Critical thinking: an interactive tool for learning medical-surgical nursing

Copyright © 2001 F.A. Davis Company

Critical Thinking An Interactive Tool for Learning Medical-Surgical Nursing

Eleanor Varsen Vanetzian, PhD, RN Associate Professor School of Nursing University of Masssachusetts Amherst, MA 01003

F. A. Davis Company • Philadelphia

Copyright © 2001 F.A. Davis Company

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103

Copyright (c) 2001 by F. A. Davis Company All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.

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To young women and men choosing a career dedicated to easing the situations of those in need of nursing care with critical, thoughtful and reflective use of knowledge.

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Preface Nurses are increasingly confronted with the need to manage problems and make decisions in complex situations that are often ambiguous and uncertain. Critical Thinking: An Interactive Tool for Learning Medical-Surgical Nursing provides students with a collection of medical-surgical case studies which they must analyze to identify problems, formulate possible nursing actions, and acquire experience that is important for autonomous practice. The workbook is designed to give students opportunities to analyze, synthesize, evaluate, and apply knowledge related to nursing management of adult and elderly patients with a selection of acute illnesses that are often exacerbations of chronic illnesses. Actual or potential problems, issues, and concerns that include psychosocial and emotional aspects of care are presented in increasingly complex patient situations. Information in the case studies is not intended to be complete or comprehensive. Missing information is as important to the process of learning as the information provided; gaps in the data stimulate curiosity. Satisfying curiosity about missing information can be a powerful stimulus to meaningful learning.

Using This Book Unit I: Critical Thinking: The Foundation contains chapters 1 and 2. Chapter 1 introduces the method to be used in this book to learn about the care of adults with medical-surgicalproblems. Richard Paul’s definition of critical thinking is accepted and the theoretical framework underlying the approach to learning is described. Chapter 2 describes the Guidelines for Preparation for Class Assignments. The guidelines are intended to stimulate curiosity about the care of patients in each of the situations. They draw attention to basic nursing information that is essential to learning about medical-surgical nursing. In addition, the guidelines provide a knowledge base that can be enhanced in class. Classroom Activities are also described in Chapter 2. Small group format or the class as a whole may be used to continue to build, broaden, and deepen knowledge of the concepts that were learned during the Preparation for Class Assignment. Unit II: Critical Thinking: Patient Problems contains chapters 3 to 15. These chapters may be used in any order, and this book can be used with any textbook of your choice. Using this method, textbooks are reference books; but they are essential reference books. In addition, students can use current articles from the nursing and allied health science literature to broaden and deepen their understanding of the knowledge they gain using this method. Unit III: Critical Thinking: Complex Client Problems contains chapter 16. This final chapter of the book includes three case studies that depict complex situations. It is my belief that students need to learn how to manage patient care in uncomplicated situations before they can manage the complicated pathophysiological processes that occur with multi-organ involvement, which is the hallmark of a complex illness. I content that this is true, although complex situations are the ones more commonly seen in actual practice. Here students have an opportunity to focus on patients with illnesses that involve one organ system at a time before considering the interaction of multiple systems that fail. Each of the chapters in Units II and III begins with an opening question-a question to keep in mind while preparing for class or completing classroom activities. The question is repeated at the end of the chapter with space to respond with thoughts about its answer. There is no right or wrong way to respond. The possibilities of responses are endless and unique to the individual, reflecting each person’s background of experiences. The question is designed to help synthesize knowledge based on the information gleaned from textbooks and the literature while providing closure to the

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chapter. The case studies in each of the chapters are intended to portray classic situations most of which are based on my experiences in practice. The names given to the patients are fictitious, and their situations are often composites of actual situations. The critical thinking questions are intended to highlight salient thinking processes used to learn about the care of patients with specific problems dealt with in each chapter. Questions are based on Paul’s critical thinking framework. The elements of thought are reintegrated, and intellectual standards are applied to learn about the care of individuals in each of the chapters. This book is appropriate for use in entry level nursing programs: associate degree, baccalaureate, and second bachelors (also known as generic master’s degree). Faculty who design continuing education courses and staff development nurses may use the workbook to strengthen critical thinking in nursing practice. The use of Paul’s model of critical thinking can be applied to a wide variety of content areas in nursing as well as at various educational levels, including graduate education.

Features ❏ Workbook-style format: Provides ample space for students to write in their information; the perforated pages allow students to submit their assignments to the instructor. ❏ Introductory chapters: Include a discussion on critical thinking and the elements of thought and step-by-step instructions on how to use the Preparation for Class Guidelines. ❏ Preparation for Class Guidelines: Help students analyze case studies and get more from the learning process. ❏ Classroom activities: Allow students as a group to anticipate, evaluate, and plan care for the patient as the patient situation changes. ❏ Learning Outcome Goals: Placed at the beginning of each chapter, they provide students with broad-based goals. ❏ Critical Thinking Revisited sections: End each chapter and provide students with an opportunity to evaluate their own critical thinking skills. ❏ Gordon’s Functional Health Patterns: Used for organizing nursing care. ❏ Instructor’s Manual: Provides instructors with guidelines and tips on evaluating and grading students’ work.

Conclusion This book provides students with a safe way to learn and test their understanding of the situation in which people find themselves when they are ill. As you use this book, it is important to keep in mind the objective of learning about the nursing care of individuals with medical and surgical problems. Equally important is the way in which your thinking skills are sharpened, your curiosity is stimulated, and your mind is tuned-in to new ways of thinking that are deeper, broader, and more responsive to the specific questions being asked. In short, observe the development of your skill in thinking critically while developing an in-depth knowledge of the nursing care of patients with medical-surgical problems.

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Preface

Copyright © 2001 F.A. Davis Company

Acknowledgments I wish to acknowledge students who have influenced the development of the learning method described in this workbook. First, Barbara Corrigan who was thoroughly involved in graduate study while enrolled in a teaching practicum with me. Quite unexpectedly, she noticed that the method I used to teach undergraduate students medical-surgical nursing reminded her of Richard Paul’s published work on critical thinking. Eventually, I read his work and found it easy to understand how Barbara related the learning method I taught with the underlying theoretical framework of Paul’s work. Subsequently, for three summers, she and I presented workshops at the International Conference on Critical Thinking and Educational Reform at Sonoma State University, one of which dealt with the method described in this workbook. I would also like to acknowledge here other students, including Kirsten Boyd, Oni Cooper, Lucy Leete, Erin Molito, and Melissa Skehan who saw the value of using critical thinking as a tool to learn about the nursing care of adults. They provided feedback that led me to develop the method further and use it as an integral part of classroom instruction. It was truly gratifying to learn that Oni’s acceptance in an important summer internship program was solidified when she explained during her interview how she used her critical thinking skills! I wish to acknowledge Joanne DaCunha, editor, for recognizing that this book may make a contribution to the evolution of critical thinking in nursing. She asked Diane Schweisguth to assist me with the development of the manuscript, and I want to thank Diane for her prompt, insightful, and cheerful guidance in making the book a reality. Finally, I wish to acknowledge my husband, Ritch, for his unending support and loving presence as well as the encouragement I received from my daughters, Elise, who is a pediatric nurse, and Sheri, who is a crisis counselor pursuing her master’s degree.

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Reviewers Linda L. Alferi, RN, MS, CS

Denise Landry, RN, MSN, EdD

Professor of Nursing

Professor

Cayuga Community College

College of Nursing and Health Professions

Auburn, New York

Marshall University Huntington, WV

Emily Drosk-Bielak, RN, PhD Associate Professor Grand Valley State University Allendale, Michigan

Judith A. Redman, RN, BScN, MEd Part-time Professor and Clinical Instructor University of Ottawa

Carole Heath, RN, MS, CS, EdD

Ottawa, Ontario, Canada

Associate Professor Department of Nursing

Peggy Trueman, RN, MSN

Sonoma State University

Faculty, Department of Nursing

Rohnert Park, CA

Gaston College Dalla,s, North Carolina

Linda Lea Kelly-Brown, RN, MA Professor New Hampshire Community Technical College Claremont, Vermont

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Contents Unit I

Critical Thinking: The Foundation 1

Chapter 1

Critical Thinking: A Theoretical Basis 3 Chapter Outline 4 Learning Outcome Goals 4 Creativity and Critical Thinking 5 Critical Thinking and Case Studies 5 Paul’s Theoretical Framework of Critical Thinking 5 A Definition of Critical Thinking 5 The Elements of Thought 5 The Traits of a Critical Thinker 7 Using Critical Thinking as a Learning Tool in Nursing 7 Summary/Conclusions 8 Suggested Readings/Resources 8

Chapter 2

Critical Thinking: Applying it to Practice 9 Chapter Outline 10 Learning Outcome Goals 10 Directions for Using the Preparation for Class Guidelines 12 The Elements of Thought 12 Intellectual Standards 12 The Preparation for Class Guidelines 12

Applying the Preparation for Class Guidelines to A Case Study 15 Case Study: A Fractured Hip 16 Preparation for Class Guidelines: Nursing Care of an Elderly Person with a Fractured Hip 16

Classroom Activities 23 Nursing Care of an Individual with a Hip Fracture 23

Suggested References/Resources 25

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Unit II

Critical Thinking: Patient Problems 27

Chapter 3

Respiratory Problems 29 Chapter Outline 30 Learning Outcome Goals 30 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 31 Case Study: Pneumonia 31 Preparation for Class: Nursing Care of a Person with Pneumonia 32 Class Activity: Nursing Care of Individuals with Adult Respiratory Distress Syndrome 41

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 43 Case Study: Chronic Airway Limitation or Chronic Obstructive Pulmonary Disease 43 Preparation for Class: Nursing Care of a Person with Chronic Airway Limitation or Chronic Obstructive Pulmonary Disease 43 Class Activity: Nursing Care of an Individual with Asthma 53

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 54 Case Study: Lung Cancer 54 Preparation for Class: Nursing Care of a Person with Lung Cancer 54 Class Activity: Nursing Care of Individuals with Laryngectomy 64

Critical Thinking Revisited 65 Suggested Readings/Resources 66

Chapter 4

Cardiovascular Problems 67 Chapter Outline 68 Learning Outcome Goals 69 Medical Nursing Care: Practice in Critical Thinking Acute Care Situations 69

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Case Study: Myocardial Ischemia Ruling Out Myocardial Infarction 69 Preparation for Class: Nursing Care of a Man with Myocardial Ischemia Ruling Out Myocardial Infarction 70 Class Activity: Nursing Care of Individuals Receiving Antithrombolytic Therapy 79

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 79 Case Study: Congestive Heart Failure 79 Preparation for Class: Nursing Care of a Person with Congestive Heart Failure 80 Class Activity: Nursing Care of Individuals with Pulmonary Edema 89

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 90 Case Study: Percutaneous Transluminal Coronary Angioplasty/Coronary Artery Bypass Graft Surgery 90 Preparation for Class: Nursing Care of a Person Undergoing Percutaneous Transluminal Coronary Angioplasty/Coronary Artery Bypass Graft 90

Surgical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 99 Class Activity: Nursing Care of Individuals with Dysrhythmias 99 Class Activity: Comparing Dysrhythmias 100 Class Activity: ECG Patterns of Dysrhythmias 100

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 102 Case Study: Peripheral Vascular Disease 102 Preparation for Class: Nursing Care of a Person with Peripheral Vascular Disease 103 Class Activity: Nursing Care of Individuals with FemoralPopliteal Bypass Graft 112 Class Activity: Nursing Care of Individuals Hypertension 112

Critical Thinking Revisited 113 Suggested Readings/Resources 114

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Chapter 5

Hematologic Problems 115 Chapter Outline 116 Learning Outcome Goals 116 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 117 Case Study: Leukemia 117 Preparation for Class: Nursing Care of a Person with Leukemia 118 Class Activity: Nursing Care of Individuals Undergoing Bone Marrow Transplantation 127

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 127 Case Study: Sickle Cell Anemia 127 Preparation for Class: Nursing Care of a Person with Sickle Cell Anemia 128 Class Activity: Nursing Care of Individuals with Thrombocytopenia 137 Class Activity: Nursing Care of Individuals with Iron Deficiency Anemia 137

Critical Thinking Revisited 138 Suggested Readings/Resources 140

Chapter 6

Gastrointestinal Problems 141 Chapter Outline 142 Learning Outcome Goals 143 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 143 Case Study: Ulcer Disease 143 Preparation for Class: Nursing Care of a Person with Ulcer Disease 144 Class Activity: Nursing Care of Individuals with Ulcer Disease 152

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 153 Case Study: Irritable Bowel Disease (Crohn’s Disease) 153

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Preparation for Class: Nursing Care of a Person with Irritable Bowel Disease (Crohn’s Disease) 153 Class Activity: Follow-up Care of an Individual with Irritable Bowel Disease (Crohn’s Disease) 162

Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations 163 Case Study: Cancer of the Bowel 163 Preparation for Class: Nursing Care of a Person with Cancer of the Bowel 164 Class Activity: Postoperative Nursing Care of an Individual Undergoing a Colostomy 173

Surgical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 174 Case Study: Ulcerative Colitis 174 Preparation for Class: Nursing Care of a Person with Ulcerative Colitis Requiring an Ileostomy 174 Class Activity: Postoperative Nursing Care of Individuals with a Temporary Diverting-Loop Ileostomy 182

Critical Thinking Revisited 185 Suggested Readings/Resources 187

Chapter 7

Liver, Biliary, and Exocrine Pancreatic Problems 189 Chapter Outline 190 Learning Outcome Goals 191 Medical Nursing Care: Practices in Critical Thinking: Acute Care Situations 191 Case Study: Cirrhosis 191 Preparation for Class: Nursing Care of a Person with Cirrhosis 192 Class Activity: Nursing Care of Individuals with Bleeding Esophageal Varices 200 Class Activity: Nursing Care of Individuals with Hepatitis 202

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 203 Case Study: Pancreatitis 203

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Preparation for Class: Nursing Care of a Person with Pancreatitis 203

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 212 Case Study: Cholelithiasis 212 Preparation for Class: Nursing Care of a Person with Cholelithiasis 212 Class Activity: Nursing Care of an Individual with Cholelithiasis 221

Surgical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 222 Class Activity: Nursing Care of Individuals with Cholecystitis 222

Critical Thinking Revisited 224 Suggested Readings/Resources 226

Chapter 8

Endocrine Problems 227 Chapter Outline 228 Learning Outcome Goals 229 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 229 Case Study: Type 2 Diabetes Mellitus 229 Preparation for Class: Nursing Care of a Person with Type 2 Diabetes Mellitus 230

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 238 Class Activity: Nursing Care of Adults with Type 1 Diabetes Mellitus 238 Class Activity: Nursing Care of Adults with Type 2 Diabetes Mellitus 239

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 240 Case Study: Hyperthiroidism 240 Preparation for Class: Nursing Care of a Person with Hyperthyroidism 241 Class Activity: Nursing Care of Individuals with Hypothyroidism 249

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Class Activity: Nursing Care of Individuals with Hypoparathyroid Function 250

Surgical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 251 Case Study: Adrenocortical Disease (Cushing’s Disease) 251 Preparation for Class: Nursing Care of a Person with Adrenocortical (Cushing’s) Disease 252 Class Activity: Nursing Care of Individuals with Adrenocortical Insufficiency (Addison’s Disease) 260 Class Activity: Nursing Care of Individuals with Pituitary Dysfunction 263 Class Activity: Nursing Care of Individuals with Acromegaly 263

Critical Thinking Revisited 264 Suggested Readings/Resources 267

Chapter 9

Reproductive Problems 269 Chapter Outline 270 Learning Outcome Goals 271 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 271 Case Study: Pelvic Inflammatory Disease 271 Preparation for Class: Nursing Care of a Woman with Pelvic Inflammatory Disease 272 Class Activity: Nursing Care of Women with Pelvic Inflammatory Disease 281

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 281 Case Study: Cancer of the Endometrium 281 Preparation for Class: Nursing Care of a Woman with Cancer of the Endometrium 282 Class Activity: Nursing Care of Women with Endometriosis 290

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 292 Case Study: Breast Cancer 292

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Preparation for Class: Nursing Care of a Woman with Breast Cancer 292 Class Activity: Nursing Care of Women with Ovarian Cancer 301 Case Study: Testicular Cancer 303 Preparation for Class: Nursing Care of a Man with Testicular Cancer 304 Class Activity: Nursing Care of Men with Testicular Cancer 313

Critical Thinking Revisited 314 Suggested Readings/Resources 316

Chapter 10

Immunologic Problems 317 Chapter Outline 318 Learning Outcome Goals 318 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 319 Case Study: Rheumatoid Arthritis 319 Preparation for Class: Nursing Care of a Person with Rheumatoid Arthritis 320

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 329 Case Study: Acquired Immunodeficiency Syndrome 329 Preparation for Class: Nursing Care of a Person with Acquired Immunodeficiency Syndrome 329 Class Activity: Nursing Care of Individuals with Systemic Lupus Erythematosus 338

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 339 Case Study: Rheumatoid Arthritis 339 Preparation for Class: Nursing Care of a Person with Rheumatoid Arthritis 340

Surgical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 348 Class Activity: Nursing Care of Individuals with Rheumatoid Arthritis Undergoing Hip Replacement Surgery 348

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Critical Thinking Revisited 350 Suggested Readings/Resources 353

Chapter 11

Musculoskeletal Problems 355 Chapter Outline 356 Learning Outcome Goals 357 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 357 Case Study: Osteomyelitis 357 Preparation for Class: Nursing Care of a Person with Osteomyelitis 358 Class Activity: Nursing Care of Individuals with Osteomyelitis 366

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 367 Case Study: Osteoporosis 367 Preparation for Class: Nursing Care of a Person with Osteoporosis 368

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 377 Case Study: Trauma 377 Preparation for Class: Nursing Care of a Person with Trauma 377 Class Activity: Nursing Care of Individuals with Trauma 385

Surgical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 387 Case Study: Amputation 387 Preparation for Class: Nursing Care of a Person Undergoing Amputation 388 Class Activity: Nursing Care of Individuals with a Below-Knee Amputation 396 Class Activity: Nursing Care of Individuals with Complications of a Fractured Hip 397

Critical Thinking Revisited 399 Suggested Readings/Resources 402

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Chapter 12

Renal Problems 403 Chapter Outline 404 Learning Outcome Goals 405 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 405 Case Study: Acute Glomerulonephritis 405 Preparation for Class: Nursing Care of a Person with Acute Glomerulonephritis 406 Class Activity: Nursing Care of Individuals with Nephrotic Syndrome 414 Class Activity: Nursing Care of Individuals with Polycystic Kidney Disease 415

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 417 Case Study: Chronic Renal Failure and Hemodialysis 417 Preparation for Class: Nursing Care of a Person with Chronic Renal Failure and Undergoing Hemodialysis 418 Class Activity: Nursing Care of Individuals with End-Stage Renal Disease and Undergoing Continuous Ambulatory Peritoneal Dialysis 426

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 428 Case Study: Renal Calculi 428 Preparation for Class: Nursing Care of a Person with Renal Calculi 428 Class Activity: Nursing Care of Men with Benign Prostatic Hypertrophy 436

Surgical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 438 Case Study: Urinary Incontinence 438 Preparation for Class: Nursing Care of a Person with Urinary Incontinence 438 Class Activity: Nursing Care of Individuals with Renal Transplantation 446 Class Activity: Nursing Care of Individuals with Urinary and Renal Dysfunction 448

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Critical Thinking Revisited 451 Suggested Readings/Resources 453

Chapter 13

Neurological Problems 455 Chapter Outline 456 Learning Outcome Goals 456 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 457 Case Study: Cerebrovascular Accident (Stroke) and Increased Intracranial Pressure 457 Preparation for Class: Nursing Care of a Person with Cerebrovascular Accident (Stroke) and Increased Intracranial Pressure 458 Class Activity: Nursing Care of Individuals with Cerebrovascular Accident (Stroke) 466 Case Study: Spinal Cord Injury 467 Preparation for Class: Nursing Care of a Person with Spinal Cord Injury 467 Class Activity: Nursing Care of Individuals with Spinal Cord Injury 476 Case Study: Infection (Meningitis) 479 Preparation for Class: Nursing Care of a Person with Infection (Meningitis) 479

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 488 Case Study: Brain Tumor 488 Preparation for Class: Nursing Care of a Man with Brain Tumor 488 Class Activity: Nursing Care of Individuals with Brain Injury 496

Critical Thinking Revisited 499 Suggested Readings/Resources 501

Chapter 14

Sensory Problems 503 Chapter Outline 504 Learning Outcome Goals 504

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Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 505 Case Study: Closed-Angle Glaucoma 505 Preparation for Class: Nursing Care of a Person with ClosedAngle Glaucoma 506 Class Activity: Nursing Care of Individuals with Otosclerosis 514

Medical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 516 Case Study: Open-Angle Glaucoma 516 Preparation for Class: Nursing Care of a Person with OpenAngle Glaucoma 516 Class Activity: Nursing Care of Individuals with Ménière’s Syndrome 525

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 526 Case Study: Cataracts 526 Preparation for Class: Nursing Care of a Person with Cataracts 526

Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations 535 Case Study: Retinal Detachment 535 Preparation for Class: Nursing Care of a Person with Retinal Detachment 535

Critical Thinking Revisited 544 Suggested Readings/Resources 546

Chapter 15

Integumentary Problems 547 Chapter Outline 548 Learning Outcome Goals 548 Medical Nursing Care: Practice in Critical Thinking: Acute Care Situations 549 Case Study: Burns 549 Preparation for Class: Nursing Care of a Person with Burns 550 Class Activity: Nursing Care of Individuals in the Acute Phase of Burn Treatment 558

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Class Activity: Nursing Care of Individuals with Burns Needing Skin Grafts 559 Class Activity: Nursing Care of Individuals Rehabilitating from the Treatment of Burns with Skin Grafting 561

Surgical Nursing Care: Practice in Critical Thinking: Acute Care Situations 561 Case Study: Malignant Melanoma 561 Preparation for Class: Nursing Care of a Person with Malignant Melanoma 562

Surgical Nursing Care: Practice in Critical Thinking: Chronic Care Situations 570 Class Activity: Nursing Care of Individuals with Malignancies of the Skin: Basal Cell and Squamous Cell Carcinoma 570

Critical Thinking Revisited 572 Suggested Readings/Resources 575

Unit III

Critical Thinking: Complex Patient Problems 577

Chapter 16

Complex Nursing Care Situations: Implications of Potential Trajectories of Illnesses 579 Chapter Outline 580 Learning Outcome Goals 580 Complex Nursing Care Situation 581 Case Study: No. 1 581 Preparation for Class 582 Class Activity 590 Class Activity 591 Class Activity 592

Complex Nursing Care Situation 593 Case Study No. 2 593 Preparation for Class 594 Class Activity 602

Complex Nursing Care Situation 604 Case Study No. 3 604 Preparation for Class 604 Contents

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Class Activity 613 Class Activity 615 Class Activity 615 Class Activity 616

Critical Thinking Revisited 617 Suggested Readings/Resources 619

Index

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UNIT

I Critical Thinking: The Foundation

Chapter 1

Critical Thinking: A Theoretical Basis...3

Chapter 2

Critical Thinking: Applying It to Practice...9

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Chapter

1 Critical Thinking: A Theoretical Basis

Copyright © 2001 F.A. Davis Company

Critical Thinking: A Theoretical Basis

Q

1

Is critical thinking a tool that students can use to deepen and broaden their knowledge of nursing care as they learn to provide care for adults with acute and chronic illnesses? Chapter Outline Learning Outcome Goals Introduction A Definition of Critical Thinking Creativity and Critical Thinking Critical Thinking and Case Studies Paul’s Theoretical Framework of Critical Thinking The Elements of Thought Intellectual Standards The Traits of a Critical Thinker Using Critical Thinking as a Learning Tool in Nursing Summary and Conclusions Suggested Readings and Resources

Learning Outcome Goals 1. To learn the definition of critical thinking used in this workbook 2. To understand how creative and critical thinking are related 3. To know the theoretical underpinnings and concepts of Paul’s framework of critical thinking 4. To understand the rationale for learning critical thinking skills in nursing today

Numerous technological, economic, social, and political forces are at work today changing the way in which healthcare is delivered in this country (Jacobs, Ott, Sullivan, Ulrich, & Short, 1997). As the healthcare system changes, nurses will increasingly be confronted with the need to manage nursing care and make decisions in situations that are often ambiguous and uncertain. If change is a consistent trend in the foreseeable future, new and emerging nursing roles will need to be built on

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new educational competencies. These competencies include learning to use thinking processes that enhance learning the content of a discipline (Brigham, 1993). Educational methods that include learning to think critically encourage students to use their prerequisite knowledge of the arts and sciences to create individualized and innovative care in nursing situations. In preparing students for a future in nursing, educators provide opportunities for students to build on their previous knowledge in new and creative ways by encouraging them to use their natural curiosity and sharpen their critical thinking skills.

A Definition of Critical Thinking There are various definitions of critical thinking, but for the purpose of the method of learning presented here, critical thinking is a tool that is used to think about a subject, situation, or project accurately and clearly, as well as deeply and broadly, in order to learn about the care of adults with medical-surgical disorders.

Creativity and Critical Thinking Although creative and critical thinking may seem like “polar opposite forms of thought to many people, they are really inseparable aspects of the best ways people are able to think” (Paul, 1993, pp. 101–112). Creative and critical thinking are related to one another. Creativity is a process of making or producing and critical thinking is a process of assessing or judging thought. Creating and assessing thought may be done simultaneously (Paul, 1993). Using the method described here, faculty and students become open to new ways of thinking about old or familiar situations. It is expected that both will recognize that there may be several equally effective ways to pose and solve problems in a given situation. Gaps in knowledge are intended to stimulate curiosity. In fact, nurses in practice seldom have complete knowledge of their patients, which means that most decisions are made in the midst of various degrees of uncertainty. In the case studies provided, the lack of complete information often makes the situation difficult to figure out. The missing information is intended to stimulate curiosity and cause students to look further to answer their questions. In the process, students’ previous knowledge may be reinforced and they may uncover new meanings.

Critical Thinking and Case Studies Case studies are central to the method described here because they reflect actual patient situations or composites of actual situations. These situations provide the context for learning about nursing care issues. Context is essential for grounding the content of thinking (Paul, 1993) in nursing situations, and both content and process are involved in critical thinking (Birx, 1993). Paul’s method is not a step-by-step approach, but rather, a process that is reflective, thoughtful, and self-evaluative (Paul, 1993). Students are taught to critique their thoughts as they use reasoning (Paul, 1994) to delve into the issues they find in the patient care situations.

Paul’s Theoretical Framework of Critical Thinking Paul’s theoretical framework of critical thinking forms the basis for the activities described in this book. The meanings of terms in the model are consistent with everyday use. According to Paul, critical thinking is a unique kind of purposeful thinking in which people examine their thinking with the intention of improving their way of thinking about a particular subject, situation, or problem. This improvement in thinking is accomplished through a process of self-criticism (Paul, 1993, pp. 134–135) that calls into question the biases, half-truths, and distortions that become part of an individual’s belief system if they remain unquestioned.

The Elements of Thought The eight elements of thought proposed by Paul (1993) will be used to learn more about the nursing care situation and develop a base of knowledge. Self-assessment and self-examination are

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essential requirements of critical thinking, and critical thinking produces predictable, well-reasoned answers when assessed all along the way. Critical thinking can be a tool for learning that is specific to a discipline, such as nursing, and the learning is possible by attending to basic conditions of thinking that Paul calls the “elements of thought.” The elements of thought stem from the process of reasoning, which is central to critical thinking. According to Paul, the elements of thought shape reasoning and provide a logical framework (Paul, 1993, pp. 20–23). The elements of thought are basic conditions of thinking that are implicit whenever information is applied, analyzed, synthesized, or evaluated. The eight elements are: 1. 2. 3. 4. 5. 6. 7. 8.

A purpose, goal, objective, or end in view A question at issue or central problem A point of view, perspective, or frame of reference An empirical dimension of reasoning, which includes data, facts, observations, experiences, evidence, or information A conceptual dimension of reasoning, which includes theories, laws, definitions, models, and principles or rules Assumptions, interpretations or taking for granted, presuppositions Implications and consequences Interpretations, inferences, conclusions, solutions that may be made, for example, since this has been shown, therefore that is possible

Intellectual Standards According to Paul (1992), using the elements of thought is not enough. When thinking critically, criteria called “universal standards” are applied that require reasoning to be clear, logical, precise, specific, accurate, plausible, consistent, significant, relevant, broad, and deep. Each of the elements of thought is described below. Examples of intellectual standards that may be applied to each element of thought demonstrate how they are used as criteria for evaluating their use. A Purpose, Goal, Objective, or End in View All reasoning has a purpose, goal, objective, or end in view. Critical thinkers are able to show the purpose of their thinking clearly in relation to a situation or a problem. When there is more than one purpose or related goal, critical thinkers can distinguish between them and state the distinction clearly. Critical thinkers identify purposes and goals that are worthwhile, significant, and achievable as opposed to those that are insignificant, trivial, or unrealistic. A Question at Issue or Central Problem All reasoning is an attempt to figure something out, settle a question, or solve a problem. Critical thinkers can state clearly what the question is and they can express the question in a variety of ways. They can break the question down into sub-questions. A critical thinker is sensitive to the type of questions being asked and distinguishes those that are significant and relevant from those that are not, and those that can be answered from those that cannot. Critical thinkers ask questions in a neutral, unbiased way that allows them to be sensitive to the assumptions that may be built into the questions they ask. A Point of View or Frame of Reference All reasoning is done from some point of view and reasoning is better when many relevant points of view are sought out, articulated clearly, and applied logically and dispassionately. Critical thinkers consistently articulate points of view other than their own, knowing that another person’s point of view may be different, especially in relation to issues that are controversial. Critical thinkers have insight into problems where they may be prejudiced, and they approach problems and issues with an appropriately broad point of view.

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An Empirical Dimension of Reasoning, Which Is Data, Evidence, or Information All reasoning is based on data, evidence, or information. Critical thinkers make assertions only when they have enough evidence to support their claim. When searching for information to figure something out, critical thinkers look for information both for and against their position. They are able to focus on relevant information and disregard what is not relevant to the issue or problem under consideration. Critical thinkers state information and evidence clearly, fairly, and coherently, drawing conclusions only to the extent that they have supporting data. A Conceptual Dimension of Reasoning, Which Includes Theories and Principles or Rules All reasoning is expressed through and shaped by concepts and ideas. Critical thinkers are aware of the key concepts and ideas they use, and they can make distinctions in their writing between those that are relevant and those that are not. Critical thinkers are able to explain the meaning and uses of the concepts and ideas they use. Assumptions, Interpretations or Inferences, Concepts or Principles All reasoning is based on assumptions. Critical thinkers make assumptions that are clear, reasonable, and consistent with and not contradictory to each other. Implications and Consequences All reasoning leads somewhere and has implications and consequences. Thinking through an issue using reasoning requires that a critical thinker understand the implications and consequences that follow from it. Critical thinkers identify and articulate a number of significant implications and consequences of their reasoning. They are able to search for the negative and positive implications of their reasoning and anticipate the likelihood of unexpected consequences. Inferences That May Be Made, for Example, Since This Has Been Shown, Therefore That Is Possible All reasoning contains inferences by which we give meaning to the data and come to a conclusion. Critical thinkers make inferences that are clear and deep, rather than superficial, and that come from the evidence and are consistent with each other.

The Traits of a Critical Thinker Independent thinking, courage, curiosity, fair-mindedness, and open-mindedness are traits of a critical thinker and another aspect of the model. Those who are critical thinkers have the courage to say what they think, the curiosity to ask deep questions, and the ability to suspend judgement and practice humility. Critical thinkers have a responsibility to act on well thought-out plans, and demonstrate a fair-mindedness that is based on reasoning. In addition to those traits, which are considered functional traits, there are traits that interfere with decision making and hinder progress when a course of action must be determined. Therefore traits such as egocentricity and sociocentricity must be recognized as unwanted. In fact, they may be counterproductive when attempting to find areas of agreement or when consensus needs to be reached.

