nerve impulses, muscle contractions, and to other cells.

Electrolyte imbalances can develop from dehydration and over-hydration.

The most common cause of electrolyte disturbances is renal failure. The
most serious electrolyte disturbances involve abnormalities in the levels of
sodium, potassium, and/or calcium.

Other electrolyte imbalances are less common, and often occur in

conjunction with major electrolyte changes. Chronic laxative abuse or severe
diarrhea or vomiting (gastroenteritis) can lead to electrolyte disturbances
combined with dehydration. People suffering from bulimia or anorexia
nervosa are especially at high risk for an electrolyte imbalance.

Kidneys work to keep the electrolyte concentrations in blood constant

despite changes in your body. For example, during heavy exercise
electrolytes are lost through sweating, particularly sodium and potassium,
and sweating can increase the need for electrolyte (salt) replacement. It is
necessary to replace these electrolytes to keep their concentrations in the
body fluids constant.

Dehydration

There are three types of dehydration:

1. Hypotonic or hyponatremic (primarily a loss of electrolytes, sodium in

particular).

2. Hypertonic or hypernatremic (primarily a loss of water).

3. Isotonic or isonatremic (an equal loss of water and electrolytes).

4. Most common type of dehydration is isotonic (isonatremic) dehydration,

which effectively equates with hypovolemia; but the distinction of isotonic
from hypotonic or hypertonic dehydration may be important when treating
people with dehydration.

5. Physiologically, dehydration is both loss of water and solutes (mainly

sodium) and lost in roughly equal quantities since they exist in blood plasma.

6. In hypotonic dehydration, intravascular water shifts to the extravascular

space and exaggerates the intravascular volume depletion for a given
amount of total body water loss.

7. Neurological complications can occur in hypotonic and hypertonic states

and lead to seizures, and the latter can lead to osmotic cerebral edema upon
rapid rehydration.

8. In more severe cases, the correction of a dehydrated state is

accomplished by the replenishment of necessary water and electrolytes
(through oral rehydration therapy or fluid replacement by IV therapy).

9. As oral rehydration is less painful, less invasive, less expensive, and easier
to provide, it is the treatment of choice for mild dehydration.

Solutions used for IV rehydration must be isotonic or hypotonic. Fig. 3.3

illustrates the mechanism for the transportation of water and electrolytes
across the epithelial cells in the secretory glands.

1. Review Table 3.8.

HESI Hint

Most common type of dehydration is isotonic (isonatremic) dehydration,

which effectively equates with hypovolemia; but the distinction of isotonic
from hypotonic or hypertonic dehydration may be important when treating
people with dehydration.

Physiologically, dehydration is both loss of water and solutes (mainly sodium)

usually lost in roughly equal quantities as to how they exist in blood plasma.

HESI Hint

1. Hypotonic or hyponatremic (primarily a loss of electrolytes, sodium in

particular).

2. Hypertonic or hypernatremic (primarily a loss of water).

3. Isotonic or isonatremic (an equal loss of water and electrolytes).

Fluid Volume Deficit: Dehydration

• Fluid volume deficit (FVD) or hypovolemia (may be acute or chronic): fluid
output exceeds the fluid intake; the body loses both water and electrolytes
from the ECF in similar proportions.

• Common sources of fluid loss are the gastrointestinal tract, polyuria, and
increased perspiration.

• Risk factors for FVD: vomiting, diarrhea, GI suctioning, sweating, decreased

intake, nausea, inability to gain access to fluids, adrenal insufficiency,
osmotic diuresis, hemorrhage, coma, third-space fluid shifts, burns, ascites,
and liver dysfunction

• Appropriate management is vital to prevent potentially life-threatening

hypovolemic shock.

• Elderly patients are more likely to develop fluid imbalances.

• The goals of management are to treat the underlying disorder and return
the extracellular fluid compartment to normal, to restore fluid volume, and to
correct any electrolyte imbalances.

Causes of Fluid Volume Deficit

• Abnormal losses through the skin, GI tract, or kidneys.

• Decrease in intake of fluid (e.g., inability to intake fluid due to oral trauma)

• Bleeding

• Movement of fluid into third space

• Diarrhea

• Diuresis

• Abnormal drainage

• Inadequate fluid intake

• Increased metabolic rate (e.g., fever, infection)

Organ Function

A. Kidneys

1. Main function of the kidneys is to filter blood and adjust the amount and
composition of fluids in the body. The total blood volume is determined by a
client’s gender, height, and weight. The average healthy adult has
approximately 5.2 to 6 L of circulating blood in the body.
2. As a result of this filtration process, the kidney selectively maintains and
excretes body fluids, producing approximately 1 to 2 L of urine (30 mL/h).

FIG. 3.3 Cell electrolytes: Diagram illustrates the mechanism for the
transportation of water and electrolytes across the epithelial cells in the
secretory glands. From
[Link] License: CC BY:
Attribution.

A set of illustrations for sodium, electrolytes, and fluid balance are as

follows:Top-left: Resting state: No activity at 30 to 40 millivolts in
[Link]-right: Neural stimulation causes influx of chlorine anions and
millivolts rises by 10 to 20 millivolts to 40 to 60 [Link]-left:
Sodium cations follow down millivolts gradient to inside the cell at 30 to 40
millivolts and water follows osmosis (from outside to inside the cell) leading
to rise in intracellular pressure with chlorine anions, sodium cations, and
[Link]-right: Increased hydrostatic pressure opens apical ports
flushing water and electrolytes at 30 to 40 millivolts.

3. Regulates sodium and potassium levels and maintains the pH level by

excreting or maintaining hydrogen ions and bicarbonate.

4. Excretes metabolic wastes and toxic substances.

5. The kidneys are also responsible for manufacturing the hormone

erythropoietin (EPO) (Fig. 3.4).

B. Lungs

1. Regulate CO2 concentration as a result of O2 and CO2 gas exchange at

the alveolar capillary beds, thus influencing the acid-base balance.

2. Water loss via lung is affected by the external temperature and humidity.

during inspiration and expiration is ∼7 mL/h. When the parameters change,

At 35°C and humidity at 75%, respectively, the loss of water via the lung

for example, this can increase or decrease the lung excretion can change to
minus 10°C and 25% lung excretion of H(2)O increases up to 20 mL/h.
(Zieliński & Przybylski, 2012)

C. Heart

1. Pumps blood with sufficient force to perfuse the kidneys, allowing the
kidneys to work effectively.
2. Potassium, sodium, and calcium electrolyte levels are crucial in
maintaining adequate electrical conductivity to help with efficient myocardial
pumping action.

D. Adrenal glands

1. Secretes aldosterone, when the body’s BP becomes low, resulting in

sodium retention (leading to water retention), thereby increasing BP and
potassium excretion to maintain homeostasis.

TABLE 3.8

Fluid Volume

Variable Deficit Excess

Description

• Occurs when the body loses water and electrolytes isotonically—i.e., in the
same proportion as exists in the normal body fluid

• Serum electrolyte levels remain normal

• Dehydration: state in which the body loses water and serum sodium levels
increase

• Occurs when the body retains water and electrolytes isotonically

• Water intoxication: state in which the body retains water and serum sodium
levels decrease

Causes

• Vomiting

• Diarrhea

• Gastrointestinal suctioning

• Sweating

• Inadequate fluid intake

• Massive edema, as in initial stage of major burns

• Ascites

• Older adults forgetting to drink

• Heart failure (HF)

• Renal failure

• Cirrhosis, liver failure

• Excessive ingestion of table salt

• Over-hydration with sodium-containing fluid

• Poorly controlled intravenous (IV) therapy, especially in young and old

clients

Symptoms

• Weight loss (1 L of fluid weight loss or gain is approximately equal to 2.2

pounds or 1 kg)

• Decreased skin turgor

• Oliguria (concentrated urine)

• Dry and sticky mucous membranes

• Postural hypotension or weak, rapid pulse

• Peripheral edema

• Increased bounding pulse

• Elevated BP

• Distended neck and hand veins

• Dyspnea; moist crackles heard when lungs auscultated

• Attention loss, confusion, aphasia

• Altered level of consciousness

Laboratory findings

• Elevated blood urea nitrogen (BUN) and creatinine

• Increased serum osmolarity

• Elevated hemoglobin and hematocrit

• Decreased BUN

• Decreased hemoglobin and hematocrit

• Decreased serum osmolality

• Decreased urine osmolality and specific gravity

Treatment and nursing care

• Strict I&O

• Replacement of fluids isotonically, preferably orally

• Water is a hypotonic fluid.

• If intravenous hydration is needed, isotonic fluids are used.

• Diuretics

• Fluid restriction

• Strict I&O

• Sodium-restricted diet

• Weighed daily

• Serum K+ monitored

FIG. 3.4 Top: Kidney → normal EPO → normal number RBCs → normal O2.
Bottom: Damaged kidney → reduced EPO → fewer RBCs → reduced O2. EPO,
Erythropoietin; RBC, red blood cell. From Brugnara, C., & Eckardt, K. U.
[2011]. Hematologic aspects of kidney disease. In M. W. Taal [Ed.], Brenner
and Rector’s: The kidney [9th ed., pp. 2081–2120]. St. Louis: Saunders.
National Kidney and Urologic Diseases Information Clearinghouse from
National Institute of Diabetes and Digestive and Kidney Diseases.

Top: A set of illustrations show healthy kidney leading to normal E P O which

leads to normal number of red blood cells which results in normal oxygen.
Bottom: A set of illustrations show damaged kidney leading to reduced E P O
which leads to fewer red blood cells which results in reduced oxygen.

E. Parathyroid glands

1. Regulates calcium and phosphorus balance levels in blood by increasing or

decreasing the manufacture of parathyroid hormone, which influences
transference of calcium and phosphorous from the bones.

F. Pituitary gland
1. Secretes antidiuretic hormone (ADH), which causes the body to retain
water by signaling the kidneys to increase the water absorption when
filtering the blood.

Electrolyte Imbalance

Clinical Assessment

Refer to Table 3.9.

TABLE 3.9

Electrolyte Imbalances

Abnormalities and Common Causes Signs and Symptoms Treatment

Hyponatremia (↓ Na)

• Diuretics

• GI fluid loss

• Hypotonic tube feeding

• D5W or hypotonic IV fluids

• Diaphoresis

• Anorexia, nausea, vomiting

• Weakness

• Lethargy

• Confusion

• Muscle cramps, twitching

• Seizures

• Na <135 mEq/L

• Restrict fluids (safer).

• If IV saline solutions prescribed, administer very slowly; use isotonic saline

if fluid restriction not effective.

Hypernatremia (↑ Na)
• Water deprivation

• Hypertonic tube feeding

• Diabetes insipidus

• Heatstroke

• Hyperventilation

• Watery diarrhea

• Renal failure

• Cushing syndrome

• Thirst

• Hyperpyrexia

• Sticky mucous membranes

• Dry mouth

• Hallucinations

• Lethargy

• Irritability

• Seizures

• Na >145 mEq/L

• Restrict sodium (Na) in the diet.

• Beware of hidden Na in foods and medications.

• Increase water intake.

Hypokalemia (↓ K)

• Diuretics

• Diarrhea

• Vomiting

• Gastric suction

• Steroid administration

• Hyperaldosteronism
• Amphotericin B

• Bulimia

• Cushing syndrome

• Fatigue

• Anorexia

• Nausea, vomiting

• Muscle weakness

• Decreased GI motility

• Dysrhythmias

• Paresthesia

• Flat T waves on ECG

• K <3.5 mEq/L

• Administer potassium (K) supplements orally or IV.

• Oral forms of K are unpleasant tasting and are irritating to the GI tract (do
not give on empty stomach; dilute).

• Never give IV bolus; must be well diluted.

• Assess renal status (i.e., urinary output) before administering.

• Encourage foods high in K (e.g., bananas, oranges, cantaloupes, avocados,

spinach, potatoes).

