High-Acuity Nursing

977 Pages·2013·105.849 MB·English

by  Kathleen Dorman Wagner, Melanie Hardin-Pierce

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High-Acuity Nursing
Sixth Edition
Global Edition
Kathleen Dorman Wagner, EdD, MSN, RN
Faculty Emerita, University of Kentucky College of Nursing
Lexington, Kentucky
Melanie G. Hardin-Pierce, DNP, RN, APRN, ACNP-BC
University of Kentucky College of Nursing
Central Baptist Hospital
Lexington, Kentucky
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The rights of Kathleen Dorman Wagner and Melanie G. Hardin-Pierce to be identified as the authors of this work have
been asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
Authorized adaptation from the United States edition, entitled High-Acuity Nursing, 6th edition, ISBN 978-0-13-302692-4
by Kathleen Dorman Wagner and Melanie G. Hardin-Pierce, published by Pearson Education © 2015.
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is urged to check the package inserts of all drugs for any change in indications of dosage and for added warnings and
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ISBN 10: 1-29-207340-3
ISBN 13: 978-1-29-207340-8
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About the Authors
Kathleen Wagner, EdD, MSN, RN, is now faculty emerita, Melanie Hardin-Pierce, DNP, RN, APRN, ACNP-BC, is
having recently retired from the University of Kentucky College an associate professor in the University of Kentucky College of
of Nursing after many years of teaching pathophysiology, patho- Nursing, where she teaches in the Doctor of Nursing Practice
pharmacology and high-acuity nursing to undergraduate nurs- program and coordinates the Acute Care Nurse Practitioner
ing students. She was also the educational consultant for the Track. She earned her Doctor of Nursing Practice degree at the
Undergraduate Nursing Program at the University of Kentucky. University of Kentucky studying oral health in mechanically
She has a doctorate in instructional systems design and contin- ventilated patients. She is a board-certified acute-care nurse
ues to work on a team developing Web-based clinical simula- practitioner who practices as a critical care intensivist in Central
tions for nursing students. Baptist Hospital, Lexington. She is active in research of critically
ill, mechanically ventilated patients, evidence-based practice,
and interdisciplinary collaboration.
5
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6 PARt 5 ▸ Tissue Perfusion
Thank You
We extend a heartfelt thanks to our con- Ecklund, Margaret M., MS, RN, CCRN, Muzzy, Angela C., MSN, RN, CCRN
tributors and reviewers, who gave their ACNP-BC University of Arizona Medical Center
time, effort, and expertise to the develop- Rochester General Hospital Tucson, AZ
ment and writing of this new edition of Rochester, NY Chapter 8, Basic Cardiac Rhythm
our book. Chapter 6, Mechanical Ventilation Monitoring
Eksterowicz, Nancy R., MSN, RNBC Nolde-Lopez, Grace, RN, MS,
Contributors
University of Virginia Health System ANP-BC
Charlottesville, VA Craig Hospital
Arzouman, Jill, MS, RN, ACNS, BC,
Chapter 4, Acute Pain Management Englewood, CO
CMSRN
(with Donna Jarzyna) Chapter 19, Acute Spinal Cord Injury
University of Arizona Medical Center
Tucson, AZ Jarzyna, Donna, MS, RN-BC, CNS-BC Priestley, Gail L., MSN, RN, ACNS-BC,
Chapter 1, High-Acuity Nursing University of Arizona Medical Center CCRN
Chapter 2, Holistic Care of the Patient and Tucson, AZ University of Arizona Medical Center
Family Chapter 4, Acute Pain Management Tucson, AZ
(with Nancy Eksterowicz) Chapter 11, Alterations in Pulmonary
Bohnenkamp, Susan, RN, MS,
Function
ACNS-BC, CCM
Kelso, Lynn A., MSN, APRN,
University of Arizona Medical Center ACNP-BC, FCCM, FAANP Snyder, Kara A., MS, RN, CCRN,
Tucson, AZ University of Kentucky CCNS
Chapter 29, Alterations in White Blood Lexington, KY University of Arizona Medical Center
Cell Function and Oncologic Emergencies Chapter 22, Alterations in Liver Function Tucson, AZ
Chapter 7, Basic Hemodynamic
Brenner, Zara R., MS, RN-BC,
Krenzer, Maureen, MS, RN, ANP, Monitoring
ACNS-BC
ACNS-BC
College at Brockport, Rochester General Hospital Thacker, Diana, BSN, RN