Using Critical Thinking as a Learning Tool in Nursing Practicing nurses regularly use the dimensions of critical thinking described by Paul (Brigham, 1993). Using the method described here, students are given opportunities to think like nurses. Students are encouraged to develop skill in thinking independently, asking difficult questions, and being fairminded and open-minded in their approach to patient care. Using Paul’s (1992) framework, students integrate their knowledge of the humanities and natural sciences to develop nursing knowledge. Students have opportunities to practice posing nursing care problems holistically, specifically addressing adults with acute and chronic illnesses. Reasoning, using the elements of thought and applying intellectual standards, is the learning tool used to find acceptable solutions in classroom situations.

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Summary and Conclusions This workbook promotes interaction between the learner and the information to be learned. The subject of thought is the care of adults with acute and chronic illness. Prior learning in similar situations caring for adults with acute and chronic illnesses becomes integrated with new information. Paul’s model of reasoning, with the elements of thought, standards, and criteria for using the elements— and the overall goal of developing the traits and abilities of critical thinkers—completes the framework for analyzing and applying nursing concepts in any setting where nursing care is provided.

Suggested Readings and Resources Birx, E. C. (1993). Critical thinking and theory based practice. Holistic Nursing Practice, 7(3), 21–27. Brigham, C. (1993). Nursing education and critical thinking: Interplay of content and thinking. Holistic Nursing Practice, 7(3), 48–54. Ennis, R. H. (1996). Critical thinking. Upper Saddle River, NJ: Prentice Hall. Jacobs, P. M., Ott, B., Sullivan, B., Ulrich, Y., & Short, L. (1997). An approach to defining and operationalizing critical thinking. Journal of Nursing Education, 36(1), 19–22. Paul, R. (1992). Critical thinking: How to prepare students for a rapidly changing world. Santa Rosa, CA: Center for Critical Thinking. Paul, R. (1993). Critical thinking: What every person needs to survive in a rapidly changing world (2nd ed.). Santa Rosa, CA: Foundation for Critical Thinking. Paul, R. (1994). Critical Thinking: How to Design Instruction So That Students Master Content in a Deep and Thoughtful Way. Paper presented at the 14th Annual International Conference on Critical Thinking and Educational Reform, p. 5. Pepa, C. A., Brown, J. M., & Alverson, E. M. (1997). A comparison of critical thinking abilities between accelerated and traditional baccalaureate nursing students. Journal of Nursing Education, 36(1), 46–48. Sedlak, C. A. (1997). Critical thinking of beginning baccalaureate nursing students during their first clinical nursing course. Journal of Nursing Education, 36(1), 11–18. Videbeck, S. L. (1997). Critical thinking: Prevailing practice in baccalaureate schools of nursing. Journal of Nursing Education, 36(1), 5–10.

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Chapter

2 Critical Thinking: Applying It to Practice

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Critical Thinking: Applying it to Practice

Q

2

How does the method work?

Chapter Outline Learning Outcome Goals Introduction Directions for Using the Preparation for Class Guidelines The Elements of Thought Intellectual Standards The Preparation for Class Guidelines Applying the Preparation for Class Guidelines to a Case Study Case Study: A Fractured Hip The Preparation for Class Guidelines: Nursing Care of a Person with a Fractured Hip Classroom Activity: Nursing Care of Individuals with Hip Fractures Suggested References and Resources

Learning Outcome Goals 1. To develop critical thinking skills through learning how to use the Preparation for Class Guidelines and the elements of thought for each Preparation for Class and Classroom Activity

The Preparation for Class Guidelines, the “Preps” (see Table 2–1), were developed as a systematic method of learning about the nursing care of adults and the elderly with acute and chronic illnesses. To master medical-surgical nursing care, students must be able to recall facts and knowledge from their courses in the humanities, arts, and natural sciences. Planning to provide medical-surgical nursing care for patients with acute and chronic illnesses means applying what you have already learned to these new situations. In addition, preparation for nursing practice in acute and chronic care settings relies on the application of learning to clinical practice.

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Table 2–1. Preparation for Class Guidelines 1. 2. 3. 4.

LITERATURE REVIEW FACTS NURSING CARE ISSUES AND CONCERNS (INCLUDE THOSE RELATED TO AGING) ASSESSMENT AND TENTATIVE NURSING DIAGNOSES a. Functional health patterns 1. Health perception–health management 2. Nutritional-metabolic function 3. Elimination 4. Activity-exercise 5. Sleep-rest 6. Cognitive-perceptual function 7. Self-perception–self-control 8. Role-relationship 9. Sexuality-reproductive function 10. Coping–stress tolerance 11. Value-belief b. Cultural aspects c. Missing information d. Tentative nursing diagnoses 1. List tentative nursing diagnoses that apply 2. Etiology 3. Defining characteristics 4. Method of validation 5. CLINICAL DATA a. Lab values 1. Given 2. Expected/normal value b. Medications 1. Given 2. Expected c. Nutrition d. Environment e. Discussion of logical fit between subjective and objective information 6. DECISION MAKING a. Nursing diagnoses and rationales 1. Level of priority 2. Whether to retain or eliminate from list b. Expected outcome 7. NURSING INTERVENTIONS a. Nursing diagnosis (retained) b. Nursing interventions (include patient teaching, preparation for testing, surgery, discharge, etc.)

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Table 2–1. Preparation for Class Guidelines (continued) 8. EVALUATION OF OUTCOMES a. Nursing diagnosis (retained) b. Outcome of care 9. HEALTHCARE PROFESSIONALS AND MEDICAL CARE NEEDED 10. ADDITIONAL QUESTIONS ABOUT THIS PATIENT’S NURSING CARE

Directions for Using the Preparation for Class Guidelines Use the format below to analyze the case studies when preparing for class and learning about the medical-surgical nursing care of young and older adults. As you respond to each section, you will need to refer to textbooks and articles in nursing journals as well as to rely on what you have previously learned as it relates to the medical and surgical nursing care of adult and elderly individuals. If you work independently you will derive the greatest benefit from this method of learning. Your preparation is intended to build on your knowledge and student experiences in a way that allows you to learn from written materials and faculty feedback as well as from one another in class. Students are likely to analyze case studies differently and conflicting recommendations are possible as students consider the cases from their own perspectives and background of experiences.

The Elements of Thought The guidelines require the use of reasoning skills to delve deeply into each situation. The tools to be used when thinking about the issues and concerns in each of the case studies are the elements of thought listed here (a more thorough explanation of each is found in Chapter 1): 1. 2. 3. 4. 5. 6. 7. 8.

A purpose, goal, objective, or end in view A question at issue or central problem A point of view, perspective, or frame of reference An empirical dimension of reasoning, which includes data, facts, observations, experiences, evidence, or information A conceptual dimension of reasoning, which includes theories, laws, definitions, models, and principles or rules Assumptions, interpretations or taking for granted, presuppositions Implications and consequences Interpretations, inferences, conclusions, solutions that may be made, for example, since this has been shown, therefore that is possible

Intellectual Standards Intellectual standards modify each of the elements of thought. It is not enough to look for purposes, and objectives, and so on. To improve your thinking, each must be done clearly, logically, precisely, specifically, accurately, and consistently. The ideas you pursue in each of the case studies will need to be those that are significant and relevant to the patient’s care. The ideas you develop will need to be broad and deep if you are to develop higher order, disciplined thinking skills.

The Preparation for Class Guidelines Any of the elements of thought could be appropriately applied to each of the guidelines. You should judge for yourself when to use them. Some suggestions are offered below to show you how this may be done.

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1. Literature Review Review the literature. Skim the sections of your nursing texts and journal articles that relate to problems similar to those of the individuals in the case studies. A clear understanding of the disease process involved in the case study is required before proceeding. Therefore, refer to that section of the medical-surgical textbook devoted to pathophysiology and review it carefully. Also review age-related changes in function when it is appropriate.

2. Facts Underline the facts in the situation as you read. Ask yourself: Can I identify the assumptions I am making as I begin to learn about the person’s nursing care in this situation? Are there justifications for my assumptions? Are my assumptions consistent with the facts and information in the situation? Is there a clear connection between my assumptions and the facts and information in this situation?

3. Nursing Care Issues and Concerns Establish nursing care issues and concerns related to the facts, including those related to aging or implications of aging. Ask yourself: Have I written the nursing care issues and concerns broadly enough? Are the issues and concerns I am identifying logical given the information and facts that I have? Are the issues and concerns I am raising reasonable at this point in the process? What assumptions did I make when relating the issues and concerns to the patient problems I have identified? Are the inferences I made when stating issues and concerns substantiated by the facts and information I found in the literature and/or in the textbook?

4. Assessment and Tentative Nursing Diagnoses Use the Functional Health Patterns (see Table 2–2) as a guide to the areas of assessment. Not every case study will include information about every pattern. Include the cultural aspects of assessment by using your knowledge of the patient’s culture to guide the nursing care to be described. Typically, the information nurses have about the patients in their care is incomplete or not as recent and up-to-date as they would like. As you consider each of the Functional Health Patterns, write down any additional assessment data you think would help you care for this individual. Use reference books to help you organize the information. Write tentative nursing diagnoses as they relate to these specific patterns. Identify etiology and defining characteristics for each diagnosis. Ask yourself: When formulating these nursing diagnoses, was the information I focused on related clearly and precisely to the individuals in the situation? Describe how each diagnosis will be validated. Validation involves looking at the way in which you determined that the diagnosis is valid. Ask yourself: Is there data to support the diagnosis? Is there someone, for example, the patient, who should be consulted or is there something I should look up to be sure the diagnosis is appropriate?

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Table 2–2. Functional Health Patterns 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

HEALTH PERCEPTION–HEALTH MANAGEMENT NUTRITIONAL-METABOLIC ELIMINATION ACTIVITY-EXERCISE SLEEP-REST COGNITIVE-PERCEPTUAL SELF-PERCEPTION–SELF-CONCEPT ROLE-RELATIONSHIP SEXUALITY-REPRODUCTIVE COPING–STRESS TOLERANCE VALUE-BELIEF

5. Clinical Data Identify clinical data for each nursing diagnosis. Ask yourself: Is there missing information? When listed, do the subjective and objective facts and information fit together logically? Are the concepts, theories, or principles related accurately to each of the nursing diagnoses? Are the concepts, theories or principles clearly connected based on the facts and information I found in the literature or in the textbook? About the patient’s laboratory (lab) values, ask yourself: What lab values would I expect to be abnormal and why? What is the normal range of those lab values? About the patient’s medications, ask yourself: What medications would I expect this person to receive? What information is given about this patient’s currently prescribed medications? Why is each being prescribed? About the patient’s nutrition, ask yourself: What nutritional issues are important in this person’s care? About the patient’s environment, ask yourself: Are modifications to this person’s environment needed to enable the person to function in the hospital? At home? At the end of this section, you will have a comprehensive presentation of the nursing care issues related to the care of people with similar problems. In the next section, you will individualize nursing care to this situation. 6. Decision Making Make decisions about the tentative nursing diagnoses you have listed, based on the level of priority of each, in the situation of the individual in the case study. Write a rationale for the way in which you prioritized them. Eliminate all except the highest priority nursing diagnoses and explain why each

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has been retained or eliminated. Identify the expected outcomes of the nursing diagnoses on this, your final list. Ask yourself: Are my decisions based on the available evidence? Can I identify the missing information that I am inferring in relation to my decisions? Are my interpretations of the data supported by the information I am given? Was my point of view broad enough in relation to the decisions I have made? Are my conclusions reasonable? 7. Nursing Interventions For each nursing diagnosis and outcome, identify the appropriate nursing interventions, including patient teaching and preparation for testing, surgery, and discharge, as appropriate. Ask yourself: Are the nursing interventions I identified relevant to the problems I have prioritized? What assumptions have I made as I identified interventions? Were my assumptions logical and relevant? 8. Evaluation of Outcomes Describe the way in which patient outcomes will be evaluated. Ask yourself: Are the outcomes consistent with the information I have about the problem in this person’s situation? What assumptions am I making about the consequences of interventions? Were the consequences realistic in this situation? Did my reasoning lead to the expected consequences? 9. Healthcare Professionals and Medical Care Needed In addition to nurses and physicians, identify which healthcare professionals will be consulted about this patient’s care and what medical care is expected in patients with this condition. Ask yourself: Are the assumptions I am making about the care involved reasonable? Are my responses based on experience? On actual practice? 10. Additional Questions about This Patient’s Nursing Care Write two or three questions you still have about this patient’s nursing care. Ask yourself: Do my questions show the need for deeper, relevant information? Or are my questions superficial?

Applying the Preparation for Class Guidelines to a Case Study Students prepare for class each week by following the directions for completing an assignment using the Preparation for Class Guidelines to trigger the elements of thought. The patient’s situation, which is described in a case study, is the context for following the guidelines. As students think about the patient’s situation, they are confronted with the need to analyze what is happening in order to make sense of the situation. In the process of using the elements of thought, students apply intellectual standards and identify the problems to be solved, goals, and outcomes or consequences of nursing care in the patient’s situation. Students review the data they have and identify information that is missing. Using the reasoning process, students describe their own points of view in particular situations. They identify principles and theories they have learned previously, in addition to assumptions and interpretations they have made of the present situation. As they make sense of the situation, students look for facts and information that reinforce thinking that is logical, accurate, deep, clear, complete, and significant. The following case study is an example of a situation that is a composite of typical situations taken from actual medical-surgical practice. In the case study, a man experiences a health disrup-

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tion (purposely written here without the complexity of underlying pathophysiology). The example is intended to show how students learn to plan postoperative care for an elderly person with a fractured hip. Once students have learned the basic principles associated with the care of elderly individuals with fractured hips they can learn about the problems that frequently coexist with such an injury and complicate care. The way in which students’ reason using the elements of thought will also be shown.

Case Study: A Fractured Hip Edward Ryder, 82 years of age, was injured in a motor vehicle accident while driving with his son. Mr. Ryder appeared sleepy, yet was easily aroused. He complained of moderately severe pain in his right hip, so his son called 911. When the emergency medical technicians arrived, they placed him on a stretcher, medicated him for pain, and transported him to the hospital. His son estimated that his father had been in that position for less than 2 hours. He also mentioned that his father was forgetful at times. In the emergency department, an x-ray of Mr. Ryder’s hip showed that the head of the right femur was fractured. Mr. Ryder had surgery to repair his femur through open reduction and internal fixation with the placement of a compression hip screw. Postoperatively, he made steady progress toward recovery, although he experienced some periods of confusion, especially late in the day. Directions: The goal of this assignment is to learn to plan postoperative care for an elderly person with a fractured hip. Use your nursing textbook, as well as laboratory and drug references, pharmacology, anatomy and physiology, and pathophysiology texts to complete this assignment. (Medical-Surgical Nursing: A Nursing Process Approach by Ignatavicius et al. [1995] and Clinical Applications of Nursing Diagnosis by Cox et al. [1997] will be used as examples for the literature review.) Imagine yourself as the student nurse who will admit Mr. Ryder to the surgical/orthopedic unit postoperatively. Plan his care from the initial postoperative assessment through the first days of his hospitalization. Follow the Preparation for Class Guidelines to complete this assignment.

Preparation for Class Guidelines: Nursing Care of a Person with a Fractured Hip 1. Literature Review Review the Literature Skim the sections of your medical-surgical nursing textbook that relate to problems similar to those of the individual in the case study. The first section related to the musculoskeletal system in the textbook describes assessment. The review of the anatomy, physiology, and assessment of musculoskeletal function is presented with special attention to the changes associated with aging. Students will notice that the next chapter is “Interventions for Clients with Musculoskeletal Problems.” Information on fractures is found in the following chapter, which includes a section on trauma. Students have had anatomy and physiology, in addition to pathophysiology courses, in preparation for medical-surgical nursing. When skimming the material, they will find content that is familiar and their independent review according to the guidelines will reinforce previous learning. Previously held assumptions, interpretations of anatomy and physiology, facts related to pathophysiology, and points of view related to understanding the material are all part of the student’s reasoning in this step of the preparation for class. In the section on hip fractures (Ignatavicius et al., 1995, p. 1470), students will find the different types of hip fracture illustrated (Figure 51–9). The stages of bone healing and complications of frac-

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tures, including compartment syndrome, fat embolism syndrome, thromboembolytic complications, infection, avascular necrosis, delayed union, nonunion, and malunion are all described on the pages that follow. Students may or may not recall the information; they may remember information differently from what was presented. Students may question the book or their own thinking for accuracy. This process of critiquing themselves, critiquing the text, and finding plausible answers can be meaningful learning (Mezirow, 1991) when compared with students’ previous experience and understanding. The next sections in the textbook describe the collaborative management of musculoskeletal trauma, which includes assessment, clinical manifestations, and psychosocial assessment in addition to laboratory and radiographic testing. The student will find that nursing diagnoses, planning, and implementation of interventions are all described. Neurovascular monitoring is described. Casts, splints, braces, types of traction, and the nursing care related to each are included in the following sections. Both a care plan and the clinical pathway from the Overlake Hospital Medical Center in Washington are shown in Ignatavicius et al. (1995, pp. 1474–1475). The care plan is limited to the physiological aspects of care, but the “Preps” call for the psychosocial and cultural aspects of care as well. Students’ review of their nursing diagnoses resources in addition to their medical-surgical nursing text (e.g., Cox et al., 1997) should include an analysis of the process of arriving at nursing diagnoses and show their path of decision making. In addition, each nursing diagnosis in Cox’s book has a section that asks: Have you selected the correct diagnosis? Alternative choices of nursing diagnosis are described with rationales as to why each may be suitable in the situation under consideration. The questioning process stimulates curiosity and critical thinking. 2. Facts Underline the Facts in the Situation Having skimmed the text and learned that a significant amount of information is already there, read the case study again to review the facts given in the narrative, underlining the facts in the case as you read. 3. Nursing Care Issues and Concerns Establish nursing care issues related to the facts, including those related to aging. Students may make the assumption that Mr. Ryder’s care should be similar to that described in the textbook. However, Mr. Ryder is elderly and they may question how his care is different because of his age. Sections of the medical-surgical textbook highlight considerations associated with aging. Generic physiological nursing diagnoses that relate to the care of any patient with a fractured hip have already been identified in the textbook care plan. Students may restate those, but there are psychosocial issues in Mr. Ryder’s situation that must be addressed also. He lives alone and experiences periods of confusion—two issues the care plan in the book does not address. These are common issues in the lives of elderly people that nurses must learn to discuss and manage. In relation to living alone, the definition of the nursing diagnosis “Social interaction, impaired” (Cox et al., 1997, p. 638) is the state in which an individual participates in an insufficient or excessive quantity of social exchange. These defining characteristics are not consistent with those found in the case study. The student who continues to read the section will find the question: “Have you selected the correct diagnosis?” There are three alternative nursing diagnoses. Of the three, “Social isolation” is appropriate when the individual is placed in or chooses isolation due to physiological, sociological, or emotional concerns. As Mr. Ryder lives alone, the diagnosis is not an actual one. According to the situation that is given, students cannot know with certainty that Mr. Ryder’s social interactions are impaired. However, in view of his living alone, students may make an assumption that he is at risk for impaired social interaction. Little is known about Mr. Ryder’s confusion. However, confusion may imply cognitive changes that are not discussed in Ignatavicius’s chapter on trauma to the hip. Therefore, students need to turn to other sources of information. Cox describes acute and chronic confusion as the “abrupt

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onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, and/or sleep-wake cycle” (Cox et al., 1997, p. 417).

4. Assessment and Tentative Nursing Diagnoses Functional Health Patterns Use the Functional Health Patterns as a guide to the areas of assessment. Not every case will include information about every pattern. Use your nursing diagnosis resource book as a reference to help you organize the information. Describe how each problem will be validated.

The Health Perception–Health Management Pattern

The conceptual information relates to Mr. Ryder’s ability to practice health management strategies with the goal of achieving self-management. Both the Health Belief Model and the Health Promotion Model are shown in Cox ’s book (Cox et al., 1997, p. 14). The developmental considerations of an 82-year-old man include decision making, self-care ability, and home safety when illness does not affect cognitive functioning. In addition, immunization to infections such as tetanus and influenza, gastrointestinal changes, skin changes, and changes in response to infection that show themselves in mental status changes such as confusion or restlessness are considered when assessing this pattern (Cox et al., 1997). Students will use the elements of thought as they think critically about Mr. Ryder’s situation and learn about the care of patients recovering from surgery to repair a fractured hip. The purpose of students’ thinking is to relate the information they are given in Mr. Ryder’s situation to the information they find in the medical-surgical textbook and nursing diagnosis book. Students will question the adequacy of the information given and what they need to find out about the postoperative care of an elderly person with a fractured hip. Mr. Ryder lives alone and he is sometimes confused. To interpret that information, students need to review the information they are given in order to relate the facts and concepts to one another. The purpose of students’ thinking in this section is to list the tentative nursing diagnoses: High risk for infection, High risk for injury, Pain related to the surgical procedure, High risk for relocation stress syndrome, Social isolation, and High risk for acute confusion. Write tentative nursing diagnoses with related factors. An example would be: High risk for injury related to trauma after the body’s defense system was disrupted. The defining characteristics would include altered clotting factors due to the site of fracture. The major risk factors include the fact that fractures of the lower extremity and pelvis are more likely to result in lifethreatening thrombi (e.g., deep vein thrombosis [DVT], which may lead to pulmonary embolism). Assessment of Mr. Ryder’s function postoperatively will require that nurses consider his risk for injury, especially in relation to positioning himself, managing his postoperative care, and later, being at home. Health seeking behaviors will need to be assessed in relation to his activity, nutrition, sleep, and rest behaviors. Students continue to consider the Functional Health Patterns, making connections between the information and facts they are given and the assumptions and inferences they make in the situation. Some examples of such thinking follow:

The Activity-Exercise Pattern

The conceptual information in Cox’s book indicates that mobility and immobility are the end points of a continuum and the underlying cause of interference with mobility determines the nature of the loss and whether immobility is temporarily or permanently limited. In the situation of a man with a

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fractured hip, interference may be temporary, with care directed toward increasing appropriate activities and exercises. The tentative nursing diagnosis with defining characteristics is: Activity intolerance, risk for actual. The Nutritional-Metabolic Pattern

The aging individual undergoes oral changes (including tooth and bone degeneration) that affect nutrition and metabolic functioning. The ability of the individual to maintain fluid volume is influenced by renal and endocrine function. Body temperature postoperatively is included in assessments of the nutritional metabolic pattern. In addition, assessment of tissue integrity, an important aspect of care for the aging individual, is included in this pattern. The Cognitive-Perceptual Pattern

The conceptual information includes acute pain related to the surgical procedure. Acute pain is defined as the sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. The defining characteristics include verbal or coded report, behaviors such as position, protective behavior, gestures, and so on. The information on related factors in Cox’s book (pp. 339–397) is limited. However, related clinical concerns include any surgical diagnosis, any traumatic injury, and infection. This section of Cox’s book indicates that this diagnosis is not usually confused with other nursing diagnoses. However, other diagnoses may contribute to pain and may accompany this diagnosis. Students complete this section by identifying the patterns and nursing diagnoses that are related. Cultural Aspects Include the cultural aspects of assessment, using your knowledge of the person’s culture, to guide the nursing care to be described. No information is provided in this particular situation about culture. However, disorders that are more common among members of one cultural group than another will be described in a way that reflects this. When this is the case, students are expected to show how care is influenced by culture. Mr. Ryder lives alone and was apparently independent. This injury may change his relationship with his son because Mr. Ryder may become more dependent on his son as a result of it. Missing Information Notice whether there is information missing. What additional assessment data do you need? Use your nursing diagnosis book as a reference to help you organize the information. Using the textbook and nursing diagnosis book, students fill in what they learn they need to know based on the description given in the book and the information that is lacking in the case situation. Students describe facts that, according to their sources, are relevant and sometimes critical information. Students will look among their references for the information they need to fill in gaps in the information and will look beyond what is obvious. They must demonstrate that they are challenging their assumption that the information they have is sufficient. Tentative Nursing Diagnoses and How They Will Be Validated List tentative nursing diagnoses and describe how each will be validated. Tentative nursing diagnoses for Mr. Ryder include: High risk for infection related to impaired physical mobility related to hip precautions, Acute pain related to the surgical procedure, High risk for injury related to subluxation or dislocation, High risk for injury related to trauma after the body’s defense system was disrupted, and Physical mobility, impaired related to hip precautions and surgical pain. Validation of nursing diagnoses is related to including patients in their own care. Students recognize the difference between activities that are the responsibility of the nursing care provider and

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those that patients must acknowledge as their self-care. Statements that students make to acknowledge patient participation and cooperation are written in this section. For example, when preparing Mr. Ryder for transfer to a chair or weight-bearing, the nurse confirms those nursing diagnoses that he has a role in the intervention and discharge to a subacute hospital where he will receive physical therapy prior to discharge home. The nurse will want to learn Mr. Ryder’s perception of his self-care ability by asking, for example, Did I understand correctly that you will need help with  when you return home? Follow-up is made explicit when it becomes part of the care plan as a result of validating the problem. 5. Clinical Data Laboratory (Lab) Values Include clinical symptoms for each nursing diagnosis. What is the expected/normal range of those lab values? Which lab values would you expect to be abnormal and why? Several enzymes are released into the blood in the presence of skeletal muscle disease and injury. Those that are elevated with skeletal injury are creatinine kinase (CK), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH). The extent of skeletal injury is not known in Mr. Ryder’s situation, but an assumption can be made that muscle tissue was injured when he fractured his hip and that there was a release of additional amounts of these enzymes, which would increase their serum levels. For example, the student would list the following:

LAB VALUES Creatinine kinase (CK)

GIVEN (list Mr. Ryder’s values)

EXPECTED/NORMAL VALUES Men: 12 to 70 U/mL Women: 10 to 55 U/mL Begins to rise 2 to 4 hours after muscle injury

Aspartate aminotransferase (AST or SGOT)

(list Mr. Ryder’s values)

Men: 8 to 20 U/L Elevations indicate muscle trauma

Lactate dehydrogenase (LDH)

(list Mr. Ryder’s values)

Total LDH: 45 to 90 U/L Elevations may indicate skeletal muscle necrosis

Serum calcium

(list Mr. Ryder’s values)

9 to 10.5 mg/dL slightly lower in elderly Hypercalcemia in the healing stages of fracture; Hypocalcemia in osteoporosis and osteomalacia

Serum phosphorus

(list Mr. Ryder’s values)

3 to 4.5 mg/dL slightly lower in elderly Hyperphosphatemia in the healing stage of bone fractures; Hypophosphatemia in osteomalacia

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Other Tests List other laboratory or diagnostic tests and the implications of the results. Radiographic studies of Mr. Ryder’s hip preoperatively assist with the location of the fracture, assessment of bone alignment, and observation of bone density. Joint condition and the smoothness of articular cartilage, as well as soft-tissue involvement, may also be evident but not clearly differentiated on an x-ray. These findings will determine which surgical procedure will be selected. Medications Which medications would you expect this person to receive? What information is given about the patient’s currently prescribed medications? Why are they being prescribed? We know little about the medications Mr. Ryder was taking preoperatively, except that he was medicated for pain before being transported to the hospital. In the postoperative period, he will be medicated for pain using drugs that are suitable for the elderly patient. He may receive analgesia on a regular schedule during the first 24 hours after surgery. Nonpharmacological methods of pain relief will be incorporated into the schedule. This will be especially important if he experiences confusion in the postoperative period. If this occurs, the clinical pathway in Ignatavicius indicates that the pharmacy will be consulted. However, in many tertiary medical centers an interdisciplinary team of professionals addresses pain control using a collaborative approach. Nutrition What nutritional issues are important in this person’s care? Bone formation and strength rely on adequate nutrition. Specifically, calcium, phosphorus, vitamin D and protein are necessary for producing new bone. Adequate fluid intake will be assessed and provided to the patient to ensure kidney function. Environment Are modifications to this person’s environment needed to enable the person to function in the hospital? At home? Mr. Ryder will use an elevated toilet seat to prevent hip flexion greater than 90 degrees. He may need ramps and a walker to ensure his safety in the hospital and at home. Discussion of Logical Fit Between Subjective and Objective Information Are there missing pieces of information? When listed, do the subjective and objective information fit together logically? If not, why? 6. Decision Making Identify the expected outcomes of the tentative nursing diagnoses on your list. Make decisions about the priority of each nursing diagnosis. Write a rationale for the way in which you prioritized them. Eliminate all except the highest priority and explain why each problem has been retained or eliminated. Retained nursing diagnoses are listed in order of priority with a rationale. Nurses’ concerns in the immediate period will be related to Mr. Ryder’s postoperative status. Therefore, maintaining his body alignment and controlling his incisional pain will receive the highest priority from the nurses caring for him. In the immediate postoperative period, Impaired physical mobility related to hip precautions and Acute pain related to the surgical procedure are the highest priority problems. Interventions such as assessing neurovascular status, applying and reapplying thromboembolic disease (TED) stockings on a 1-hour on/off basis, when ordered, and monitoring the pressure on the patient’s skin will be instituted. Acute pain related to the surgical procedure is also a high priority. Interventions such as monitoring the use of patient-controlled analgesia (PCA) or administering analgesic narcotics in the

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immediate postoperative period will be expected. The outcome of adequate pain relief will be comfort and the ability to participate in procedures to enhance respiration and circulation (e.g., cough, deep breathe, and turn according to postoperative orders). Other nursing diagnoses in order of priority are: High risk for injury related to subluxation or dislocation, High risk for injury related to trauma after the body’s defense system was disrupted, and Nutrition, altered, less than body requirements. 7. Nursing Interventions Next to each problem and outcome, identify nursing interventions. Include patient teaching, preparation for testing and surgery, and discharge, as appropriate. One problem with interventions and outcome will be described below as an example of how students will continue to follow the guidelines. The interventions and outcome for High risk for injury related to subluxation or dislocation are as follows:

INTERVENTIONS

OUTCOME

1. Place an abduction pillow between the patient’s legs while he is in bed.

The patient’s hips and legs will remain in anatomical alignment.

2. Turn the patient as directed by postoperative orders.

The patient will not dislocate his operative hip or experience subluxation.

3. Do not flex the patient’s operative hip more than 90 degrees. 4. The patient should use an elevated toilet seat. 5. The patient should sit in a straight-back chair. 6. Teach the patient not to cross his legs when sitting in a chair.

8. Evaluation of the Outcome Describe the way in which the patient’s outcome will be evaluated. Mr. Ryder will progress toward the expected outcome according to the critical path. 9. Healthcare Professionals and Medical Care Needed In addition to nurses and physicians, which healthcare professionals will be consulted about this patient’s care? What medical care do patients with this condition usually require? Physical therapists will prepare Mr. Ryder for discharge to a rehabilitation facility or to a subacute area until he has gained the strength he needs to function on his own at home. A dietitian may be consulted to ensure that the patient has an adequate, balanced diet. His caloric, protein, and fluid needs may need to be increased for healing to take place.

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10. Additional Questions about This Patient’s Nursing Care Write two or three questions you still have about this patient and the nursing care. Is rehabilitation in a subacute setting different from rehabilitation in a facility designated for rehabilitation? Are there complications that may be anticipated and prevented after fracture of the femur? What is an expected period of recovery for someone who has fractured a hip?

Classroom Activities Each Classroom Activity is planned to extend the learning that began when students completed their Preparation for Class assignment. Complications during the course of an illness provide an appropriate focus for classroom activities. Complications may be preventable. Therefore, students have an opportunity to discuss patient education, health promotion, prevention of functional deterioration, and so on. An example of the Classroom Activity used with the musculoskeletal case study follows. As noted above, students have already read about complications of musculoskeletal injury. Directions are provided that are specific for each classroom activity.

Classroom Activity: Nursing Care of Individuals with Hip Fractures Directions: Work in groups no larger than three, read each of the four continuations of the case study, and for each, respond to the questions below. As your group answers each question, remember to discuss how you interpreted the information you were given, your point of view concerning the situation, any assumptions you made about missing information, and the consequences of nursing actions. Take notes on the discussion and be prepared to report to the class.