Hyperkalemia (↑ K)

• Hemolyzed serum sample produces pseudohyperkalemia

• Oliguria

• Acidosis

• Renal failure

• Addison disease

• Multiple blood transfusions

• Muscle weakness
• Bradycardia

• Dysrhythmias

• Flaccid paralysis

• Intestinal colic

• Tall T waves on ECG

• K >5.0 mEq/L

• Eliminate parenteral K from IV infusions and medications.

• Administer 50% glucose with regular insulin.

• Administer cation exchange resin (Kayexalate).

• Monitor ECG.

• Administer calcium (Ca) gluconate to protect the heart.

• IV loop diuretics may be prescribed.

• Renal dialysis may be required.

Hypocalcemia (↓ Ca)

• Renal failure

• Hypoparathyroidism

• Malabsorption

• Pancreatitis

• Alkalosis

• Diarrhea

• Numbness

• Tingling of extremities

• Convulsions

• Positive Trousseau sign

• Positive sign

• Ca <8.5 mEq/L

• At risk for tetany

• Administer Ca supplements orally 30 min before meals.

• Administer Ca IV slowly; infiltration can cause tissue necrosis.

• Increase Ca intake (e.g., dairy products, greens).

Table Continued

Abnormalities and Common Causes Signs and Symptoms Treatment

Hypercalcemia (↑ Ca)

• Hyperparathyroidism

• Malignant bone disease

• Prolonged immobilization

• Excess Ca supplementation

• Muscle weakness

• Constipation

• Anorexia

• Nausea, vomiting

• Polyuria

• Polydipsia

• Neurosis

• Dysrhythmias

• Ca >10.5 mEq/L

• Eliminate parenteral Ca.

• Administer agents such as calcitonin to reduce Ca.

• Avoid CA-based antacids.

• Renal dialysis may be required.

Hypomagnesemia (↓ Mg)

• Alcoholism

• Malabsorption

• Diabetic ketoacidosis
• Prolonged gastric suction

• Diuretics

• Anorexia, distention

• Neuromuscular irritability

• Depression

• Disorientation

• Mg <1.5 mEq/L

• Administer MgSO4 IV.

• Encourage foods high in magnesium (Mg; e.g., meats, nuts, legumes, fish,
and vegetables).

Hypermagnesemia (↑Mg)

• Renal failure

• Adrenal insufficiency

• Excess replacement

• Flushing

• Hypotension

• Drowsiness, lethargy

• Hypoactive reflexes

• Depressed respirations

• Bradycardia

• Mg >2.5 mEq/L

• Avoid Mg-based antacids and laxatives.

• Restrict dietary intake of foods high in Mg.

Hypophosphatemia (↓ pH)

• Refeeding after starvation

• Alcohol withdrawal

• Diabetic ketoacidosis
• Respiratory alkalosis

• Paresthesias

• Muscle weakness

• Muscle pain

• Mental changes

• Cardiomyopathy

• Respiratory failure

• pH <2.0 mEq/L

• Correct underlying cause.

• Administer oral replacement of phosphates with vitamin D.

Hyperphosphatemia (↑ pH)

• Renal failure

• Excess intake of phosphorus

• Short-term: tetany symptoms

• Long-term: phosphorus precipitation in nonosseous sites

• pH >4.5 mEq/L

• Administer aluminum hydroxide with meals to bind phosphorus.

• Dialysis may be required if renal failure is underlying cause.

ECG, Electrocardiogram; GI, gastrointestinal; IV, intravenous.

Clinical Judgment Measures

Refer to Table 3.9.

HESI Hint

Potassium imbalances are potentially life threatening and must be corrected

immediately. A low magnesium level often accompanies a low potassium,
especially with the use of diuretics. Magnesium must be corrected to
normalize potassium.

Intravenous Therapy
Description: IV solutions are used to supply electrolytes, nutrients, and water
(Table 3.10).

Administration of IV Therapy

A. The purpose and duration of the IV therapy are determined by the

underlying condition/situation. This also determines the type of equipment,
such as vascular access device, including IV tubing and the size of the
catheter.

B. Types of vascular devices for IV administration

1. Peripheral

2. Central

C. Gloves must be worn during venipunctures and when discontinuing an IV

line.

D. Assess the IV and insertion site frequently (minimum of every 2 hours) for
the prescribed rate of infusion and for patency.

E. Intermittent IV therapy may be given through a saline lock; flushing per

facility policy.

F. IV tubing and dressing should be changed according to facility policy.

G. When the IV catheter is discontinued, apply pressure to the site for 1 to

3 minutes for peripheral lines and 5 to 10 minutes for central lines after the
catheter is removed (central lines are only removed by provider orders, and
nurses must be educated on removal to prevent air embolism), and inspect
the tip of the catheter to ensure it is intact; then document.

HESI Hint

For central line removal (central lines are only removed by provider orders
and nurses must be educated on removal to prevent air embolism), inspect
the tip of the catheter to ensure it is intact; then document.

TABLE 3.10

Types of IV Solutions

Isotonic Hypotonic Hypertonic

• Have an osmolality close to the extracellular fluid (ECF).

• Do not cause red blood cells to swell or shrink

• Indicated for intravascular dehydration

• Isotonic solutions

• → Normal saline (0.9% NS)

• → Lactated Ringer’s solution (LR)

• → 5% dextrose in water (D5W is on the low end of isotonic; some sources

classify it as hypotonic)

• Used to treat intravascular dehydration (not enough fluid in vascular

system)

• Common type of dehydration

• Examples: dehydration caused by running, labor, fever, etc.

• Have an osmolality lower than the ECF.

• Cause fluid to move from ECF to intracellular fluid (ICF).

• Indicated for cellular dehydration.

• Used in the management of the patient who is both volume depleted and
hyperosmolar (e.g., in cases of hypernatremia or hyperglycemia).

• Hypotonic solutions

• → 0.5% normal saline (HNS or 0.45% NS)

• → 2.5% dextrose in 0.45% saline (D2.5 45% NS)

• → 0.33 NaCl allows kidneys to retain needed amounts water

• → 0.225% NaCl most hypotonic fluid available

• → 2.5 dextrose in water (D2.5W) to treat dehydration and decrease sodium

and potassium levels

• Used to treat intracellular dehydration (cells have too many osmoles, need
to drive fluid into the cells).

• Not a common occurrence.

• Examples: dehydration caused by prolonged dehydration (may also see in

clients who are on total parenteral nutrition for prolonged periods)

• Have an osmolality higher than the ECF.

• Indicated for intravascular dehydration with interstitial or cellular over-
hydration.

• To be used with extreme caution.

• High concentrations of dextrose are given for caloric replacement such as

intravenous (IV) hyperalimentation into a central vein for rapid dilution.

• Hypertonic saline solutions are available but used only when serum
osmolality is dangerously low.

• Hypertonic solutions

• → 5% dextrose in lactated Ringer’s (D5LR)

• → 5% dextrose in 0.45% saline

• → 5% dextrose in 0.9% saline (D5NS)

• → 3% Na

• → 5% NaCl

• → 10% dextrose in water (D10W)

• → 20% dextrose in water (20W) acts as osmotic diuretic

• → 50% dextrose in water (50% DW)

• Used to treat intravascular dehydration with cellular or interstitial over-

hydration.

• Examples: dehydration resulting from surgery; blood loss causes

intravascular dehydration, but the tissue cuts inflame and pull fluid into the
area, causing interstitial over-hydration; may also see with ascites and third-
spacing

Flow Rate Calculation

Several formulas exist for calculating IV flow rates.

Infusion pumps are used when measurement of exact flow is necessary.

Using the following steps for IV calculation will ensure proper calculation:

1. mL/h: Total mL fluid to be given/Total hours to be administered = mL/h

(rate for IV infusions on a pump)

2. gtts/min: Total mL fluid to be given/Total minutes to be administered ×

gtts/mL = gtts/min (rate for IV infusions by gravity)
Complications Associated With IV Administration

Occlusion/catheter damage (Table 3.11)

A. Infection/phlebitis (Table 3.12)

HESI Hint

If an IV catheter is suspected as the causative factor of sepsis, the catheter

should be removed and blood cultures drawn and sent to the laboratory.

B. Dislodgment/migration/incorrect placement (Table 3.13)

C. Skin erosion/hematomas/scar tissue formation over

port/infiltration/extravasation (Table 3.14)

D. Pneumothorax/hemothorax/air emboli/hydrothorax (Table 3.15)

HESI Hint

Flushing a saline lock: Attach NS prefilled Luer lock syringe by twisting the
syringe to the positive pressure cap. Inject 3 to 5 mL of solution using
turbulent stop-start technique. Flush until visibly clear. Do not bottom out
syringe (leave 0.2 to 0.5 mL in the syringe).

Acid–Base Balance

Description: An acid–base balance must be maintained in the body because

alterations can result in alkalosis or acidosis.

A. Maintaining the acid–base balance is imperative and involves three

systems:

1. Chemical buffer system

2. Kidneys

3. Lungs

B. Acid–base balance is determined by the hydrogen ion concentration in

body fluids.

1. Normal range is 7.35 to 7.45 expressed as the pH (Fig. 3.5).

2. A pH level below 7.35 indicates acidosis.

3. A pH level above 7.45 indicates alkalosis.

4. Measurement is made by examining ABGs (Table 3.16).

Chemical Buffer System

Chemical buffers act quickly to prevent major changes in body fluid pH by

removing or releasing hydrogen ions. The buffer systems in the human body
are extremely efficient, and different systems work at different rates taking
seconds for the chemical buffers in the blood to make adjustments to pH.

TABLE 3.11

Occlusion/Catheter Damage

Assess for: Peripheral Central Interventions

Leaks around the insertion site X X Discontinue infusion; either

restart peripheral intravenous (IV) or notify physician about central line.

Pinholes, leaks, and tears X Discontinue infusion; then notify

physician about central line.

Blood return X X Gently flush and attempt to draw back blood.

Inability to infuse fluid X X Starting from the insertion site, double-

check for kinks in tubing or catheter.

Needleless adapter placement, if a port or IV catheter tip lodged against the

venous wallX X Reposition the client’s extremity for peripheral
catheter; for central catheter, reposition the client.

Pain in shoulder, neck, or arm X Discontinue the infusion and notify

physician about central line.

Neck or shoulder edema X Discontinue the infusion and notify

physician about central line.

Suture damage X Secure with a sterile transparent, self-adhesive

dressing and notify physician.

Do not use syringes less than a 10 mL to irrigate because the PSI would be
too high and possibly damage the catheter.

Do not irrigate forcefully.

TABLE 3.12

Infection/Phlebitis
Assess for: Peripheral Central Interventions

Insertion site for redness, drainage, edema, or tenderness X X

Peripheral IVs → Use aseptic and antiseptic techniques when starting an IV

line and when caring for IV site.

Central IVs → Use sterile technique when inserting and changing central
dressings.

Temperature X X Monitor temperature for fever.

Laboratory work X Monitor white blood cell (WBC) with differential

count/for central lines twice weekly.

IV fluids X Ensure parental IV fluids bags are changed out every

24 h or according to institution’s policy.

IV tubing X X Change IV tubing according to institution’s policy.

IV dressings X X Change IV dressings according to institution’s

policy; avoid getting dressing wet and/or soiled.

TABLE 3.13

Dislodgement/Migration/Incorrect Placement

Assessment: Site: Peripheral Site: Central Usual Interventions

Length of catheter X X

Provide tubing long enough for client movement.

Anchor the catheter to the client.

Measure and record length of catheter.

Discontinue the infusion and notify physician about probable dislodged

intravenous (IV) line.