State University of New York Rochester, NY Kentucky Organ Donor Affiliates
Brockport, NY Chapter 23, Alterations in Pancreas Lexington, KY
and Function (with Zara Brenner) Chapter 38, Solid Organ and
Rochester General Hospital Hematopoietic Stem Cell Transplantation
Rochester, NY Lach, Helen W., PhD, RN, GCNS-BC (with Kathleen Wagner)
Chapter 23, Alterations in Pancreas Saint Louis University School of Nursing
Function (with Maureen Krenzer) St. Louis, MO Welsh, Darlene, PhD, RN
Chapter 3, The Older Adult High-Acuity University of Kentucky College
Cisney, Kathy Lea, MSN, APRN-BC, Patient (with Kristine L’Ecuyer) of Nursing
CWOCN, C Ped Lexington, KY
University of Kentucky Chandler Medical L’Ecuyer, Kristine M. RN, MSN, CCNS, Chapter 13, Alterations in Cardiac
Center CNL Function (with Kathleen Wagner)
Lexington, KY Saint Louis University School of Nursing Chapter 14, Alterations in Myocardial
Chapter 29, Complex Wound St. Louis, MO Tissue Perfusion
Management Chapter 3, The Older Adult High-Acuity
Patient (with Helen W. Lach)
Dirkes, Susan, MSA, RN, CCRN Accuracy Reviewer
Nursing Resource Consultants LLC Moore, Kathryn, DNP, RN, ACNP-BC,
Naples, FL GNP-BC, CCRN, CEN Rachel Kinder, PhD, RN
Chapter 25, Alterations in Fluid and Emory University Associate Professor
Electrolyte Balance Atlanta, GA Western Michigan University
Chapter 26, Acute Kidney Injury Chapter 35, Acute Burn Injury Bowling Green, KY
6
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▸ Thank You 7
Reviewers Phyllis D. Wille, RN, MS, FNP-C, CNN Antoinette France, MSNed, RN, CCRN
Danville Area Community College Salt Lake Community College
Angie Koller, MSN, RN Danville, Ilinois Salt Lake City, Utah
Ivy Tech Community College-Central
Indiana Melissa A. Bathish, PhD(c), RN, Donna Molyneaux, PhD, RN
Indianapolis, IN CPNP-PC Gwynedd-Mercy College
University of Michigan School Gwynedd Valley, Pa
Deanna L. Reising, PhD, RN, of Nursing
ACNS-BC, ANEF Ann Arbor, MI Karen Loving, MSN, RNC
Indiana University School of Nursing Gwynedd-Mercy College
Bloomington, IN Judy Stauder, MSN, RN Gwynedd Valley, PA
Stark State College
Collin Bowman-Woodall, MS, RN North Canton, Ohio Deborah Barlock, MSN, RN
Samuel Merritt University Cleveland State University
San Mateo, CA Elizabeth G. Mencel, RN, MSN, CNE Cleveland, OH
Montgomery County Community
Jody Crossman, RN BSN  College,   Becky Brown, MSN, BSN
City College of San Francisco Blue Bell, PA College of Southern Idaho
San Francisco, CA Twin Falls, ID
Laura B. Sutton, PhD, ACNS-BC
Sandra Wolfe Citty, PhD, ARNP-BC University of Florida College of Nursing Joni Goldwasser, MSN, APRN, FNP-BC
University of Florida Gainesville, FL Radford University Waldron College
Gainesville, Florida School of Nursing
Kristiann T. Willliams, DNP, APRN, Radford, Virginia
Diane Mulbrook, MA, RN FNP-C
Mount Mercy University Weber State University Bonnie Kirkpatrick, RN, MS, CNS
Cedar Rapids, IA Ogden, Utah The Ohio State University
Columbus, OH
Sheri Tesseyman, RN, MS Jennie M. Wood, PhD, RN, CNE
Westminster College School of Nursing Youngstown State University Karen Kulhanek, MA, BSN
and Health Sciences Youngstown, OH Kellogg Community College
Salt Lake City, Utah Battle Creek, MI
Michele Ochoa Oross, RN, BS, MPA
Sue Gosse, Ph.D., RN City College of San Francisco Gail Nelson, MSN, BSN
Eastern Illinois University San Francisco, CA Westminster College School of Nursing
Charleston, IL Salt Lake City, UT
Heather Kendall, RN, MSN,
Barbara Farris, MSN, RN CCRN-CMC-CSC Raywattie Sooklall, PhD, MSN, BSN
Radford University School of Nursing Missouri Western State University Palm Beach State College
Radford, VA St. Joseph, MO Lake Worth, FL
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Preface
When the first edition of High-Acuity Nursing was published in Purpose of the text
1992, the term high-acuity was largely confined to leveling patient
The High-Acuity Nursing text delivers critical information focus-
acuity for determining hospital staffing needs rather than being
ing on the adult patient, using learner-focused, active learning
applied to a type of nursing care or education. Since that time,
principles, with concise language and a user-friendly format.