Scenario A Mr. Ryder returned to the orthopedic unit postoperatively. He progressed as expected during the next 48 hours. However, the following day, he complained of calf pain and had a positive Homans’ sign. The nurse noted some swelling and tenderness to touch in the area. His temperature was 100.6°F orally, his heart rate (HR) was 104, and he was tachypneic. He explained to his nurse that he regretted being unable to carry out the leg exercises in bed as requested.

Scenario B Mr. Ryder returned to the orthopedic unit and had an uneventful recovery for the first several days. One evening during his first postoperative week, the nurse noted that he was flushed and warm. His temperature was 101°F orally and he complained of feeling warm and tired. He had no appetite and was feeling “awful.”

Scenario C Mr. Ryder recovered from surgery without complications. He was transferred to a subacute hospital to receive physical therapy. He progressed well for a while and then complained of pain in his hip. The nurse assessed the extent and severity of his pain. She asked him to extend his legs on the bed. She observed that his right leg was shorter than his left and that it was rotated internally.

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Scenario D Mr. Ryder’s recovery was uneventful as his discharge date approached. One evening he complained of dyspnea and said he felt restless. His temperature was 104°F, his HR 126, and his respiratory rate 36. He became agitated and somewhat confused about his surroundings. The nurse auscultated his lungs and noted diffuse crackles in the periphery.

Questions 1. What further assessment data is needed and why? Responses will vary based on the students’ experiences and what each remembers from reading when preparing for class. All of the follow-up scenarios could provide more information. Scenario A Scenario B Scenario C Scenario D 2. Given the information you have, what do you think is happening in the new situation? Once you have identified the problem, explain the pathophysiology involved. Below are the complications listed by Classroom Activity scenarios: A. Deep vein thrombosis B. Infection postoperatively C. Dislocated femur D. Fat embolism syndrome Scenario A Scenario B Scenario C Scenario D 3. What actions will the nurse take in each situation? Scenario A Scenario B Scenario C Scenario D

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4. What outcomes are expected for each nursing action/intervention? How will nurses work together with the patient and others to accomplish the goals of care? Scenario A Scenario B Scenario C Scenario D Finally, a word to students about participation in the classroom activities. The classroom activities require discussion and that each group report its decisions and solutions to the class. Although it may appear difficult at times, be encouraged to assert your ideas and prepare to support them, listen to members of your group and evaluate their positions, and make decisions based on the discussion of ideas that are expressed. By all means have fun with this assignment.

Suggested References and Resources Brookfield, S. (1987). Facilitating critical thinking. San Francisco: Jossey-Bass. Cox, H. C., Hinz, M. D., Lubno, M. A., Newfield, S. A., Ridenour, N. A., Slater, M. M., and Sridaromont, K. L. (1997). Clinical applications of nursing diagnosis: Adult, child, women’s, psychiatric, gerontic, and home health considerations (3rd ed.). Philadelphia: F. A. Davis. Ignatavicius, D. D., Workman, M. L., & Mishler, M. A. (1995). Medical-surgical nursing: a nursing process approach. Philadelphia: W. B. Saunders. Mezirow, J. (1990). Fostering critical reflection in adulthood. San Francisco: Jossey-Bass. Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco: Jossey-Bass. Paul, R. (1992). Critical thinking: What every person needs to survive in a rapidly changing world (2nd ed.). Santa Rosa, CA: Center for Critical Thinking. Paul, R. (1993). Critical thinking: How to prepare students for a rapidly changing world. Santa Rosa, CA: Center for Critical Thinking. Paul, R. (1994). Critical Thinking: How to Design Instruction So That Students Master Content in a Deep and Thoughtful Way. Paper presented at the 14th International Critical Thinking Conference, Sonoma State University, Rohnert Park, CA. Vanetzian, E. V., & Corrigan, B. A. (1994). Designing Case Studies to Stimulate Curiosity to Learn. Paper presented at the 14th Annual International Conference on Critical Thinking and Educational Reform, Sonoma State University, Rohnert Park, CA. Vanetzian, E. V., & Corrigan, B. A. (1995). “Prep” for Class and Classroom Activity: Key to Critical Thinking. Paper presented at the 15th Annual International Conference on Critical Thinking and Educational Reform, Sonoma State University, Rohnert Park, CA. Vanetzian, E. V., & Corrigan, B. (1996). “Prep” for class and class activity: Key to critical thinking. Nurse Educator, 21(2), 45–48.

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UNIT

II Critical Thinking: Patient Problems

Chapter 3

Respiratory Problems...29

Chapter 4

Cardiovascular Problems...67

Chapter 5

Hematologic Problems...115

Chapter 6

Gastrointestinal Problems...141

Chapter 7

Liver, Biliary, and Exocrine Pancreatic Problems...189

Chapter 8

Endocrine Problems...227

Chapter 9

Reproductive Problems...269

Chapter 10

Immunologic Problems...317

Chapter 11

Musculoskeletal Problems...355

Chapter 12

Renal Problems...403

Chapter 13

Neurological Problems...455

Chapter 14

Sensory Problems...503

Chapter 15

Integumentary Problems...547

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Chapter

3 Respiratory Problems

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Respiratory Problems

Q

3

How do problems of oxygenation from respiratory dysfunction show themselves in the patterns of an individual’s lifestyle?

Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Pneumonia Preparation for Class: Nursing Care of a Person with Pneumonia Class Activity: Nursing Care of Individuals with Adult Respiratory Distress Syndrome Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Chronic Airway Limitation or Chronic Obstructive Pulmonary Disease Preparation for Class: Nursing Care of a Person with Chronic Airway Limitation or Chronic Obstructive Pulmonary Disease Class Activity: Nursing Care of Individuals with Asthma Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Lung Cancer Preparation for Class: Nursing Care of a Person with Lung Cancer Class Activity: Nursing Care of Individuals with Laryngectomy Critical Thinking Revisited Suggested Readings and Resources

Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with respiratory dysfunction 2. To apply principles related to the disruption of gas exchange when caring for individuals with respiratory problems

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3. To prepare patients for pulmonary procedures, treatments, and surgery 4. To plan care for the postoperative patient with pulmonary disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in this situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Pneumonia Mr. Perry, 46 years of age, who has smoked a pack of cigarettes for the past 19 years, recently increased his smoking to two packs a day. He states that his productive coughing, which used to be limited to the early morning hours after first waking up, now continues throughout the day. He is now complaining of a sharp, stabbing pain that increases when he takes a deep breath, along with symptoms of shaking chills, high fever, weakness, and “generally not feeling well” that began rather suddenly. A sputum specimen obtained in the emergency room was blood streaked and mucoid and a chest x-ray shows bilateral multilobar consolidation.

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Preparation for Class: Nursing Care of a Person with Pneumonia

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

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4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

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d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals with Adult Respiratory Distress Syndrome Directions: To complete this section, read the situation and answer the questions that follow. Mr. Perry was admitted to the hospital for intravenous antibiotic therapy to treat his pneumonia; however, his response to therapy was minimal. Four days after admission to the unit, Mr. Perry complained of lethargy and headache. The nurse noted that he had become restless, agitated, and confused. Auscultation of his lungs continued to reveal crackles bilaterally in the upper lobes. His skin was flushed and dry, his sputum production was less than when he was first admitted, and he was dyspneic and tachynpneic. Knowing that Mr. Perry was not responding to the prescribed antibiotic and bronchodilators as expected, the nurse administered prescribed nasal oxygen at a low liter flow rate and immediately notified the physician. The physician ordered a chest x-ray stat and arterial blood gases (ABGs). The ABGs showed hypoxemia and the chest x-ray showed bilateral, “fluffy” pulmonary infiltrates.

Questions 1. Describe the pathophysiology of adult respiratory distress syndrome (ARDS).

2. List hypothetical results of Mr. Perry’s ABG analysis and explain the significance of the values.

3. What is the significance of Mr. Perry’s chest x-ray?

4. List the goals of nursing care for Mr. Perry.

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5. Describe the nursing interventions that will be expected during the immediate period after a diagnosis of ARDS.

a. At what rate should oxygen be delivered?

b. Explain the rationale for making that decision.

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Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Chronic Airway Limitation or Chronic Obstructive Pulmonary Disease Mr. Adams, 65 years of age, was discharged after a brief hospitalization to stabilize an acute respiratory infection. Three days later, at 5 P.M. he was brought to the emergency department by his anxious wife. His skin tone was a dark bluish red and his breathing was rapid with a prolonged inspiratory phase and markedly reduced expiratory phase. He was sitting upright on the emergency room gurney with his hands and arms reaching over a bedside table and using the muscles of his shoulders to breathe. Mr. Adams could not speak in sentences—he answered questions in short phrases. He managed to explain that he was uncomfortable, hot, and in pain. His wife stated that during the last 10 hours, his fluid intake had been approximately 300 mL with only a scant urinary output. She also stated that Mr. Adams had begun smoking again after his discharge and described his cough as weak with a slightly increased amount of thick, yellow sputum that was difficult to expel. ABGs were obtained along with a sputum sample for culture and sensitivity (C & S). His ABGs revealed pH:7.31; partial pressure of arterial carbon dioxide (PaCO2): 50 mm Hg; partial pressure of arterial oxygen (PaO2): 68 mm Hg; and bicarbonate (HCO3):24. Oxygen via nasal cannula was started, but showed no significant improvement in his breathing pattern. He was then intubated to access secretions and provide oxygen-enriched air.

Preparation for Class: Nursing Care of a Person with Chronic Airway Limitation or Chronic Obstructive Pulmonary Disease

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

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3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

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7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

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d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals with Asthma Directions: To complete this section, read the situation and answer the questions that follow. On a brisk and cold autumn morning in New England, Anne Brown, 21 years of age, returned home breathless after jogging in her neighborhood. Her mother, who was a nurse, noted Anne’s wheezing on expiration and panic in her daughter’s facial expressions. She also observed her labored breathing, depth, and rapid rate of respiration. Her mother’s fears were confirmed when Anne managed to speak and told her how difficult it was to breathe. Because Anne’s situation was urgent, her mother knew that while time was important, she also needed to be reassuring to her daughter. She moved calmly and purposefully and drove Anne to the community hospital emergency room. In the emergency room, nursing assessment included Anne’s response to the dyspnea scale as a measure of her perception of her own breathing difficulty. Anne rated her breathing as difficult, indicating the farthest end of the scale. After ABGs were drawn, Anne was started on oxygen via a nasal cannula and placed on a pulse oximeter and cardiac monitor. Her ABGs on admission revealed the following: pH:7.29; PaCO2: 63 mm Hg; and PaO2 55 mm Hg. The saturation of arterial blood with oxygen (SaO2) fluctuated between 75 and 85 percent. When Anne did not immediately respond to inhaled bronchodilators, intravenous corticosteroids were administered. An indwelling arterial catheter was inserted for regular monitoring of her ABG levels. Beta-agonists were administered intravenously and Anne eventually showed the expected response to the therapies. Her pH increased to 7.36; PaCO2 decreased to 43 mm Hg; PaO2 increased to 95 mm Hg; and SaO2 stabilized at 97 percent. Questions 1. What physiological factors affect the interpretation of ABG findings?

2. Rate the following spirometry findings as increased or decreased when Anne was first admitted to the emergency room:

Peak Expiratory Flow Rate (PEFR):

Increased

Decreased

Forced Expiratory Volume (FEV1):

Increased

Decreased

Forced Vital Capacity (FVC):

Increased

Decreased

Functional Residual Capacity (FRC):

Increased

Decreased

Total Lung Capacity (TLC):

Increased

Decreased

Residual Volume:

Increased

Decreased

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3. What nursing measures are indicated immediately?

4. Consider how long-term illness with symptoms of asthma differs from long-term illness with symptoms of chronic obstructive pulmonary disease (COPD). Using examples, explain why they are different.

Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Lung Cancer Martin Thomas, 58 years of age, was hospitalized because of an increasingly productive cough and complaints of fatigue and feelings of breathlessness when he climbs stairs or walks a distance. He had a continuous cold and cough. His wife explained that he was less and less active because of his breathing difficulties. Assessment revealed a barrel chest, weakness in his extremities, anorexia, nausea, vomiting, and fever. He had been smoking two to three packs of cigarettes a day for the last 30 years and was trying to reduce or stop the habit. His chest x-ray showed an area of infiltration and pulmonary function tests showed restrictive and obstructive patterns. His hemoglobin was elevated. Cytological studies of sputum samples revealed malignant cells. Mr. Thomas was diagnosed with non-small-cell-lung carcinoma (non–SCLC) based on histologic and cytologic testing of tissue samples obtained from biopsies during fiberoptic bronchoscopy. A lesion was found in the parenchema of his right lung. He was advised of the option for surgical removal of the tumor, and agreed to have a lobectomy. Prepare Mr. Thomas preoperatively and then plan his care in the postoperative period.

Preparation for Class: Nursing Care of a Person with Lung Cancer

Preparation for Class Guidelines 1. Literature Review

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2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

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6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

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d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

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Given

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Expected/Normal Values

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b. Medications

Medications

Given

Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

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Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

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Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals with Laryngectomy Directions: To complete this section, read the situation and answer the questions that follow. Brenda Marshall, 52 years of age, is married and has three school-age daughters. She is employed by an international airline as a flight attendant instructor and has a history of smoking one pack of cigarettes a day for 9 years, then two packs a day for the last 30 years. She experiences hoarseness and voice changes that cannot be accounted for by the overuse of her voice or by a cold. Her dentist advised her to see her physician because she had leukoplakia on the epithelium of her throat. Mrs. Marshall did see her physician, but not until after she had developed a productive cough that produced blood-tinged mucus, significant weight loss, and enlarged lymph nodes.

Questions 1. How many pack-years has Mrs. Marshall smoked?

2. Describe leukoplakia in terms Mrs. Marshall can understand.

3. Discuss the nursing implications of three types of therapeutic management of laryngeal cancer in relation to patient preparation and education, outcomes of therapy, and complications.

4. Mrs. Marshall was advised to have a total laryngectomy. She needed to be prepared for surgery. Plan preand postoperative care including preoperative teaching, demonstration of breathing and communication techniques, and airway management in the immediate and distant future.

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Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: How do problems of oxygenation from respiratory dysfunction show themselves in the patterns of an individual’s lifestyle? B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions you made initially that were later challenged because of new information or facts you learned?

3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

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6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Allee, M., Miles, L., & Spilman, M. F. (1996). Dimensions of clinical practice. Excellence in respiratory nursing practice: exemplars and commentaries. Perspectives in Respiratory Nursing, 7(4), 1, 3–6. Boucher, M. A. (1996). When laryngectomy complicates care. RN, 59(8), 40–45. Brewin, A. (1997). Comparing asthma and chronic obstructive pulmonary disease (COPD). Nursing Standard, 12(4), 49–55. Chiramannil, A. (1998). Clinical snapshot: Lung cancer. American Journal of Nursing, 98(4), 46–47. Crawford, A. (1997). Chronic lung disease: An invisible disability. Community Nurse, 3(2), 18, 20–21. Dirkes, S. (1996). Liquid ventilation: New frontiers in the treatment of ARDS. Critical Care Nurse, 16(3), 53–58. Donohoe, H. (1998). The concerns of young people with asthma. Practice Nurse, 15(4), 228–229. Haynes, V. L. (1996). Critical care extra. Caring for the laryngectomy patient. American Journal of Nursing, 96(5 Nurse Pract Extra ED), 16B, 16D, 16F. Kenny, M. F. (1997). Action stat. Acute pulmonary edema. Nursing, 27(11), 33. Ketelaars, C. A. J., et al (1998). Effects of specialized community nursing care in patients with chronic obstructive pulmonary disease. Heart & Lung, 27(2), 109–120. Kowal, C. E. (1997). Disease management. Improving asthma care in the outpatient setting. Medical Interface, 10(7), 87–89. Mamaril, M. E., & Zeltt, K. E. (1997). Care of the arthroscopy patient with noncardiogenic pulmonary edema . . . acute respiratory distress syndrome. Orthopaedic Nursing, 16(2). Nally, A. T. (1996). Critical care of the patient with lung cancer. AACN Clinical Issues: Advanced Practice in Acute & Critical Care,7(1), 79–94, 177–178. Rudkin, S. (1996). Home support for patients on long-term oxygen therapy. Nursing Times, 92(34), 34–35. Rudkin, S. (1997). Changing lives . . . respiratory nurse specialist Sharon Rudkin. Nursing Standard, 12(9), 20–21. Shellenbarger, T., & Narielwala, S. (1996). Caring for the patient with laryngeal cancer at home. Home Healthcare Nurse, 14(2), 80–90. Van Orden, W. C. (1998). Emergency! Acute pulmonary edema. RN, 61(1), 36–41.

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Chapter

4 Cardiovascular Problems

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Cardiovascular Problems

Q

4

What are the similarities and differences in managing an individual’s problems of oxygenation due to cardiovascular dysfunction and those due to respiratory dysfunction?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Myocardial Ischemia Ruling Out Myocardial Infarction Preparation for Class: Nursing Care of a Person with Myocardial Ischemia Ruling Out Myocardial Infarction Class Activity: Nursing Care of Individuals Receiving Antithrombolytic Therapy Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Congestive Heart Failure Preparation for Class: Nursing Care of a Person with Congestive Heart Failure Class Activity: Nursing Care of Individuals with Pulmonary Edema Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Percutaneous Transluminal Coronary Angioplasty (PTCA)/Coronary Artery Bypass Graft (CABG) Surgery Preparation for Class: Nursing Care of a Person Undergoing PTCA/CABG Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations Class Activity: Nursing Care of Individuals with Dysrhythmias Class Activity: Comparing Dysrhythmias Class Activity: Electrocardiogram Patterns of Dysrhythmias Medical-Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Peripheral Vascular Disease Preparation for Class: Nursing Care of a Person with Peripheral Vascular Disease

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Class Activity: Nursing Care of Individuals with Femoral-Popliteal Bypass Graft Class Activity: Nursing Care of Individuals with Hypertension Critical Thinking Revisited Suggested Readings and Resources

Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with cardiovascular dysfunction 2. To apply principles related to the disruption of hemodynamic and/or vascular function when caring for individuals with cardiovascular problems 3. To prepare patients for cardiovascular procedures, treatments, and surgery 4. To plan care for the postoperative patient with cardiovascular disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in this situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Myocardial Ischemia Ruling Out Myocardial Infarction Martin Williams, 57 years of age, came to the emergency room at 2:44 A.M. complaining of chest pain. His wife was with him and she appeared very worried. Mr. Williams stated that he

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was seldom ill, but that for three weeks he had experienced tightness in his chest that radiated to his left arm. On admission, he was short of breath, his color was pale and ashen and he complained that his “stomach felt upset.” Mrs. Williams stated that her husband weighed 192 lb and was 5 ft 11 in tall. Nursing assessment showed that his temperature was 102.4°F; his blood pressure (BP) 95/60 mm Hg; his heart rate (HR) was irregular, fluctuating between 96 and 116 beats per minute, and his respiratory rate (RR) was 36. He wheezed on auscultation of his lungs. Oxygen was started at 2L by nasal cannula; an electrocardiogram (ECG) was performed; blood was drawn for a complete blood count (CBC), serum electrolytes, and cardiac enzymes; and Mr. Williams was placed on a cardiac monitor. A chest x-ray was taken at his bedside. The emergency room physician treated Mr. Williams’s myocardial ischemia to rule out an acute myocardial infarction (MI). Mrs. Williams described her husband as very hard working. However, he was in danger of losing his job in a manufacturing plant because of cutbacks in his company. He smoked two packs of cigarettes each day “on and off” for 40 years. His brother, 15 years older than Mr. Williams, had a “heart attack” when he was in his fifties.

Preparation for Class: Nursing Care of a Man with Myocardial Ischemia Ruling Out Myocardial Infarction

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

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9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals Receiving Antithrombolytic Therapy Directions: To complete this section, read the situation and answer the questions that follow. Mr. Williams will undergo antithrombolytic therapy.

Questions 1. What complications are possible after a myocardial infarction?

2. What will Mr. Williams be taught to minimize the risks of further deterioration in his condition?

3. How do antithrombolytic agents work?

Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Congestive Heart Failure Evelyn McComb, a 78-year-old widow, noticed that she felt “tired a lot lately.” Her son even commented that his mother seemed to lack interest in her usual activities and that she seemed to be a bit confused in her responses to everyday situations. Mrs. McComb had developed a cough, so her son made an appointment with her healthcare provider. The nurse practitioner saw Mrs. McComb and noted crackles in the bases of her lungs, a lower than normal blood pressure and slight tachycardia (based on previous recordings), and a slight weight gain in the seven months since her last regular check-up. Suspecting that Mrs. McComb may be experiencing heart failure, the nurse practitioner consulted with the physician. The physician agreed with the nurse practitioner’s assessment and Mrs. McComb was prescribed digoxin, furosemide (Lasix), and potassium chloride.

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Preparation for Class: Nursing Care of a Person with Congestive Heart Failure

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals with Pulmonary Edema Directions: To complete this section, read the situation and answer the questions that follow. For a while, Mrs. McComb was able to manage her heart failure quite well with her medications (digoxin, furosemide, and potassium chloride) and adjustments to her lifestyle, such as making sure she rested between periods of increased activity. She ate a well-balanced diet with optimal nutritional intake and was progressing well. She experienced no adverse effects of treatment. Then Mrs. McComb decided that she must have been cured because she was experiencing none of her previous symptoms. When she used the last of her medications, she stopped taking them. Soon after, Mrs. McComb noticed that regardless of her activity level, she felt more and more tired and weak. In addition to fatigue and weakness, she also began to experience coughing, dyspnea, anorexia, and a weight gain despite having a decreased appetite. Her clothes were beginning to feel uncomfortable and she was unable to wear her regular shoes. Mrs. McComb’s son called his mother’s physician, who advised him to take his mother to the community hospital emergency room, which he did. Assessment revealed that restful sleep was possible for Mrs. McComb only when she was in the upright position with pillows and that she had become anxious, withdrawn, and depressed. Mrs. McComb appeared malnourished and her son explained that his mother was unable to cope with routine activities of daily living. Over the next few hours, Mrs. McComb’s condition deteriorated.

Questions 1. Are Mrs. McComb’s complaints consistent with right or left ventricular failure? Give reasons for your answer.

2. How will her condition be diagnosed? Explain the parameters of hemodynamic monitoring.

3. Briefly outline what you expect her medical management to be.

4. Provide a detailed description of the nursing management of Mrs. McComb.

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Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Percutanous Transluminal Coronary Angioplasty (PTCA)/Coronary Artery Bypass Graft (CABG) Surgery Mr. Janus had experienced many years of myocardial ischemia, which was controlled with medication, modification of his diet, and an exercise program. He was admitted to the hospital for treatment of the progression of his cardiac disease. Mr. Janus was scheduled to undergo cardiac catheterization with percutaneous transluminal coronary angioplasty (PTCA). If the PTCA was unsuccessful, he was told that he would be prepared for coronary artery bypass graft (CABG) surgery. Mr. Janus had the necessary preoperative tests as an outpatient. He was interviewed by the anesthesiologist before the nurse entered his room to assess his present status and admit him to the unit. He was apprehensive and his wife was present during the assessment.

Preparation for Class: Nursing Care of a Person Undergoing PTCA/CABG

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

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9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Class Activity: Nursing Care of Individuals with Dysrhythmias Directions: To complete this section, read the situation and answer the questions that follow. Gordon Stone, 72 years of age, has a history of pericarditis and is being treated for atrial fibrillation. He has been managed for many years on different medications, including digoxin to depress the conduction of impulses through his heart and procainamide to suppress the formation of ectopic beats. In the past, he was given an activity prescription and placed on verapamil, a calcium channel blocker, for short-term management to slow his heart rate. Despite his medications and attempts to adhere to the activity schedule, Mr. Stone experienced numerous episodes of tachycardia, dizziness, weakness, and dyspnea that required treatment in the emergency room of the local hospital. He was usually discharged home when his cardiac status improved and stabilized. On the advice of his physician, Mr. Stone was admitted for evaluation of further control of his condition. His ECG showed the characteristic irregular ventricular response of a supraventricular or atrial dysrythmia.

Questions 1. What is atrial fibrillation?

2. Explain the rationale for each of Mr. Stone’s medications.

3. Why was Mr. Stone experiencing problems with activity tolerance?

4. What are the most appropriate nursing diagnoses for Mr. Stone?

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Class Activity: Comparing Dysrhythmias Directions: Using the format below, compare the nursing and medical management of individuals with atrial, ventricular, and junctional dysrhythmias by noting the similarities and differences in symptoms, medical treatment, and nursing management.

ATRIAL DYSRHYTHMIAS

JUNCTIONAL DYSRHYTHMIAS

VENTRICULAR DYSRHYTHMIAS

Complaints/ symptoms

Nursing management

Medical/ pharmacological management

Class Activity: ECG Patterns of Dysrhythmias Directions: Draw the ECG pattern and list the ECG characteristics of each rhythm identified below. 1. A normal ECG pattern (normal sinus rhythm): Why is it normal?

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2. Atrial Fibrillation:

3. Premature Ventricular Complexes (PVCs):

4. Junctional Escape Rhythm:

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5. Ventricular Fibrillation:

6. Choose a dysrhythmia not listed above and draw its ECG pattern.

Medical-Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Peripheral Vascular Disease Betty Smythe, an 86-year-old widow, had recurrent infections in her feet and toes that were managed with immediate attention and warm water soaks. The problem areas usually healed without further concern. One day her son noticed that the skin around her right great toe was sloughing off and exposing underlying tissues. Concerned that this time his mother’s skin was not healing, he made an appointment for her to see her primary care physician. The physician ordered an antibiotic and advised her to return for follow-up care. The antibiotic caused her to have diarrhea, so she was told to discontinue its use and to soak her foot in warm water with epsom salts. Mrs. Smythe continued the treatment for several months without noting any improvement. Her foot became swollen and reddened when in a depen-

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dent position and painful and almost white when elevated. She was unwilling to be seen by a physician and refused medical treatment. Her condition deteriorated to the point where her pain was unbearable at night. When she visited her son, he heard her wailing in pain throughout the night. He went into her room and found his mother confused and protecting her feet and toes. After contacting her physician, Mrs. Smythe’s son took his mother to the community hospital emergency room. Mrs. Smythe was admitted for an arteriogram of her right leg with the possibility of a bypass graft of the occluded vessels in her leg.

Preparation for Class: Nursing Care of a Person with Peripheral Vascular Disease

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

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1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

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b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

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Expected/Normal Values

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b. Medications

Medications

Given

Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

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Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

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Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

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Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals with Femoral-Popliteal Bypass Graft Directions: To complete this section, read the situation and answer the questions that follow. Mrs. Smythe’s arteriogram showed occlusive arterial disease. A femoral-popliteal bypass graft was performed and she was placed on bed rest.

1. Describe the postoperative nursing care for Mrs. Smythe.

2. Prepare her for discharge to rehabilitation.

Class Activity: Nursing Care of Individuals with Hypertension Directions: To complete this section, read the situation and answer the questions that follow. Pete Gardner, 37 years of age, went to a blood pressure screening clinic where he learned that his BP was 140/90 mm Hg. The nurse recommended that he be seen by the nurse practitioner for follow-up monitoring of his blood pressure. A complete physical and psychosocial assessment revealed that Mr. Gardner was a salesman whose job required him to be away from home during the week. While traveling he stayed in various hotels and ate most of his meals in restaurants. Mr. Gardner was overweight for his height, drank alcohol regularly, and smoked one-and-a-half packs of cigarettes a day. He was a divorced father of three boys who lived with their mother and visited him on the weekends. His father was treated for hypertension for many years before he died at 58 years of age after having a “heart attack.”

Questions 1. Identify the expected outcomes for someone in Mr. Gardner’s situation.

2. Plan an educational intervention for Mr. Gardner that includes modification of risk factors.

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Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: What are the similarities and differences in managing an individual’s problems of oxygenation due to cardiovascular dysfunction and those due to respiratory dysfunction?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions you made initially that were later challenged because of new information or facts you learned?

3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

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5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Apple, S. (1996). New trends in thrombolytic therapy. RN, 53(1), 30–35. Bernat, J. J. (1997). Smoothing the CABG patient’s road to recovery. American Journal of Nursing, 97 (2 Contin Care Extra Ed), 22–27. Field, D. (1997). Cardiovascular assessment, Part 2. Nursing Times, 93(39), 55–57. Foote, M. (1997). Heart failure: Helping your patient help herself. Nursing, 27(4 Home Health), 32aaa–bbb, 32ddd. Jaarsma, T., et al (1997). Maintaining the balance: Nursing care of patients with chronic heart failure. International Journal of Nursing Studies, 34(3), 213–221. Juran, N. B., et al (1996). Survey of current practice patterns for percutaneous transluminal coronary angioplasty. American Journal of Critical Care, 5(6), 442–448. Thomason, T., & Carlson, B. (1997). Nursing care of patients with acute myocardial infarction: Results of a national survey. Critical Care Nurse, 17(5), 23–33. Weeks, S. M. (1996). Caring for patients with heart failure. Nursing, 26(3), 52–53. Yager, M. (1996). Right ventricular infarction in the emergency department: A review of pathophysiology, assessment, diagnosis, treatment, and nursing care. Journal of Emergency Nursing, 22(4), 288–292.

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Chapter

5 Hematologic Problems

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Hematologic Problems

Q

5

How are dysfunctions of the hematologic system expressed as problems of oxygenation in adults and the elderly?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Leukemia Preparation for Class: Nursing Care of a Person with Leukemia Class Activity: Nursing Care of Individuals Undergoing Bone Marrow Transplantation Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Sickle Cell Anemia Preparation for Class: Nursing Care of a Person with Sickle Cell Anemia Class Activity: Nursing Care of Individuals with Thrombocytopenia Class Activity: Nursing Care of Individuals with Iron Deficiency Anemia Critical Thinking Revisited Suggested Readings and Resources

Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with hematologic dysfunction 2. To apply principles related to increased risk for infection, disruptions in clotting, and decreased oxygenation when caring for individuals with hematologic problems 3. To prepare patients for hematologic procedures, treatments, and surgery

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4. To plan care for the postoperative patient with hematologic disease 5. To plan care of the patient having chemotherapy

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in this situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Leukemia Isabelle Morgan, a 20-year-old college student, experienced weakness, profound fatigue, bleeding gums, fever, headaches, and generalized pain. She had just returned from her summer vacation and during the previous few weeks was busy moving into an apartment near the campus. When she finally had an opportunity to “put her feet up” she realized how tired she was. Her roommate suggested that she have a physical examination at the university clinic. There, the physician ordered routine blood studies, including a complete blood count (CBC), which showed that her leukocyte count was over 100,000/mL. He referred her to the university’s major medical center, where she was diagnosed with leukemia. Once diagnosed, Ms. Morgan was admitted for chemotherapy, which began almost immediately. Ms. Morgan was aloof and teary eyed whenever her family or friends visited her in the hospital. Gradually, she became combative whenever she was asked to participate in her own care. She refused to bathe, avoided eating breakfast, often refused her lunch, and picked at her dinner. Ms. Morgan’s mother expressed concern that she was unable to understand her daughter’s reaction to her situation.

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Preparation for Class: Nursing Care of a Person with Leukemia

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals Undergoing Bone Marrow Transplantation Directions: To complete this section, read the situation and answer the questions that follow. Testing showed that Ms. Morgan would benefit from a bone marrow transplant. Ms. Morgan was angry that a transplant was necessary, and lacking knowledge about the procedure, she was concerned and wanted to know what it involved. Questions 1. What are the priorities of care when preparing Ms. Morgan for a bone marrow transplant?

2. What teaching is indicated for Ms. Morgan?

3. How is the bone marrow donor prepared for the procedure?

4. What teaching is indicated for the donor?

Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Sickle Cell Anemia Ben Jones, 23 years of age, was diagnosed with sickle cell anemia during childhood. Experiencing pain and severe swelling of his joints and bone pain, he was admitted to the hospital in sickle cell crisis. While in the hospital, his hemoglobin ranged from 7 to 10mg/100mL and his bilirubin remained elevated. Mr. Jones told the nurse that he was currently unable to cope with his day-to-day problems and his life.

