■ Give prescribed analgesics.
■ Assist with early ambulation, but don’t allow the patient to sit for an ex-tended period.
■ If amputation has occurred, check the residual limb carefully for drainage and note and record its color and amount and the time.
■ Elevate the residual limb as ordered.
■ Monitor for signs and symptoms of fluid or electrolyte imbalance, renal failure, or stroke.
■ Check vital signs, intake and output, distal pulses, neurologic status, and bowel sounds.
■ Refer the patient to a physical and occupational therapist, if indicated.
PAT I E N T T E A C H I N G Be sure to cover:
■ the disorder, diagnosis, and treatment
■ medications and potential adverse reactions
■ when to notify the physician
■ dietary restrictions
■ regular exercise program
■ foot care
■ signs and symptoms of graft occlusion
■ signs and symptoms of arterial insufficiency and occlusion
■ avoidance of constrictive clothing, or crossing legs
■ risk factor modification
■ avoidance of temperature extremes
■ referral to a podiatrist for foot care as needed
■ how to access a smoking-cessation program as indicated.
PAT H O P H YS I O L O G Y
■ Tracheal and bronchial linings overreact to various stimuli, causing episodic smooth-muscle spasms that severely constrict the airways.
■ Mucosal edema and thickened secretions further block the airways.
■ Immunoglobulin (Ig) E antibodies, attached to histamine-containing mast cells and receptors on cell membranes, initiate intrinsic asthma attacks.
■ When exposed to an antigen such as pollen, the IgE antibody combines with the antigen. On subsequent exposure to the antigen, mast cells de-granulate and release mediators.
■ The mediators cause the bronchoconstriction and edema of an asthma attack.
■ During an asthma attack, expiratory airflow decreases, trapping gas in the airways and causing alveolar hyperinflation.
■ Atelectasis may develop in some lung regions.
■ The increased airway resistance initiates labored breathing.
CA U S E S
■ Animal dander
■ Bronchoconstriction
■ Cold air
■ Drugs, such as aspirin, beta-adrenergic blockers, and nonsteroidal inflammatory drugs
■ Emotional stress
■ Exercise
■ Food additives containing sulfites and any other sensitizing substance
■ Genetic factors
■ Hereditary predisposition
■ House dust mites or mold
■ Kapok or feather pillows
■ Pollen
■ Psychological stress
■ Sensitivity to allergens or irritants such as pollutants (extrinsic or atopic asthma)
■ Internal, nonallergenic factors (intrinsic or nonatopic asthma)
■ Tartrazine dye, a common coloring agent in some foods and drugs
■ Viral infections
A S S E S S M E N T F I N D I N G S
■ Intrinsic asthma typically preceded by severe respiratory tract infections, especially in adults; may be aggravated by irritants, emotional stress, fa-tigue, endocrine changes and temperature and humidity variations
■ Exposure to a particular allergen followed by sudden onset of dyspnea and wheezing and by tightness in the chest accompanied by a cough that produces thick, clear, or yellow sputum
■ Visibly dyspneic
■ Ability to speak only a few words before pausing for breath
■ Use of accessory respiratory muscles
■ Diaphoresis
■ Increased anteroposterior thoracic diameter (if severe)
■ Hyperresonance
■ Tachycardia; tachypnea; mild systolic hypertension
■ Inspiratory and expiratory wheezes
■ Prolonged expiratory phase of respiration
■ Diminished breath sounds
■ Cyanosis, confusion, and lethargy indicating the onset of life-threatening status asthmaticus and respiratory failure
T E S T R E S U LT S
■ Arterial blood gas (ABG) analysis reveals hypoxemia.
■ Serum IgE level is increased from an allergic reaction.
■ Complete blood count with differential shows increased eosinophil count.
■ Chest X-rays may show hyperinflation with areas of focal atelectasis.
■ Pulmonary function studies show decreased peak flows and forced expi-ratory volume in 1 second, low-normal or decreased vital capacity, and in-creased total lung and residual capacities.
■ Skin testing identifies specific allergens.
■ Bronchial challenge testing shows the clinical significance of allergens identified by skin testing.
■ Pulse oximetry measurements show decreased oxygen saturation.
T R E AT M E N T
■ Identification and avoidance of precipitating factors
■ Desensitization to specific antigens
■ Establishment and maintenance of a patent airway
■ Fluid replacement
■ Activity as tolerated
■ Bronchodilators
■ Corticosteroids
■ Histamine antagonists
■ Leukotriene antagonists
■ Anticholinergic bronchodilators
A S T H M A 47
■ Low-flow oxygen
■ Antibiotics
■ Heliox trial (before intubation)
■ I.V. magnesium sulfate (controversial because of potential for causing res-piratory depression)
ALERT The patient with increasingly severe asthma who doesn’t respond to drug therapy is usually admitted for treatment with corticosteroids, epinephrine, and sympatho mimetic aerosol sprays. He may require endotracheal intubation and me-chanical ventilation.
K E Y PAT I E N T O U T C O M E S The patient will:
■ maintain adequate ventilation
■ maintain a patent airway
■ use effective coping strategies
■ report feelings of comfort
■ maintain skin integrity.