Edema, drainage, and coiling of catheter X X

Neck distention or distended neck veins X X

Client complaints of gurgling sounds X X

Change in patency of catheter X X

Chest radiograph X X
Cardiac dysrhythmias

Hypotension

X X

TABLE 3.14

Skin Erosion/Hematomas/Scar Tissue Formation Over

Port/Infiltration/Extravasation

Assess for: Peripheral Central Interventions

Loss of tissue or separation at exit site X X

Dilute medications adequately.

Follow institutional protocol for administration of vesicant drugs.

Change intravenous (IV) line within the time frame outlined in institutional
protocol.

Provide gentle skin care at exit/insertion site.

Avoid selecting site over a joint.

Anchor the catheter well.

Drainage at exit site X X

Erythema and edema at exit site X X

Spongy feeling at exit site X X

Labored breathing X X

Complaints of pain X X

TABLE 3.15

Pneumothorax/Hemothorax/Air Emboli/Hydrothorax

Assess for: Peripheral Central Interventions

Subcutaneous emphysema X X

Use clot filters when infusing blood and blood products.

Avoid using veins in the lower extremities.

Prevent fluid containers from becoming empty.

Check valves and micropore filters on vented Y-type infusions or piggyback

infusions, which allow solutions to run simultaneously. Air may be introduced
into the line if the containers become empty.

If air embolism is suspected, place patient in left lateral Trendelenburg

position.

Chest pain X X

Dyspnea and hypoxia X X

TachycardiaX X

Hypotension X X

Confusion X X

Nausea X X

TABLE 3.16

Arterial Blood Gas Comparisons

Acid–Base Conditions pH PCO 2 (mm Hg) HCO 3 (mEq/L)

Normal 7.35–7.45 35–45 21–28

Respiratory acidosis ↓ ↑ Normal

Respiratory alkalosis ↑ ↓ Normal

Metabolic acidosis ↓ Normal ↓

Metabolic alkalosis ↑ Normal ↑

FIG. 3.5 Relationship of Sodium Bicarbonate to Carbonic Acid. From Potter, P.

A., & Perry, A. G. [2009]. Fundamentals of nursing [7th ed.]. St. Louis: Mosby.

An illustration of a balanced weighing scale shows respiratory with 1-part

carbonic acid marked at left and metabolic with 20 parts bicarbonate marked
at right. A double headed arrow at bottom of scale shows normal (7.35 to
7.45) marked at center, acidosis and death (6.8) marked from center to left,
and alkalosis (7.8) and death marked from center to right.

The respiratory tract can adjust the blood pH upward in minutes by exhaling
CO2 from the body.

The renal system can also adjust blood pH through the excretion of hydrogen
ions (H+) and the conservation of bicarbonate, but this process takes hours
to days to have an effect.

The buffer systems functioning in blood plasma include plasma proteins,

phosphate, and bicarbonate and carbonic acid buffers.

The kidneys help control acid–base balance by excreting hydrogen ions and
generating bicarbonate that helps maintain blood plasma pH within a normal
range. Protein buffer systems work predominantly inside cells.

A. The main chemical buffer is the bicarbonate–carbonic acid (HCO3-H2CO3)

system.

B. The bicarbonate-carbonic acid buffer works in a fashion similar to

phosphate buffers. The bicarbonate is regulated in the blood by sodium, as
are the phosphate ions. When sodium bicarbonate (NaHCO3) comes into
contact with a strong acid, such as HCl, carbonic acid (H2CO3), which is a
weak acid, and NaCl are formed. When carbonic acid comes into contact with
a strong base, such as NaOH, bicarbonate and water are formed.

1. With 20 times more bicarbonate than carbonic acid, this capture system is
most efficient at buffering changes that would make the blood more acidic.
This is useful because most of the body’s metabolic wastes, such as lactic
acid and ketones, are acids. Carbonic acid levels in the blood are controlled
by the expiration of CO2 through the lungs.

2. Excess CO2 in the body alters the ratio and creates an imbalance. Other
chemical buffers involve:

a. Phosphate

b. Protein

c. Hemoglobin

d. Plasma

Lungs
A. Control CO2 content through respirations (carbonic acid content).

B. Control, to a small extent, water balance (CO2 + H2O = H2CO3).

C. Release excess CO2 by increasing respiratory rate.

D. Retain CO2 by decreasing respiratory rate.

Kidneys

A. Regulate bicarbonate levels by retaining and reabsorbing bicarbonate as

needed.

B. Provide a very slow compensatory mechanism (can require hours or days).

C. Cannot help with compensation when metabolic acidosis is created by

renal failure.

Determining Acid–Base Disorders

A. In uncompensated acid-base disturbances:

B. Arrows are used to indicate whether the pH, PCO 2, or HCO3 is high (↑),
low (↓), or within normal limits (WNL) (←→).

C. When pH is high (↑), alkalosis is present.

D. In respiratory disorders, the HCO3 is normal, and the arrows for pH and
PCO 2 point in opposite directions. The tables should demonstrate the
arrows.

E. In metabolic disorders, the PCO 2 is normal, and the arrows for pH and
HCO3 point in the same direction or are equal (Table 3.17).

F. The body will begin to compensate in acid–base disorders to bring the pH

back within the normal range of 7.35 to 7.45 (Tables 3.18 and 3.19).

G. Example: for a client with a pH of 7.29 (↓), a PCO 2 of 50 (↑), and an

HCO3 of 28 (←→):

1. Determine the pH: acidosis.

2. Determine the PCO 2: respiratory.

3. Determine HCO3: not metabolic.

4. Respiratory acidosis is the disorder (Table 3.20).

TABLE 3.17
Analysis of Arterial Blood Gases

Component Description Values

pH

• Measures hydrogen ion (H+) concentration

• ↑ in ions (acidosis) reflects in pH

• ↓ in ions (alkalosis) reflects in pH

• 7.35–7.45

• <7.35

• >7.45

PCO 2

• Partial pressure of CO2 in arteries

• Respiratory component of acid-base regulation

• Hypercapnia/hypoventilation (respiratory acidosis)

• Hypocapnia/hyperventilation (respiratory alkalosis)

• 35–45 mm Hg

• >45 mm Hg

• <35 mm Hg

HCO3

• Measures serum bicarbonate

• May reflect primary metabolic disorder or compensatory mechanism to

respiratory acidosis

• Metabolic acidosis

• Metabolic alkalosis

• Normal 21–28 mEq/L

• <21 mEq/L

• >28 mEq/L
TABLE 3.18

Determining Respiratory vs. Metabolic and Acidosis vs. Alkalosis

(7.35–7.45) (35–45 mm Hg) (21–28 mEq/L)

R (+) pH (–) PaCO 2 Alkalosis

O (–) pH(+) PaCO 2 Acidosis

M (+) pH (+) HCO3 Alkalosis

E (–) pH(–) HCO3 Acidosis

TABLE 3.19

Determining Compensated or Partial Compensated or Uncompensated

pH → PaCO 2 → HCO3 → Compensation

Normal Abnormal Abnormal FULLY

Abnormal Abnormal Abnormal PARTIAL

Abnormal Normal Abnormal UNCOMPENSATED

Abnormal Abnormal Normal UNCOMPENSATED

TABLE 3.20

Potential Causes of Acid–Base Conditions

Condition Primary Cause Contributing Causes

Respiratory acidosis

• Hypoventilation

• COPD (primary cause)

• Pulmonary disease

• Drugs

• Obesity

• Mechanical asphyxia
• Sleep apnea

Metabolic acidosis

• Addition of large amounts of fixed acids to body fluids

• Lactic acidosis (circulatory failure)

• Ketoacidosis (diabetes, starvation)

• Phosphates and sulfates (renal disease)

• Acid ingestion (salicylates)

• Secondary to respiratory alkalosis

• Adrenal insufficiency

Respiratory alkalosis

• Hyperventilation

• Overventilation on a ventilator

• Response to acidosis

• Bacteremia

• Thyrotoxicosis

• Fever

• Hepatic failure

• Response to hypoxia

• Hysteria

Metabolic alkalosis

• Retention of base or removal of acid from body fluids

• Excessive gastric drainage

• Vomiting

• Potassium depletion (diuretic therapy)

• Burns

• Excessive NaHCO3 administration

5. Determine state of compensation: The client’s ABG reflects an
uncompensated state → indicating more interventions need to be
implemented (Biga et al., 2020).

HESI Hint

The acronym “ROME” can help you remember: Respiratory, Opposite,

Metabolic, Equal.

Review of Fluid and Electrolyte Balance

1. List four common causes of fluid volume deficit.

2. List four common causes of fluid volume overload.

3. Identify two examples of isotonic IV fluids.

4. List three systems that maintain acid–base balance.

5. Cite the normal ABGs for the following:

A. pH

B. PCO 2

C. HCO3

6. Determine the following acid–base disorders:

A. pH 7.50, PCO 2 30, HCO3 28

B. pH 7.30, PCO 2 42, HCO3 20

C. pH 7.48, PCO 2 42, HCO3 32

D. pH 7.29, PCO 2 55, HCO3 28

See Answer Key at the end of this text for suggested responses.

Electrocardiogram

Description: The visual representation of the electrical activity of the heart

reflected by changes in the electrical potential at the skin surface, which is a
record of the heart’s electrical events that precede them (Fig. 3.6).

A. The visual representation of an ECG can be recorded as a tracing on a

strip of graph paper or seen on an oscilloscope.
FIG. 3.6 Electrocardiogram (ECG) and Cardiac Electrical Activity(A) Normal
electrical conductivity of the heart (B) Normal electrical intervals for atrial
and ventricular conductivity (C) Schematic of atrial and ventrical electrical
conductivity of the heart. From Ignatavicius, D. D., & Workman, M. L. [2020].
Medical surgical nursing: Patient-centered collaborative care [10th ed.]. St.
Louis: Saunders. A and B, From Patton, K. T., & Thibodeau, G. A. [2020].
Anatomy and physiology. St. Louis: Mosby.

A) E C G deflections: The horizontal axis represents time and vertical axis

represents voltage. The E C G shows the following deflections: P or atrial
depolarization, followed by Q R S segment as ventricular depolarization (and
atrial repolarization) and T or ventricular repolarization (0.4, 0.15). The.B) E C
G intervals:The horizontal axis represents time and vertical axis represents
voltage. The E C G shows the following intervals: P R interval is from 0.12 to
0.20 seconds; Q T interval is under 0.38; Q R S interval is under 0.10
seconds; and S T segment consists of the short plateau between S and T.C)
An illustration of longitudinal section of heart shows R A with S A node
pointing at P wave of E C G tracing, A V node pointing at P R interval, R V and
L V pointing at Q R S segment (depolarization) and T wave (repolarization).

B. The following conditions can interfere with normal heart functioning:

1. Disturbances of rate or rhythm

2. Disorders of conductivity

3. Enlarged heart chambers

4. Presence of MI

5. Fluid and electrolyte imbalances

C. Each ECG should include identifying information:

1. Patient’s name and identification number

2. Location, time, and date of recording

3. Age, gender, and current cardiac and noncardiac medications

4. Height, weight, and BP

5. Clinical diagnosis and current clinical status

6. Any unusual position of the client during the recording

7. If present, thoracic deformities, respiratory distress, and muscle tremor

HESI Hint

Blood flow through the heart:

An illustrative flowchart shows circulatory system as follows:• From heart’s

right atrium deoxygenated blood flows through right A V valve, right
ventricle, and pulmonary S L valve to pulmonary artery which carries it to
lungs.• In lungs arteries carrying deoxygenated blood branches into
arterioles followed by capillaries from where oxygenated blood is carried by
venules which converge to form veins which joins pulmonary veins.• In heart
pulmonary veins carry oxygenated blood to left atrium from where blood
flows through left AV valve, left ventricle, and aortic S L valve to aorta.•
Aorta divides into arteries of each organ followed by branching into arterioles
of each organ and capillaries of each organ.• Deoxygenated blood from
capillaries of each organ is carried by venules of each organ which forms
veins of each organ and later merge into vena cava which carries the
deoxygenated blood to right atrium.