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Preparation for Class: Nursing Care of a Person with Sickle Cell Anemia

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals with Thrombocytopenia Directions: To complete this section, read the situation and answer the questions that follow. Rachael Kline, 25 years of age, noticed that her gums bled whenever she brushed her teeth and recalled that recently she had bled for an unusually prolonged time when she had a nosebleed. Ms. Kline mentioned this in passing to the nurse at the clinic where she worked. The nurse asked her to have a CBC drawn, which showed that her platelet count was less than 20,000/mL. After contacting her physician, Ms. Kline was admitted to the local hospital, but she wanted to wait until after her wedding, scheduled in the near future, for a complete examination and evaluation of her problem. Nursing assessment also revealed that she and her fiancé wanted to have children. She is 5 ft 6 in tall and weighs 134 lb.

Questions 1. What assumptions can you make about Ms. Kline’s physiological situation?

2. What nursing care is indicated to address her highest priority problem?

3. What are the implications of Ms. Kline’s diagnosis for her functioning in various aspects of her life?

Class Activity: Nursing Care of Individuals with Iron Deficiency Anemia Directions: To complete this section, read the situation and answer the questions that follow. Irene Mendoza, 33 years of age, was examined by her nurse practitioner (NP) several weeks after the delivery of her third child. She complained of feeling extremely weak, tired, dizzy, and short of breath. She had so little strength that she was unable to lift and carry her 2-year-old son into the car. Mrs. Mendoza asked whether her craving for ice chips was in any way associated with her other symptoms. In addition, she complained of inflamed mucous membranes and cracking in the corners of her lips. Her NP ordered a CBC, which indicated that her hemoglobin was 9 g/dL Mrs. Mendoza explained to the nurse that she had not noticed any unusual bleeding, but that she was afraid of what her symptoms might indicate.

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Questions 1. Plan nursing interventions that address the data in the highest priority situation.

2. What are the expected outcomes of those interventions?

3. How will the consequences of Mrs. Mendoza’s therapy be monitored?

Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: How are dysfunctions of the hematologic system expressed as problems of oxygenation in adults and the elderly?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

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2. Describe the assumptions you made about individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions you made initially that were later challenged because of new information or facts you learned?

3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

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8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Bassett, C. (1996). Caring for surgical patients with sickle cell disease. Nursing Standard, 10(33), 38–39. Jackson, T., McKeag, N., & Stuart, J. (1997). Care after bone marrow transplantation, Part 3. Nursing Times, 93(11), 48–49. Jackson, T. (1997). Leukaemia: The role of the nurse. Nursing Times, 93(8 Prof Dev), 5–8. Rausch, M., & Pollard, D. (1998). Management of the patient with sickle cell disease. Journal of Intravenous Nursing, 21(1), 27–40. Torrance, C., & Jordan, S. (1995). Bionursing: Signs of iron deficiency. Nursing Standard, 10(12–14), 29–31.

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Chapter

6 Gastrointestinal Problems

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Gastrointestinal Problems

Q

6

What are the fundamental differences in the underlying pathophysiology of the various gastrointestinal problems discussed in this chapter that inf luence nursing management and patient prognosis?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Ulcer Disease Preparation for Class: Nursing Care of a Person with Ulcer Disease Class Activity: Nursing Care of Individuals with Ulcer Disease Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Irritable Bowel Disease (Crohn’s Disease) Preparation for Class: Nursing Care of a Person with Irritable Bowel Disease Class Activity: Follow-up Care of an Individual with Irritable Bowel Disease (Crohn’s Disease) Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Cancer of the Bowel Preparation for Class: Nursing Care of a Person with Cancer of the Bowel Class Activity: Postoperative Nursing Care of Individuals with a Colostomy Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Ulcerative Colitis Preparation for Class: Nursing Care of a Person with Ulcerative Colitis Requiring an Ileostomy Class Activity: Postoperative Nursing Care of Individuals with a Temporary Diverting-Loop Ileostomy Critical Thinking Revisited Suggested Readings and Resources

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Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with gastrointestinal dysfunction 2. To apply principles related to nutritional disruptions when caring for individuals with gastrointestinal problems 3. To prepare patients for gastrointestinal procedures, treatments, and surgery 4. To plan care for the postoperative patient with gastrointestinal disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in this situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Ulcer Disease Edie Holland, 75 years of age, has a history of smoking and was diagnosed with ulcer disease after several years of taking nonsteroidal anti-inflammatory drugs (NSAIDs) to treat her arthritis. Her difficulties began when she experienced dull, gnawing pains and burning sensations in her midepigastrium area. The pain was relieved by eating. Mrs. Holland noticed that she was limiting her nutritional intake to soft, bland foods and had eliminated fruits and

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vegetables from her diet. However, when her stomach emptied a short time later, the same dull, gnawing pains returned. Her husband gave her antacids to extend the relief from pain. The antacids were effective for some time, but Mrs. Holland noticed that when she took milk of magnesia she developed diarrhea, and when she took amphogel she developed constipation. In any case, the relief was short lived and she needed to find a way to treat her symptoms with more long-lasting effect.

Preparation for Class: Nursing Care of a Person with Ulcer Disease

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

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1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

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b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

146

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

148

Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Ulcer Disease Directions: Respond to each of the following. 1. Compare risk factors for peptic, gastric, and stress ulcers. 2. Identify patient teaching in relation to prevention of peptic, gastric, and stress ulcers.

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3. Describe the pathophysiology of peptic, gastric, and stress ulcers. 4. List the appropriate laboratory and procedural tests for the detection of peptic, gastric, and stress ulcers. 5. What are the clinical symptoms of peptic, gastric, and stress ulcers? 6. Identify the medical management and surgical procedures related to the treatment of peptic, gastric, and stress ulcers. Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Irritable Bowel Disease (Crohn’s Disease) Kevin Lacey, a 20-year-old junior in a liberal arts college, began having abdominal pain from cramps and diarrhea that were not relieved by a bowel movement. Because eating and drinking seemed to stimulate his intestinal activity, he began reducing his food intake, which did not relieve the cramps and diarrhea. His nutritional status began to deteriorate. Mr. Lacey was surprised at the amount of weight he had lost and the fatigue he experienced, which was caused by the development of an underlying anemia. His abdomen was distended, he had cramps, and he noted blood in his stool. Mr. Lacey felt miserable and was confused about why this was happening to him. He explained his feeling of not having any control over his illness to the nurse in the college’s health clinic. An appointment was made for him to be seen by a gastroenterologist, who admitted him to the hospital for testing and evaluation. A barium enema showed the characteristic “string sign,” which indicated constriction of the intestine, and a computed tomography (CT) scan showed that the wall of his bowel had thickened, but there was no evidence of adhesions or fistulas anywhere in the small or large intestine. Mr. Lacey was given intravenous fluids and began steroid therapy.

Preparation for Class: Nursing Care of a Person with Irritable Bowel Disease (Crohn’s Disease)

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

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3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

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7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

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d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

156

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

158

Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Follow-up Care of an Individual with Irritable Bowel Disease (Crohn’s Disease) Directions: To complete this section, read the situation and answer the questions that follow. Mr. Lacey was discharged, with follow-up care to continue in his home. He had to take a leave of absence from school until he was strong enough to return.

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Questions 1. What are the priorities for Mr. Lacey’s care after discharge?

2. What expected outcomes of nursing care can be anticipated?

3. Identify specific ways in which nurses can intervene in his care.

Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Cancer of the Bowel Richard McKinsey, 55 years of age, wanted to practice illness prevention and health promotion activities. He had no family history of colon cancer, but when he learned of the high incidence of colon cancer in adults over 55 years of age, he underwent a routine colonoscopy. He believed that he had no symptoms of disease, so he was stunned when the colonoscopy showed a lesion in his ascending colon. The physician removed tissue for a biopsy and reported that

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the tumor was an adenocarcinoma, originating in the epithelial lining of the intestine. In retrospect, Mr. McKinsey was able to identify symptoms that he had mistaken for normal patterns. He recalled complaining of dull abdominal pain and occasional black tarry stools. Because of the location of the lesion, he was prepared for abdominoperineal resection with a permanent sigmoid colostomy. His surgery was scheduled immediately. As you plan his nursing care, limit your preparation for class to his preoperative care and the first 48 hours of his postoperative care.

Preparation for Class: Nursing Care of a Person with Cancer of the Bowel

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

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2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

166

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

168

Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Postoperative Nursing Care of an Individual Undergoing a Colostomy Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Postoperatively, Mr. McKinsey progressed as expected. His abdominal wound was clean and intact and his perineal wound had a drain in place that was to be removed gradually. The slight swelling of his stoma was receding and the small amount of normal oozing after surgery had resolved.

Questions 1. When planning care for Mr. McKinsey identify the problems that focus attention on the following physical aspects of recovery: respiratory, circulatory, nutritional, and integumentary.

2. Write expected outcomes for the emotional/psychological issues in Mr. McKinsey’s care.

3. Plan a patient education program that will have as its goal to enhance Mr. McKinsey’s self-care abilities.

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Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Ulcerative Colitis Martha Douglas was 28 years of age when she was diagnosed with ulcerative colitis. She was in the midst of a budding career in advertising. By her 40th birthday, she was established in the industry, although she had endured many years of symptoms from exacerbations of the disease. During one week she had had as many as 20 bloody stools a day and she complained to her partner of abdominal cramps and of feeling weak and dizzy. She is 5 ft 5 in tall and weighs 102 lb. Ms. Douglas was hospitalized for evaluation with the strong possibility that she would undergo surgery to create an ileoanal anastomosis. Her partner was very supportive of her decision to have the surgery and recognized that she was in a great deal of pain and that her symptoms interfered with the lifestyle she had chosen. As planned, a temporary, diverting-loop ileostomy was created to allow the ileoanal anastomosis to heal. Ms. Douglas tolerated the procedure very well. As you plan her nursing care, your preparation for class should include preoperative as well as postoperative care.

Preparation for Class: Nursing Care of a Person with Ulcerative Colitis Requiring an Ileostomy

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

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9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

176

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

178

Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Postoperative Nursing Care of Individuals with a Temporary Diverting-Loop Ileostomy Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Ms. Douglas’s postoperative period was uneventful.

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Questions 1. What facts about Ms. Douglas’s response to the surgery were necessary to: a. Gauge fluid replacement therapy?

b. Determine the timing for removal of nasogastric suction?

c. Determine replacement of electrolytes?

d. Provide optimal pain relief?

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2. What are the implications for care when fecal diversion is performed in the small intestine?

3. What assumptions can be made about the changes in Ms. Douglas’s lifestyle in the three months or so that she will adjust to living with an ileostomy?

4. What is your point of view with respect to the care of someone in Ms. Douglas’s situation?

5. How soon after surgery would fecal drainage be expected to begin?

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Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: What are the fundamental differences in the underlying pathophysiology of the various gastrointestinal problems discussed in this chapter that influence nursing management and patient prognosis?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about the individuals in the situations, including older adults, before beginning this assignment. Were they accurate and realistic? Were there assumptions you made initially that were later challenged because of new information or facts you learned?

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3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more thorough, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

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7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Edwards, M. (1996). Silent suffering . . . irritable bowel syndrome. Practice Nurse, 12(10), 628, 630. Friedman, G. (1998). Peptic ulcer disease. Clinical Symposia, 40(5), 2–32. Podolski, J. L. (1996). Recent advances in peptic ulcer disease: Heliocobacter pylori infection and its treatment. Gastroenterology Nursing, 19(4), 128–136. Rezents, K. J., Foster, R. B., & Goldstein, M. D. The As, Bs, Cs, Ds, & Es of hepatitis. AAOHN Journal, 46(4), 205–219.

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Chapter

7 Liver, Biliary, and Exocrine Pancreatic Problems

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L i v e r, B i l i a r y, a n d E x o c r i n e Pancreatic Problems

Q

What are the similarities and differences in lifestyle that may affect the onset of the problems discussed in this chapter?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Cirrhosis Preparation for Class: Nursing Care of a Person with Cirrhosis Class Activity: Nursing Care of Individuals with Bleeding Esophageal Varices Class Activity: Nursing Care of Individuals with Hepatitis Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Pancreatitis Preparation for Class: Nursing Care of a Person with Pancreatitis Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Cholelithiasis Preparation for Class: Nursing Care of a Person with Cholelithiasis Class Activity: Nursing Care of Individuals with Cholelithiasis Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations Class Activity: Nursing Care of Individuals wtih Cholecystitis Critical Thinking Revisited Suggested Readings and Resources

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Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with liver, biliary, and/or exocrine pancreatic dysfunction 2. To apply principles related to the disruption of metabolic function when caring for individuals with liver, biliary, and/or exocrine pancreatic problems 3. To prepare patients for procedures, treatments, and surgery involving the liver, biliary system, and/or exocrine pancreas 4. To plan care for the postoperative patient with liver, biliary, and/or exocrine pancreatic disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in this situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Cirrhosis Leo Weber, 63 years of age, was taken by ambulance to the emergency room because of changes in his mental status. The admission assessment showed that he had a grossly distended abdomen, bilateral 4+ edema, and jaundiced sclera and skin. He had difficulty answering the nurse’s questions and was preoccupied with vigorously scratching his arms and

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legs. His wife, who explained that she was a recovering alcoholic, stated that her husband had been a very heavy drinker and was diagnosed with cirrhosis of the liver many years ago. He had a history of peptic ulcer disease (PUD) and gout and he smoked two packs of cigarettes a day. Mr. Weber was admitted to the hospital. He was placed on bed rest with the head of his bed elevated 30 degrees, was weighed daily, and had accurate measurements made of his intake and output. He was placed on a 500 mg sodium, high-calorie, low-protein diet and restricted to 1000 mL of fluid each day. His medications included lactulose 30 mL PO tid and vitamin K (AquaMEPHYTON) 2 mg IM for three days. One unit of salt-poor albumin was ordered to be infused daily for three days. A paracentesis set was placed at his bedside.

Preparation for Class: Nursing Care of a Person with Cirrhosis

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Bleeding Esophageal Varices Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Soon after admission to the unit, Mr. Weber began having occult blood in his stools. The nurses noted that the occult blood in his stools became melena. He was more and more

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anxious as the days went on. As his condition deteriorated, he complained of epigastric fullness and weakness, and he appeared restless. Close monitoring of bleeding tendencies; a soft, bland diet; and rest were indicated. Interventions to prevent bleeding were not effective. Eventually, Mr. Weber had an episode of hematemesis that required proctoscopy to determine the site of the bleeding before instituting therapy.

Questions 1. Are there assumptions you can make about deterioration in Mr. Weber’s physical condition in relation to pathophysiology?

2. What additional information is needed to plan care for Mr. Weber in this critical situation?

3. Describe each of the following therapies to control the bleeding of esophageal varicies and give a rationale for the use of each: a. Vasopressin

b. Balloon tamponade

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c. Endoscopic sclerotherapy

d. Transjugular intrahepatic portosystemic shunt

Class Activity: Nursing Care of Individuals with Hepatitis Directions: To complete this section, answer the questions about hepatitis that follow. 1. Using the chart below, compare the mode of transmission, incubation period, type of immunity, signs and symptoms of illness, and predicted outcome of hepatitis A, B, C, D, and E.

MODE OF TRANSMISSION

INCUBATION PERIOD

TYPE OF IMMUNITY

Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E

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SIGNS AND SYMPTOMS OF ILLNESS

PREDICTED OUTCOME

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2. Describe patient teaching in relation to preventing the transmission of hepatitis. Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Pancreatitis Donna Ross, 43 years of age, was readmitted to the hospital one week after being discharged from the hospital following a cholecystectomy. She complained of severe left upper quadrant pain that radiated to her back. She was brought to the unit on a stretcher, nauseous and vomiting. The most comfortable position for her was lying with her knees drawn up to her chest. On admission, blood work was drawn that indicated she had abnormal elevations of blood glucose, amylase, and white blood count. A computed tomography (CT) scan was performed stat, which showed acute pancreatitis. The physician’s orders included the following: • • • • •

Bed rest Nasogastric (NG) tube, low suction IV Lactated Ringers 150 mL/h Meperidine 75–100 mg IM q4h prn for pain Nizatidine 150 mg PO bid

Preparation for Class: Nursing Care of a Person with Pancreatitis

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

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10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

206

Given

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Expected/Normal Values

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b. Medications

Medications

Given

Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

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Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

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Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

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Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Cholelithiasis The problem for Lisa Tucker, 36 years of age, began when she woke up during the night, nauseated and vomiting. The previous evening she had eaten out at a fast-food restaurant with her young family. She had eaten a hamburger, french-fried potatoes, and fried onion rings. She wondered if her upset stomach was due to spoiled food. In addition to nausea and vomiting, Mrs. Tucker complained of pain and tenderness as well as rigidity in the upper right side of her abdomen. She also felt hot, feverish, and generally sick. Her husband woke up wondering what was wrong. Mrs. Tucker complained that the pain was excruciating and that it radiated to her right shoulder. She asked her husband to take her to the emergency room of the local community hospital. In the emergency room, nursing assessment revealed that Mrs. Tucker had experienced epigastric distress in the past, but that this time it was far more severe than it had ever been. Her symptoms persisted and her temperature was 101.6°F, heart rate (HR) 104, and respiratory rate (RR) 30 and shallow. She is 5 ft 3 in tall and weighs 175 lb. The emergency room physician ordered tests, including an abdominal x-ray. He diagnosed cholelithiasis and recommended that Mrs. Tucker be admitted to the hospital for care of this acute illness (due to the inflammatory process) and exploration of her options for treatment. As you plan her nursing care, include in your preparation for class nursing care only after she was admitted to the unit and during the period when she will make decisions about the future management of her problem. Also include the various medical and surgical options available for someone with cholelithiasis.

Preparation for Class: Nursing Care of a Person with Cholelithiasis

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

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3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

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7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

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d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

216

Given

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Expected/Normal Values

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b. Medications

Medications

Given

Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

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Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

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Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

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Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Cholelithiasis Directions: To complete this section, plan the nursing care of each of the options identified in the Preparation for Class, including postoperative care and discharge planning.

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Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Class Activity: Nursing Care of Individuals with Cholecystitis Directions: To complete this section, plan the nursing care of individuals with cholecystitis in relation to each of the treatment options available.

Questions 1. What is the recommended dietary management of cholecystitis?

2. What drugs are used to dissolve small gallstones visualized on x-ray?

3. What nonsurgical methods are available to remove gallstones? Explain the methods listed below: a. Dissolving gallstones

b. Extracoporeal shock-wave lithotripsy

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c. Intracorporeal lithotripsy

4. What surgical methods are used to manage cholecystitis? Explain the methods listed below: a. Cholecystectomy

b. Laproscopic cholecystectomy

c. Percutaneous cholecystectomy

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Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically.

A. Answer the chapter opening question: What are the similarities and differences in lifestyle that may affect the onset of the problems discussed in this chapter?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions you made initially that were later challenged because of new information or facts you learned?

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3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

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7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Ambrose, M. S., & Dreher, H. M. (1996). Pancreatitis: Managing a flare-up. Nursing, 26(4), 33–40. Anonymous. (1996). Hepatitis A & B: The nurse’s role. Nursing Standard, 10(32RCN Nurs Update), 5–26. Anonymous. (1996). Self-test. Understanding the gastrointestinal system: Intestinal obstruction, pancreatitis, and hepatic encephalopathy. Nursing, 26(3), 28–29. Finlay, T. (1996). Making sense of the care of patient’s with pancreatitis. Nursing Times, 92(32), 38–39. Garaza, A., & Forshner, L. (1997). Hepatitis update. RN, 60(12), 39–44. Giacchino, S., & Houdek, D. (1998). Ruptured varices! Act fast. RN, 61(5), 33–36. Huston, C. J. (1996). Ruptured esophageal varices. American Journal of Nursing, 96(4 Nurse Pract Extra Ed), 43. McEwen, D. R. (1996). Management of alcoholic cirrhosis of the liver. AORN Journal, 64(2), 209, 211–216, 218–220. Meissner, J. E. (1997). Disease review. Caring for patients with pancreatitis. Nursing, 27(10), 50–51. Wright, I. O. (1998). Esophageal varices: Treatment and implications. Gastroenterology Nursing, 21(1), 2–5.

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Chapter

8 Endocrine Problems

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Endocrine Problems

Q

8

Why is endocrine dysfunction often expressed in behavioral changes in addition to physical symptoms?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Type 2 Diabetes Mellitus Preparation for Class: Nursing Care of a Person with Type 2 Diabetes Mellitus Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Class Activity: Nursing Care of Adults with Type 1 Diabetes Mellitus Class Activities: Nursing Care of Adults with Type 2 Diabetes Mellitus Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Hyperthroidism Preparation for Class: Nursing Care of a Person with Hyperthyroidism Class Activity: Nursing Care of Individuals with Hypothyroidism Class Activity: Nursing Care of Individuals with Hypoparathyroid Function Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Adrenocortical Disease (Cushing’s Disease) Preparation for Class: Nursing Care of a Person with Adrenocortical Disease (Cushing’s Disease) Class Activity: Nursing Care of Individuals with Adrenocortical Insufficiency (Addison’s Disease) Class Activity: Nursing Care of Individuals with Pituitary Dysfunction Class Activity: Nursing Care of Individuals with Acromegaly Critical Thinking Revisited Suggested Readings and Resources

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Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with endocrine dysfunction 2. To apply principles related to the disruption of regulatory and metabolic mechanisms when caring for individuals with endocrine problems 3. To prepare patients for endocrine procedures, treatments, and surgery 4. To plan care for the postoperative patient with endocrine disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in the situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Type 2 Diabetes Mellitus Sara Hardy is a 52-year-old married woman who was diagnosed four years ago with type 2 diabetes mellitus (formerly known as non-insulin-dependent diabetes mellitus [NIDDM]). At the time, she weighed 186 lb and was 5 ft 3 in tall. The diagnosis was based on her history of risk factors, her symptoms, and the results of glucose tolerance testing. Her physician recommended that she attend diabetes education classes at a local hospital. The physician prescribed glyburide (DiaBeta) 15 mg PO daily, a 1500-calorie meal plan, and daily exercise.

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During classes Mrs. Hardy learned to distinguish physical fluctuations in blood glucose levels. She increased her activity level by walking several times a week, controlled her nutritional intake, and maintained her blood glucose within the range of 120 to 200 mg/dL for more than seven years (with a weight loss of 23 lb). Recently her blood glucose levels were consistently higher. Mrs. Hardy had lost an additional 29 lb despite her increased nutritional intake. She complained of feeling weak, without enough energy to carry out her routine activities. Her daughter insisted that she consult her physician, who prescribed NPH insulin (Humulin N) in divided doses of 10 units SC before breakfast and 5 units SC before dinner. Her meal plan remained unchanged.

Preparation for Class: Nursing Care of a Person with Type 2 Diabetes Mellitus

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Class Activity: Nursing Care of Adults with Type 1 Diabetes Mellitus Directions: To complete this section, read the situation and answer the questions that follow.

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Mattie Hanks, 43 years of age, had a long-standing history of type 1 diabetes mellitus (formerly known as insulin-dependent-diabetes mellitus [IDDM]). Recently she was troubled by symptoms of a urinary tract infection and a fever of 101°F and higher. She did not report her fever to her physician because she thought she could manage it by increasing her fluid intake. When performing self-blood glucose monitoring (SBGM), Mrs. Hanks found that her blood glucose was 300mg/dL. She was also experiencing hunger, thirst, and frequent voiding.

Questions 1. What would you expect Mrs. Hardy to know about her present situation?

2. What action will Mrs. Hardy need to take?

3. What potential complications is Mrs. Hardy averting?

Class Activity: Nursing Care of Adults with Type 2 Diabetes Mellitus Directions: To complete this section, read the situation and answer the questions that follow. Timothy Johnson, 58 years of age, was recently diagnosed with type 2 diabetes mellitus and placed on glyburide, an oral hypoglycemic agent. While visiting his daughter, who is a nurse, he became flushed and tachycardic and felt nauseous.

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Questions 1. What actions will Mr. Johnson’s daughter take?

2. What questions would she ask to uncover the source of the problem?

3. Compare how a 24-year-old man who was newly diagnosed with type 1 diabetes mellitus would proceed in a similar situation.

Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Hyperthyroidism Elsie Cardin, a 46-year-old mother of six children, recently became impatient and irritable and experienced difficulty relating to her husband and friends. One day, with little provocation, she exploded in a tirade that caused her to seek medical attention. Physical assessment by the nurse practitioner revealed that she had lost 15 lb and was having difficulty sleeping. Her vital signs were increased significantly: temperature 101°F, blood pressure (BP) 180/100 mm Hg, heart rate (HR) 104, and respiratory rate (RR) 32. Mrs. Cardin complained of feeling intolerably hot and sweating without understanding why. She also had some diarrhea accompanied by abdominal cramps and pain. The nurse practitioner ordered blood tests that mea-

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sured thyroid hormone production, in particular, triiodothyronine (T3) and thyroxine (T4), thyroid stimulating hormone, thyroid radioactive iodine uptake, and thyroid autoantibodies.

Preparation for Class: Nursing Care of a Person with Hyperthyroidism

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

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b. Medications

Medications

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

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Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

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Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Hypothyroidism Directions: To complete this section, read the expected outcomes listed below, which are appropriate in planning care for adults with hypothyroidism. The client will: a. Report relief of cold intolerance.

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b. Return to normal bowel functioning and tolerate progressively increasing exercises. c. Report no chest pain, decreased fatigue, and less breathlessness with increased activity. d. Describe medication administration correctly, including rationale; desired and adverse, reportable effects; and the need for long-term, follow-up medical care. e. Explain the rationale for attending to his or her respiratory status until it is restored to normal. f. Show improvement in intellectual functioning by increasing spontaneous social and environmental interaction. g. Show no signs of the complications of myxedema. Questions 1. What nursing diagnoses and interventions apply to the outcomes given? a. b. c. d. e. f. g.

Class Activity: Nursing Care of Individuals with Hypoparathyroid Function Directions: To complete this section, read the situation and answer the questions that follow. Jane Jones, 23 years of age, had a previous history of subtotal thyroidectomy. Recently she had experienced persistent pain and spasms in her legs. Because of her past surgery, her serum calcium and phosphate levels were drawn. She was found to be hypocalcemic with hyperphosphatemia. Questions 1. What is the underlying pathophysiology of hypoparathyroidism?

2. Which goal(s) of therapy is(are) appropriate in Ms. Jones’s situation?

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3. What symptoms, in addition to the tetany described above, are further indications of this problem?

4. What will Ms. Jones’s nursing care include in relation to essential minerals and vitamins?

Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Adrenocortical Disease (Cushing’s Disease) Mary Lambert, a 77-year-old woman with osteoarthritis, had progressed in the control of musculskeletal symptoms from using nonsteroidal anti-inflammatory drugs (NSAIDs) to using oral steroids. Her treatment had continued for several years with significant relief of symptoms. However, Mrs. Lambert’s physician was increasingly concerned that this therapy was causing her to have untoward side effects. He noted on physical examination that she complained about how easily she bruised and that her physical appearance was changing. Mrs. Lambert had gained weight, especially in her abdominal area, but she also had thinning of her arms and legs. In addition, she complained of feeling weak and tired and that her sleep was interrupted at night because of a persistent backache. At her physician’s direction, blood studies were done that showed she had hypernatremia, hyperglycemia, and hypokalemia and her differential count indicated a reduced number of eosinophils. Plasma and urinary cortisol levels were obtained at different times in the diurnal cycle, that revealed little variation in plasma levels.

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Preparation for Class: Nursing Care of a Person with Adrenocortical Disease (Cushing’s Disease)

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

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4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Adrenocortical Insufficiency (Addison’s Disease) Directions: To complete this section, read the situation and answer the questions that follow. Lawrence Mello, 27 years of age, complained that he felt like “an old man.” Not long ago, he had been a happy bachelor and a successful salesman for a computer company. Lately, however, he felt weak and was easily fatigued at work. On a recent business trip, Mr. Mello found

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it difficult to cope with his client’s demands. When he returned to his own home, he confined himself to bed because of weakness and other physical complaints. He attributed all of his symptoms to a “virus.” He had lost his appetite and at times he seemed confused. His skin appeared to be tanned, which he was unable to explain. Questions Supply the rationale for each of the following nursing interventions in Mr. Mello’s care: 1. Monitor vital signs for hypotension and/or tachycardia.

2. Provide rest periods and encourage energy conservation.

3. Avoid stressors until corticosteroids take effect.

4. Provide a high sodium and low potassium diet and liquids.

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5. Assess for gastrointestinal (GI) problems: anorexia, nausea, vomiting, diarrhea, pain, and weight loss.

6. Weigh daily.

7. Assess for hyperpigmentation.

8. Monitor patient’s status if fluids or foods must be withheld for lab work or x-ray.

9. Administer IV corticosteroids and normal saline, as ordered.

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Class Activity: Nursing Care of Individuals with Pituitary Dysfunction Directions: On the chart below, compare the nursing management of individuals with excess or insufficient hormonal function in terms of their behavior, physical symptoms, and social functioning.

Anterior Pituitary

HYPERPITUITARY

HYPOPITUITARY

HYPERPITUITARY

HYPOPITUITARY

Behavior Physical symptoms Social functioning

Posterior Pituitary

Behavior Physical symptoms Social functioning

Class Activity: Nursing Care with Individuals with Acromegaly Directions: To complete this section, read the situation and answer the questions that follow. Carlton Marlow, 62 years of age, noticed changes in his hands and face that had become more pronounced with time. His hands and face were swelling and causing disfigurement, so he sought medical care. Mr. Marlow’s physician told him that he had a pituitary tumor. When the tumor was removed, he was told that it was benign. He complained of being clumsy and fatigued and of feeling dyspneic.

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Questions 1. What further assessment data are needed?

2. What nursing interventions are indicated?

Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: Why is endocrine dysfunction often expressed in individuals’ behavior as well as their physical symptoms?

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B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you had about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions that you made initially that were later challenged because of new information or facts you learned?

3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

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5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

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Suggested Readings and Resources Drass, J. A. (1996). Caring for patients with insulin-dependent diabetes mellitus. Nursing, 26(8), 46. Drass, J. A. (1996). Caring for patients with non-insulin-dependent diabetes mellitus. Nursing, 26(9), 48–49. Drass, J. A., & Patterson, A. (1996). Type II diabetes: Exploring treatment options. American Journal of Nursing, 96(11), 45–50. Gumowski, J., & Loughran, M. (1996). Diseases of the adrenal gland. Nursing Clinics of North America, 31(4), 747–768. Hernandez, D. (1998). Microvascular complications of diabetes: Nursing assessment and intervention. American Journal of Nursing, 98(6), 26–32. Jankowski, C. B. (1996). Irradiating the thyroid: How to protect yourself and others. American Journal of Nursing, 96(10), 50–54. McKennis, A., & Waddington, C. (1997). Nursing interventions for potential complications after thyroidectomy. ORL-Head & Neck Nursing, 15(1), 27–35. Streff, M. M., & Pachucki-Hyde, L. C. (1996). Management of the patient with thyroid disease. Nursing Clinics of North America, 31(4), 779–796.

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Chapter

9 Reproductive Problems

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Reproductive Problems

Q

To what extent are self-care practices dependable for preventing and detecting early problems that lead to reproductive dysfunction?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Pelvic Inflammatory Disease Preparation for Class: Nursing Care of a Woman with Pelvic Inflammatory Disease Class Activity: Nursing Care of Women with Pelvic Inflammatory Disease Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Cancer of the Endometrium Preparation for Class: Nursing Care of a Woman with Cancer of the Endometrium Class Activity: Nursing Care of Women with Endometriosis Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Breast Cancer Preparation for Class: Nursing Care of a Woman with Breast Cancer Class Activity: Nursing Care of Women with Ovarian Cancer Case Study: Testicular Cancer Preparation for Class: Nursing Care of a Man with Testicular Cancer Class Activity: Nursing Care of Men with Testicular Cancer Critical Thinking Revisited Suggested Readings and Resources

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Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with reproductive dysfunction 2. To apply principles related to the disruption of reproductive ability, selfimage, and sexuality when caring for individuals with reproductive problems 3. To prepare patients for reproductive procedures, treatments, and surgery 4. To plan care for the postoperative patient with reproductive problems

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Preparations for class are organized to provide the knowledge base for classroom activities. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in the situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Pelvic Inflammatory Disease Gladys Morse, 20 years of age, came to the emergency room for treatment of severe abdominal pain, cramping, fever with chills, and a general feeling of “being sick.” Assessment revealed that the “sick feelings” began several weeks before, but that she had been unwilling to seek help. Ms. Morse revealed that she has many different sexual partners and that, although she believed that protection during intercourse was important, she did not protect herself or her partners regularly.