the meaning of the term high-acuity nursing has been evolving to
The book’s design breaks down complex information into small,
increasingly represent a distinct category of nursing that denotes
discrete chunks for easy understanding. Self-testing is provided
care of complex patients outside of the critical care setting.
throughout the text, using short section quizzes and Posttests.
For the purposes of this textbook, we continue to define high-
All answers to the section review quizzes are provided to give
acuity in a way that is consistent with our original intent–that it
learners immediate feedback on their command of section con-
represents a level of patient problems beyond uncomplicated acute
tent before proceeding to the next chapter section.
illness on a health–illness continuum. The high-acuity nurse then,
The chapters in this book focus on the relationship between
cares for complex patients with unpredictable outcomes across
pathophysiology and the nursing process with the following
care settings (to include critical care). Today, high-acuity patients
goals in mind
are found in many health care settings, from high-skill long-term
facilities to critical-care units. The patient population is older and 1. To revisit and translate critical pathophysiological concepts
faces an increased number of health issues upon entering the pertaining to the high-acuity adult patient in a clinically
health-care system. Hospitalized patients are being discharged applicable manner.
earlier, often in a poorer state of health. In the home-health set- 2. To examine the interrelationships among physiological
ting, nurses provide care to patients with mechanical ventilators, concepts.
central venous catheter lines, IV antibiotic therapy, and compli-
3. To enhance clinical decision-making skills.
cated injuries. Whereas critical-care units are considered specialty
4. To provide immediate feedback to the learner regarding
areas within the hospital walls, much of the knowledge required
assimilation of concepts and principles.
to work within those specialties is generalist in nature. It is this
5. To provide self-paced learning.
generalist knowledge base that is needed by all nurses who work
with patients experiencing complex care problems to assure com- Ultimately, the goal is for the learner to be able to approach
petent and safe nursing practice. patient care conceptually, so that care is provided with a strong
underlying understanding of its rationale.
This book is appropriate for use in multiple educational
New to this Edition
settings, including undergraduate nursing students, novice
The sixth edition of the book has undergone a chapter reorgani- nurses, novice critical-care nurses, and home-health nurses. It
zation based on feedback from faculty and students. also serves as a review book for the experienced nurse wanting
updated information about high-acuity nursing for continuing
• All chapters have been updated and many have been reorga-
education purposes. Hospital staff development departments
nized and expanded.
will find it useful as supplemental or required reading for nurs-
• Bulleted chapter summaries are included on the Student
ing staff, or high-acuity/critical-care classes.
Resources site.
• Answers to the Clinical Reasoning Checkpoint exercises are
Organization of the text
now available on the Student Resources site.
• Posttest items have been revised to reflect changes in content The book is divided into ten parts: Introduction to High-Acuity
and are written using NCLEX style; answers and their ratio- Nursing, Therapeutic Support of the High-Acuity Patient,
nales are located on the Student Resources website. Pulmonary, Cardiovascular, Neurological, Gastrointestinal,
Fluid and Electrolytes, Hematologic, Nutrition and Metabolism,
• Emerging Evidence boxes have been updated.
and Multisystem Dysfunction.