N U R S I N G I N T E R V E N T I O N S
■ Give prescribed drugs.
■ Place the patient in high Fowler’s position.
■ Encourage pursed-lip and diaphragmatic breathing.
■ Administer prescribed humidified oxygen.
■ Monitor ABG results, pulmonary function test results, and pulse oxime-try.
■ Adjust oxygen according to the patient’s vital signs and ABG values.
■ Assist with intubation and mechanical ventilation, if appropriate.
■ Perform postural drainage and chest percussion, if tolerated.
■ Suction an intubated patient as needed.
■ Treat the patient’s dehydration with I.V. or oral fluids as tolerated.
■ Anticipate bronchoscopy or bronchial lavage.
■ Keep the room temperature comfortable.
■ Use an air conditioner or a fan in hot, humid weather.
■ Check vital signs and intake and output.
■ Monitor response to treatment.
■ Watch for signs and symptoms of theophylline toxicity and complica-tions of corticosteroids.
■ Auscultate breath sounds.
■ Assess level of anxiety.
■ Refer the patient to a local asthma support group through the American Lung Association or Asthma and Allergy Foundation of America.
PAT I E N T T E A C H I N G Be sure to cover:
■ the disorder, diagnosis, and treatment
■ medications and potential adverse reactions
■ when to notify the physician
■ avoidance of known allergens and irritants
■ metered-dose inhaler or dry powder inhaler use
■ pursed-lip and diaphragmatic breathing
■ use of peak flow meter
■ effective coughing techniques
■ maintaining adequate hydration.
Atrial fibrillation
D E S C R I P T I O N
■ Rhythm disturbance of the atria
■ Characterized by an irregularly irregular cardiac rate and rhythm (see Recognizing atrial fibrillation, page 50)
PAT H O P H YS I O L O G Y
■ Rapid discharges from numerous ectopic foci in the atria lead to erratic and uncoordinated atrial rhythm.
CA U S E S
■ Atrial fibrosis
■ Cardiomyopathy
■ Cardiothoracic surgery
■ Heart failure
■ Hypersympathetic state associated with acute alcohol ingestion
■ Hypertension
■ Hyperthyroidism
■ Myocardial infarction (MI)
■ Pericarditis
■ Pulmonary embolism
■ Valvular disease
AT R I A L F I B R I L L AT I O N 49
A S S E S S M E N T F I N D I N G S
■ Palpitations
■ Fatigue
■ Dyspnea
■ Chest pain
■ Syncope
■ Irregular pulse; possible tachycardia
■ Hypotension
■ Signs of heart failure
T E S T R E S U LT S
■ Cardiac enzymes show myocardial damage (with MI).
■ Thyroid function studies reveal hyperthyroidism.
■ Complete blood count shows decreased hemoglobin level and hematocrit, if blood loss has occurred.
■ Chest X-ray may reveal pulmonary edema.
■ Echocardiogram or transesophageal echocardiography may reveal valvu-lar disease, left ventricuvalvu-lar dysfunction, or atrial clots.
■ Electrocardiogram may reveal irregular rhythm.
■ Holter monitoring may reveal paroxysmal atrial fibrillation.
RECOGNIZING ATRIAL FIBRILLATION
The following rhythm strip shows atrial fibrillation.
䡲 Rhythm: irregular 䡲 Rate: atrial — indiscernible;
ventricular — 130 beats/minute 䡲 P wave: absent; replaced by fine
fibrillatory waves
䡲 PR interval: indiscernible 䡲 QRS complex: 0.08 second 䡲 T wave: indiscernible 䡲 QT interval: unmeasurable 䡲 Other: none
T R E AT M E N T
■ Possible electrical cardioversion
■ Atrial fibrillation suppression pacemaker
■ Ablation
■ Low-fat, low-sodium diet
■ Fluid restriction, if indicated
■ Planned rest periods as needed
■ Calcium channel blockers
■ Beta-adrenergic blockers
■ Other antiarrhythmics
■ Cardiac glycosides
■ Anticoagulants
K E Y PAT I E N T O U T C O M E S The patient will:
■ report ways to reduce activity intolerance
■ identify effective coping mechanisms to manage anxiety
■ discuss the causes of fatigue
■ verbalize understanding of medication regimen.
N U R S I N G I N T E R V E N T I O N S
■ Give prescribed drugs.
■ Encourage the patient and his family to talk about feelings and concerns.
■ Plan rest periods.
■ Check vital signs at rest and after physical activity, intake and output, and daily weight.
■ Monitor for signs and symptoms of embolism and abnormal bleeding.
■ Refer the patient to programs such as “Coumadin Clinic” where available, or instruct him to contact his physician within 3 days to arrange follow-up testing to monitor anticoagulant therapy.
PAT I E N T T E A C H I N G Be sure to cover:
■ the disorder, diagnosis, and treatment
■ medications and potential adverse reactions
■ when to notify the physician
■ instructions on how to monitor pulse
■ anticoagulation precautions and the need for regular blood testing
■ abnormal bleeding
■ signs and symptoms of embolic events.
AT R I A L F I B R I L L AT I O N 51