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Preparation for Class: Nursing Care of a Woman with Pelvic Inflammatory Disease (PID)

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

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4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Women with Pelvic Inflammatory Disease Directions: To complete this class activity, read the following continuation of the situation and answer the questions that follow. Ms. Morse had a speedy recovered from her acute illness. On a follow-up visit to the community health clinic, she asked the nurse to help her understand how to protect herself from further infection.

Questions 1. What objectives are appropriate for patient teaching in this situation?

2. How will patient teaching be planned and implemented for Ms. Morse?

Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Cancer of the Endometrium Christina Nelson, 71 years of age, noticed a bloody vaginal discharge long after her menopause had ended. Because of severe symptoms during her menopause, she had agreed to treatment with unopposed estrogen replacement therapy, which she took for the first several years after the onset of menopause. (This treatment was current before progesterone began to be commonly used to oppose the detrimental effects of estrogen alone.) When the bloody vaginal discharge appeared, Mrs. Nelson immediately made an appointment to see her gynecologist. A complete physical examination and diagnostic tests were performed to determine the cause of the bleeding. The tests included a biopsy of endometrial tissue, which showed an adenocarcinoma. Mrs. Nelson’s options for care were explained and she decided on and was prepared for a radical hysterectomy.

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Preparation for Class: Nursing Care of a Woman with Cancer of the Endometrium

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

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4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Women with Endometriosis Directions: To complete this section, read the situation and answer the questions that follow. Tracy Golden, 25 years of age, experienced dysmenorrhea that was not like her usual menstrual cramps. The pain in her abdomen, vagina, and back began a day of two before her

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menstrual period and lasted a few days. She was sexually active and noted that intercourse was painful. She usually experienced diarrhea and nausea during that “time of the month.”

Questions 1. What goals can you identify that may be priorities for someone in Ms. Golden’s situation?

2. Prepare a pre- and postoperative teaching plan for Ms. Golden using principles of teaching and learning.

3. What are the goals of immediate and long-term care in the situation?

4. What nursing interventions are indicated?

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5. Prepare a teaching plan based on Ms. Golden’s self-care needs after her discharge from the hospital.

Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Breast Cancer Mary Forrester, 69 years of age, has had routine mammograms since her 50th birthday. Her four children were all breast-fed. She began menopause when she was 49 years of age and it ended approximately 10 years later. She experienced “hot flashes” until she began taking estrogen. After her last mammogram at the breast center of her community hospital, the radiologist explained that there had been changes in her right breast that indicated a need for a repeat mammogram. A mass was visualized that required biopsy. The biopsy was positive for cancerous cells. Mrs. Forrester was provided with options for therapy and she chose to have a simple mastectomy. Following surgery, she returned to the unit from the postanesthesia care unit (PACU) with a dressing over the incision and Jackson-Pratt suction in place. She asked the nurse if the surgeons had been able to remove all of the tumor.

Preparation for Class: Nursing Care of a Woman with Breast Cancer

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

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3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

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7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

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d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

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Given

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b. Medications

Medications

Given

Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

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Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Women with Ovarian Cancer Directions: To complete this section, read the situation and answer the questions that follow. Brenda Davidson and her husband celebrated her 50th birthday by taking a cruise to several islands near the Equator. Their happiness was marred only by her vague complaints of pelvic pressure, abdominal discomfort, and urinary frequency. She attributed her symptoms either

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to having indulged in the buffet tables at all hours of the day and night during the cruise or to a urinary tract infection. When they returned home, Mrs. Davidson immediately made an appointment with her physician. The nurse practitioner (NP) in the office thoroughly assessed Mrs. Davidson. The assessment revealed that Mrs. Davidson had had irregular periods for some time, with menorrhagia and tenderness of her breasts. During the assessment, Mrs. Davidson admitted that her gastrointestinal symptoms were vague but persistent, and that abnormal menses had been long-standing symptoms. In discussing her options with her doctor, she expressed concern about having a hysterectomy. She wanted to know whether she would be able to maintain her intimate relationship with her husband after the operation and whether he would still find her attractive.

Questions 1. How is cancer of the ovary staged?

2. What assumptions can be made about the stage of Mrs. Davidson’s cancer at diagnosis?

3. What are the treatment choices for women with ovarian cancer and what criteria are used to make decisions about treatment? Why?

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4. What testing is indicated in the assessment of ovarian cancer?

5. What are the priorities of pre- and postoperative care?

6. What are the priorities of patient education for Mrs. Davidson during radiation therapy?

Case Study: Testicular Cancer Jack MacDonald, 25 years of age, was watching his favorite football team play a winning game over their competition. The announcers began discussing the situation of one of the players who had recently been diagnosed with testicular cancer. During a time-out, they described his symptoms, which included pain in the abdomen, backache, and weight loss. As Mr. MacDonald listened to the discussion by the two announcers, he mentally checked off the symptoms they were describing in relation to himself. He had noted the same symptoms, in addition to enlargement of his left testicle, which was not accompanied by pain. He was alarmed by what he heard and how what they said about the player paralleled his own experience. The following Monday morning, Mr. MacDonald called his doctor’s office and made an appointment to be examined. Blood studies, intravenous urography, and lymphangiography were done, which were all positive for presence and metastasis of cancer. A computed tomography (CT) scan was also done to determine the extent of the metastasis to the lymph nodes in the retroperitoneum and to the lungs. Mr. MacDonald was prepared for surgery as the first step in the management of his condition.

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Preparation for Class: Nursing Care of a Man with Testicular Cancer

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Men with Testicular Cancer Directions: To complete this section, answer the following questions in relation to Mr. MacDonald.

Questions 1. What assumptions can be made about Mr. MacDonald’s therapy during the postoperative period?

2. What nursing care is indicated in this situation following adjuvant therapies?

3. What are the psychosocial concerns that nurses should pursue in Mr. MacDonald’s care?

4. What patient education is vital to detect testicular cancer early and to prevent undetected spread of the disease?

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Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically.

A. Answer the chapter opening question: To what extent are self-care practices dependable for preventing and detecting early problems that lead to reproductive dysfunction?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions you made initially that were later challenged because of new information or facts you learned?

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3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

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7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Barker, J., & Harcourt, D. (1998). Breast cancer: Giving women a more proactive role. Nursing Times, 94(13), 58–59. Bassett, C., & McSherry, R. (1996). Testicular cancer. British Journal of Nursing, 5(3), 169–170. Bob, P. S. S., & Famolare, N. E. (1998). Teaching and communication strategies: Working with the hospitalized adolescent with pelvic inflammatory disease. Pediatric Nursing, 24(1), 17–20, 29–30. Briggs, F. E. (1996). Newly diagnosed women with breast cancer: The nurse’s role. Nurse Practitioner: American Journal of Primary Health Care, 21(4), 153–155. Chaplin, B. (1996). Breast cancer: The role of the nurse, Part 2. Nursing Times, 92(11), 5–8. Jary, J., & Franklin, L. (1996). The role of the specialist nurse in breast cancer. Professional Nurse, 11(10), 664–665. Kinsey, R., & Van Gerpen, R. (1997). The diagnosis of breast abnormalities: Nursing implications. Nebraska Nurse, 30(2), 41–42. Maffeo, R. (1997). Cancer care. Managing testicular cancer. Nursing, 27(5), 32hn6, 32hn8. Tucci, R. A., & Bartels, K. L. (1998). Ovarian cancer surgery: A clinical pathway. Clinical Journal of Oncology Nursing, 2(2), 65–66.

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Chapter

10 Immunologic Problems

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Immunologic Problems

Q

10

How are problems of immunological dysfunction similar to and different from each other?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Rheumatoid Arthritis Preparation for Class: Nursing Care of a Person with Rheumatoid Arthritis Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Acquired Immunodeficiency Syndrome Preparation for Class: Nursing Care of a Person with Acquired Immunodeficiency Syndrome Class Activity: Nursing Care of Individuals with Systemic Lupus Erythematosus Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Rheumatoid Arthritis Preparation for Class: Nursing Care of Individuals with Rheumatoid Arthritis Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations Class Activity: Nursing Care of a Person with Rheumatoid Arthritis Undergoing Hip Replacement Surgery Critical Thinking Revisited Suggested Readings and Resources

Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with immunologic dysfunction

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2. To apply principles related to the disruption of protective mechanisms when caring for individuals with immunologic problems 3. To prepare patients for immunologic procedures, treatments, and surgery 4. To plan care for the postoperative patient with immunologic disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in the situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Rheumatoid Arthritis Judy Newman, 37 years of age, experienced stiffness in and swelling of the joints of both hands and wrists in the morning. Her symptoms resulted in unusual clumsiness while making breakfast for her husband and three children. She was surprised when she dropped her coffee cup one morning. Looking back she remembered that she did not feel the cup in her hand. Pain was not as much of a problem as the stiffness she felt. Her hands, elbows, knees, and toes felt warm and appeared red, as though inflamed. In addition to the changes in her joints, Mrs. Newman did not feel well. She noticed an unintended weight loss. The changes were particularly troubling at this time in her life, as she was looking forward to returning to school and planning a career. When she consulted her physician, he advised Mrs. Newman of the need for testing. During the assessment, Mrs. Newman explained that she had some discomfort and that she feared knowing the outcome of the testing.

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Preparation for Class: Nursing Care of a Person with Rheumatoid Arthritis

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Acquired Immunodeficiency Syndrome Tom Madison, 38 years of age, went to the emergency department of a major urban medical center three weeks after being discharged from the medical center for treatment of toxoplasmosis. He has been human immunodeficiency virus (HIV) positive for more than eight years. Currently unemployed, he has been living with his partner for the past two years. The admission nursing history was obtained from his partner because it was difficult for Mr. Madison to speak. Before he became too fatigued to work, he was a carpenter/electrician. He occasionally used alcohol, but was otherwise drug-free. Mr. Madison’s primary problem was difficulty swallowing and a sore throat. He had more difficulty swallowing cold liquids than hot ones and complained of a burning chest pain while swallowing. His cough was productive of clear sputum, and cultures showed that he had Pneumocystis carinii. He is 5 ft 6 in tall and weighs 118 lb. He has also had loose stools for several days, but not fever, chills, hemoptysis, abdominal pain, or shortness of breath. Physical examination revealed thinning hair, a clear nasopharynx, and an oropharynx with erythematous ulcerations on his tonsillar fossa and under his tongue. His vital signs were: temperature 99.1°F, heart rate (HR) 120 beats per minute, respiratory rate (RR) 24, and blood pressure (BP) 120/78 mm Hg. His lungs were clear to auscultation (CTA). An IV of dextrose 5 percent (D5) normal saline solution at 150 mL/h was ordered. He would also receive acyclovir (Zovirax) 5mg/kg (270 mg) IV q8h to be administered over 1 hour.

Preparation for Class: Nursing Care of a Person with Acquired Immunodeficiency Syndrome

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

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3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

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7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

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d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

332

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Systemic Lupus Erythematosus Directions: To complete this section, read the situation and answer the questions that follow. Leah Martin, 31 years of age, is married and has two school-age children. She was admitted to the local hospital to determine the cause of swelling and tenderness in her knee and elbows. Nursing assessment revealed that she had been uncomfortable staying out in

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the sun during the previous summer months—she had developed an intolerance to the sun that was unusual for her. She had a butterfly-shaped, reddened rash over her cheeks. During the assessment, her husband left the room to call home and tell the babysitter that he would be home in a short while. Mrs. Martin explained that her doctor had told her that she would be hospitalized because she had a rare disorder of the immune system. She had many questions about her condition. Although she was trying to control her emotions, she wiped the tears from her eyes when her husband left the room. “What am I to do?” she asked. Mrs. Martin’s physician ordered aspirin (ASA) 600 mg PO tid and prednisone 30 mg PO tid. He scheduled plasmapheresis in the afternoon and again in five days. A cyclophosphamide (Cytoxan) IV was scheduled to be administered the next day. Mrs. Martin began a regular diet with 2-g sodium restriction. Her oral temperature was 102.8°F. She complained that she had been more tired than usual lately. She was placed on bed rest with increased activity as tolerated and a chest x-ray was ordered.

Questions 1. Describe nursing responsibilities during plasmapheresis.

2. Discuss patient teaching in this situation, including attention to Mrs. Martin’s lifestyle, self-medication, symptom management, and activity intolerance.

Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Rheumatoid Arthritis Mrs. Newman was treated for rheumatoid arthritis and 10 years later was admitted for surgery. Nursing history revealed that she had managed the pain in her joints fairly well. She progressed from using salicylates to using nonsteroidal anti-inflammatory drugs (NSAIDs)

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and then corticosteroids. The pain became particularly severe in her hips and even large doses of corticosteroids did not relieve it effectively. She consulted her physician, who advised her to undergo testing.

Preparation for Class: Nursing Care of a Person with Rheumatoid Arthritis

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

342

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Class Activity: Nursing Care of Individuals with Rheumatoid Arthritis Undergoing Hip Replacement Surgery Directions: To complete this section, read the situation and answer the questions that follow.

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Kimberly Ragsdale, 63 years of age, had been diagnosed with rheumatoid arthritis as a young woman. Her physician had managed her arthritis traditionally with medications and prescribed exercises and weight control. This therapy had been very successful in controlling the symptoms of her disease for many years. When those measures were no longer allowing her the mobility she needed, Mrs. Ragsdale agreed to the option she was given of having bilateral hip replacements. She was prepared for the first surgery before being admitted and then was hospitalized for the surgery. Her hip was replaced with a noncemented prosthesis. The surgery was uncomplicated and she returned to the unit.

Questions 1. What are the priorities of nursing care for Mrs. Ragsdale in the immediate postoperative period?

2. Why did you arrange the priorities as you did?

3. What are the complications of hip replacement surgery and how are they prevented and detected?

4. When does patient education begin in this situation and what will it entail?

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5. What are the specific considerations for patient discharge to subacute care?

6. How will Mrs. Ragsdale be prepared for discharge home after subacute care?

Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: How are problems of immunological dysfunction similar to and different from each other?

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B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions you made initially that were later challenged because of new information or facts you learned?

3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

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5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

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Suggested Readings and Resources Ailinger, R. L., & Dear, M. R. (1997). An examination of the self-care needs of clients with rheumatoid arthritis. Rehabilitation Nursing, 22 (3), 135–140. Crofts, P., & DíCruz, D. (1997). Systemic lupus erythematosus, Part 2: The role of the nurse. Nursing Standard, 11(44), 40–42, 44. Davidhizar, R., & Shearer, R. A. (1996). Nursing care of the client with AIDS. Journal of Practical Nursing, 46 (4), 30–40. Gio-Fitman, J. (1996). The role of psychological stress in rheumatoid arthritis. MEDSURG Nursing, 5(6), 422–426. Hicken, I., & Butterworth, T. (1996). AIDS and community nursing care. International Journal of Palliative Nursing, 2(1), 35–42. Howser, R. L. (1996). Challenging diagnosis. Nursing care of a patient with lupus cerebritis. DCCN: Dimensions of Critical Care Nursing, 15(5), 254–262. Krug, B. (1997). Rheumatoid arthritis and osteoarthritis: A basic comparison. Orthopaedic Nursing, 16(5), 73–75. Leininger, S. M. (1998). Caring for a patient with a total hip replacement. Nursing, 28 (4 Hosp Nurs), 32hn12, 32hn14. Pigg, J. S. (1997). Case management of the patient with arthritis: Implementing case management across the continuum—the transition of the orthopaedic patient. Proceedings of selected papers, NAON 1996 Fall Case Management Conference, New Orleans, LA, Nov14–16, 1996. Orthopaedic Nursing, (Suppl), 33–40, 65. Ryan, S. (1997). Rheumatology: Professional issues, Part 3. Nursing Times, 93(16), 55–60. Ryan, S., & Seymour, J. (1997). Rheumatology: The role of the nurse, Part 2. Nursing Times, 93(15), 61–64. Voyce, M. (1998). Update: Rheumatoid arthritis. Professional Nurse, 13(7), 441–445.

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Chapter

11 Musculoskeletal Problems

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Musculoskeletal Problems

Q

Is there an overall functional deficit that individuals share when they have musculoskeletal problems?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Osteomyelitis Preparation for Class: Nursing Care of a Person with Osteomyelitis Class Activity: Nursing Care of Individuals with Osteomyelitis Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Osteoporosis Preparation for Class: Nursing Care of a Person with Osteoporosis Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Trauma Preparation for Class: Nursing Care of a Person with Trauma Class Activity: Nursing Care of Individuals with Trauma Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Amputation Preparation for Class: Nursing Care of a Person Undergoing Amputation Class Activity: Nursing Care of Individuals with a Below-the-Knee Amputation Class Activity: Nursing Care of Individuals with Complications of a Fractured Hip Critical Thinking Revisited Suggested Readings and Resources

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Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with musculoskeletal dysfunction 2. To apply principles related to the disruption of mobility when caring for individuals with musculoskeletal problems 3. To prepare patients for musculoskeletal procedures, treatments, and surgery 4. To plan care for the postoperative patient with musculoskeletal disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in the situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Osteomyelitis Jesse Dean, 38 years of age, was recovering from a comminuted fracture of his left tibia, which he sustained in a motor vehicle accident. Several weeks after the accident, he experienced swelling, warmth, pain, and tenderness in his healed leg. He had noticed these symptoms appear rather gradually, but when they did, he recognized them as the symptoms he had been told by the nurse to watch out for and report, which he did. An x-ray was taken and showed areas of decalcification, necrosis of the bone, and new bone formation. Mr. Dean was admitted to the hospital for intravenous antibiotic therapy and immobilization of his leg. Further testing was indicated.

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Preparation for Class: Nursing Care of a Person with Osteomyelitis

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Osteomyelitis Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Mr. Dean was discharged from the hospital with follow-up care in his home. He lived alone, but had many family members in the area who were willing to make daily visits to assume

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his nursing care needs. The situation was well managed for some time, but an area of his leg continued to be problematic. In fact, his skin began to slough and a sinus that drained purulent material became visible. The pain, swelling, warmth in the area, and erythema returned. He also had a low-grade fever.

Questions 1. What do you suspect is happening to Mr. Dean, based on his symptoms as described in the case study?

2. What are the priorities of care for Mr. Dean at this time?

3. What intervention is indicated and why?

Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Osteoporosis Carmen Harrison, 75 years of age, raised four children, all of whom were breast-fed. She is slender and tall, although she jokes with her grandchildren that she seems to be shrinking. Her blond hair is now almost completely gray. She had never enjoyed spending much time in the sun, even when she was young. Mrs. Harrison used to complain of back pain that radi-

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ated down her leg. As the years passed, she noted that her posture was more stooped than before and that she was becoming more isolated. There were many activities she used to enjoy that no longer interested her.

Preparation for Class: Nursing Care of a Person with Osteoporosis

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Trauma Nathan Young is a 36-year-old man who came to the emergency department following an automobile accident in which he sustained a fracture of his left tibia. He was evaluated by the orthopedic surgeon, who scheduled him for open reduction/internal fixation of the fracture as soon as the operating room became available, which was in an estimated two to three hours. In the meantime, he was admitted to the orthopedic unit. When Mr. Young arrived on the unit, the neurovascular checks made of his right lower extremity were unchanged from the assessments made in the emergency room. The nurses noted that he had decreased sensation, motor weakness, diminished pulses, and slower capillary refill. The physician was notified and neurovascular assessments were increased to every 15 minutes. Mr. Young was prepared for surgery with teaching, emotional, and physical care.

Preparation for Class: Nursing Care of a Person with Trauma

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

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9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

380

Given

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Expected/Normal Values

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b. Medications

Medications

Given

Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

382

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

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Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals with Trauma Directions: To complete this section, read the following continuations of the situation and answer the questions that follow. Also, see the sections in your textbook on compartment syndrome and fat embolism, which are potential complications of musculoskeletal trauma. After being admitted to the unit, Mr. Young lost the ability to dorsiflex his right foot and toes, and the skin color in his right extremity became very pale.

Questions 1. What assumptions can you make about Mr. Young’s situation based on the neurovascular assessment findings?

The physician was notified and Mr. Young’s case was made an immediate operative priority. He was taken to the operating room within an hour of his arrival on the orthopedic unit. His surgical course was uneventful. Postoperatively, Mr. Young was placed in a long-leg plaster splint that incorporated his foot. His neurovascular assessment findings were all within the normal range. The physician’s orders included “to loosen the cast padding for any signs of numbness or tingling or muscle weakness in the right foot and/or toes.” Mr. Young was carefully evaluated for the next 24 hours for any signs of compromise in his neurovascular status. During the nurses’ evening shift the following day, he became dyspneic, restless, and confused. His respiratory rate (RR) increased to more than 30 breaths per minute and his heart rate (HR) increased to more than 140 beats per minute. The nurse took his temperature and it was over 103°F.

Questions 1. What assumptions can you make based on these objective symptoms?

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2. What do you expect Mr. Young’s nursing and medical management will include?

Mr. Young’s situation improved steadily and he was prepared for discharge in 10 days.

Questions 1. What patient teaching will Mr. Young need to care for himself at home?

2. What symptoms will Mr. Young need to report to his physician and why are they important?

Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Amputation Dorothy Barker, an 86-year-old widow of four years, had a family history and long-standing diagnosis of peripheral vascular disease. Although she was becoming increasingly forgetful, she was an active woman who was self-sufficient in her care. The only symptom of her vascular disease was an occasional skin break resulting in lesions on her great toe. The problem was probably due to poorly fitted shoes. When a skin lesion appeared, Mrs. Barker would soak her feet. Eventually the lesion would heal and she would return to her daily activities, which included walking in her neighborhood. Her problem required no other treatment for many years.

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Subsequently, when Mrs. Barker had an infection, the usual measures were no longer effective. She experienced severe pain in her legs when they were elevated on the bed during the night. The skin breakdown and infection on her toe spread to all of the toes on her right foot. Initially, she was treated with femoral-popliteal bypass graft and amputation of her right toes. The surgery was successful for a short time, but later the graft became occluded. Urokinase was used to free the clot occluding the bypass grafted arteries of her right leg, but the treatment was only temporary. The wound on her foot from the original amputation became infected. Below-the-knee amputation was recommended. Mrs. Barker’s sons and daughters thought about the prospect of having their mother undergo amputation. Despite the anguish of putting their mother through surgery, they advised her to have the surgery, but discussions between them indicated that they were not in agreement about the surgery. Mrs. Barker’s deteriorating cognitive status made it difficult for her to understand what was being said at times, although there were times when she appeared to understand exactly what was happening. She had no other underlying physical problems and she was not taking any medications regularly. She gave consent for the surgery and was admitted to the hospital for belowthe-knee amputation of her right leg.

Preparation for Class: Nursing Care of a Person Undergoing Amputation

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

390

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with a Below-the-Knee Amputation Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. After the amputation, Mrs. Barker’s suture line healed without complications and she was transferred for rehabilitation and for fitting a prosthesis. She was unwilling to look at her

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right leg, and when she did, she questioned the appearance of her leg and wondered why it was different from her left leg. At times she thought her leg was still there and wanted to walk to the bathroom from her bedside.

Questions 1. What are the priorities for Mrs. Barker’s care?

2. How will Mrs. Barker’s rehabilitation be managed?

Class Activity: Nursing Care of Individuals with Complications of Fractured Hip Directions: To complete this section, read the situation and answer the questions that follow. Ellen Delay, 75 years of age, was hospitalized for treatment of a broken hip and was admitted to the orthopedic unit. She was prepared for an x-ray, which would determine the extent of her injury.

Questions 1. What instruction will you provide before the x-ray and how will you help Mrs. Delay cope with her new situation?

Mrs. Delay returned to the unit after her x-ray complaining of being hungry and thirsty.

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Questions 1. What action(s) will you take?

A left femoral neck fracture was diagnosed and Mrs. Delay was advised to have her hip repaired surgically. She decided on and was prepared for an “open reduction and internal fixation” of her hip. Her complete blood count (CBC), electrolyte levels, urinalysis, electrocardiogram (ECG), and chest x-ray were all within normal parameters.

Questions 1. What influence does Mrs. Delay’s age have on these laboratory findings?

2. Describe Mrs. Delay’s preparation for surgery in the morning.

After three days Mrs. Delay appeared to be progressing well, except that the nurse noted a slight swelling on Mrs. Delay’s left calf during her assessment of neurovascular status. The nurse compared Mrs. Delay’s left and right legs to see whether they differed in circumference and asked Mrs. Delay to dorsiflex her left foot, which caused her discomfort. The nurse charted a positive Homan’s sign.

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Questions 1. What complication of an acute venous disorder might this signify?

2. What other assessment data will the nurse want?

Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: Is there an overall functional deficit that individuals share when they have musculoskeletal problems?

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B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions that you made initially that were later challenged because of new information or facts you learned?

3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

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5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

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Suggested Readings and Resources Cavalieri, R. J. (1998). Nursing presence in osteoporosis research. American Journal of Nursing, 98(6), 60, 62–63. Calhoun, J. H., Laughlin, J. T., & Mader, J. T. (1998). Osteomyelitis: Diagnosis, staging, management. Patient Care, 32 (2), 93–94, 99–102, 105–106. Darovic, G. (1997). Caring for patients with osteoporosis. Nursing, 27(5), 50–51. Donohue, S. J. (1997). Lower limb amputation 1: Indications and treatment. British Journal of Nursing, 6(17), 970, 972, 974–977. Donohue, S. J. (1997). Lower limb amputation 2: Once the decision to amputate has been made. British Journal of Nursing, 6(18), 1048, 1050–1052. Donohue, S. J. (1997). Lower limb amputation 3: The role of the nurse. British Journal of Nursing, 6(20), 1171–1172, 1174, 1187–1191. Hefti, D. (1995). Complications of trauma: The nurse’s role in prevention. Orthopaedic Nursing, 14(6), 9–16. Quantock, C., Beynon, J., Gill, J., & Beale, J. (1995). Structure of bone care osteoporosis management. Practice Nurse, 10(4), 262–263. Wright, A. (1998). Nursing interventions with advanced osteoporosis. Home Healthcare Nurse, 16(3), 144–152. Yetzer, E. A. (1996). Helping the patient through the experience of an amputation. Orthopaedic Nursing, 15(6), 45–49.

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Chapter

12 Renal Problems

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Renal Problems

Q

12

Are there similarities and differences in the onset of illness and the course of disease when the underlying problem is renal dysfunction?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Acute Glomerulonephritis Preparation for Class: Nursing Care of a Person with Acute Glomerulonephritis Class Activity: Nursing Care of Individuals with Nephrotic Syndrome Class Activity: Nursing Care of Individuals with Polycystic Kidney Disease Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Chronic Renal Failure and Hemodialysis Preparation for Class: Nursing Care of a Person with Chronic Renal Failure and Undergoing Hemodialysis Class Activity: Nursing Care of Individuals with End-stage Renal Disease and Undergoing Continuous Ambulatory Peritoneal Dialysis Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Renal Calculi Preparation for Class: Nursing Care of a Person with Renal Calculi Class Activity: Nursing Care of Men with Benign Prostatic Hypertrophy Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Urinary Incontinence Preparation for Class: Nursing Care of a Person with Urinary Incontinence Class Activity: Nursing Care of Individuals with Renal Transplantation Class Activity: Nursing Care of Individuals with Urinary and Renal Dysfunction Critical Thinking Revisited Suggested Readings and Resources

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Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with renal dysfunction 2. To apply principles related to the obstruction of renal and urinary flow as well as disruptions of normal waste removal when caring for individuals with renal problems 3. To prepare patients for renal procedures, treatments, and surgery 4. To plan care for the postoperative patient with renal disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in the situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Acute Glomerulonephritis Angie Kilgore, 33 years of age, kept a scheduled appointment with the nurse practitioner for routine follow-up after the delivery of her infant son six months before. Assessment of her vital signs indicated that she had a slightly elevated blood pressure and physical examination revealed tenderness in the costovertebral angle area. The nurse practitioner learned that Mrs. Kilgore had had an episode of flulike symptoms with a sore throat and fever several days earlier, which caused her to feel feverish and have a slight headache. Routine urinalysis revealed the presence of blood and albumin in her urine. Although her symptoms

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had receded, Mrs. Kilgore complained of not feeling very well and of some facial swelling and flank pain. The nurse practitioner referred her to the physician who explained that her symptoms required a more in-depth evaluation. Mrs. Kilgore was advised to make arrangements for admission to the hospital for further testing and treatment of acute glomerulonephritis.

Preparation for Class: Nursing Care of a Person with Acute Glomerulonephritis

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

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2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

408

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

410

Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Nephrotic Syndrome Directions: To complete this section, read the situation and answer the questions that follow. Doris Winter, 39 years of age, had been controlling her diabetes with insulin for 23 years. She was admitted to the hospital for evaluation of weight gain associated with dependent edema. She complained of puffy eyes and intermittent headaches that were moderately severe. She

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was tired and felt irritated because she needed to make arrangements for the care of her two children while she was hospitalized. Routine laboratory findings specific for nephrotic syndrome showed that she had proteinuria, hypoalbuminemia, and hyperlipidemia.

Questions 1. What are Mrs. Winter’s highest priority nursing diagnoses and why?

2. What are the recommended nursing interventions for Mrs. Winter?

3. How will the underlying pathophysiological process in Mrs. Winter’s case be managed?

Class Activity: Nursing Care of Individuals with Polycystic Kidney Disease Directions: To complete this section, read the situation and answer the questions that follow. Martin Miller, 40 years of age, was admitted to the hospital for evaluation of his increasingly troublesome symptoms, which began several years before. He had a distended abdomen, flank pain, and palpable kidneys that were tender when touched. He explained that he had hematuria, loss of appetite, nausea, and had vomited the previous evening. Mr. Miller said he was familiar with these symptoms because he remembered that his father had had an illness that required a nephrectomy when his father was in his early fifties. His father had been treated with analgesics and antibiotics until he died at 63 years of age.

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Questions 1. Complete the following statements of nursing diagnoses, which were identified as high priorities in his care: a. Fluid volume excess related to

b. Anticipatory grieving related to

c. Pain related to

d. High risk for ineffective individual coping related to

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2. What are the nursing interventions related to each?

3. How are the nursing diagnoses arranged in order of their priority?

Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Chronic Renal Failure and Hemodialysis Lisa Whitman, 44 years of age, was admitted to the hospital for a renal transplant. She was diagnosed with chronic renal failure (CRF) after being diagnosed with type 1 diabetes mellitus when she was seven years of age. Her diabetes was controlled on bid dosing of insulin until a few months before when she began complaining of increasing lethargy. Her systolic blood pressure was elevated to over 200 mm Hg. Her diminishing urine output and fluctuations in her blood sugar level, which had previously been under control, were worrisome signs of renal failure. During the previous winter she had begun complaining of flu-like symptoms. She experienced anorexia, nausea, and vomiting. Her serum glucose level rose over 800 mg/dL. Ms. Whitman was admitted to the hospital in diabetic ketoacidosis (DKA) and severe fluid overload. Her current urine output was approximately “2 cups” a day. Hemodialysis was begun: An arteriovenous (AV) shunt was created in her left forearm and she was maintained on a schedule of dialysis three times a week. Ms. Whitman’s condition was stabilized and she was discharged home on hemodialysis.

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Preparation for Class: Nursing Care of a Person with Chronic Renal Failure and Undergoing Hemodialysis

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

420

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

422

Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with End-Stage Renal Disease and Undergoing Continuous Ambulatory Peritoneal Dialysis Directions: To complete this section, read the situation and answer the questions that follow.