Right-sided heart failure → edema of periorbital, extremities, ascites

Left-sided heart failure leads to congestive heart failure → pulmonary

edema/muffled heart sounds (From Patton, K. T., Thibodeau, G. A. [2022].
Anatomy and physiology [11th ed.]. St. Louis: Mosby.)

Superior/inferior VENA CAVA (unoxygenated)→Right ATRIUM→(Tricuspid

Valve)→Right VENTRICLE→(Pulmonic Valve) Pulmonary Artery→LUNGS (gas
exchanged at alveoli—oxygenated)→Left ATRIUM→(Mitral Valve)→Left
VENTRICLE→(Aortic Valve)→Aorta

Review the three structures that control the one-way flow of blood through
the heart:

Atrioventricular valves

Tricuspid (right side)

Mitral (left side)

Semilunar valves

Pulmonic (in pulmonary artery)

Aortic (in aorta)

Chordae tendineae
Papillary muscles

D. The standard ECG is the 12-lead ECG.

E. Bedside monitoring through telemetry is more commonly seen in the

clinical setting.

1. Telemetry uses three or five leads transmitted to an oscilloscope.

2. Graphic information is printed either on request or at any time the set

parameters are transcended.

F. A portable continuous monitor (Holter monitor) can be placed on the client

to provide a magnetic tape recording. While wearing a Holter monitor, the
client is instructed to keep a diary concerning:

1. Activity

2. Medications

3. Chest pains

G. The ECG graph paper consists of small and large squares (Fig. 3.7).

1. The small squares represent 0.04 second each; five of these small squares
combine to form one large square.

2. Each large square represents 0.20 second (0.04 second × 5). Five large
squares represent 1 second. Calculation of heart rate uses the 6-second rule
(Box 3.5):

a. Easiest means of calculating the heart rate.

b. This cannot be used when the heart rate is irregular.

c. Thirty large squares equal one 6-second time interval.

d. Count the number of RR intervals in the 30 large squares and multiply by

10 to determine the heart rate for 1 minute (the R is the high peak on the
strip; Fig. 3.8, Box 3.5).

H. Composition of the ECG: normal ECG contains waves, intervals, segments,

and one complex, as defined below. Wave: A positive or negative deflection
from baseline that indicates a specific electrical event. The waves on an ECG
include the P wave, Q wave, R wave, S wave, T wave, and U wave.

1. P wave: atrial systole

a. Represents depolarization of the atrial muscle.

b. Should be rounded and without peaking or notching

2. QRS complex: ventricular systole

a. Represents depolarization of the ventricular muscle.

b. Normally follows the P wave.

c. Is measured from the beginning of the QRS to the end of the QRS
(normal <0.12 second).

d. T wave: ventricular diastole

1. Represents repolarization of the ventricular muscle.

2. Follows the QRS complex.

3. Usually is slightly rounded, without peaking or notching.

HESI Hint

The T wave represents repolarization of the ventricle, so this is a critical time

in the heartbeat. This action represents a resting and regrouping stage so
that the next heartbeat can occur. If defibrillation occurs during this phase,
the heart can be thrust into a life-threatening dysrhythmia.

3. ST segment

a. Represents early ventricular repolarization.

b. Is measured from the end of the S wave to the beginning of the T wave.

4. PR interval

a. Represents the time required for the impulse to travel from the atria
(sinoatrial node), through the atrioventricular (AV) node, to the Purkinje
fibers in the ventricles.

b. Is measured from the beginning of the P wave to the beginning of the QRS
complex.

c. Represents AV nodal function (normal 0.12 to 0.20 second).

5. U wave

a. Is not always present.

b. Is most prominent in the presence of hypokalemia.

6. QT interval
a. Represents the time required to completely depolarize and repolarize the
ventricles.

b. Is measured from the beginning of the QRS complex to the end of the T
wave.

7. RR interval

a. Reflects the regularity of the heart rhythm.

b. Is measured from one QRS to the next QRS.

FIG. 3.7 Composition of Electrocardiogram (ECG) [Link] ECG’s

waveforms are measured in amplitude (voltage) and duration (time). From
Ignatavicius, D. D., & Workman, M. L. [2020]. Medical-surgical nursing:
Patient-centered collaborative care [10th ed.]. St. Louis: Saunders.

An electrocardiogram plotting amplitude (voltage) at vertical axis and

Duration (time) at horizontal axis shows a typical E C G tracing. The
electrocardiogram is followed by an enlarged view of a square containing 5
columns and 5 rows with vertical axis measuring 5 millimeters equal to 0.5
millivolts and horizontal axis measuring 5 millimeters equal to 0.20 seconds.
The grid square is followed by a single square with vertical axis measuring 1
millimeter equal to 0.1 millivolts and horizontal axis measuring 1 millimeter
equal to 0.04 seconds.

BOX 3.5 Methods of Estimating Heart Rate Using an Electrocardiogram

Tracing

1. Measure the interval between consecutive QRS complexes, determine the

number of small squares, and divide 1500 by that number. This method is
used only when the heart rhythm is regular.

2. Measure the interval between consecutive QRS complexes, determine the

number of large squares, and divide 300 by that number. This method is
used only when the heart rhythm is regular.

3. Determine the number of RR intervals within 6 s and multiply by 10. The

electrocardiogram paper is conveniently marked at the top with slashes that
represent 3-s intervals. This method can be used when the rhythm is
irregular. If the rhythm is extremely irregular, an interval of 30 to 60 s should
be used.
4. Count the number of big blocks between the same point in any two
successive QRS complexes (usually R wave to R wave) and divide into 300
because there are 300 big blocks in 1 min. It is easiest to use a QRS that falls
on a dark line. If little blocks are left over when counting big blocks, count
each little block as 0.2, add this to the number of big blocks, and then divide
by 300.

5. The memory method relies on memorization of the following sequence:

300, 150, 100, 75, 60, 50, 43, 37, 33, 30. Find a QRS complex that falls on
the dark line representing 0.2 s or a big block, and count backward to the
next QRS complex. Each dark line is a memorized number. This is the
method most widely used in hospitals for calculating heart rates for regular
rhythms.

6. Calculation of heart rate. In this example, the heart rate using the big
block method is 300 divided by four big blocks (between QRS complexes), or
75 beats/min. The memory method is also demonstrated with a heart rate of
75 beats/min.

Figure from Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical

nursing: Patient-centered collaborative care (7th ed.). St. Louis: Saunders.
Data from Monahan, F. D., Sands, J. K., Neighbors, M., Marek, J. F., & Green-
Nigro, C. J.. (2007). Phipps’ medical-surgical nursing: Health and illness
perspectives (8th ed.). St. Louis:Mosby; Ignatavicius, D. D., & Workman, M. L.
(2013). Medical-surgical nursing: Patient-centered collaborative care (7th
ed.). St. Louis: Saunders.

FIG. 3.8 The Cardiac Conduction System. From Ignatavicius, D. D., &
Workman, M. L. [2020]. Medical-surgical nursing: Patient-centered
collaborative care [10th ed.]. St. Louis: Saunders.

An illustration of longitudinal section of heart shows labels from top to

bottom as follows: S A node, A V node, bundle of His, right bundle branch,
left bundle branches, and Purkinje fibers. An E C G tracing at right shows
following components from left to right: P wave, P R segment or interval, Q R
S complex, S T segment, Q T interval, and T wave. Atriums point at P wave,
bundle of His points at P R segment, and ventricle part points at Q R S
complex.

HESI Hint
Observe the patient for tolerance of the current rhythm. This information is
the most important data the nurse can collect on a patient with an
arrhythmia.

HESI Hint

NGN-NCLEX-RN questions are likely to relate to early recognition of

abnormalities and associated clinical actions. Remember to monitor the
patient as well as the machine! Feel the pulse! Listen to the heart. Evaluate
the blood pressure. If the ECG monitor shows a severe dysrhythmia but the
client is sitting up quietly watching television without any sign of distress,
assess to determine whether the leads are attached properly.

Review of Electrocardiogram

1. Identify the waveforms found in a normal ECG.

2. In an ECG reading, which wave represents depolarization of the atrium?

3. In an ECG reading, what complex represents depolarization of the

ventricle?

4. What does the PR interval represent?

5. If the U wave is most prominent, what condition might the nurse suspect?

6. Describe the calculation of the heart rate using an ECG rhythm strip.

7. What is the most important assessment data for the nurse to obtain in a
client with an arrhythmia?

8. Calculate the rate of this rhythm strip.

See Answer Key at the end of this text for suggested responses.

Perioperative Care

Description: The perioperative period includes client care before surgery

(preoperative), during surgery (intraoperative), and after surgery
(postoperative).

A. The nurse’s role is to

1. Educate and advocate

2. Reduce anxiety

3. Promote an uncomplicated perioperative period for the client and family

B. Surgery is performed under aseptic conditions in either a hospital or an
alternative hospital setting (ambulatory surgical center or healthcare
provider’s office).

C. Patient safety is a serious concern during the perioperative period. Steps

should be implemented to ensure safety. Surgical risk factors refer to
Table 3.21.

Preoperative Care

Description: Care provided from the time the client and family make the
decision to have surgery until the client is taken to the operative suite

Data to Obtain When Taking a Preoperative Clinical History

A. Age

B. Allergies to medications, foods, and topical antiseptics (iodine, betadine,

hibiclens)

C. Current medications: prescriptions, over-the-counter, and herbal

preparations (Box 3.6)

D. History of medical and surgical problems of the patient and immediate

family members

E. Previous surgical experiences

F. Previous experience with anesthesia

G. Tobacco, alcohol, and drug abuse

H. Understanding of surgical procedure and risks involved

I. Coping resources

J. Cultural and ethnic factors that may affect surgery (Box 3.6)

Key Components of Preoperative Teaching Plans

A. Regulations concerning valuables, jewelry, dentures, and hearing aids.

B. Food and fluid restrictions such as nothing by mouth (NPO) timing or

exceptions per prescription by healthcare provider.

C. Invasive procedures such as urinary catheters, IVs, nasogastric (NG)

tubes, enemas, and vaginal preparations.

D. Preoperative medications
E. OR, transportation, skin preparation, postanesthesia

From Ignatavicius, D. D., & Workman, M. L. [2013]. Medical-surgical clinical:

Patient-centered collaborative care [7th ed.]. St. Louis: Saunders.

TABLE 3.21

Surgical Risk Factors

Age The very young and very old are greater surgical risks than children
and adults.

Nutrition Obesity and malnutrition increase surgical risk.

Fluid and Electrolyte Dehydration and hypovolemia increase surgical risk

because of imbalances in calcium, magnesium, potassium, and phosphorus.

General Health:

Any infection or pathology increases surgical risk.

1. Cardiac conditions: Angina, MIs, hypertension, heart failure; well-controlled

cardiac problems pose little risk.

2. Blood coagulation disorders can lead to severe bleeding, hemorrhage, and

shock.

3. Upper respiratory tract infections (surgery is usually delayed when the

client has an upper respiratory infection) and COPD are exacerbated by
general anesthesia and adversely affect pulmonary function.

4. Renal disease, such as a renal insufficiency, impairs fluid and electrolyte

regulation.

5. Uncontrolled diabetes mellitus predisposes clients to wound infection and

delayed healing.

6. Liver disease impairs the liver’s ability to detoxify medications used during
surgery to produce prothrombin or to metabolize nutrients for wound
healing.