• Oncological emergencies, hypertensive crises, and acute
Part One: Introduction to High-Acuity Nursing is c omposed
aortic problems and crises have been added.
of three introductory chapters with topics that apply across
• A new chapter has been added focusing on metabolic
high-acuity problems, including an introduction to h igh-acuity
responses to stress that complicate the patient’s illness and
nursing and the care of high-acuity patients, and important
recovery, such as thyroid and adrenal gland issues.
considerations when caring for the high-acuity older adult. Part
• The Table of Contents is now annotated with chapter section Two: Therapeutic Support of the High-Acuity Patient, is com-
titles for ease of checking chapter contents. posed of six chapters that focus on supportive interventions,
• The Related Pharmacotherapy boxes now include adult including pain management, nutrition s upport, mechanical
dosages. ventilation, hemodynamic monitoring, basic cardiac rhythm
8
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▸ Preface 9
monitoring, and complex wound management. Parts Three that strong foundational knowledge about the basis of disease
through Ten cover topics that represent the more common com- improves learner understanding of the associated disease mani-
plex health problems, assessments, and treatments associated festations and rationales for treatment.
with high-acuity adult patients.
All chapters contain Learning Outcomes, Section Review Summary
Questions, Clinical Reasoning Checkpoint, Chapter Summary
and Posttest. Each chapter is divided into small sections that This text focuses on major problems and therapies frequently
cover one facet of the chapter’s topic (e.g., pathophysiology or encountered in high-acuity patients. It is not designed as a com-
nursing management), and each section ends with a short self- prehensive textbook of adult medical-surgical or critical-care
assessment review quiz. Key words are bolded throughout the nursing. The book’s format reduces learner feelings of being
chapters to indicate glossary terms defined in the textbook’s overwhelmed by complex information. Learners are more apt
Glossary. Parts 3 through 10 of the book are composed of two to feel in command of the concepts, giving them the confidence
different types of chapters, including Determinants and Assess- to proceed to the more complex concepts. The sixth edition of
ment chapters and Alterations chapters. High-Acuity Nursing has maintained the overall look and feel
of the previous editions, with some valuable changes. Although
Determinants and Assessment Chapters Each the sixth edition has been reorganized, we have not compro-
part begins with an overview of normal concepts that pro- mised our interactive approach. The ultimate goal of this book
vides a solid foundation for understanding the diseases being continues to be to enhance the preparation of nurses for prac-
presented. Normal anatomy and physiology are reviewed and tice in today’s health care settings.
relevant diagnostic tests and assessments are profiled. The Kathleen Dorman Wagner
therapeutic support and disease-focused (Alterations) chap- Melanie G. Hardin-Pierce
ters draw heavily on the normal concepts, diagnostic tests,
and assessments covered in their respective Determinants and
Acknowledgments
Assessment chapters.
With any publication, there are several years of sweat and tears that
Alterations Chapters Following each Determinants and go into its development. To our Development Editors, Pam Lappies
Assessment chapter is a series of organ- or concept-specific chap- and Elizabeth Cosgrove, thank you both so much for your patience,
ters that focus on a single topic area. The majority of Alterations diligence, sense of humor and work ethic—the book would have
chapters are based on body systems (e.g., Chapter 10, Alterations never made it to fruition without your hard work. It has been a
in Pulmonary Function) and include the p athophysiology, as- true pleasure to work with you! We would also like to warmly
sessments, diagnostic testing, and collaborative management of acknowledge the wonderful work of our Accuracy Reviewer, Dr.
disorders commonly seen in high-acuity adult patients. Several Rachel Kinder, PhD, RN, whose meticulous scrutiny of the infor-
Alterations chapters focus on complications of high-acuity ill- mation in the book chapters made our work much easier and sig-
ness, such as multiple organ dysfunction syndrome and sen- nificantly enhanced the quality and accuracy of the book. Finally,
sory motor complications of acute illness. The pathophysiologic our warm thanks also to our Posttest item writer, Pamela Fowler,
basis of disease is emphasized in this textbook with the belief who significantly added to the value of the Posttests.
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