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Pam Kelly, an active 52-year-old woman, requested continuous ambulatory peritoneal dialysis (CAPD) as her treatment of choice for end-stage renal disease. She wanted to be able to have her treatment at home and control the procedure herself.

Questions 1. What are the principles of physics that guide the action of CAPD?

2. Compare hemodialysis and peritoneal dialysis in each of the following categories:

HEMODIALYSIS

PERITONEAL DIALYSIS

Number of treatments a week

Number of hours for a treatment

The semipermeable membrane is

Access for fluid and solute exchange

Care of the access

Complications

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Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Renal Calculi Phyllis Wagner, 66 years of age, noticed a dull, aching, constant pain in the lumbar region of her back. During the night, she noticed that the pain changed somewhat, radiating toward her groin. She was nauseated and vomited moderate amounts of stomach contents twice. In addition, she complained of diarrhea and intermittent abdominal pain. Mrs. Wagner felt the urge to void, but was only able to pass small amounts of blood-tinged urine. Her temperature was 101°F. Renal ultrasonography showed stones in the pelvis of her left kidney. A urine specimen was sent to the laboratory for culture and sensitivities. Her physician ordered meperidine hydrochloride (Demerol) 100 mg IM, q4–6h prn for relief of pain.

Preparation for Class: Nursing Care of a Person with Renal Calculi

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Men with Benign Prostatic Hypertrophy Directions: To complete this section, read the situation and answer the questions that follow. William Kendal, 79 years of age, was diagnosed with benign prostatic hypertrophy (BPH). For many years, his problem was asymptomatic. However, recently he began noticing intermittent hesitation and diminished force of his urinary stream once he began voiding. Even after

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he finished voiding, he felt that some urine remained in his bladder. In fact, he noticed that his underwear was moist following urination. When these symptoms were disrupting his usual daily activities and work schedules, he sought the advice of the nurse practitioner in his workplace. She referred him to a urologist, who, after assessment and evaluation, admitted him to the local hospital for surgery.

Questions 1. Are there additional symptoms of BPH that are not part of Mr. Kendal’s situation? And if so, what are they?

2. List various surgical treament options for someone with BPH.

3. Next to each of the surgical treatments, show how patient care is planned in the postoperative period of recovery.

4. Plan patient teaching for a man undergoing each of the surgical procedures for prostate removal.

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Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Urinary Incontinence Mrs. Worthington, 73 years of age, is 5 ft tall and weighs 150 lb. She raised three children and is the grandmother of eight children. She lives on the ground floor of an apartment house within walking distance of the grocery stores and restaurants in her town. Her children live within several miles of her home. Recently Mrs. Worthington noticed that small amounts of urine escaped each time she sneezed or coughed. This led to her needing to change clothing during the day because of the dampness in her perineal area. She felt that the main reason for her incontinence was that she could not reach the bathroom in time. After a complete evaluation of the problem by her doctor, she was told that she was infection-free. She was not taking any medications that would cause this problem. The nurse practitioner suggested weight reduction and an exercise intended to strengthen her pubococcygeal muscle. The nurse taught her to strengthen this muscle by stopping urine flow several times during voiding. Mrs. Worthington found this a difficult exercise in the beginning, but with time and persistence, she succeeded at it. The exercise and weight reduction were successful in reducing her incontinence. However, approximately three years later, the problem returned insidiously. Her physician suggested surgery to correct the problem and she consented.

Preparation for Class: Nursing Care of a Person with Urinary Incontinence

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

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9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Renal Transplantation Directions: To complete this section, read the situation and answer the questions that follow. Marge Young, 53 years of age, was maintained on hemodialysis for several years. She had discussed the prospect of renal transplant with the nurse and physician. When given the option, she agreed to transplant because she believed that a transplant would enable her to lead a

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normal life, whereas the three times weekly schedule of hemodialysis was limiting. Her name was placed on a list awaiting an appropriate kidney donor. Finally, she received a call from her physician’s office informing her that she could be admitted for renal transplantation.

Questions 1. Plan Mrs. Young’s preoperative care, including explanations of the assumptions you made for each of the interventions you planned.

2. What do you think Mrs. Young will be most concerned about in the postoperative period? Why?

3. What are the goals of care for Mrs. Young in the postoperative period?

4. What is a main therapy after a kidney transplant?

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5. How is kidney rejection identified?

6. How is renal function monitored?

7. What are the patient teaching considerations for the individual who is discharged home?

Class Activity: Nursing Care of Individuals with Urinary and Renal Dysfunction Directions: The following are common nursing diagnoses of adults with urinary and renal dysfunction. Relate each to a potential patient situation and identify appropriate interventions. Provide the rationale for using each intervention. 1. Fluid volume excess related to decreased renal blood flow.

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2. Fluid volume excess related to lack of information about dietary restriction.

3. Altered renal perfusion related to obstruction of renal blood supply.

4. Potential sexual dysfunction related to treatment or surgery.

5. High risk for body image disturbance related to weight gain and edema.

6. Social isolation related to fear of incontinence.

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7. Pain related to obstruction.

8. Altered patterns of urinary elimination related to incontinence.

9. Powerlessness related to perceived lack of control over the situation.

10. Sleep pattern disturbance related to interrupted sleep.

11. Potential for injury related to presence of catheter, shunt, and/or peritoneal access.

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Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: Are there similarities and differences in the onset of illness and the course of disease when the underlying problem is renal dysfunction?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions that you made initially that were later challenged because of new information or facts you learned?

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3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

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7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Angelucci, P. A. (1997). Caring for patients with benign prostatic hyperplasia. Nursing, 27(11), 54–55. Colangelo, R. M., Stillman, M. J., Kessler-Fogil, D., & Kessler-Hartnett, D. (1997). The role of exercise in rehabilitation for patients with end-stage renal disease. Rehabilitation Nursing, 22(6), 288–292, 302, 336. Dunetz, P. S. (1997). Coordinating care for dialysis patients. Nursing, 27(9 Hosp Nurs), 32hn1–2, 32hn4. Harries, F. (1996). Psychosocial care in end-stage renal failure. Professional Nurse, 12(2), 124–126. Kelly, M. (1996). Chronic renal failure. American Journal of Nursing, 96(1), 36–37. Turner, L. W., Faile, P., Wang M. Q., & Fu, Q. (1997). Dietary management in the patient with chronic renal failure. American Journal of Nursing, 97 (9),16B, 16D, 16F.

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Chapter

13 Neurological Problems

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Neurological Problems

Q

13

What symptoms do patients with many different neurological problems have in common?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Cerebrovascular Accident (Stroke) and Increased Intracranial Pressure Preparation for Class: Nursing Care of a Person with Cerebrovascular Accident (Stroke) and Increased Intracranial Pressure Class Activity: Nursing Care of Individuals with Cerebrovascular Accident (Stroke) Case Study: Spinal Cord Injury Preparation for Class: Nursing Care of a Person with Spinal Cord Injury Class Activity: Nursing Care of Individuals with Spinal Cord Injury Case Study: Infection (Meningitis) Preparation for Class: Nursing Care of a Person with Infection (Meningitis) Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Brain Tumor Preparation for Class: Nursing Care of a Person with Brain Tumor Class Activity: Nursing Care of Individuals with Brain Injury Critical Thinking Revisited Suggested Readings and Resources

Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with neurological dysfunction 456

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2. To apply principles related to the disruption of integration of muscular and neurological function when caring for individuals with neurological problems 3. To prepare patients for neurological procedures, treatments, and surgery 4. To plan care for the postoperative patient with neurological disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in the situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Cerebrovascular Accident (Stroke) and Increased Intracranial Pressure Thomas Mann, 54 years of age, was brought to the hospital by his wife, who found him unconscious on the floor beside his bed that morning. He was still unconscious when admitted to the unit. The right side of his body was flaccid and his face and mouth drooped on the right. In the emergency room his vital signs were: blood pressure (BP) 160/90 mm Hg; heart rate (HR)88 beats per minute; respiratory rate (RR) 16, deep and stertorious; temperature 99.8°F; and weight 225 lb. Funduscopic examination revealed papilledema. Mr. Mann’s wife explained that her husband owned and managed a restaurant. She said he had no previous medical problems and no known allergies. On the morning of admission, her husband was getting out of bed when he became unconscious and fell on the bedroom floor. Mr. Mann was admitted to the unit with a diagnosis of cerebrovascular accident (CVA). He did not respond to verbal or painful stimuli and his right-sided paralysis persisted. His

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vital signs on admission to the unit were: BP 170/80 mm Hg; HR 76 beats per minute; RR 12, deep and regular; and temperature 99.9°F rectally. His pupils were equal and reacted to light. Mr. Mann was placed on bed rest with head of his bed elevated 30 degrees. Oxygen was started at 5 L/min via nasal cannula. He was placed on NPO status and an IV infusion of dextrose 5 percent (D5)/0.45 normal saline solution at 1,000 mL was ordered to run for 24 hours. A dexamethasone (Decadron, SK-Dexamethasone) 10 mg IV was administered stat and followed with a dexamethasone 5 mg IV q4h. He also received 5,000 units of heparin stat and was begun on a continuous IV infusion of heparin at 1,000 units/h.

Preparation for Class: Nursing Care of a Person with Cerebrovascular Accident (Stroke) and Increased Intracranial Pressure

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

460

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Cerebrovascular Accident (Stroke) Directions: Make two lists that contrast the functional and mental abilities of someone with right versus left hemiplegia.

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RIGHT CVA (LEFT-SIDED HEMIPLEGIA)

LEFT CVA (RIGHT-SIDED HEMIPLEGIA)

Functional abilities

Mental abilities

Case Study: Spinal Cord Injury Lynda Fox, a 20-year-old college student, was brought to the emergency unit on a stretcher. Her head and neck were splinted to prevent movement during transportation in the ambulance. She was accompanied by a friend who explained that Ms. Fox fell from a deck where she had been sitting on a chair and landed on her feet. Ms. Fox suffered spinal cord trauma at the level of C5 and C6. Her respiratory functioning was poor and she was unable to move her extremities. Her neurological exam revealed that she had no reflexes below the level of injury. She had lost proprioception and sensation below her arms and was unresponsive to sensations of pain, pressure, touch, or temperature. She was drowsy but easily aroused, and had asked where she was and why everyone was buzzing around her. Ms. Fox was experiencing spinal shock and the effects of quadriplegia in relation to the functioning of all organ systems during the acute phase of injury.

Preparation for Class: Nursing Care of a Person with Spinal Cord Injury

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

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3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

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7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

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d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

470

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Spinal Cord Injury Directions: To complete this section, read the situation and answer the questions that follow. Several days after spinal shock resolved, Ms. Fox experienced a pounding headache, profuse diaphoresis, sudden rise in blood pressure, nasal congestion, and bradycardia.

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Questions 1. What complication of spinal cord injury do these symptoms indicate?

2. How should the complication be managed?

Ms. Fox began complaining of chest pain and shortness of breath. Thrombophlebitis with pulmonary embolism was suspected.

Questions 1. Why is the person with spinal cord injury at risk for these complications?

2. How are thrombophlebitis and pulmonary embolism treated?

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3. Orthostatic hypotension is a common complication of spinal cord injury above the level of T7. Why is this a common complication?

4. How is orthostatic hypotension managed by nurses?

As Ms. Fox began to recover, she started to act out her anger against her caregivers and her family.

Questions 1. What psychological responses will be observed in the young adult with spinal cord injury?

2. How can nurses intervene in order to assist with the various responses?

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Case Study: Infection (Meningitis) Jack Mohan, 38 years of age, developed symptoms of an upper respiratory infection that persisted long after he expected. His headache and fever were complicated by a stiff neck and memory impairment. His partner realized that his symptoms had gone beyond a common cold when he noted skin lesions that looked like a purplish rash. He took Mr. Mohan’s temperature orally and was alarmed to find that it was 102.6°F. His partner attributed Mr. Mohan’s lethargy and unresponsiveness to the elevated temperature. He called Mr. Mohan’s physician, who advised him to bring Mr. Mohan to the emergency room. In the emergency room, signs of meningeal irritation were confirmed with tests of nuchal rigidity and positive Kernig’s and Brudzinski signs.

Preparation for Class: Nursing Care of a Person with Infection (Meningitis)

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

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Given

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Expected/Normal Values

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b. Medications

Medications

Given

Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

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Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

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Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

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Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Brain Tumor Otherwise healthy, Elvin Smith, 68 years of age, experienced persistent dull frontal headaches, which interfered with his usual activities. His headaches occurred in the early morning and became more intense when he coughed or moved suddenly. He also experienced an episode of projectile vomiting not associated with food intake. The vomiting led to a doctor’s visit and the suspicion that he was having symptoms of increased intracranial pressure that may or may not be related to the presence of a brain tumor. While awaiting admission to the hospital for evaluation of his symptoms, Mr. Smith had a seizure, with movement localized on the left side of his body. On admission to the unit, he experienced confusion, speech dysfunction, and a gait disorder. His family was included in discussion about his options for treatment, specifically, surgical removal of the tumor.

Preparation for Class: Nursing Care of a Person with Brain Tumor

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

490

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Brain Injury Directions: To complete this section, read the situation and answer the questions that follow. Mike Glassman, an 18-year-old high school senior, suffered a severe head injury when the truck he was driving was struck by a bus. He was unresponsive at the scene of the accident

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and his pupils were fixed and dilated. His Glasgow Coma Scale score was 3. He was intubated to protect his airway and brought to the hospital, where he was admitted to the Intensive Care Unit. Once stabilized, he was subsequently transferred to the Neurological Observation Unit. He was awake and alert, but somewhat agitated. The physician’s orders included: • • • • • • • • • • • •

Elevating the head of bed at 30 degrees at all times Phenytoin sodium (Dilantin) Dexamethasone (Decadron, SK-Dexamethasone) Famotidine (Pepcid) Furosemide (Lasix) Lorazepam (Ativan) NPO TPN Vital signs and neurological checks q1h Contacting the physician for O2 saturation less than 97 percent Seizure precautions Fluid restriction

Questions 1. Explain the rationale for each of these orders.

2. Develop a plan of care for Mike by establishing immediate goals and expected outcomes of emergent care; identify and prioritize appropriate nursing interventions.

Mike was found having a seizure: his eyes were rolled back, both of his extremities were rigid, his neck was hyperextended, a frothy sputum was being expelled from his mouth, and he was incontinent of urine.

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Questions 1. Describe the nursing management of a patient having a seizure.

Mike’s neurological condition improved very slowly. His mother and father visited him constantly, while a neighbor stayed with his 13-year-old sister. It was apparent that his parents were not eating or sleeping well. His mother was distraught and asked you how long it will be before she “gets her son back.”

Questions 1. How would you respond to Mike’s mother?

2. What nursing interventions may be helpful to this family?

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Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination into your ability to think critically.

A. Answer the chapter opening question: What symptoms do patients with many different neurological problems have in common?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions that you made initially that were later challenged because of new information or facts you learned?

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3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

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7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Aron, L. J. (1996). Nurses’ changing roles in SCI care. Rehab Management. The Interdisciplinary Journal of Rehabilitation, 10(1), 67–69. Barch, C., Spilker, J., Bratina, P., Rapp, K., Daley, S., Donnarumma, R., Sailor, S., Braimah, J., & Kongable, G. (1997). Nursing management of acute complications following rt-PA acute ischemic stroke. Journal of Neuroscience Nursing, 29(6), 367–372, 397–401. Booth, B., & Warren, A. (1996). Stroke: The role of the nurse, Part 2. Nursing Times, 92(28 Prof Dev), 5–8. Cooper, M. (1996). Acute care of the spinal cord injured. AXON, 17(4), 76–80. Fowler, S., Durkee, C. M., & Webb, D. J. (1996). Rehabilitating stroke patients in the acute care setting. MEDSURG Nursing, 5(5), 327–32. Gilliand, E. R. (1996). The day treatment program: Meeting rehabilitation needs for SCI in the changing climate of health care reform. SCI Nursing, 13(1), 6–9. Hafsteinsdottir, T. B. (1996). Neurodevelopmental treatment: Application to nursing and effects on the hemiplegic stroke patient. Journal of Neuroscience Nursing, 28(1), 36–47. Hart, G. (1997). Evaluating research outcomes: Frequently selected nursing diagnoses for the rehabilitation client with stroke. Rehabilitation Nursing, 22(1), 46–47. Hayn, M. A., & Fisher, T. R. (1997). Stroke rehabilitation: Salvaging ability after the storm. Nursing, 27(3), 40–46, 48. Heinmann, A. W., Kirk, P., Hastie, B. A., Semik, P., Hamilton, B. B., Linacre, J. M., Wright, B. D., & Granger, C. (1997). Relationships between disability measures and nursing effort during medical rehabilitation for patients with traumatic brain and spinal cord injury. Archives of Physical Medicine & Rehabilitation, 78(2),143–149.

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Hinkle, J. L. (1997). New developments in managing transient ischemic attack and acute stroke. AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 8(2), 205–213. Kirkevold, M. (1997). The role of nursing in the rehabilitation of acute stroke patients: Toward a unified theoretical perspective. Advances in Nursing Science, 19(4), 55–64. Lucke, K. T. (1997). Knowledge acquisition and decision-making: Spinal cord injured individuals’ perceptions of caring during rehabilitation. SCI Nursing, 14(3), 87–95. Mitchell, G. J. (1996). Pretending: A way to get through the day. Nursing Science Quarterly, 9(3), 92–93. Moore, K. (1997). The role a spinal tap plays in meningitis diagnosis. RN, 60(8), 66. O’Hanlon-Nichols, T. (1996). Intracranial tumors. American Journal of Nursing, 96(Nurse Pract Extra Ed), 38–39. Phair, L. (1996). Dementia: The role of the nurse. Nursing Times, 92(25Prof Dev), 5–8. Pulsford, D. (1997). Therapeutic activities for people with dementia: What, why, and why not? Journal of Advanced Nursing, 26(4), 704–709. Williams, J., & Rees, J. (1997). The use of dementia care mapping as a method of evaluating care received by patients with dementia: An initiative to improve quality of life. Journal of Advanced Nursing, 25(2), 316–323. Woodrow, P. (1996). Approaches to the care of people with dementia. Professional Nurse, 11(8), 502–504. Wirtz, K. M., La Favor, K. M., & Ang, R. (1996). Managing chronic spinal cord injury: Issues in critical care. Critical Care Nurse, 16(4), 24–28, 30–32, 34–37.

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Chapter

14 Sensory Problems

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Sensory Problems

Q

14

When viewing a person holistically, why is the management of sensory problems important to the quality of a person’s life?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Closed-Angle Glaucoma Preparation for Class: Nursing Care of a Person with Closed-Angle Glaucoma Class Activity: Nursing Care of Individuals with Otosclerosis Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Open-Angle Glaucoma Preparation for Class: Nursing Care of a Person with Open-Angle Glaucoma Class Activity: Nursing Care of Individuals with Ménière’s Syndrome Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Cataracts Preparation for Class: Nursing Care of a Person with Cataracts Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations Case Study: Retinal Detachment Preparation for Class: Nursing Care of a Person with Retinal Detachment Critical Thinking Revisited Suggested Readings and Resources

Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with sensory dysfunction

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2. To apply principles related to disruptions of the ability to interact with the environment when caring for individuals with sensory problems 3. To prepare patients for sensory procedures, treatments, and surgery 4. To plan care for the postoperative patient with sensory problems

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in the situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care?

Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Closed-Angle Glaucoma Anne Hernandez, a 68-year-old photographer who had processed her own film in a dark room for many years, began to experience periods of blurred vision, frontal headache, and eye pain. In addition to these symptoms, she was puzzled by the halos she saw around white lights on the streets when she drove home late at night. She attributed these sensations to stress and fatigue. However, when the pain in her right eye became excruciating and unbearable, she sought help. Mrs. Hernandez was admitted to the hospital for relief of the pain. She experienced nausea and vomited, feeling very uncomfortable lying in bed. She could not keep her eyes open without squinting and turning her head away from the light to try to keep her eyes from tearing.

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Preparation for Class: Nursing Care of a Person with Closed-Angle Glaucoma

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

510

Given

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals with Otosclerosis (Conductive Hearing Loss) Directions: To complete this section, read the situation and answer the questions that follow. Mark Gordon, 53 years of age, realized that he was losing his hearing in the same way that his father had. He was told that his hearing loss needed to be evaluated. He asked what treatment options were available.

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Questions 1. Provide information about options for treating otosclerosis.

2. Describe nursing care for one of the options you describe.

3. Prepare a teaching plan to educate Mr. Gordon in the use of a hearing aid (in case he chooses that option).

4. Prepare a teaching plan to educate Mr. Gordon about stapedectomy, the surgical procedure to treat his hearing loss.

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Medical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Open-Angle Glaucoma Roseanne Moore, a 75-year-old retired plumber, had a history of type 2 diabetes mellitus. During a recent eye examination, she was told by the opthamologist that she had increased intraocular pressure (IOP). When telling the nurse her history, she explained that she noticed she was bumping into objects at home that were apparently in her way. She realized that she was experiencing visual changes that were so insidious in their onset that she was unaware until now that she even had them. In addition to an IOP of 30 mm Hg, the opthamologist noted optic cupping.

Preparation for Class: Nursing Care of a Person with Open-Angle Glaucoma

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

518

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

520

Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

522

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Class Activity: Nursing Care of Individuals with Ménière’s Syndrome Directions: To complete this section, read the situation and answer the questions that follow. Aline Craig, 73 years of age, experienced severe vertigo accompanied by nausea and vomiting. The vertigo made her feel light-headed, off-balance, and unsteady. During such episodes she had a loud, low-pitch roaring tinnitus, and she noticed that she had lost her hearing in her left ear.

Questions 1. Describe the nursing management of problems due to balance disorders by completing the nursing diagnostic statements below and identifying appropriate short- and long-term goals. Provide etiologies, a rationale, and several interventions for each of the following nursing diagnoses: High risk for injury

Social isolation

Self-care deficit

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Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Cataracts Maury Berry, 81 years of age, noted that the vision in his left eye was becoming progressively “weaker.” No pain was associated with his visual loss, but his eye appeared cloudy and his vision was blurred. He could not discriminate colors. Eventually it began to interfere with his bird carving, a hobby he took up after retirement and thoroughly enjoyed. His ophthalmologist suggested that he have the cataract surgically removed.

Preparation for Class: Nursing Care of a Person with Cataracts

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

528

Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

530

Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

532

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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533

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Case Study: Retinal Detachment James Gustav, 60 years of age, noticed flashes of light and “floaters” for several weeks. He was examined by his ophthalmologist, who scheduled him for regular visits to monitor his symptoms and their progression. When he experienced the onset of loss of vision in the upper part of his visual field, he was admitted to the hospital for treatment of retinal detachment. Mr. Gustav described his symptoms as like a “shade were being drawn over part of my visual field.” He did not complain of pain. However, he was very anxious about the meaning of his symptoms.

Preparation for Class: Nursing Care of a Person with Retinal Detachment

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

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11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

538

Given

Critical Thinking: An Interactive Tool for Learning Medical-Surgical Nursing

Expected/Normal Values

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b. Medications

Medications

Given

Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

540

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Critical Thinking: An Interactive Tool for Learning Medical-Surgical Nursing

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

542

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Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

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Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically.

A. Answer the chapter opening question: When viewing a person holistically, why is the management of sensory problems important to the quality of a person’s life?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions you made initially that were later challenged because of new information or facts you learned?

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3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

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7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Hooper, M. (1997). Prompt treatment for chemical eye injuries. Nursing Standard, 11(36), 40–43. McAllen, P. A. (1996). Managing Meniere’s disease. American Journal of Nursing, 96(6 Nurse Pract Extra Ed):16E-F, 16H.

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Chapter

15 Integumentary Problems

Copyright © 2001 F.A. Davis Company

Integumentary Problems

Q

15

Why are problems of the integumentary system sometimes treated as systemic problems?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Medical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Burns Preparation for Class: Nursing Care of a Person with Burns Class Activity: Nursing Care of Individuals in the Acute Phase of Burn Treatment Class Activity: Nursing Care of Individuals with Burns Needing Skin Grafts Class Activity: Nursing Care of Individuals Rehabilitating from the Treatment of Burns with Skin Grafting Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations Case Study: Malignant Melanoma Preparation for Class: Nursing Care of a Person with Malignant Melanoma Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations Class Activity: Nursing Care of Individuals with Malignancies of the Skin: Basal Cell and Squamous Cell Carcinoma Critical Thinking Revisited Suggested Readings and Resources

Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with integumentary dysfunction

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2. To apply principles related to the disruption of normal protective functions provided by the skin when caring for individuals with integumentary problems 3. To prepare patients for integumentary procedures, treatments, and surgery 4. To plan care for the postoperative patient with integumentary disease

The case studies in this chapter are divided into medical and surgical management of acute and chronic illnesses. Each Preparation for Class is organized to provide the knowledge base for each Classroom Activity. In both the acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about normal or healthy functioning and how are the assumptions different when someone has abnormal or unhealthy functioning (an illness or a disease)? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in the situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Medical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Burns Patrick Andrews, age 34, was starting the fire for the long-awaited neighborhood cookout when the accident happened. As he threw the match on the gasoline-soaked charcoal, the flames swept from the barbecue pit and caused a flash explosion. He was able to move away and roll on the ground to stop the burning but he felt enough pain to want professional care. It was already mid-afternoon when Mr. Andrews was brought to the emergency room of the large tertiary care center in the nearby city. Upon arrival, physical assessment revealed involvement of his face, neck, both hands, arms, upper thighs, and anterior chest. He had deep partial thickness injury to both hands, partial thickness burns on his right arm and half of his chest. All other areas had superficial thickness burns. It was estimated that less than 15 percent of his total body surface area (TBSA) was affected. He was conscious and oriented to person, time, and place. His pupils were equal and reacted to light. His respirations were 16, spontaneous and mildly labored. Mr. Andrews’s breath sounds were clear at the bases of the

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lung, but wheezes were noted in his anterior, upper chest. He had circumoral redness and swelling. His mouth was tinged with the effects of smoke but his oral pharynx was pink and moist. He had mild hoarseness, but did not complain of difficulty breathing. He had a positive gag reflex. His cardiovascular rate and rhythm were high normal. The hair on his head and his eyelashes was singed in a patchy pattern and one ear was burned. His eyes did not appear to be affected. His uninvolved skin was warm and dry. His distal pulses were positive and palpable with no jugular vein distention or peripheral edema. Mr. Andrews’s gastrointestinal and genitourinary systems were apparently not involved. His abdomen was soft and nontender. His last meal was before noon and he had not voided since then. His musculoskeletal system was unremarkable. Although he was in good condition on arrival, he was kept in the emergency room for monitoring in view of his respiratory status. His hands, wrists, chest, and upper thighs were dressed with silvadene and an intravenous was started. His wife, who had stayed at home with their two preschool-aged children was called to come to the emergency room and Mr. Andrews was prepared for admission and treatment of impending shock. As you plan his nursing care, limit your preparation for class to the emergent period.

Preparation for Class: Nursing Care of a Person with Burns

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

Critical Thinking: An Interactive Tool for Learning Medical-Surgical Nursing

551

Copyright © 2001 F.A. Davis Company

11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

552

Etiology

Defining Characteristics

Critical Thinking: An Interactive Tool for Learning Medical-Surgical Nursing

Method of Validation

Copyright © 2001 F.A. Davis Company

5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

Critical Thinking: An Interactive Tool for Learning Medical-Surgical Nursing

553

Copyright © 2001 F.A. Davis Company

b. Medications

Medications

554

Given

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Expected

Copyright © 2001 F.A. Davis Company

c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

Critical Thinking: An Interactive Tool for Learning Medical-Surgical Nursing

555

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7. Nursing Interventions

Nursing Diagnosis (Retained)

556

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity: Nursing Care of Individuals in the Acute Phase of Burn Treatment Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Mr. Andrews completed the emergent phase of his illness without incident and entered the acute phase.

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Questions 1. What does Mr. Andrews’s nursing care involve in relation to each body system during the acute phase of his illness?

2. How are the nursing interventions prioritized in relation to the care described above?

3. What patient education is indicated for Mr. Andrews and his wife?

Class Activity: Nursing Care of Individuals with Burns Needing Skin Grafts Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Mr. Andrews’s burns required skin grafting to his chest, hands, and arms.

Questions 1. What types of grafts are available for covering wounds of the chest, hands, and arms?

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2. How are grafts applied?

3. If autografts are used, what are the donor site selection criteria?

4. What care is recommended for donor sites when autografts are used?

5. What are the priorities for patient education when grafts are applied to wounds?

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Class Activity: Nursing Care of Individuals Rehabilitating From the Treatment of Burns with Skin Grafting Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Mr. Andrews did well enough during the acute phase of recovery that he was prepared for rehabilitation.

Questions 1. What are the nursing concerns related to the physical aspects of rehabilitation in this final stage of Mr. Andrews’s recovery?

2. How will the nurses determine what attention needs to be given to the psychosocial aspects of Mr. Andrews’s rehabilitation?

Surgical Nursing Care: Practice in Critical Thinking Acute Care Situations

Case Study: Malignant Melanoma Katie McAndy, a 33-year-old woman with red hair and blue eyes, had a lesion with irregular, elevated edges. Her friend, a nurse, was the one who first noticed it and was extremely concerned because it was palpable and presented a combination of colors—including black, brown, and gray in some areas. She advised Ms. McAndy to visit a dermatologist for a biopsy, which she did. The biopsy revealed that the lesion was a superficial spreading melanoma. Ms. McAndy was admitted to the hospital for surgical removal of the lesion.

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Preparation for Class: Nursing Care of a Person with Malignant Melanoma

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

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3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Surgical Nursing Care: Practice in Critical Thinking Chronic Care Situations

Class Activity: Nursing Care of Individuals with Malignancies of the Skin: Basal Cell and Squamous Cell Carcinoma Directions: To complete this section, read the two situations and answer the questions that follow.

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Lorraine Nelson had the same fair skin and blue eyes as many other Swedish women. She liked to be out in the sun during the summer, but she rarely, if ever, tanned. After years of sun exposure without protection, she noted a small, waxy nodule with pearly borders and telangiectatic vessels on the side of her nose. She was able to cover the area with makeup, but eventually she sought the advise of her physician about it. Jane Winston noticed that an area on her thigh that was previously irritated had changed somewhat. It appeared rough, thickened, and scaly. In addition, it began bleeding unexpectedly. She was concerned that the area might become infected and made an appointment to have her nurse practitioner evaluate the lesion.

Questions 1. Is the fact that lesions appear on skin that has not been exposed to the sun or skin that has been sun exposed skin relevant to the type of cancer the women have?

2. How are skin lesions diagnosed?

3. What are the treatment modalities for basal cell carcinoma?

4. What are the criteria will Lorraine use for choosing a treatment modality?

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5. What are the priorities for patient education in relation to skin cancer prevention?

Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: Why are problems of the integumentary system sometimes treated as systemic problems?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

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2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions you made initially that were later challenged because of new information or facts you learned?