7. Obesity exacerbates risk.

Medications (prescribed and OTCs)

1. Anticoagulants (increase blood coagulation time)

2. Tranquilizers (may cause hypotension)

3. Heroin (decreases CNS response)

4. Antibiotics (may be incompatible with anesthetics)

5. Diuretics (may precipitate electrolyte imbalance)

6. Steroids

7. Over-the-counter herbal preparations

8. Vitamin E

BOX 3.6 Factors Affecting Patterns of Disease

Ethnic group (may be less relevant in multiethnic cultures)

Gender

Socioeconomic factors and lifestyle considerations

Lifestyle decisions

Geographic location

Age (place in the life cycle; i.e., infant, adult, older adult). Data from
Copstead, L.-E., & Banasik, J. (2014). Pathophysiology (5th ed.). St. Louis:
Saunders.

F. Postoperative procedures:

1. Respiratory care, such as ventilator, incentive spirometer, deep breather,

splinting.

2. Activity, such as range of motion, leg exercises, early ambulation, turning.

3. Pain control, such as IM medications, patient-controlled analgesia (PCA)

4. Dietary restrictions

5. ICU or postanesthesia care unit (PACU) orientation (recovery room).

Preoperative Checklist Information

A. Informed consent, surgical consent, signed by the surgeon and the client,
and witnessed by the nurse. Consent to treatment must be obtained before
administration of any narcotics or other medications affecting the client’s
cognition. (Follow facility policy for consent validity).
B. Site is marked by the person performing surgery. Before the incision is
initiated, all team members confirm identity, procedure, site of surgery, and
consents.

C. History and physical examination (by healthcare provider) are noted in

chart with validity per facility policy.

D. Preop lab or diagnostic tests completed as ordered.

E. Identification band is on client and allergies are noted.

F. Contact lenses, glasses, dentures, partial plates, wigs, jewelry, artificial

eyes, prostheses, makeup, and nail polish have been removed per facility
policy or as prescribed by healthcare provider.

G. Client has voided or been catheterized.

H. Client is in hospital gown.

I. Vital signs: BP, temperature, pulse, and respirations have been taken.

J. Premedications, including antibiotics, have been given; types and times

have been noted.

K. Skin preparation has been performed (if prescribed by healthcare provider

or physician):

Based on facility policy

L. Vital signs completed.

M. Signature of nurse certifies completion of list.

HESI Hint

Marking the operative site is required for procedures involving right/left

distinctions, multiple structures (fingers, toes), and levels (spinal
procedures). Site marking should be done with the involvement of the client.

Intraoperative Care

Description: From the time the client is received in the operative suite until
admission to the PACU, an OR nurse is in charge of care.

A. Maintain quiet during induction.

B. Maintain safety:
1. Conduct client identification: right client, right procedure, and right
anatomic site.

2. Ensure that sponge, needle, and instrument counts are accurate. Counts
are to be done and verified and documented by two personnel before,
during, before closing incision(s), and end of the surgery.

3. Position client during procedure to prevent injury.

4. Strictly adhere to asepsis during all intraoperative procedures.

5. Ensure adequate functioning suction setups are in place.

6. Take responsibility for correct labeling, handling, and deposition of any and
all specimens.

C. Monitor physical status.

1. If excessive blood loss occurs, calculate effect on client.

2. Report changes in pulse, temperature, respirations, and BP to surgeon, in

conjunction with anesthesiologist/certified registered nurse anesthetist
(CRNA).

3. Positioning the patient is a critical part of every procedure and usually

follows administration of the anesthetic.

D. Provide psychological support:

1. Provide emotional support to client and family immediately before, during,

and after surgery.

2. Arrange with physician to provide information to the family if surgery is

prolonged or complications or unexpected findings occur.

3. Communicate emotional state of client to other healthcare team

members.

Postoperative Care

Description: From admission to discharge or until client has recovered

A. Initially, the patient may go PACU.

B. On arrival, the client is assessed for vital signs (BP, pulse, respirations,
temperature), level of consciousness, skin color and condition, dressing
location and condition, IV fluids, drainage tubes, position, and O2 saturation
levels.
C. When client has been stabilized, and it has been prescribed by the
healthcare provider, the client is then discharged or transferred to the
general clinical unit or the ICU.

D. Immediate postoperative clinical care should include:

1. Monitoring for signs of shock and hemorrhage: hypotension, narrow pulse

pressure, rapid weak pulse, cold moist skin, increased capillary filling time,
and decreased urine output (Table 3.22)

2. Positioning client on side (if not contraindicated) to prevent aspiration and

to allow client to cough out airway; side rails should be up at all times

3. Providing warmth with heated blanket

4. Managing nausea and vomiting with antiemetic drugs and NG suctioning

5. Managing pain with IV analgesics (Table 3.26).

6. Checking with anesthesiologist about intraoperative medications before

administering pain medications

7. Determining intraoperative irrigations and instillations with drains to help

evaluate amount of drainage on dressing and in drainage collection devices

TABLE 3.22

Common Postoperative Complications

Postoperative Complication Occurrence Interventions for Prevention

Urinary retention 8–12 h postoperatively

• Monitor hydration status and encourage oral intake if allowed.

• Offer bedpan or assist to commode.

Pulmonary problems

• Atelectasis

• Pneumonia

• Embolus

1–2 days postoperatively

• Assist client to turn, cough, deep breathe every 2 h.

• Keep client hydrated.

• Enable early ambulation.

• Provide early incentive spirometer.

Wound-healing problems 5–6 days postoperatively

• Teach splinting of incision when client coughs.

• Monitor for signs of infection, malnutrition, and dehydration.

• Provide high-protein diet.

Urinary tract infections 5–8 days postoperatively

• Oral fluid intake.

• Emptying of bladder every 4–6 h.

• Monitor intake and output.

• Avoid catheterization if possible.

Thrombophlebitis 6–14 days postoperatively

• Leg exercises every 8 hr while in bed.

• Early ambulation.

• Apply antiembolic (TED) stockings or sequential compression devices as

prescribed; remove TEDs every 8 h and reapply.

• Avoid pressure that may obstruct venous flow; do not raise knee gatch on
bed; do not place pillows beneath knees; client should avoid crossing legs at
knees.

• Low-dose heparin may be used prophylactically.

Decreased gastrointestinal peristalsis

• Constipation

• Paralytic ileus

2–4 days postoperatively

• Nasogastric tubing to decompress gastrointestinal tract.

• Client to limit use of narcotic analgesics, which decrease peristalsis.

• Encourage early ambulation.

8. Most PACU settings use a scoring system to determine whether the client
meets the criteria to be discharged from the PACU.

9. Handoff report should be in an SBAR ∗ format:

HESI Hint

Wound dehiscence is separation of the wound edges; it is more likely to

occur with vertical incisions. Wound dehiscence usually occurs after the early
postoperative period, when the client’s own granulation tissue is “taking
over” the wound, after absorption of the sutures has begun. Evisceration of
the wound is protrusion of intestinal contents (in an abdominal wound) and is
more likely in clients who are older, diabetic, obese, or malnourished, and
who have prolonged paralytic ileus. Good.

HESI Hint

NGN-NCLEX-RN items may focus on the nurse’s role in terms of the entire
perioperative process.

Example: A 43-year-old mother of two teenage daughters enters the hospital

to have her gallbladder removed in a same-day surgery using an endoscope
instead of an incision. What clinical needs will dominate each phase of her
short hospital stay?

Preparation phase: education about postoperative care, including NPO,

assistance with meeting family needs

Operative phase: assessment, management of the operative suite

Postanesthesia phase: pain management, postanesthesia precautions

Postoperative phase: prevention of complications, assessment for pain

management, and teaching about dietary restrictions and activity levels

HESI Hint

NGN-NCLEX-RN items may focus on delivery of safe effective care.

Time Out, and Hand-Off (SBAR) communication are all best practices
implemented to prevent serious medical error during the perioperative
period. Time Out occurs before making the incision, and the entire surgical
team pauses as the surgical site listed on the consent is read aloud. The
entire team confirms that this information is correct. The Hand-Off (SBAR)
communication is the transfer of relevant patient information during the
perioperative period, which is standardized and must include an opportunity
to ask and to respond to questions.

Review of Perioperative Care

1. List five variables that increase surgical risk.

2. Why is a client with liver disease at increased risk for operative

complications?

3. Preoperative teaching should include demonstration and explanation of

expected postoperative client activities. What activities should be included?

4. What items should the nurse assist the client in removing before surgery?

5. How is the client positioned in the immediate postoperative period, and

why?

6. List three nursing judgment measures that prevent postoperative wound

dehiscence and evisceration.

7. Identify three nursing judgment measures that prevent postoperative

urinary tract infections.

8. Identify nursing judgment measures that prevent postoperative paralytic

ileus.

9. List four nursing judgment measures that prevent postoperative

thrombophlebitis.

10. During the intraoperative period, what activities should the OR nurse
perform to ensure safety during surgery?

11. How is handoff given?

See Answer Key at the end of this text for suggested responses.

HIV Infection

Description: Infection with human immunodeficiency virus (HIV). The

infection is a blood-borne pathogen. Exposure to this blood pathogen is
generally acquired through contact of infected blood or blood products,
unprotected sex with an infected individual, or fetal exposure from an
infected mother through placental transmission or exposure of maternal
bodily fluids during birth. In the United States, according to the Centers for
Disease Control (CDC) an estimated 1.2 million people in the United States
had HIV at the end of 2018, the most recent year for which this information is
available. Of those people, about 14%, or 1 in 7, did not know they had HIV.
HIV is a virus that attacks the body’s immune system. If HIV is not treated, it
can lead to acquired immunodeficiency syndrome (AIDS) (see Box 3.5).

Unfortunately, HIV cannot be cured; however, with proper medication people

with HIV can have a productive and long life. Additionally, as long as the
person with HIV is compliant their partners can be protected from HIV
infection. By taking antiretroviral therapy or ART, people with HIV can live
longer and prevent transmitting HIV to their sexual partners. In addition,
there are effective methods to prevent getting HIV through sex or drug use,
including pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis
(PEP).

A. Since HIV is caused by a retrovirus, it is the retrovirus that destroys CD4

cells or T helper cells which assist the immune system to stay healthy. It is
the CD4 cells that keep people healthy and protect them from disease.

B. Once the retrovirus enters the cell it begins to copy CD4+ T-cells, which
are the major catalysts for cellular and humoral immune responses against
exogenous antigens. CD4+ T-cells remain stable by homeostatic
mechanisms. HIV binds to the CD4 molecule and replicates on the surface of
helper T-cells. This causes the destruction of CD4+ T-cells, which leads to a
decrease in the population of T-cells.

C. The destruction of the CD4 T-cell causes depletion in the number of CD4 T-
cells and a loss of the body’s ability to fight infection. Individuals with fewer
than 200 cells/mm3, which is one indication for the diagnosis of AIDS, are at
risk for opportunistic infections. In adults, a normal CD4 cell count ranges
from 500 to 1200 cells/mm 3 (0.64 to 1.18 × 109/L). Normal value ranges
may vary slightly among different laboratories. Some labs use different
measurements or test different samples (Diao et al., 2020).

TABLE 3.23

Stages of HIV

Stage Description and Symptoms

Primary infection (acute HIV infection or acute HIV syndrome)

CD4 T-cell counts of at least 800 cells/mm3

• Flu-like symptoms, fever, malaise

• Mononucleosis-like illness, lymphadenopathy, fever, malaise, rash

• Symptoms usually occur within 3 weeks of initial exposure to HIV, after

which the person becomes asymptomatic

HIV asymptomatic (CDC Category A)

CD4 T-cell counts more than 500 cells/mm3

• No clinical problems

• Characterized by continuous viral replication

• Can last for many years (10 years or longer)

HIV symptomatic (CDC Category B)

CD4 T-cell counts between 200 and 499 cells/mm3

• Persistent generalized lymphadenopathy

• Persistent fever

• Weight loss, diarrhea

• Peripheral neuropathy

• Herpes zoster

• Candidiasis

• Cervical dysplasia

• Hairy leukoplakia, oral

Acquired immunodeficiency syndrome (CDC Category C)

CD4 T-cell counts less than 200 cells/mm3

• Occurs when a variety of bacteria, parasites, or viruses overwhelm the

body’s immune system

• Once classified as Category C, the patient remains classified as Category C;

this has implications for entitlements (e.g., health benefits, housing, food
stamps).