3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

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6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

7. Did you notice whether the concepts, theories and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

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Suggested Readings and Resources Anonymous. (1996). Wound care handbook. Nursing, 26(8), 42–45. Anthony, D. M. (1996). The formation of pressure sores and the role of nursing care. Journal of Wound Care, 5(4), 192–194. Barr, J. E., & Cuzzell, J. (1996). Wound care clinical pathway: A conceptual model. Ostomy Wound Management, 42(7), 18–24, 26. Carrougher, G. J. (1997). Management of fluid and electrolyte balance in thermal injuries: Implications for perioperative nursing practice. Seminars in Perioperative Nursing, 6(4), 201–209. Crookes, M. (1997). Making a fresh start. Nursing Times, 93(23), 68, 70, 72. Edwards, K. (1996). Burns. Emergency Nurse, 4(3), 9–15, insert 1p. Finlayson, E., & McArthur, E. (1997). Treatment of unhealed burns with severe complications. Journal of Wound Care, 6(6), 260–262. Fowler, A. (1996). Superficial partial thickness burns of the hands. Nursing Standard, 11(6), 56, 59, 61. Greenfield, E., & Jordan, B. (1996). Advances in burn wound care. Critical Care Nursing Clinics of North America, 8(2), 203–215. Hess, C. T. (1998). Wound care: Treating a stage 3 pressure ulcer. Nursing, 28(2), 20. Hess, C. T. (1998). Wound care: Keeping tabs on a pressure ulcer. Nursing, 28(1), 18. Knight, C. L. (1996). The chronic wound management decision tree: A tool for long-term care nurses. Journal of Wound Care, 23(2), 92–99. Lamond, D., & Farnell, S. (1998). The treatment of pressure sores: A comparison of novice and expert nurses’ knowledge, information use, and decision accuracy. Journal of Advanced Nursing, 27(2), 280–286. Lehman, C. A. (1998). Preventing pressure ulcers with something old and SUMPINU-acronym. Nursing, 28(6). Poston, J. (1996). Sharp debridement of devitalized tissue: The nurse’s role. British Journal of Nursing, 5(11), 655–656, 658–662. Stevens, P. (1996). Management of traumatic wounds: A nursing perspective. World Council of Enterostomal Therapists Journal, 16(2), 10–11, 14–16. Stotts, N. A., & Deitrich, C. E. (1997). Care of patients with leg ulcers: A nursing perspective. Geriatric Nursing-American Journal of Care for the Aging, 18(6), 255–259. Sulton, L. L. (1997). Postoperative nursing care of the burn patient. Seminars in Perioperative Nursing, 6(4), 236–241. White, C. (1997). Wound cleansing: Guidelines for A&E staff. Nursing Times, 93(2), 46, 48. Wickham, N. (1997). Pressure area care in A&E, Part 1. Emergency Nurse, 5(3), 26–31. Wilson, R. E. (1996). Care of the burn patient. Ostomy Wound Management, 42(8), 16–18, 20–22, 24–26. Young, G. (1996). A district perspective—district nursing—wound care. Nursing Times, 92(39 J Wound Care Nurs), 76, 78.

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UNIT

III Critical Thinking: Complex Patient Problems

Chapter 16

Complex Nursing Care Situations: Implications of Potential Trajectories of Illnesses

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Chapter

16 Complex Nursing Care Situations Implications of Potential Trajectories of Illnesses

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Complex Nursing Care Situations

Q

16

How does planning care for patients with exacerbations of complex chronic conditions differ from the care of patients with acute dysfunction limited to a single physiological system?

Chapter Outline Chapter Outline Learning Outcome Goals Introduction Complex Nursing Care Situations Case Study 1 Preparation for Class Class Activity Case Study 2 Preparation for Class Class Activity Case Study 3 Preparation for Class Class Activity Critical Thinking Revisited Suggested Readings and Resources

Learning Outcome Goals 1. To use reasoning skills to learn about the care of patients with complex, chronic conditions 2. To apply principles related to the disruption of multiple body systems when caring for individuals with complex, chronic conditions 580

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3. To prepare patients with complex, chronic conditions for procedures, treatments, and surgery 4. To plan care for postoperative patients with complex, chronic conditions

The case studies in this chapter are divided into medical and surgical management of the acute exacerbation of chronic illnesses. Each Preparation for Class is organized to provide background knowledge for each Classroom Activity. In both acute and chronic care situations, your knowledge of anatomy, physiology, and pathophysiology is the basis for learning about the care of individuals with these problems, and you are being asked to apply intellectual standards to the elements of reasoning when learning about the care of these individuals. Your thinking in relation to each of the situations may be in response to such questions as: What assumptions have been made about behaviors that lead to chronic illness and how are the assumptions different when illness is not due to unhealthy habits? Do you have all the facts necessary to begin to plan the care of someone with problems similar to those of the individual in the case study? Are there principles and theories that can be applied in this situation? What is the purpose of thinking about this situation? Are you aware of your point of view in the situation and why you have that point of view? Are you aware of the consequences of the interventions you are recommending as you plan the care? Complex Nursing Care Situation

Case Study: 1 Martha Hitchcock is a 76-year-old woman who lived alone in an apartment after the death of her elderly sister. Martha was her sister’s caretaker until her sister died, although she herself had many physical problems. She was diagnosed with type 2 diabetes mellitus, which was treated with oral hypoglycemic agents, NPH, and regular insulin. In addition, she took nonsteroidal anti-inflammatory drugs (NSAIDs) for treatment of arthritis of her hips and knees for many years. Her physical condition remained stable until one morning, while getting out of the shower, she tripped and fell. She felt excruciating pain in her right thigh and was unable to move from the floor where she had fallen. When her friend came by a half an hour later, she found Martha on the floor and called 911. The emergency team splinted and immobilized Martha’s leg before taking her to the emergency room of the local medical center. On admission to the emergency room, her blood pressure (BP) was 195/105 mm Hg, her temperature was 101°F, her heart rate (HR) was 100 beats per minute, her respiratory rate (RR) was 28, and her blood glucose level was 365 mg/dL. Chest auscultation indicated crackles in the bases of both lungs. She was medicated for pain. Skeletal x-rays showed a spiral fracture of her femur and her chest x-ray showed fluid accumulations. She was transferred to an orthopedic unit for stabilization of her hip fracture and to plan her care in preparation for surgical treatment. Martha arrived on the unit accompanied by her friend, who said that she would stay until Martha was settled and plans for her care had been made. Martha was sleepy and uncom-

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fortable trying to move around in her bed. While the nurses were admitting Martha to the unit, it became clear to them that she was confused and disoriented. Her friend explained that this was not at all like Martha. The physician applied traction to her femur until she could be scheduled for an open reduction with internal fixation (ORIF) of her femur.

Preparation for Class

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

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2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

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c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

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Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Martha’s confusion increased in the hours following her admission to the unit. However, she was scheduled for surgery the next day.

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Questions 1. How will the nurse manage Martha’s confusion?

2. What plans will the nurse make to manage the underlying problems related to Martha’s diabetes and her arthritis?

3. What specific plans will be made to prepare Martha for surgery?

Class Activity Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Martha returned from the recovery room following uncomplicated ORIF. She was still experiencing the effects of the spinal anesthesia and pain medications administered in the recovery room.

Questions 1. What are the highest priority concerns, when Martha returns to the orthopedic unit, in relation to her confusion, diabetes, and arthritis?

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2. Address each of the concerns and plan her care in relation to each of them.

3. What assessments will nurses need to make to anticipate and avoid the common complications of musculoskeletal injury and surgical repair?

4. Address each assessment by planning Martha’s care based on the assumption that she experiences each of these complications.

Class Activity Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Martha recovered from her surgery in a timely way. Her confusion cleared in the days following her surgery as the medications she was given for pain and to induce sleep were tapered off. She made good progress with physical therapy and was ambulating with a walker and ready for discharge to a long-term care center for subacute care and completion of rehabilitation.

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Questions 1. What are the most important assessment data to provide the facility in relation to Martha’s care?

2. How will Martha be prepared for transfer to the new facility?

3. What specific teaching will Martha need as she is moved to the new facility, assuming that she will be discharged home after her rehabilitation?

Complex Nursing Care Situation

Case Study 2 Joanne Wilensky, 63 years of age, was diagnosed with hypothyroidism and osteoarthritis. For several years, her thyroid dysfunction was controlled with a daily thyroid supplement and her arthritis was treated with NSAIDs, which provided some relief. However, she began experiencing gastritis and her kidney function tests revealed elevated blood urea nitrogen (BUN) and creatinine levels signifying renal impairment. The use of steroids was not recommended. The severe pain in both of her hips with motion and weight-bearing was disabling, causing her to limit movement drastically. Her nurse practitioner (NP) advised her to lose weight in an attempt to reduce the strain of her 270 lb on her musculoskeletal system. Based on her dietary history, the NP worked with Ms. Wilensky to plan her diet. Together, they decided to limit her

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caloric consumption by reducing her fat and carbohydrate intake and maintaining her protein intake at its usual level. Over the following six months, Ms. Wilensky lost a total of 60 lb, but her pain and increasing immobility persisted. Her NP referred her to an orthopedic surgeon for consultation and recommendations regarding surgical management of her hip pain. After the appropriate tests and x-rays, the orthopedic surgeon met with her to discuss bilateral total hip replacement. Ms. Wilensky agreed to the surgery and planned to have her left hip replaced followed by right hip replacement when her recovery was complete from the first surgery. Ms. Wilensky had a smooth course preoperatively and in the early postoperative period. She was transferred to the intensive care unit (ICU) from the recovery room several hours after the surgery. In the hours that followed, the nurses noted the insidious onset of nausea and agitated behavior. The nurses monitored her status, which indicated that she was tachycardic, hypertensive, and diaphoretic. She became delirious and disoriented. Her history indicated that she regularly consumed alcohol preoperatively. Her record indicated that her surgeon had advised her not to drink for several days before being admitted for the surgery. However, the nurses questioned whether she had abstained and they suspected that Ms. Wilensky was showing symptoms of alcohol withdrawal. Ms. Wilensky began having tremors and was hallucinating uncontrollably.

Preparation for Class Directions: The aspects of patient care related to musculoskeletal surgery were addressed in previous chapters. Preparation for class should focus on the postoperative situation in which Ms. Wilensky is withdrawing from alcohol use.

Preparation for Class Guidelines 1. Literature Review

2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

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4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

7. Self-perception–self-control

8. Role-relationship

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9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

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Etiology

Defining Characteristics

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Method of Validation

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5. Clinical Data a. Lab values

Lab Values

Given

Expected/Normal Values

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b. Medications

Medications

598

Given

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Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Ms. Wilensky’s withdrawal from alcohol was eased with the use of medications.

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Questions 1. What assessments are indicated in the period following immediate withdrawal from alcohol?

2. What are the priorities of care for Ms. Wilensky in that period?

3. What measures will the nurses institute and why?

4. How will the nurses know their actions were effective?

5. What education is needed to prevent complications in the postoperative period once her delirium tremors (DTs) were controlled?

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Complex Nursing Care Situation

Case Study 3 Lawrence Price is a divorced man, 54 years of age, with a pack-a-week history of cigarette smoking. He smoked from 9 to 48 years of age—until it was no longer possible because his cough was relentless and often nonproductive. He was experiencing increasing dyspnea, and he was using his accessory muscles to breathe. His family pleaded with him to quit. When his daughters were teenagers, they learned about the effects of smoking in school and feared that their father would die of lung cancer. Through the years, he was treated for pneumonia, chronic bronchitis, and emphysema. All of these problems persisted. Later he was diagnosed with polycythemia, but not until the diagnosis of cor pulmonale was made did he finally quit. He was increasingly fatigued and weak and had considerable dependent edema. He appeared overweight from the edema and his skin was a dusky color. His right-sided heart failure was kept under control with diuretics and by moderating his fluid intake. These measures were effective until he contracted a respiratory virus infection. One night Mr. Price experienced extreme restlessness, apprehension, and such labored breathing that his daughter brought him into the emergency room at 3:00 A.M. His daughter was told that her father’s heart failure had become more severe, that both the right and left sides of his heart were involved and his lungs were filling with fluid. The physician explained that he was in pulmonary edema. He was placed on a cardiac monitor, and intubated to improve his ability to oxygenate and to remove secretions that he was unable to cough up effectively. He was treated with oxygen, morphine, bronchodilators, and vasodilators. A phlebotomy was considered unless his condition improved immediately.

Preparation for Class

Preparation for Class Guidelines 1. Literature Review

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2. Facts Underline the facts in the situation

3. Nursing Care Issues and Concerns (include those related to aging)

4. Assessment and Tentative Nursing Diagnoses a. Functional health patterns

1. Health perception–health management

2. Nutritional-metabolic function

3. Elimination

4. Activity-exercise

5. Sleep-rest

6. Cognitive-perceptual function

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7. Self-perception–self-control

8. Role-relationship

9. Sexuality-reproductive function

10. Coping–stress tolerance

11. Value-belief

b. Cultural aspects

c. Missing information

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d. Tentative nursing diagnoses

Tentative Nursing Diagnoses

Etiology

Defining Characteristics

Method of Validation

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5. Clinical Data a. Lab values

Lab Values

608

Given

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Expected/Normal Values

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b. Medications

Medications

Given

Expected

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c. Nutrition

d. Environment

e. Discussion of logical fit between subjective and objective information

6. Decision Making

Nursing Diagnosis (List All Tentative)

610

Level of Priority (Provide Rationale)

Retain or Eliminate (Provide Rationale)

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Expected Outcome

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7. Nursing Interventions

Nursing Diagnosis (Retained)

Nursing Interventions

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8. Evaluation of Outcomes

Nursing Diagnosis (Retained)

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Outcome of Care

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9. Healthcare Professionals and Medical Care Needed

10. Additional Questions about This Patient’s Nursing Care

Class Activity Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Because his condition was critical, Mr. Price was transferred to the cardiac care unit (CCU) for monitoring of his pulmonary and cardiac status.

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Questions 1. What are the priorities of care for Mr. Price?

2. What are the nursing priorities of care, if they are different from those identified above?

3. What are the expected outcomes of Mr. Price’s care in the first few hours after his transfer to the CCU?

4. What is the long-term expected outcome that signifies stabilization of Mr. Price’s condition?

5. How will Mr. Price be prepared to learn about his care?

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6. Are there discharge plans that can be anticipated? How can the nurse begin planning for discharge while Mr. Price is still in the CCU?

Class Activity Directions: To complete this section, read the following continuation of the situation and answer the questions that follow. Mr. Price’s condition stabilized in the CCU and he was transferred to the cardiac step down unit. His daughter was determined to have him return to live with her family. She was visiting one day when she asked the nurse what they could expect in terms of her father’s care and prognosis.

Questions 1. How will you respond to her?

Class Activity Mr. Price’s daughter is interested in learning more about the underlying pathophysiology of her father’s problem. She explains that she smokes and is concerned that she will also become ill.

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Questions 1. What actions will the nurse initiate?

Class Activity Mr. Price will need to take a diuretic, a bronchodilator, a vasodilator, and an antibiotic after discharge.

Questions 1. What basic patient education will be required for someone taking medications in those categories of drugs?

2. How will the nurse proceed with patient education?

3. How will the nurse evaluate his learning in relation to medication administration?

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4. How will the nurse evaluate his learning in relation to managing his chronic illness?

Critical Thinking Revisited In this section, you will perfom a self-assessment and self-examination of your ability to think critically. A. Answer the chapter opening question: How does planning care for patients with exacerbations of complex chronic conditions differ from the care of patients with acute dysfunction limited to a single physiological system?

B. Answer the following questions: 1. Was the purpose or goal of providing nursing care for the individuals in the situations logical and clearly understood?

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2. Describe the assumptions you made about the individuals in the situations, including older adults, before you began this assignment. Were they accurate and realistic? Were there assumptions that you made initially that were later challenged because of new information or facts you learned?

3. When formulating nursing diagnoses, identifying interventions, and evaluating outcomes, was the information you focused on related clearly and precisely to the individuals in the situations? Was there information missing that may have assisted you to be more complete, accurate, and precise?

4. Did you identify inferences you made when assessing, diagnosing, planning, and evaluating nursing care that were consistent with, and relevant to, the priorities of care in each of the situations?

5. Was your point of view broad enough, logical, and realistic when considering each situation in the case studies?

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6. Was the problem to be solved or the question at issue usually identified broadly enough, logical, and relevant?

7. Did you notice whether the concepts, theories, and principles you used to plan care for each of the individuals in the situations were clear and relevant?

8. Were the implications for identifying missing information and the consequences of nursing intervention relevant to the care of each of the individuals in the situations?

Suggested Readings and Resources Engstrom, C., Persson L., Larsson S., & Sullivan, M. (1999). Long-term effects of a pulmonary rehabilitation programme in outpatients with chronic obstructive disease: A randomized controlled study. Scandinavian Journal of Rehabilitation Medicine, 31(4), 207–213.

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Lewis, A. M. (1999). Respiratory emergency! Nursing, 29(8), 62–64. Miller, V. G. (1999). Health outcomes for persons with diabetes. Nurse Practitioner Forum, 10(4), 201–203. Myrick, H., & Anton, R. F. (1998). Treatment of alcohol withdrawal. Alcohol Health & Research World, 22(1), 38–43. Ondus, K. A., Hujer M. E., Mann A. E., & Mion, L. C. (1999). Substance abuse and the hospitalized elderly. Orthopedic Nursing, 18(4), 27–36. Perri, J. F., Bishop F. M., & Amundsen, D. E. (1998). The problem patient: Pulmonary edema in a young man after postoperative extubation. Hospital Practice, 33(3), 95, 99–100. Powell, A. H. (1999). Alcohol withdrawal in critical care. DCCN—Dimensions of Critical Care Nursing, 18(6), 24–28. Quittan, M., Sturm, B., Wiesinger, G. F., Pacher, R., & Fialka-Moser, V. (1999). Quality of life in patients with chronic heart failure: A randomized controlled trial for changes induced by a regular exercise program. Scandinavian Journal of Rehabilitation Medicine, 31(4), 223–228. Saitz, R. (1999). Introduction to alcohol withdrawal. Alcohol Health & Research World, 22(1), 5–12. Segatore, M., Adams, D., & Lange, S. (1999). Managing alcohol withdrawal in the acutely ill hospitalized adult. Journal of Neuroscience Nursing, 31(3), 129–141. Seigh, P. J. (1999). Emergency! Pulmonary edema: Will you have to intubate? American Journal of Nursing, 99(1), 43. Trevisan, L. A., Boutros, N., Petrakis, I. L., & Krystal, J. H. (1998). Complications of alcohol withdrawal: Pathophysiological insights. Alcohol Health & Research World, 22(1), 61–66. Van Orden, W. C. (1998). Emergency! Acute pulmonary edema. RN, 61(1), 36–41. Warren-Boulton, E., Greenberg, R., Lising, M., & Gallivan, J. (1999). Nurse Practitioner, 24(12), 14, 16, 19–20.

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Index Page numbers followed by “t” indicate tables. Abdominal distention, in cirrhosis, 191 in polycystic kidney disease, 415 Acquired immunodeficiency syndrome, case study of, 329 Preparation for Class Guidelines in, 329–338 Acromegaly, class activity in, 263–264 Activity-exercise pattern, in Functional Health Patterns, 11t, 14t in Preparation for Class Guidelines, case study of, 18–19 Acute glomerulonephritis, case study of, 405–406 Preparation for Class Guidelines in, 406–414 Acyclovir, in acquired immunodeficiency syndrome, 329 Addison’s disease, class activity in, 260–263 Adenocarcinoma, bowel, case study of, 164 Adrenocortical disease, case study of, 251 Preparation for Class Guidelines in, 252–260 Adrenocortical insufficiency, class activity in, 260–263 Adult respiratory distress syndrome, case study of, 41 class activity in, 41–42 Aging, case study of, 16–25 in Preparation for Class Guidelines, 10, 11t–12t, 12–15 AIDS See Acquired immunodeficiency syndrome Airway limitation, chronic, case study of, 43 Preparation for Class Guidelines in, 43–52

Alcoholism, in cirrhosis, 191–192 in complex nursing care situation, 594 Amphogel, in ulcer disease, 144 Amputation, case study of, 387–388 class activity in, 396–397 Preparation for Class Guidelines in, 388–396 Anastomosis, ileoanal, in ulcerative colitis, 174 Anemia, iron deficiency, class activity in, 137 in irritable bowel disease, 153 sickle cell, case study of, 127 Preparation for Class Guidelines in, 128–136 Angioplasty, percutaneous transluminal coronary, case study of, 90 Preparation for Class Guidelines in, 90–98 Anorexia, in chronic renal failure, 417 Antacids, in ulcer disease, 144 Antibiotics, in osteomyelitis, 357 in pneumonia, 41 Antithrombolytic therapy, class activity in, 79 Arterial blood gases, in asthma, 53 in chronic obstructive lung disease, 43 Arteriovenous shunt, in hemodialysis, 417 Arthritis, in complex nursing care situations, 581, 593–594 Preparation for Class Guidelines in, 594–602 rheumatoid, case studies of, 319, 339–340 class activity in, 348–350 Preparation for Class Guidelines in, 320–328, 340–348

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Aspartate aminotransferase, normal values of, 20t in Preparation for Class Guidelines, case study of, 20 Aspirin, in systemic lupus erythematosus, 339 Assessment, in Preparation for Class Guidelines, 11t, 13 case study of, 18–20 Assumptions, in Paul’s theoretical framework of critical thinking, 6–7 Asthma, case study of, 53 questions on, 53–54 Atrial dysrhythmias, class activities in, 99–101 Atrial fibrillation, case study of, class activities in, 99–101 Auditory disorders See Sensory problems; specific conditions

Barium enema, in irritable bowel disease, 153 Basal cell carcinoma, class activity in, 570–572 Below-knee amputation, class activity in, 396–397 Benign prostatic hypertrophy, class activity in, 436–437 Biliary problems, 189–226 cholecystitis as, class activity in, 222–223 cholelithiasis as, case study of, 212 class activity in, 221 Preparation for Class Guidelines in, 212–221 critical thinking review of, 224–226 learning outcome goals in, 191 Bilirubin, in sickle cell anemia, 127 Bleeding esophageal varices, in cirrhosis, 200–201 Bleeding gums, in leukemia, 117 in thrombocytopenia, 137 Blood disease See Hematologic problems; specific conditions Blood gases, arterial, 43, 53 Blood glucose concentrations, in type 1 diabetes mellitus, 239 in type 2 diabetes mellitus, 230 Blood pressure, in congestive heart failure, case study of, 70 in hypertension, case study of, 112 in myocardial ischemia, case study of, 70 Bone marrow transplantation, in leukemia, class activity in, 127 Bone necrosis, in osteomyelitis, 357 Bowel disease, irritable, case study of, 153 class activity in, 162–163 Preparation for Class Guidelines in, 153–162 malignant, case study of, 163–164 class activity in, 173 Preparation for Class Guidelines in, 164–172 Brain tumor, case study of, 488 Preparation for Class Guidelines in, 488–496 Breast cancer, case study of, 292 Preparation for Class Guidelines in, 292–301

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Breathing disorders See Respiratory problems; specific conditions Bronchodilators, in asthma, 53 Burn injury, case study of, 549–550 class activities in, in acute phase, 558–559 skin grafting and, 559–561 Preparation for Class Guidelines in, 549–558 Bypass grafting, coronary artery, case study of, 90 Preparation for Class Guidelines in, 90–98 femoral-popliteal, amputation after, 388 case study of, 103 class activity in, 112 Preparation for Class Guidelines in, 103–111

Calcium, normal values of, 20t in Preparation for Class Guidelines, 20 Calculi, renal, case study of, 428 Preparation for Class Guidelines in, 428–436 Cancer, bowel, case study of, 163–164 class activity in, 173 Preparation for Class Guidelines in, 164–172 endometrial, case study of, 281 laryngeal, class activity in, 64 lung, case study of, 54 Preparation for Class Guidelines in, 54–63 ovarian, class activity in, 301–303 skin, case study of, 561 class activity in, 570–572 Preparation for Class Guidelines in, 562–570 testicular, case study of, 303 class activity in, 313 Preparation for Class Guidelines in, 303–312 Carcinoma, basal cell, class activity in, 570–572 squamous cell, class activity in, 570–572 Cardiac dysrhythmias, class activities in, 99–102 Cardiovascular problems, 67–114 case studies of, of angioplasty and bypass surgery, 90 of congestive heart failure, 79, 89 of myocardial ischemia, 69–70 of peripheral vascular disease, 102–103 class activities in, in dysrhythmias, 99–102 in femoral-popliteal bypass, 112 in hypertension, 112 in pulmonary edema, 89 critical thinking review of, 113–114 learning outcome goals in, 69 Preparation for Class Guidelines in, in angioplasty and bypass graft, 90–98 in congestive heart failure, 80–88 in myocardial ischemia, 70–78 in peripheral vascular disease, 102–111 Case studies, biliary, of cholelithiasis, 212 cardiovascular, of congestive heart failure, 79, 89 of coronary artery bypass grafting, 90 of myocardial ischemia, 60–70

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of percutaneous transluminal coronary angioplasty, 90 of peripheral vascular disease, 102–103 class activities and, 23–25 complex, of diabetes, arthritis, and trauma as, 581–582 of dyspnea and heart failure, 604 of hypothyroidism and osteoarthritis, 593–594 critical thinking and, 5 endocrine, adrenocortical disease as, 251 hyperthyroidism as, 240–241 type 2 diabetes mellitus as, 229–230 gastrointestinal, of cancer of the bowel, 163–164 of irritable bowel disease, 153 of ulcer disease, 143–144 of ulcerative colitis, 174 hematologic, of bone marrow transplantation, 127 of iron deficiency anemia, 137 of leukemia, 117, 127 of sickle cell anemia, 127 of thrombocytopenia, 137 hepatic, of cirrhosis, 191–192 of esophageal varices, 200–201 immunologic, of acquired immunodeficiency syndrome, 329 of rheumatoid arthritis, 319, 339–340 integumentary, of burn injury, 549 of malignant melanoma, 561 musculoskeletal, of amputation, 387–388 of osteomyelitis, 357 of osteoporosis, 367–368 of trauma, 377 neurological, of brain tumor, 488 of cerebrovascular accident, 457–458 of meningitis, 479 of spinal cord injury, 467 pancreatic, pancreatitis as, 203 Preparation for Class Guidelines and, 15–23, 20t, 22t renal, of acute glomerulonephritis, 405–406 of chronic renal failure and hemodialysis, 417 of renal calculi, 428 of urinary incontinence, 438 reproductive, of breast cancer, 292 of endometrial cancer, 281 of pelvic inflammatory disease, 271 of testicular cancer, 303 respiratory, of adult respiratory distress syndrome, 41 of asthma, 53 of chronic obstructive pulmonary disease, 43 of laryngectomy, 64 of lung cancer, 54 of pneumonia, 31, 41 sensory, of cataracts, 526 of closed-angle glaucoma, 506 of open-angle glaucoma, 516 of retinal detachment, 535

Cataracts, case study of, 526 Preparation for Class Guidelines in, 526–534 Cerebrovascular accident, case study of, 457 class activity in, 466–467 Preparation for Class Guidelines in, 458–466 Chemotherapy, in leukemia, 117 Chest pain, in myocardial ischemia, 69–70 Chest radiography, in pneumonia, 31, 41 Cholecystectomy, pancreatitis after, case study of, 203 Cholecystitis, class activity in, 222–223 Cholelithiasis, case study of, 212 class activity in, 221 preparation for Class Guidelines in, 212–221 Chronic airway limitation, case study of, 43 Preparation for Class Guidelines in, 43–52 Chronic obstructive pulmonary disease, case study of, 43 Preparation for Class Guidelines in, 43–52 Chronic renal failure, hemodialysis and, case study of, 417 Preparation for Class Guidelines in, 418–426 Cigarette smoking, in chronic obstructive lung disease, 43 in cirrhosis, 192 in complex nursing care situation, 604 in hypertension, 112 in laryngeal cancer, 64 in lung cancer, 53 in myocardial ischemia, 69–70 in pneumonia, 31 in ulcer disease, 143 Cirrhosis, case study of, 191–192 class activity in, 200–201 Preparation for Class Guidelines in, 192–200 Class activities, case studies in, of acquired immunodeficiency syndrome, 338–339 of acromegaly, 263–264 of adrenocortical insufficiency, 260–263 of adult respiratory distress syndrome, 41 of antithrombolytic therapy, 79 of asthma, 53 of below-knee amputation, 396–397 of bleeding esophageal varices, 200–202 of bone marrow transplantation, 127 of brain injury, 496–498 of burn injury, 558–561 of cardiac dysrhythmias, 99–102 of cerebrovascular accident, 466–467 of cholecystitis, 222–223 of cholelithiasis, 221 of colostomy, 173 of continuous ambulatory peritoneal dialysis, 426–427 of diabetes, arthritis, and trauma, 590–593 of dyspnea and heart failure, 613–617 of endometriosis, 290–291 of end-stage renal disease, 426–427

Index

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Class activities — Continued of femoral-popliteal bypass grafting, 112 of hepatitis, 202–203 of hip fracture, 23–25 of hip fracture complications, 397–399 of hypertension, 112 of hypoparathyroidism, 250–251 of hypothyroidism, 249–250 of hypothyroidism and arthritis, 602–604 of iron deficiency anemia, 137 of irritable bowel disease, 162–163 of laryngectomy, 64 of Ménière’s syndrome, 525 of nephrotic syndrome, 414–415 of osteomyelitis, 366–367 of otosclerosis, 514–515 of ovarian cancer, 301–302 of pelvic inflammatory disease, 281 of pituitary dysfunction, 263 of polycystic kidney disease, 415–417 of pulmonary edema, 89 of renal transplantation, 446–448 of rheumatoid arthritis, 348–350 of skin cancer, 570–572 of spinal cord injury, 476–478 of systemic lupus erythematosus, 338–339 of temporary ileostomy, 182–184 of testicular cancer, 313 of thrombocytopenia, 137 of trauma, 386–387 of type 1 diabetes mellitus, 238–239 of type 2 diabetes mellitus, 239–240 of ulcer disease, 152–153 of urinary and renal dysfunction, 448–450 need for student participation in, 25 questions in, 24–25 Clinical data, in Preparation for Class Guidelines, 11t, 14 Closed-angle glaucoma, case study of, 506 Preparation for Class Guidelines in, 506–514 Cognitive-perceptual pattern, in Functional Health Patterns, 11t, 14t in Preparation for Class Guidelines, case study of, 19 Colitis, ulcerative, case study of, 174 class activity in, 182–184 Preparation for Class Guidelines in, 174–182 Colonoscopy, in bowel cancer, 163 Colostomy, in bowel cancer, 164, 173 Competencies, critical thinking and, 4–5 Complete blood count, in iron deficiency anemia, 137 in leukemia, 117 in thrombocytopenia, 137 Complex nursing care situations, 579–619 case studies in, of diabetes, arthritis, and trauma, 581–582 of dyspnea and heart failure, 604 of hypothyroidism and osteoarthritis, 593–594

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class activities in, in diabetes, arthritis, and trauma, 590–593 in dyspnea and heart failure, 613–617 in hypothyroidism and arthritis, 594–602 critical thinking review of, 617–619 learning outcome goals in, 580–581 Preparation for Class Guidelines in, in diabetes, 582–590 in dyspnea, 604–613 in hypothyroidism, 602–604 Computed tomography, in irritable bowel disease, 153 in pancreatitis, 203 in testicular cancer, 303 Conceptual reasoning, in Paul’s theoretical framework of critical thinking, 6–7 Conductive hearing loss, class activity in, 514–515 Confusion, in case studies, of complex nursing care situation, 581–582 of congestive heart failure, 79 defined, 17–18 Congestive heart failure, case study of, 79, 89 class activity in, 89 Preparation for Class Guidelines in, 80–88 Consequences, in Paul’s theoretical framework of critical thinking, 6–7 Context, critical thinking and, 5 Coping-stress tolerance, in Functional Health Patterns, 11t, 14t Coronary angioplasty, percutaneous transluminal, case study of, 90 Preparation for Class Guidelines in, 90–98 Coronary artery bypass grafting, case study of, 90 Preparation for Class Guidelines in, 90–98 Corticosteroids, in adrenocortical disease, 251 in asthma, 53 in irritable bowel disease, 153 in rheumatoid arthritis, 340 in systemic lupus erythematosus, 339 Cough, in acquired immunodeficiency syndrome, 329 in chronic obstructive lung disease, 43 in complex nursing care situation, 604 in congestive heart failure, 79, 89 in laryngeal cancer, 64 in lung cancer, 54 in pneumonia, 31 urinary incontinence and, 438 Courage, as trait of critical thinker, 7 Cracked lips, in iron deficiency anemia, 137 Crackles, in congestive heart failure, 79 in pneumonia, 41 Creatinine kinase, normal values of, 20t in Preparation for Class Guidelines, case study of, 20 Creativity, critical thinking and, 5 Critical thinking, defined, 5