CDC, Centers for Disease Control; HIV, human immunodeficiency virus.

D. Individuals experiencing an acute infection includes fever,
lymphadenopathy, and sore throat (Table 3.23), which are also symptoms of
acute HIV and referral for testing is suggested.

Complications

HIV infection weakens your immune system, making you much more likely to
develop many infections and certain types of cancers.

Infections Common to HIV/AIDS

• Pneumocystis pneumonia (PCP). This fungal infection can cause severe

illness. Although it has declined significantly with current treatments for
HIV/AIDS, in the United States PCP is still the most common cause of
pneumonia in people infected with HIV.

• Candidiasis (thrush). Candidiasis is a common HIV-related infection. It

causes inflammation and a thick, white coating on your mouth, tongue,
esophagus, or vagina.

• Tuberculosis (TB). In resource-limited nations, TB is the most common

opportunistic infection associated with HIV. It's a leading cause of death
among people with AIDS.

• Cytomegalovirus (CMV). This common herpes virus is transmitted in body

fluids such as saliva, blood, urine, semen, and breast milk. A healthy immune
system inactivates the virus, and it remains dormant in your body. If your
immune system weakens, the virus resurfaces—causing damage to your
eyes, digestive tract, lungs, or other organs.

• Cryptococcal meningitis. Meningitis is an inflammation of the membranes

and fluid surrounding your brain and spinal cord (meninges). Cryptococcal
meningitis is a common central nervous system infection associated with
HIV, caused by a fungus found in soil.

• Toxoplasmosis. This potentially deadly infection is caused by Toxoplasma

gondii, a parasite spread primarily by cats. Infected cats pass the parasites in
their stools, which may then spread to other animals and humans.
Toxoplasmosis can cause heart disease, and seizures occur when it spreads
to the brain.

Cancers Common to HIV/AIDS

• Lymphoma. This cancer starts in the white blood cells. The most common
early sign is painless swelling of the lymph nodes in your neck, armpit or
groin.

• Kaposi’s sarcoma. A tumor of the blood vessel walls, Kaposi's sarcoma

usually appears as pink, red, or purple lesions on the skin and mouth. In
people with darker skin, the lesions may look dark brown or black. Kaposi’s
sarcoma can also affect the internal organs, including the digestive tract and
lungs.

Other Complications

• Wasting syndrome. Untreated HIV/AIDS can cause significant weight loss,

often accompanied by diarrhea, chronic weakness, and fever.

• Neurological complications. HIV can cause neurological symptoms such as

confusion, forgetfulness, depression, anxiety, and difficulty walking. HIV-
associated neurocognitive disorders (HANDs) can range from mild symptoms
of behavioral changes and reduced mental functioning to severe dementia
causing weakness and inability to function.

• Kidney disease. HIV-associated nephropathy (HIVAN) is an inflammation of

the tiny filters in your kidneys that remove excess fluid and wastes from your
blood and pass them to your urine. It most often affects black or Hispanic
people.

• Liver disease. Liver disease is also a major complication, especially in

people who also have hepatitis B or hepatitis C.

E. Initially, an individual commonly experiences an acute infection that

includes fever, lymphadenopathy, and sore throat (see Table 3.23), which are
also symptoms of acute HIV. Healthcare providers can refer clients and
recommend access to laboratory-based follow-up or immediate testing with
point-of-care tests performed on finger-stick whole blood or oral secretions or
immediate HIV repeat testing with an additional HIV point-of-care test.

F. No HIV test can detect HIV immediately after infection. If there has been
an exposure to HIV in the last 72 hours, discuss PEP.

G. The time between when a person gets HIV and when a test can accurately
detect it is called the window period. The window period varies from person
to person and also depends on the type of HIV test.

H. Initial symptoms may occur 2 to 4 weeks post–first exposure to HIV, after

which the person becomes asymptomatic. Persons infected with HIV can
transmit the virus to others any time after infection has occurred, whether
they are symptomatic or asymptomatic. CDC tracks HIV diagnoses among
racial and ethnic groups such as American Indian/Alaska Native, Asian,
Black/African American, Hispanic/Latino, Native Hawaiian and other Pacific
Islander, White, and multiracial people. The CDC site that is most helpful is
[Link]

I. Nucleic Acid Test (NAT)—A NAT can usually tell you if you have HIV infection
10 to 33 days after exposure.

J. Antigen/Antibody Test—An antigen/antibody test performed by a laboratory

on blood from a vein can usually detect HIV infection 18 to 45 days after
exposure. Antigen/antibody tests done with blood from a finger prick take
longer to detect HIV (18 to 90 days after an exposure).

K. Antibody Test—An antibody test can take 23 to 90 days to detect HIV

infection after an exposure. Most rapid tests and self-tests are antibody tests.
In general, antibody tests that use blood from a vein detect HIV sooner after
infection than tests done with blood from a finger prick or with oral fluid.

L. Current CDC definition of acquired immunodeficiency syndrome (AIDS;

end-stage infection). According to the CDC definition, a patient has AIDS if
they are infected with HIV and have a CD4+ T-cell count below 200 cells/μL,
a CD4+ T-cell percentage of total lymphocytes of less than 14%, or one of
the defining illnesses.

A high viral load is generally considered about 100,000 copies, but you could
have 1 million or more. The virus is at work making copies of itself, and the
disease may progress quickly. A lower HIV viral load is below 10,000 copies
(HIV testing Overview, [Link] 2020)

When people with HIV don’t get treatment, they typically progress through
three stages. But HIV medicine can slow or prevent progression of the
disease. With the advancements in treatment, progression to Stage 3 is less
common today than in the early days of HIV. Untreated, HIV typically turns
into AIDS in about 8 to 10 years. When AIDS occurs, your immune system
has been severely damaged. You'll be more likely to develop opportunistic
infections or opportunistic cancers—diseases that wouldn't usually cause
illness in a person with a healthy immune system.

N. Risk groups for acquiring HIV include the following:

1. Have sex with many partners (men or women).

2. Have unsafe sex with an infected person.

3. Share needles to take drugs or steroids.

4. Have unprotected sex for drugs or money.

5. Have another sexually transmitted infection (STI).

To help prevent the spread of HIV:

• Use treatment as prevention (TasP). If you're living with HIV, taking HIV
medication can keep your partner from becoming infected with the virus. If
you make sure your viral load stays undetectable—a blood test doesn't show
any virus—you won't transmit the virus to anyone else. Using TasP means
taking your medication exactly as prescribed and getting regular checkups.

• Use post-exposure prophylaxis (PEP) if you've been exposed to HIV. If you

think you've been exposed through sex, needles, or in the workplace, contact
your doctor or go to the emergency department. Taking PEP as soon as
possible within the first 72 hours can greatly reduce your risk of becoming
infected with HIV. You will need to take medication for 28 days.

• Use a new condom every time you have sex. Use a new condom every time
you have anal or vaginal sex. Women can use a female condom. If using a
lubricant, make sure it's water-based. Oil-based lubricants can weaken
condoms and cause them to break. During oral sex use a nonlubricated, cut-
open condom or a dental dam—a piece of medical-grade latex.

• Consider preexposure prophylaxis (PrEP). The combination drugs

emtricitabine plus tenofovir (Truvada) and emtricitabine plus tenofovir
alafenamide (Descovy) can reduce the risk of sexually transmitted HIV
infection in people at very high risk. PrEP can reduce your risk of getting HIV
from sex by more than 90% and from injection drug use by more than 70%,
according to the CDC and Prevention. Descovy hasn't been studied in people
who have receptive vaginal sex.

Clinical Assessment

A. Obtain prescription for and review laboratory testing. CDC recommends

that everyone between the ages of 13 and 64 get tested for HIV at least
once. People at higher risk should get tested more often.

1. All pregnant women should be tested to begin treatment as early as

possible to reduce the risk of transmitting HIV to the child.
2. Refer to the CDC for current testing guidelines:
[Link]

3. HIV treatment should be initiated as quickly as possible after diagnosis.

HESI Hint

An individual exposed to HIV may remain asymptomatic for many years

dependent on various factors and if he or she is actively under a medical
regimen of antiretroviral therapy (ART). The stages of HIV infection are
presented in Box 3.8.

Clients usually are not admitted to the hospital for treatment until their HIV
status has progressed to an “AIDS” diagnosis.

From CDC. About HIV. Retrieved from:

[Link]

A. Clinical Symptoms

1. Extreme fatigue

2. Loss of appetite and unexplained weight loss of more than 10 pounds in

2 months

3. Swollen glands

4. Leg weakness or pain

5. Unexplained fever for more than 1 week

6. Night sweats

7. Unexplained diarrhea

8. Dry cough; may represent PCP

9. White spots in the mouth and throat; may represent candidiasis

10. Painful blisters; may represent shingles

11. Painless, purple-blue lesions on the skin

12. Confusion, disorientation

13. In women, recurrent vaginal infections that are resistant to treatment

B. Opportunistic infections
Refer to Table 3.24. See “What is HIV”:
[Link] and Box 3.7.

Tuberculosis Infection Control, CDC, 2021.

HESI Hint

HIV clients with tuberculosis require respiratory isolation.

Tuberculosis can be transmitted in virtually any setting. Clinicians should be

aware that transmission has been documented in healthcare settings where
healthcare workers and patients come in contact with persons with infectious
tuberculosis (TB) who:

• Have unsuspected TB disease,

• Have not received adequate or appropriate treatment, or

• Have not been separated from others.

Clinical Assessment and Interventions

A. Assess respiratory functioning frequently.

B. Avoid known sources of infection.

C. Use strict asepsis for all invasive procedures.

D. Obtain vital signs frequently.

E. Plan activities to allow for rest periods.

F. Elevate HOB.

G. Refer client to nutritionist.

H. Offer small, frequent feedings.

I. Weigh daily.

J. Encourage client to avoid fatty foods.

K. Monitor for skin breakdown and offer good skin care.

L. Use safety precautions for clients with neurologic symptoms or loss of

vision.

M. Orient client who is confused.

HESI Hint
Standard Precautions

• Wash hands, even if gloves have been worn to give care.

• Wear examination gloves for touching blood or body fluids or any nonintact
body surface.

• Wear gowns during any procedure that might generate splashes

(e.g., changing clients with diarrhea).

• Use masks and eye protection during activity that might disperse droplets
(e.g., suctioning).

TABLE 3.24

Recommendations for HIV Testing and Prevention of HIV (of Adults,

Adolescents, and Pregnant Women in Health Care Settings)

Recommendations Population

Routine HIV screening in healthcare settings Everyone between the ages

of 13 and 64 at least once as part of routine health care

HIV Tests for Screening (Listed Below)

Antibody tests Detect the presences of antibodies. Most rapid test and
home tests are antibody tests (usually initial HIV test).

Antigen/antibody tests

Detect HIV antibodies and antigens (antigens are produced in a person

infected with HIV prior to antibody development).

Rapid antigen/antibody tests are available.

Nucleic acid tests (NATs) Looks for actual virus in the blood (very
expensive; not routine). Used for recent high-risk exposure or possibility of
early symptoms of HIV.

HIV, Human immunodeficiency virus.

Data from [Link]

BOX 3.7 What Are the Stages of HIV?

When people with human immunodeficiency virus (HIV) don’t get treatment,
they typically progress through three stages. But HIV medicine can slow or
prevent progression of the disease. With the advancements in treatment,
progression to Stage 3 is less common today than in the early days of HIV.

Stage 1: Acute HIV Infection

• People have a large amount of HIV in their blood. They are very contagious.

• Some people have flu-like symptoms. This is the body’s natural response to
infection.

• But some people may not feel sick right away or at all.

• If you have flu-like symptoms and think you may have been exposed to
HIV, seek medical care and ask for a test to diagnose acute infection.

• Only antigen/antibody tests or nucleic acid tests (NATs) can diagnose acute
infection.

Stage 2: Chronic HIV Infection

• This stage is also called asymptomatic HIV infection or clinical latency.

• HIV is still active but reproduces at very low levels.

• People may not have any symptoms or get sick during this phase.

• Without taking HIV medicine, this period may last a decade or longer, but
some may progress faster.

• People can transmit HIV in this phase.

• At the end of this phase, the amount of HIV in the blood (called viral load)
goes up and the CD4 cell count goes down. The person may have symptoms
as the virus levels increase in the body, and the person moves into Stage 3.

• People who take HIV medicine as prescribed may never move into Stage 3.

Stage 3: Acquired Immunodeficiency Syndrome

• The most severe phase of HIV infection.

• People with AIDS have such badly damaged immune systems that they get
an increasing number of severe illnesses, called opportunistic infections.

• People receive an AIDS diagnosis when their CD4 cell count drops below
200 cells/mm, or if they develop certain opportunistic infections.
• People with AIDS can have a high viral load and be very infectious.

AIDS, Acquired immunodeficiency syndrome. From CDC. About HIV. Retrieved

from: [Link]

BOX 3.8 Benefits of Routine Screening for HIV

Diagnosing human immunodeficiency virus (HIV) quickly and linking people

to treatment immediately are crucial to achieving further reduction in new
HIV infections.

Primary care providers (PCPs) are the front line for detecting and preventing
the spread of HIV. The Centers for Disease Control and Prevention (CDC) is
asking PCPs to:

• Conduct routine HIV screening at least once for all their patients

• Conduct more frequent screenings for patients at greater risk for HIV

• Link all patients who test positive for HIV to medical treatment, care, and
prevention services

From CDC. Available at:

[Link]

A. Provide emotional, cultural, and spiritual support for the grieving client
who is losing all relationships and skills.

B. Provide emotional support for significant others: family, family of choice,

partners, and friends.

C. Administer IV fluids for hydration, as prescribed.

D. Administer total parenteral nutrition (TPN) as prescribed.

E. Administer agents that treat specific opportunistic infections and

medications for HIV (Table 3.25)

F. See FDA-Approved HIV Medicines: [Link]

hiv/fact-sheets/fda-approved-hiv-medicines

HESI Hint

The CDC does not recommend excluding pregnant healthcare workers from
caring for patients with known CMV infection. Healthcare workers should be
careful with all patients they encounter. Spread of CMV requires direct
contact with virus-containing secretions. Hand washing and using gloves are
excellent ways to prevent infection.
Pediatric HIV Infection

Description: Infection with HIV in infants and children

A. Sources of infection in pediatric clients

B. The risk of mother-to-child transmission of HIV during pregnancy, delivery,

and breastfeeding is as high as 25% to 30% in the absence of treatment.
With the implementation of HIV testing, counseling, antiretroviral medication,
delivery by cesarean section prior to onset of labor, and discouraging
breastfeeding, vertical transmission has decreased to less than 2% in the
United States (Nesheim, FitzHarris, Mahle, & Lampe, 2019).

C. For infants acquiring HIV before or around delivery, disease progression

occurs rapidly in the first few months of life and often leads to death. Over
80% of HIV-infected infants who are well at 6 weeks progress to become
eligible to start ART before 6 months of age. Early determination of HIV
exposure and definitive diagnosis are thus critical. Therefore,

D. All infants and children should have their HIV exposure status established
at their first contact with the health system, ideally before 6 weeks of age. To
facilitate this, all Maternal, Neonatal and Child service delivery points in
health facilities should offer HIV serological testing to mothers and their
infants and children. In most cases the HIV status is established by asking
about maternal HIV testing in pregnancy, labor, or postpartum period
checking the child's and/or mother's health card, offering a rapid antibody
test to all infants and/or mothers whose HIV status is unknown, especially
where the national HIV prevalence is > 1%.

E. The exact mechanism of mother-to-child transmission of HIV remains

unknown. Transmission may occur during intrauterine life, delivery, or
breastfeeding. The greatest risk factor for vertical transmission is thought to
be advanced maternal disease, such as AIDS, likely because of a high
maternal HIV viral load. Unfortunately, it has been reported that 30% of
pregnant women are not tested for HIV during pregnancy, and another 15%
to 20% receive no or minimal prenatal care, thereby allowing for potential
newborn transmission. (Peterson & Ramus, 2020; Rahangdale & Cohan,
2008).

TABLE 3.25

Opportunistic Infections
Pneumocystis carinii Pneumonia Kaposi Sarcoma Cryptosporidiosis
Candidiasis of Oral Cavity and Esophagus

• Fever

• Dry cough

• Dyspnea at rest

• Chills

• Purple-blue lesions on skin, often arms and legs

• Invasion of gastrointestinal tract, lymphatic system, lungs, and brain

• Severe watery diarrhea (may be 30–40 stools per day)

• Abdominal cramps

• Nausea

• Electrolyte imbalance

• Malaise

• Thick white exudate in the mouth

• Unusual taste to food

• Retrosternal burning

• Oral ulcers

Cryptococcal MeningitisCytomegalovirus (CMV) Retinitis CMV Colitis

Disseminated CMV

• Headache

• Changes in level of consciousness

• Nausea, vomiting

• Stiff neck

• Blurred vision

• Most common CMV infection in persons with acquired immunodeficiency

syndrome

• Impaired vision in one or both eyes

• Can lead to blindness

• Diarrhea

• Malabsorption of nutrients

• Weight loss

• Malaise

• Fever

• Pancytopenia

• Weight loss

• Positive cultures from blood, urine, or throat

Perirectal Mucocutaneous Herpes Simplex Virus Lymphomas of Central

Nervous System Tuberculosis (TB) HIV Encephalopathy

• Severe pain

• Bleeding, rectal discharge

• Ulceration in the rectal area

• Change in mental status

• Apathy

• Psychomotor slowing

• Seizures

• Pulmonary and extrapulmonary

• Lymphatic and hematogenous TB are common

• Negative skin testing does not rule out TB

• Memory loss and impaired concentration

• Apathy

• Depression

• Psychomotor slowing (most prominent symptom)

• Incontinence

• CT scan findings: diffuse atrophy and ventricular enlargement

TABLE 3.26
Routes of Administration for Analgesics

RouteAdministration

Oral

• Preferred method of administration

• Drug level peak: 1–2 h

Intramuscular

• Acceptable method of managing acute short-term pain

• Onset 30 min; peak effect 1–3 h; duration of action: 4 h

Rectal

• Useful for clients with nausea and inability to take analgesics by mouth

• Useful for home care and for elderly clients as an alternative to per os (by
mouth, PO) and intravenous (IV) administration

• Reduced effectiveness with constipation

IV bolus (IV push)

• Provides the most rapid onset (5 min) but has the shortest duration (1 h)

• Useful for acute pain, such as a client in labor

Patient-controlled analgesia (PCA)

• Ideal method of pain control; client is able to prevent pain by self-

administering smaller doses of the narcotic (usually morphine) as soon as
the first sign of discomfort arises

• Usually administered IV

• A predetermined dose and a set lockout interval (5–20 min) are prescribed
by physician; pump is calibrated to deliver the specified dose whenever
client hits the button

• Lock-out mechanism prevents overdose

• Pump can record number of times the client uses the pump and the
cumulative dose delivered

Continuous subcutaneous narcotic infusion (CSI)

• Useful for clients who are nil by mouth (NPO) but require prolonged
administration of parenteral narcotics

• Provides a constant level of analgesia by continuous infusion of a narcotic

• Site should be inspected every 8 h and changed at least every 7 days.

• Risk for respiratory depression

Continuous epidural analgesia

• Catheter threaded into epidural space with continuous infusion of fentanyl

citrate, morphine, or other narcotic analgesics

• Risk for respiratory depression

Transdermal patches

• Applied to skin (self-adhesive or with overlay to secure patch)

• Also used to deliver hormonal therapy, nitroglycerin, and nicotine

• Sites for application and frequency of application are specific to each

medication

• Document removal of old patch, site, and application date and time of new
patch

F. Viral testing (e.g., PCR) should be conducted at 4 to 6 weeks of age for

infants known to be HIV-exposed, or at the earliest possible opportunity for
those seen after 4 to 6 weeks of age.

G. Urgent HIV antibody testing should be carried out for any infant or child
presenting with signs, symptoms, or medical conditions that indicate HIV.

H. Infants with detectable HIV antibodies should go on for a viral test.

I. Every child should be evaluated for HIV exposures (Rivera & Frye, 2020)

J. Clinical Assessment

1. Risk groups

a. Infants born to mothers who are HIV-positive

b. Hemophiliacs

c. Infants and children who have received blood transfusions

2. Clinical Symptoms
a. Failure to thrive

b. Lymphadenopathy

c. Organomegaly

d. Neuropathy

e. Cardiomyopathy

f. Chronic recurrent infections such as thrush

g. Unexplained fevers

HESI Hint

• Because of the persistence of the maternal HIV antibody, infants younger

than 18 months require virologic assays that directly detect HIV in order to
diagnose HIV infection.

• Preferred virologic assays include HIV bDNA polymerase chain reaction

(PCR) and HIV RNA assays. The HIV PCR DNA qualitative test is usually less
expensive.

• Further virologic testing in infants with known perinatal HIV exposure is

recommended at 2 weeks, 4 weeks, and 4 months.

• An antibody test to document seroreversion to HIV antibody–negative

status in uninfected infants is no longer recommended (Rivera & Frye, 2020).

HESI Hint

The focus of NGN-NCLEX-RN questions are likely to be assessment, analysis,

synthesis of treatment implications and outcomes, and the impact of clinical
assessment of signs of the disease and management of complications
associated with HIV.

Clinical Judgment Measures Interventions

A. Avoid exposure to persons with infections.

B. Administer no live virus vaccines.

C. Teach the family to

1. Use gloves when diapering the child.

2. Clean any soiled surfaces (wearing gloves).

3. Identify signs of opportunistic infections.

D. Monitor growth parameters.

E. Support use of social services.

F. Support child’s attending school as much as child is able.

G. Assist in community and school education programs.

Review of HIV Infection

1. Identify the ways HIV is transmitted.

2. Vertical transmission (from mother to fetus) occurs how often if the

mother is not treated during pregnancy?

3. Describe standard precautions.

4. What does the CD4 T-cell count describe?

5. Why does the CD4 T-cell count drop in HIV infections?

6. Describe the ways a pediatric client might acquire HIV infection.

See Answer Key at the end of this text for suggested responses.

Pain

Pain: In light of research documenting the dramatic rise of opioid addiction

and opioid-related deaths, delegates at the 2016 American Medical
Association (AMA) meeting voted to stop treating pain as the fifth vital sign
because they believe it is likely that the initiative, along with other factors,
has exacerbated the opioid crisis (Anson, 2016).

Description: An individual’s subjective experience of physical discomfort from

illness or injury. Consider multidimensional pain questionnaire used to
measure patients’ response to postoperative pain therapy is the Overall
Benefit of Analgesic Score (OBAS)

A. Client’s pain often goes unrecognized and untreated.

1. Healthcare professionals are increasingly better educated about

identifying, assessing, and managing pain.

B. An individual’s response to pain is influenced by several factors:

1. Anxiety: reduction of anxiety can help to control pain.

2. Past experience with pain: the more pain experienced in childhood, the
greater the perception of pain in adulthood.
3. Culture and religion: cultural and religious practices learned from one’s
family play an important role in determining how a person experiences and
expresses pain.

4. Gender affects the expression of pain.

5. Communication, whether it is a language barrier and/or a client who is

unable to speak.

6. Altered level of consciousness.

C. Pain is classified as either acute or chronic.

1. Acute pain

a. Is temporary (30 days in relationship to injury; no longer than 6 months)

b. Occurs after an injury to the body

c. Includes postoperative pain, labor pain, and renal calculus pain

2. Chronic pain (usually lasting beyond 6 months after initial injury)

a. Nonmalignant (e.g., low back pain, rheumatoid arthritis)

b. Intermittent (e.g., migraine headaches)

c. Malignant, associated with neoplastic diseases

Theory of Pain

A. Gate control theory: Pain impulses travel from the periphery to the gray
matter in the dorsal horn of the spinal cord along small nerve fibers.

A “gating” mechanism called the substantia gelatinosa, a collection of

cells in the gray area (dorsal horns) of the spinal cord. Found at all levels of
the cord, it receives direct input from the dorsal (sensory) nerve roots,
especially those fibers from pain and thermoreceptors, which will either open
to or close off the transmission of pain impulses to the brain.

1. Stimulation of large, fast-conducting sensory fibers opposes the input from

small pain fibers, thus blocking pain transmission.

2. Modalities used: Stimulation of large fibers by massage, heat, cold,

acupuncture, transcutaneous electrical nerve stimulation (TENS).

B. Endorphin/enkephalin theory
1. Endorphins: naturally occurring compounds that have morphine-like
qualities; they modulate pain by preventing the conduction of pain impulses
in the CNS.

2. Enkephalins: specific neurotransmitters that bind with opiate receptors in

the dorsal horn of the spinal cord; they modulate pain by closing the gate
and stopping the pain impulse.

3. Modalities used: stimulation of endogenous opiate release through

acupuncture, placebos, TENS.

Clinical Assessment

A. Location: Pain may be localized, radiating, or referred.

B. Intensity: Ask client to rate pain before and after an intervention such as
medication (use scale such as 0 to 10, with 0 being no pain).

C. Comfort: Often clients can describe what relieves pain better than they
can describe the pain itself.

D. Quality: Pain may be sharp, dull, aching, sore, etc.

E. Chronology: Ask client when pain started, what time of day it occurs, how
often it appears, how long it lasts, whether it is constant or intermittent,
whether the intensity changes.

F. Subjective experience: Determine what decreases or aggravates pain,

what other symptoms are associated with pain, what interventions provide
relief, what limitations the pain inflicts.

HESI Hint

The alphabet mnemonic “PQRST” is an easy tool to use when assessing and
documenting a client’s experience of pain.

P Provocative and Palliative or Aggravating Factors

What provokes the painful sensation?

What makes it worse or better?

Q Quality Type of sensation → dull, aching, sharp, stabbing, burning

R Region or Location, Radiation Where is the pain located and does it

radiate anywhere?

S Severity Ask the client to rate pain on a scale.

T Timing

How long has it been hurting?

How often does it occur?

When did it occur?

U Understanding Ask the client what he or she thinks may be the

cause or the problem causing the pain.

From Ignatavicius, D. D., Workman, L. M., Rebar, C., LaCharity, L. A., &
Kumagai, C. K. (2018). Medical-surgical nursing: Concepts for
interprofessional collaborative care (9th ed.). St. Louis: Saunders.

Clinical Judgment Measures for Pain Management

1. Pharmacologic interventions, Route of administration (Table 3.27)

a. Non-narcotics, nonsteroidal anti-inflammatory drugs

b. Act by means of a peripheral mechanism at level of damaged tissue by

inhibiting prostaglandin and other chemical mediator syntheses involved in
pain

c. Show antipyretic activity through action on the hypothalamic heat-

regulating center to reduce fever

d. Examples: salicylate—aspirin nonsalicylates, acetaminophen ibuprofen

2. Narcotic mixed agonists/antagonists

a. Bind to both a receptor that produces pain relief, which is the agonist
portion, and to another receptor that does not produce a physiologic effect,
which is the antagonist portion. Patients are less likely to have respiratory
depression.

b. May cause withdrawal symptoms if administered after client has been

receiving narcotics.

c. Produce side effects, including drowsiness, occasionally, nausea, and

psychomimetic effects, such as hallucinations and euphoria.

d. Examples: butorphanol nalbuphine

3. Narcotics
a. Act as opioids, binding with specific opiate receptors throughout the CNS
to reduce pain perception.

b. Cause such side effects such as nausea and vomiting, constipation,

respiratory depression, and CNS depression.

c. Examples: hydromorphone morphine sulfate (see Table 3.27)

HESI Hint

For narcotic-induced respiratory depression, naloxone may be administered

as prescribed by the healthcare provider.

TABLE 3.27

Onset of Commonly Administrated Narcotics

Medication Mode OnsetComments

Codeine

PO

IM or SC

30–45 min

10–30 min

• Do not administer discolored injection solutions

• May also be prescribed as an antitussive or antidiarrheal

Hydromorphone

PO

IM

IV

30 min

15 min

10–15 min

• Fast-acting, potent narcotic

• More likely to cause appetite loss than other narcotics

Morphine sulfate

PO

IM

IV

60–90 min

10–30 min

10 min

• Drug of choice in relieving pain associated with myocardial infarction

• May cause transient decrease in blood pressure

• Drug of choice for use with chronic cancer pain

Fentanyl citrate

IM

IV

Intradermal

Intrabuccal

Intrathecal

7–15 min

Within 5 min

Within 12 h

5–15 min

Immediate

• Synthetic narcotic

• Acts quicker; less duration

IM, Intramuscular; IV, intravenous, PO, per os (by mouth); SC, subcutaneous.

A. Adjuvants to analgesics
1. Are given in combination with an analgesic to potentiate or enhance the
analgesic’s effectiveness.

2. Are helpful in controlling discomfort associated with pain, such as nausea,

anxiety, and depression (e.g., promethazine).

HESI Hint

Use noninvasive methods for pain management when possible:

Relaxation exercises

Distraction

Imagery

Biofeedback

Interpersonal skills

Physical care: altering positions, touch, hot and cold applications

Clinical Assessment of Pain Relief Techniques

A. Pain (see Table 3.27).

B. Response to pharmacologic intervention: tolerance to pharmacologic

interventions may occur—that is, the client physiologically requires
increasingly larger doses to provide the same effect.

1. The first sign of tolerance is a decreased duration of a drug’s

effectiveness.

2. The need for increased doses can be the result of increased pain rather
than tolerance (e.g., clients with advanced cancer) (Table 3.28).

HESI Hint

Narcotic analgesics are preferred for pain relief because they bind to the
various opiate receptor sites in the CNS. Morphine is often the preferred
narcotic (remember, it causes respiratory depression).

Another agonist is methadone. Narcotic antagonists block the attachment of

narcotics such as naloxone to the receptors. Once naloxone has been given,
additional narcotics cannot be given until the naloxone effects have passed.

Review of Pain

1. What modalities are associated with the gate control pain theory?
2. How does past experience with pain influence current pain experience?

3. What modalities are thought to increase the production of endogenous

opiates?

TABLE 3.28

Pain Relief Techniques

Noninvasive

Cutaneous stimulation that is useful alone or in combination with other pain

management techniques

• Heat and cold applications decrease pain and muscle spasm.

• Transcutaneous electrical nerve stimulation (TENS) provides continuous

mild electrical current to the skin via electrodes.

• Massage provides a simple, inexpensive, and effective method of pain

relief.

• Distraction diverts client’s attention from the pain; useful during short
periods of pain or during painful procedures such as intravenous
venipunctures.

• Relaxation can be used as a distraction and to facilitate sedation or sleep;

it rarely decreases pain sensation.

• Biofeedback techniques enable control of autonomic responses

(tachycardia, muscle tension) to pain through electrical feedback.

Invasive

Any procedure that invades the body and is used to relieve pain

• Nerve blocks involve injection of anesthetic into or near a nerve to

decrease pain pathways (e.g., deadening area for dental work, regional
anesthesia used in obstetrics).

• Neurosurgical procedures include surgical or chemical (alcohol) interruption

of nerve pathways; it is commonly used in clients with cancer who have
severe pain.
• Acupuncture is the insertion of needles at various points in the body to
relieve pain.

4. What six factors should the nurse include when assessing the pain
experience?

5. What mechanism is involved in the reduction of pain through the

administration of nonsteroidal anti-inflammatory drugs (NSAIDs)?

6. If narcotic agonist/antagonist drugs are administered to a client already

taking narcotic drugs, what may be the result?

7. List four side effects of narcotic medications.

8. What is the antidote for narcotic-induced respiratory depression?

9. What is the first sign of tolerance to pain analgesics?

10. Which route of administration for pain medications has the quickest
onset and the shortest duration?

11. List the six modalities that are considered noninvasive,

nonpharmacologic pain relief measures.

See Answer Key at the end of this text for suggested responses.

Death and Grief

Description: Death completes the life cycle. Grief is the process an individual
goes through to deal with loss. How each person deals with these situations
depends on the individual. An individual’s past experiences, coping skills,
and what other stresses he or she may have going on in his or her life can
largely affect how the person responds and reacts to these situations.

Clinical Assessment

Types of Death

There are five modes of death (natural, accident, suicide, homicide, and
undetermined).

A. Stages of preparing for an expected death may not be sequential. An

individual may fluctuate between the stages. An individual may not
experience every stage.

1. Denial
a. Coping style used to protect self/ego.

b. Noncompliance, refusal to seek treatment, ignoring of symptoms.

c. Changing the subject when speaking about illness.

d. Stating, “Not me, it must be a mistake.”

2. Anger

a. Often directing it at family or healthcare team members

b. Stating, “Why me? It’s not fair.”

3. Bargaining

a. Making a deal with God to prolong life.

b. Usually not sharing this with anyone, keeping it a very private experience.

4. Depression

a. Results from the losses experienced because of health status and

hospitalization.

b. Anticipating the loss of life.

5. Acceptance

a. Accepting of the inevitable

b. Beginning to separate emotionally

B. Stages of dealing with loss (grief)

1. Shock, disbelief, rejection, or denial

a. Anger and crying

b. Conflicting emotions

c. Anger toward the deceased

d. Guilt

e. Preoccupation with loss

2. Resolution

a. Process taking up to 1 year or more

b. Renewed interest in activities

C. Complicated grief

1. Unresolved grief

a. Determine level of dysfunction

2. Physical symptoms similar to those of the deceased

3. Clinical depression

4. Social isolation

5. Failure to acknowledge loss

Clinical Judgment Measures

A. Encourage client to express anger in a supportive, nonthreatening

environment.

B. Discourage rumination.

C. Assist client in giving up idealized perception of deceased; point out

misrepresentations.

D. Encourage interaction with others.

E. Assist client with identification of support systems.

F. Consult spiritual leader as indicated by client need and preference.

G. Assist client toward a comfortable, peaceful death.

HESI Hint

Do not take away the coping style used in a crisis state.

Denial is a very useful and needed tool for some at the initial stage. Support,
do not challenge, unless it hinders or blocks treatment, endangering the
patient.

Review of Death and Grief

1. Identify the five stages of grief associated with dying.

2. A client has been told of a positive breast biopsy report. She asks no
questions and leaves the healthcare provider’s office. She is overheard
telling her husband, “The doctor didn’t find a thing.” What coping style is
operating at this stage of grief?
3. Your client, an incest survivor, is speaking of her deceased father, the
perpetrator. “He was a wonderful man, so good and kind. Everyone thought
so.” What would be the most useful intervention at this time?

4. Your client feels responsible for his sister’s death because he took her to
the hospital where she died. “If I hadn’t taken her there, they couldn’t have
killed her.” It has been 1 month since her death. Is this response indicative of
a normal or a complicated grief reaction?

5. Mrs. Green lost her husband 3 years ago. She has not disturbed any of his
belongings and continues to set a place at the table for him nightly. Is this
response indicative of a normal or a complicated grief reaction?

See Answer Key at the end of this text for suggested responses.