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Crohn’s disease, case study of, 153 class activity in, 162–163 Preparation for Class Guidelines in, 153–162 Cultural aspects, in Preparation for Class Guidelines, 11t case study of, 19 Curiosity, as trait of critical thinker, 7 Cushing’s disease, case study of, 251 Preparation for Class Guidelines in, 252–260 Cyclophosphamide, in systemic lupus erythematosus, 339

Decision making, in Preparation for Class Guidelines, 11t, 14–15 case study of, 21–22 Defining characteristics, in Preparation for Class Guidelines, 11t, 14 Dermatologic problems, 547–574 See also Integumentary problems Dexamethasone, in brain injury, 497 in cerebrovascular accident, 458 Diabetes mellitus, type 1, chronic renal failure in, 417 class activity in, 238–239 nephrotic syndrome in, 414–415 type 2, case studies of, 229–230, 581–582 class activities in, 239–240, 590–593 in complex nursing care situation, 581–593 Preparation for Class Guidelines in, 230–238, 582–590 Diabetic ketoacidosis, in chronic renal failure, 417 Dialysis, continuous ambulatory peritoneal, in endstage renal disease, 426–427 Diarrhea, in irritable bowel disease, 153 in renal calculi, 428 Dietitians, in Preparation for Class Guidelines, case study of, 22 Digoxin, in atrial fibrillation, 99 in congestive heart failure, 79, 89 Disfigurement, in acromegaly, 263 Diverting-loop ileostomy, in ulcerative colitis, 174 Dysmenorrhea, in endometriosis, 290–291 Dyspnea, in asthma, 53 in chronic obstructive lung disease, 43 in complex nursing care situation, 604 in congestive heart failure, 89 in iron deficiency anemia, 137 in lung cancer, 54 in myocardial ischemia, 69–70 in spinal cord injury, 477 Dysrhythmias, cardiac, class activities in, 99–102

Ear disorders, Ménière’s syndrome as, 525 otosclerosis as, 514–515 Edema, in cirrhosis, 191 in nephrotic syndrome, 414

pulmonary, case study of, 89 class activity in, 89 in complex nursing care situation, 604 Educational competencies, critical thinking and, 4–5 Egocentricity, as hindrance to critical thinking, 7 Elderly patient, case study of, class activities and, 23–25 Preparation for Class Guidelines and, 16–23, 20t, 22t Electrocardiography, dysrhythmia patterns of, 100–102 Elements of thought, in Paul’s theoretical framework of critical thinking, 5–6 in Preparation for Class Guidelines, 12 Elimination, in Functional Health Patterns, 11t, 14t Empirical reasoning, in Paul’s theoretical framework of critical thinking, 6–7 Endocrine problems, 227–266 case studies of, of adrenocortical disease, 251 of hyperthyroidism, 240–241 of type 2 diabetes mellitus, 229–230 class activities in, in acromegaly, 263–264 in adrenocortical insufficiency, 260–263 in hypoparathyroidism, 250–251 in hypothyroidism, 249–250 in pituitary dysfunction, 263 in type 1 diabetes mellitus, 238–239 in type 2 diabetes mellitus, 239–240 critical thinking review of, 264–266 learning outcome goals in, 229 Preparation for Class Guidelines in, in adrenocortical disease, 252–260 in hyperthyroidism, 241–249 in type 2 diabetes mellitus, 230–238 Endometrial cancer, case study of, 281 Preparation for Class Guidelines, 282–290 Endometriosis, class activity in, 290–291 End-stage renal disease, continuous peritoneal ambulatory dialysis in, 426–427 Environment, in Preparation for Class Guidelines, 11t, 14 case study of, 21 Enzyme release, in skeletal muscle injury, case study of, 20, 20t Esophageal varices, bleeding, in cirrhosis, 200–201 Estrogen replacement therapy, in endometrial cancer, 281 Exercise, urinary incontinence and, 438 Exocrine pancreatic problems, 189–226 learning outcome goals in, 191 pancreatitis as, case study of, 203 Preparation for Class Guidelines in, 203–211 Eye disorders See Sensory problems; specific conditions

Facial swelling, in acute glomerulonephritis, 406 Fair-mindedness, as trait of critical thinker, 7 Famotidine, in brain injury, 497

Index

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Fatigue, in adrenocortical disease, 251 in adrenocortical insufficiency, 260–261 in congestive heart failure, 79, 89 in iron deficiency anemia, 137 in irritable bowel disease, 153 in leukemia, 117 in lung cancer, 54 in nephrotic syndrome, 415 Femoral fracture, in complex nursing care situation, 581–582 Femoral head fracture, case study of, class activities and, 23–25 Preparation for Class Guidelines and, 16–23, 20t, 22t Femoral-popliteal bypass, in peripheral disease, amputation after, 388 case study of, 103 class activity in, 112 Preparation for Class Guidelines in, 103–111 Fever, in cholelithiasis, 212 in hip fracture, 23–24 in hyperthyroidism, 240 in leg fracture, 386 in leukemia, 117 in meningitis, 479 in myocardial ischemia, 69–70 in osteomyelitis, 367 in pelvic inflammatory disease, 271 in pneumonia, 31 in systemic lupus erythematosus, 339 in type 1 diabetes mellitus, 239 Flank pain, in acute glomerulonephritis, 405–406 in polycystic kidney disease, 415 Foot infections, in peripheral vascular disease, case study of, 102–103 Fractured hip, case studies of, complications in, 397–399 class activities in, 23–25, 397–399 Preparation for Class Guidelines and, 16–23, 20t, 22t Fractured leg, case studies of, 377, 581–582 class activities in, 386–387, 590–593 in complex nursing care situation, 581–582 osteomyelitis after, 357 Frame of reference, in Paul’s theoretical framework of critical thinking, 6 Functional Health Patterns, in Preparation for Class Guidelines, case study of, 18–19 Preparation for Class Guidelines and, 13, 14t Furosemide, in brain injury, 497 in congestive heart failure, in myocardial ischemia, 79, 89

Gallbladder problems, 189–226 cholecystitis as, class activity in, 222–223 cholelithiasis as, case study of, 212 class activity in, 221

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Preparation for Class Guidelines in, 212–221 critical thinking review of, 224–226 learning outcome goals in, 191 Gastrointestinal problems, 141–187 case studies of, of cancer of the bowel, 163–164 of irritable bowel disease, 153 of ulcer disease, 143–144 of ulcerative colitis, 174 class activities in, colostomy as, 173 in irritable bowel disease, 162–163 temporary ileostomy as, 182–184 ulcer disease as, 152–153 critical thinking review of, 185–187 learning outcome goals in, 143 Preparation for Class Guidelines in, in cancer of the bowel, 164–172 in irritable bowel disease, 153–162 in ulcer disease, 144–152 in ulcerative colitis, 174–182 Glasgow Coma Scale, in brain injury, 497 Glaucoma, closed-angle, case study of, 506 Preparation for Class Guidelines in, 506–514 open-angle, case study of, 516 Preparation for Class Guidelines in, 516–524 Glomerulonephritis, acute, case study of, 405–406 Preparation for Class Guidelines in, 406–414 Glyburide, in type 2 diabetes mellitus, 229, 239 Goals, in Paul’s theoretical framework of critical thinking, 6 Gout, in cirrhosis, 192 Grafting, coronary artery bypass, case study of, 90 Preparation for Class Guidelines in, 90–98 femoral-popliteal bypass, amputation after, 388 in peripheral disease, 103–112 skin, in burn injury, 559–561 Gum bleeding, in leukemia, 117 in thrombocytopenia, 137

Head injury, class activity in, 496–498 Headache, in brain tumor, 488 in meningitis, 479 in nephrotic syndrome, 414 in spinal cord injury, 476 Health perception-health management pattern, in Functional Health Patterns, 11t, 14t in Preparation for Class Guidelines, case study of, 18 Healthcare professionals, in Preparation for Class Guidelines, 12t, 16 case study of, 22 Healthcare system, changes in, critical thinking and, 4–5 Hearing loss, in Ménière’s syndrome, 525 in otosclerosis, 514 Heart disease See Cardiovascular problems; specific diseases

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Heart dysrhythmias, case study of, class activities in, 99–102 Heart failure, in complex nursing care situation, 604 congestive, case study of, 79, 89 class activity in, 89 Preparation for Class Guidelines in, 80–88 Heart surgery, coronary artery bypass, case study of, 90 Preparation for Class Guidelines in, 90–98 Hematemesis, in bleeding esophageal varices, 201 Hematologic problems, 115–140 case studies of, of bone marrow transplantation, 127 of iron deficiency anemia, 137 of leukemia, 117, 127 of sickle cell anemia, 127 of thrombocytopenia, 137 class activities in, in bone marrow transplantation, 127 in iron deficiency anemia, 137 in thrombocytopenia, 137 critical thinking review of, 138–140 learning outcome goals in, 116–117 Preparation for Class Guidelines in, in leukemia, 118–126 in sickle cell anemia, 128–136 Hematuria, in polycystic kidney disease, 415 in renal calculi, 428 Hemiplegia, in cerebrovascular accident, 457, 466–467 Hemodialysis, chronic renal failure and, case study of, 417 Preparation for Class Guidelines in, 418–426 renal transplantation and, 446 Hemoglobin count, in iron deficiency anemia, 137 in sickle cell anemia, 127 Heparin, in cerebrovascular accident, 458 Hepatic problems See Liver problems; specific conditions Hepatitis, class activity in, 202–203 types of, 202, 202t Hip fracture, aging and, 17–18 case studies of, complications in, 397–399 class activities in, 397–399 principles of, 23–25 complications of, 16–17 case studies of, 23–24 management of, 17 Preparation for Class Guidelines in, principles of, 16–23, 20t, 22t Hip replacement surgery, in complex nursing care situation, 594 in rheumatoid arthritis, class activity in, 348–350 Hoarseness, in laryngeal cancer, 64 Homan’s sign, in hip fracture, 398 Human immunodeficiency virus, in acquired immunodeficiency syndrome, 329 Hyperphosphatemia, in hypoparathyroidism, 250

Hypertension, case study of, class activity in, 112 in chronic renal failure, 417 Hyperthyroidism, case study of, 240–241 Preparation for Class Guidelines in, 241–249 Hypocalcemia, in hypoparathyroidism, 250 Hypoparathyroidism, class activity in, 250–251 Hypothyroidism, case study of, in complex nursing care situation, 593–594 class activities in, 249–250 in complex nursing care situation, 602–604 Preparation for Class Guidelines in, in complex nursing care situation, 594–602

Ileoanal anastomosis, in ulcerative colitis, 174 Ileostomy, temporary diverting-loop, in ulcerative colitis, 174 Immunologic problems, 317–352 case studies of, of AIDS, 329 of rheumatoid arthritis, 319, 339–340 class activities in, in acquired immunodeficiency syndrome, 338–339 in rheumatoid arthritis, 348–350 in systemic lupus erythematosus, 338–339 critical thinking review of, 350–352 learning outcome goals in, 318–319 Preparation for Class Guidelines in, in AIDS, 329–338 in rheumatoid arthritis, 320–328 Implications, in Paul’s theoretical framework of critical thinking, 6–7 Incontinence, urinary, case study of, 438 Preparation for Class Guidelines in, 438–446 Independence, as trait of critical thinker, 7 Infarction, possible myocardial, case study of, 69–70 Preparation for Class Guidelines in, 70–78 Infections, in osteomyelitis, 357, 367 in peripheral vascular disease, 102–103, 388 Inferences, in Paul’s theoretical framework of critical thinking, 6–7 Insulin, in type 1 diabetes and renal disease, 414, 417 in type 2 diabetes mellitus, 230, 581 Integumentary problems, 547–574 case studies in, of burn injury, 549 of malignant melanoma, 561 class activities in, in burn injury, 558–561 in skin cancer, 570–572 critical thinking review of, 572–574 learning outcome goals in, 548–549 Preparation for Class Guidelines in, in burn injury, 550–558 in malignant melanoma, 562–570 Intellectual standards, in Paul’s theoretical framework of critical thinking, 6–7 in Preparation for Class Guidelines, 12 Interpretations, in Paul’s theoretical framework of critical thinking, 6–7

Index

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Intracranial pressure elevation, in brain tumor, 488 stroke and, case study of, 457 class activity in, 466–467 Preparation for Class Guidelines in, 458–466 Iron deficiency anemia, class activity in, 137 Irritability, in hyperthyroidism, 240 Irritable bowel disease, case study of, 153 class activity in, 162–163 Preparation for Class Guidelines in, 153–162 Ischemia, myocardial, case study of, 69–70 Preparation for Class Guidelines in, 70–78

Jaundice, in cirrhosis, 191 Joint stiffness, in rheumatoid arthritis, 319 Joint swelling, in rheumatoid arthritis, 319 in sickle cell anemia, 127 Junctional dysrhythmias, class activities in, 100–101

Ketoacidosis, diabetic, in chronic renal failure, 417 Kidney disease See also Renal problems; specific conditions end-stage, continuous peritoneal ambulatory dialysis in, 426–427 polycystic, 415–417 Kidney failure, chronic, case study of, 417 Preparation for Class Guidelines in, 418–426 Kidney stones, case study of, 428 Preparation for Class Guidelines in, 428–436 Kidney transplantation, class activities in, 446–448

Laboratory values, normal, 20t in Preparation for Class Guidelines, 11t, 14 case study of, 19t Lactate dehydrogenase, normal values of, 20t in Preparation for Class Guidelines, case study of, 20 Laryngeal cancer, class activity in, 64 Laryngectomy, class activity in, 64 Learning outcome goals, in cardiovascular problems, 69 in complex nursing care situations, 580–581 in endocrine problems, 229 in gastrointestinal problems, 143 in hematologic problems, 116–117 in immunologic problems, 318–319 in integumentary problems, 548–549 in liver problems, 191 in musculoskeletal problems, 357 in neurological problems, 456–457 in renal problems, 405 in reproductive problems, 271 in respiratory problems, 30–31 in sensory problems, 504–505 in theoretical basis for critical thinking, 4 Learning tool, critical thinking as, 7

628

Index

Leg fracture, case studies of, 377, 581–582 class activities in, 386–387, 590–593 in complex nursing care situation, 581–582 osteomyelitis after, 357 Lethargy, in chronic renal failure, 417 in meningitis, 479 Leukemia, case study of, 117 class activity in, 127 Preparation for Class Guidelines in, 118–126 Leukocyte count, in leukemia, 117 Leukoplakia, in laryngeal cancer, 64 Literature review, of hip fracture, 16–17 in Preparation for Class Guidelines, 11t, 13 case study of, 16–17 Liver problems, 189–226 bleeding esophageal varices as, class activity in, 200–202 cirrhosis as, case study of, 191–192 Preparation for Class Guidelines in, 192–200 critical thinking review of, 224–226 hepatitis as, class activity in, 202–203 learning outcome goals in, 191 Lorazepam, in brain injury, 497 Lung cancer, case study of, 54 Preparation for Class Guidelines in, 54–63 Lung disease See also other conditions chronic obstructive, case study of, 43 Preparation for Class Guidelines in, 43–52 Lupus erythematosus, systemic, class activity in, 338–339

Malaise, in pelvic inflammatory disease, 271 Malignant melanoma, case study of, 561 Preparation for Class Guidelines in, 562–570 Mastectomy, case study of, 292 Medical care, in Preparation for Class Guidelines, 12t, 16 Medications, in Preparation for Class Guidelines, 11t, 14 case study of, 21 Melanoma, malignant, case study of, 561 Preparation for Class Guidelines in, 562–570 Melena, in bleeding esophageal varices, 200 Memory impairment, in meningitis, 479 Ménière’s syndrome, class activity in, 525 Meningitis, case study of, 479 Preparation for Class Guidelines in, 479–487 Menorrhagia, in ovarian cancer, 302 Mental impairment, in amputation, 388, 396–397 in cirrhosis, 191 in complex nursing care situation, 581–582 Meperidine, in pancreatitis, 203 in renal calculi, 428 Milk of magnesia, in ulcer disease, 144 Missing information, in Preparation for Class Guidelines, 11t case study of, 19

Copyright © 2001 F.A. Davis Company

Motor vehicle accident, brain injury in, 496–497 leg fracture in, 377, 386 osteomyelitis after, 357 Mucous membrane inflammation, in iron deficiency anemia, 137 Multiple disorders See Complex nursing care situations Musculoskeletal problems, 355–401 case studies of, of amputation, 387–388 of osteomyelitis, 357 of osteoporosis, 367–368 of trauma, 377 class activities in, in below-knee amputation, 396–397 in hip fracture complications, 397–399 in osteomyelitis, 366–367 in trauma, 386–387 critical thinking review of, 399–401 learning outcome goals in, 357 Preparation for Class Guidelines in, in amputation, 388–396 in osteomyelitis, 358–366 in osteoporosis, 368–376 in trauma, 377–385 Myocardial infarction, possible, case study of, 69–70 Preparation for Class Guidelines in, 70–78 Myocardial ischemia, case studies of, possible infarction and, 69–70 surgery and, 90 class activity in, 79 Preparation for Class Guidelines in, 70–78

Nausea, in cholelithiasis, 212 in chronic renal failure, 417 in Ménière’s syndrome, 525 in pancreatitis, 203 in polycystic kidney disease, 415 in renal calculi, 428 Nephrotic syndrome, class activity in, 414–415 Neurological problems, 455–501 case studies of, of brain tumor, 488 of cerebrovascular accident, 457–458 of meningitis, 479 of spinal cord injury, 467 class activities in, in brain injury, 496–498 in cerebrovascular accident, 466–467 in spinal cord injury, 476–478 critical thinking review of, 499–501 learning outcome goals in, 456–457 Preparation for Class Guidelines in, in brain tumor, 488–496 in cerebrovascular accident, 458–466 in meningitis, 479–487 in spinal cord injury, 467–476 Neurovascular impairment, in leg fracture, 377, 386–387 Nizatidine, in pancreatitis, 203

Non-small cell lung cancer, case study of, 54 Preparation for Class Guidelines in, 54–63 Nonsteroidal anti-inflammatory drugs, in adrenocortical disease, 251 in complex nursing care situations, 581, 593 in rheumatoid arthritis, 339 in ulcer disease, 143 Nosebleeds, in thrombocytopenia, 137 Nursing care issues, in Preparation for Class Guidelines, 11t, 13 case study of, 17–18 Nursing diagnoses, in Preparation for Class Guidelines, 12t, 14–15 case study of, 19–20 Nursing interventions, in Preparation for Class Guidelines, 12t, 15 case study of, 22, 22t Nutrition, in Preparation for Class Guidelines, 11t, 14 case study of, 21 Nutritional-metabolic pattern, in Functional Health Patterns, 11t, 14t in Preparation for Class Guidelines, case study of, 19

Objective, in Paul’s theoretical framework of critical thinking, 6 Obstructive pulmonary disease, chronic, case study of, 43 Preparation for Class Guidelines in, 43–52 Occult blood, in bleeding esophageal varices, 200 Ocular disorders See Sensory problems; specific conditions Open-angle glaucoma, case study of, 516 Preparation for Class Guidelines in, 516–524 Open-mindedness, as trait of critical thinker, 7 Oseoarthritis, hypothyroidism and, in complex nursing care situation, 593–603 Osteomyelitis, case study of, 357 class activity in, 366–367 Preparation for Class Guidelines in, 358–366 Osteoporosis, case study of, 367–368 Preparation for Class Guidelines in, 368–376 Otosclerosis, class activity in, 514–515 Outcome evaluation, in Preparation for Class Guidelines, 12t, 15 case study of, 22 Outcome goals, learning See Learning outcome goals Ovarian cancer, class activity in, 301–303

Pain, in bowel cancer, 164 in cholelithiasis, 212 in endometriosis, 290–291 flank, in acute glomerulonephritis, 405–406 in polycystic kidney disease, 415 in hip fracture, 23

Index

629

Copyright © 2001 F.A. Davis Company

Pain — Continued in hypoparathyroidism, 250 in irritable bowel disease, 153 in leukemia, 117 in osteomyelitis, 357, 367 in osteoporosis, 367–368 in pancreatitis, 203 in pelvic inflammatory disease, 271 in peripheral vascular disease, 388 in renal calculi, 428 in rheumatoid arthritis, 339–340 in sickle cell anemia, 127 in testicular cancer, 303 in ulcer disease, 143–144 Pain relief, in Preparation for Class Guidelines, 21–22 Pancreatic problems, exocrine, 189–226 critical thinking review of, 224–226 learning outcome goals in, 191 pancreatitis as, 203–211 Pancreatitis, case study of, 203 Preparation for Class Guidelines in, 203–211 Paralysis, in cerebrovascular accident, 457–458, 466–467 in spinal cord injury, 467 Parathyroid disease, hypoparathyroidism as, 250–251 Patient problems, in Preparation for Class Guidelines, 11t, 13 case study of, 18 Patient-controlled analgesia, in Preparation for Class Guidelines, 21–22 Paul’s theoretical framework of critical thinking, 5–7 elements of thought in, 5–6 intellectual standards in, 6–7 Pelvic inflammatory disease, case study of, 271 class activity in, 281 Preparation for Class Guidelines in, 272–280 Percutaneous transluminal coronary angioplasty, case study of, 90 Preparation for Class Guidelines in, 90–98 Pericarditis, case study of, class activity in, 99 Peripheral vascular disease, case study of, 103, 112 amputation in, 387–388 class activity in, 112 Preparation for Class Guidelines in, 102–111 Peritoneal dialysis, continuous ambulatory, in endstage renal disease, 426–427 Perspective, in Paul’s theoretical framework of critical thinking, 6 Phenytoin, in brain injury, 497 Phosphorus, normal values of, 20t in Preparation for Class Guidelines, case study of, 20 Photosensitivity, in systemic lupus erythematosus, 338–339 Physical therapists, in Preparation for Class Guidelines, 22 Pituitary dysfunction, class activity in, 263 Pituitary tumor, in acromegaly, 263

630

Index

Platelet count, in thrombocytopenia, 137 Pneumocystis carinii infection, in acquired immunodeficiency syndrome, 329 Pneumonia, case study of, 31, 41 class activity in, 41–42 Preparation for Class Guidelines in, 32–40 Polycystic kidney disease, class activity in, 415–417 Posture, in osteoporosis, 368 Potassium chloride, in congestive heart failure, in myocardial ischemia, 79, 89 Practical applications of critical thinking, 9–25 class activities in, 23–25 outcome goals in, 10 Preparation for Class Guidelines in, 10, 11t–12t, 12–23 Prednisone, in systemic lupus erythematosus, 339 Premature ventricular complex, class activities in, 101 Preparation for Class Guidelines, 10–23 application to case study of, 15–23, 20t, 22t in biliary problems, cholelithiasis as, 212–221 in cardiovascular problems, angioplasty and bypass graft as, 90–98 congestive heart failure as, 80–88 myocardial ischemia as, 70–78 peripheral vascular disease as, 102–111 in complex situations, diabetes and arthritis as, 582–590 dyspnea and heart failure as, 604–613 hypothyroidism and arthritis as, 594–602 components of, 11t–12t directions for using, 12–15 in endocrine problems, in adrenocortical disease, 252–260 in hypothyroidism, 241–249 in type 2 diabetes mellitus, 230–238 Functional Health Patterns in, 13, 14t in gastrointestinal problems, cancer of the bowel as, 164–172 irritable bowel disease as, 153–162 ulcer disease as, 144–152 ulcerative colitis as, 174–182 in hematologic problems, leukemia as, 118–126 sickle cell anemia as, 128–136 in immunologic problems, AIDS as, 329–338 rheumatoid arthritis as, 320–328 in integumentary problems, burn injury as, 550–558 malignant melanoma as, 562–570 in liver problems, cirrhosis as, 192–200 in musculoskeletal problems, amputation as, 388–396 osteomyelitis as, 358–366 osteoporosis as, 368–376 trauma as, 377–385 in neurological problems, brain tumor as, 488–496 cerebrovascular accident as, 458–466 meningitis as, 479–487 spinal cord injury as, 467–476

Copyright © 2001 F.A. Davis Company

in pancreatic problems, pancreatitis as, 203–211 purpose of, 10 in renal problems, acute glomerulonephritis as, 406–414 chronic renal failure as, 418–426 renal calculi as, 428–436 urinary incontinence as, 438–446 in reproductive problems, breast cancer as, 292–301 endometrial cancer as, 282–290 pelvic inflammatory disease as, 272–280 testicular cancer as, 304–311 in respiratory problems, chronic lung disease as, 43–52 lung cancer as, 54–64 pneumonia as, 32–40 in sensory problems, cataracts as, 526–534 closed-angle glaucoma as, 506–514 open-angle glaucoma as, 516–524 retinal detachment as, 535–543 Presuppositions, in Paul’s theoretical framework of critical thinking, 6–7 Procainamide, in atrial fibrillation, 99 Prostatic hypertrophy, benign, class activity in, 436–437 Prosthesis, hip, in rheumatoid arthritis, 349 leg, after amputation, 396 Pruritus, in cirrhosis, 191–192 Pubococcygeal muscle exercise, urinary incontinence and, 438 Pulmonary disease, chronic obstructive, case study of, 43 Preparation for Class Guidelines in, 43–52 Pulmonary edema, case study of, 89 class activity in, 89 Purpose, in Paul’s theoretical framework of critical thinking, 6

Quadriplegia, in spinal cord injury, 467 Question, in Paul’s theoretical framework of critical thinking, 6

Radiography, in cholelithiasis, 212 in irritable bowel disease, 153 in osteomyelitis, 357 in Preparation for Class Guidelines, 21 Rash, in systemic lupus erythematosus, 339 Reasoning, in Paul’s theoretical framework of critical thinking, 6–6 Rehabilitation, in Preparation for Class Guidelines, case study of, 23 Renal calculi, case study of, 428 Preparation for Class Guidelines in, 428–436 Renal disease, end-stage, continuous peritoneal ambulatory dialysis in, 426–427

Renal failure, chronic, case study of, 417 Preparation for Class Guidelines in, 418–426 Renal problems, 403–453 case studies in, of acute glomerulonephritis, 405–406 of chronic renal failure, 417 of renal calculi, 428 of urinary incontinence, 438 class activities in, in continuous ambulatory peritoneal dialysis, 426–427 in end-stage renal disease, 426–427 in nephrotic syndrome, 414–415 in polycystic kidney disease, 415–417 in renal transplantation, 446–448 in urinary and renal dysfunction, 448–450 critical thinking review of, 451–453 learning outcome goals in, 405 Preparation for Class Guidelines in, in acute glomerulonephritis, 406–414 in chronic renal failure, 418–426 in renal calculi, 428–436 in urinary incontinence, 438–446 Renal transplantation, class activities in, 446–448 Reproductive problems, 269–316 case studies in, of breast cancer, 292 of endometrial cancer, 281 of pelvic inflammatory disease, 271 of testicular cancer, 303 class activities in, in endometriosis, 290–291 in ovarian cancer, 301–302 in pelvic inflammatory disease, 281 in testicular cancer, 313 critical thinking review in, 314–316 learning outcome goals in, 271 Preparation for Class Guidelines in, in breast cancer, 292–301 in endometrial cancer, 282–290 in pelvic inflammatory disease, 272–280 in testicular cancer, 304–313 Respiratory problems, 29–66 case studies of, of adult respiratory distress syndrome, 41 of asthma, 53 of chronic obstructive pulmonary disease, 43 of laryngectomy, 64 of lung cancer, 54 of pneumonia, 31, 41 class activities in, of adult respiratory distress syndrome, 41 of asthma, 53 of laryngectomy, 64 of pneumonia, 41 critical thinking review of, 65–66 learning outcome goals in, 30–31 Preparation for Class Guidelines in, in chronic lung disease, 43–52 in lung cancer, 54–64 in pneumonia, 32–40

Index

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Copyright © 2001 F.A. Davis Company

Retinal detachment, case study of, 535 Preparation for Class Guidelines in, 535–543 Rheumatoid arthritis, case studies of, 319, 339–340 hip replacement and, class activity in, 348–350 Preparation for Class Guidelines in, 320–328, 340–348 Role-relationship, in Functional Health Patterns, 11t, 14t

Seizure, in brain injury, 497 in brain tumor, 488 Self-assessment, in Paul’s theoretical framework of critical thinking, 5–6 Self-examination, in Paul’s theoretical framework of critical thinking, 5–6 Self-perception-self-control, in Functional Health Patterns, 11t, 14t Sensory problems, 503–546 case studies in, of cataracts, 526 of closed-angle glaucoma, 506 of open-angle glaucoma, 516 of retinal detachment, 535 class activities in, in Ménière’s syndrome, 525 in otosclerosis, 514–515 critical thinking review of, 544–546 learning outcome goals in, 504–505 Preparation for Class Guidelines in, cataracts as, 526–534 in closed-angle glaucoma, 506–514 in open-angle glaucoma, 516–524 in retinal detachment, 535–543 Sexual factors, in pelvic inflammatory disease, 271 Sexuality-reproductive patterns, in Functional Health Patterns, 11t, 14t Sickle cell anemia, case study of, 127 Preparation for Class Guidelines in, 128–136 Skin breakdown, in peripheral vascular disease, 387–388 Skin cancer, case study of, 561 class activity in, 570–572 Preparation for Class Guidelines in, 562–570 Skin disorders, 547–574 See also Integumentary problems Skin grafting, in burn injury, 559–561 Sleep-rest, in Functional Health Patterns, 11t, 14t Smoking history, in chronic obstructive lung disease, 43 in cirrhosis, 192 in complex nursing care situation, 604 in hypertension, 112 in laryngeal cancer, 64 in lung cancer, 53 in myocardial ischemia, 69–70 in pneumonia, 31 in ulcer disease, 143 Sneezing, urinary incontinence and, 438 Sociocentricity, as hindrance to critical thinking, 7

632

Index

Speech impairment, in brain tumor, 488 Spinal cord injury, case study of, 467 class activity in, 476–478 Preparation for Class Guidelines in, 467–476 Spirometry, in asthma, 53t Squamous cell carcinoma, class activity in, 570–572 Standards, in Paul’s theoretical framework of critical thinking, 6–7 in Preparation for Class Guidelines, 12 Stiffness, joint, in rheumatoid arthritis, 319 Stool abnormalities, in bleeding esophageal varices, 200–201 in bowel cancer, 164 in irritable bowel disease, 153 in ulcerative colitis, 174 Stroke, case study of, 457 class activity in, 466–467 Preparation for Class Guidelines in, 458–466 Student participation, as integral to class activities, 25 Subjective-objective information correlation, in Preparation for Class Guidelines, 11t, 14 case study of, 21 Surgery, coronary artery bypass, case study of, 90 Preparation for Class Guidelines in, 90–98 femoral-popliteal bypass, case study of, 103 class activity in, 112 Swallowing impairment, in acquired immunodeficiency syndrome, 329 Swelling, facial, in acute glomerulonephritis, 406 joint, in acromegaly, 263 in rheumatoid arthritis, 319 in sickle cell anemia, 127 in systemic lupus erythematosus, 338 Systemic lupus erythematosus, class activity in, 338–339

Temporary diverting-loop ileostomy, in ulcerative colitis, 174 Tentative nursing diagnoses, in Preparation for Class Guidelines, 11t, 13, 14t case study of, 19–20 Testicular cancer, case study of, 303 class activity in, 313 Preparation for Class Guidelines in, 303–312 Theoretical basis for critical thinking, 3–8 definitions in, 5 healthcare system changes and, 4–5 as nursing learning tool, 7 outcome goals in, 4 Paul’s framework of, 5–7 personal traits in, 7 Thought elements, in Paul’s theoretical framework of critical thinking, 5–6 in Preparation for Class Guidelines, 12 Thrombocytopenia, class activity in, 137

Copyright © 2001 F.A. Davis Company

Thyroid disease, hyperthyroidism as, 240–249 hypothyroidism as, 249–250 Tibial fracture, case study of, 377 class activity in, 386–387 osteomyelitis after, 357 Tinnitus, in Ménière’s syndrome, 525 Toe amputation, in peripheral vascular disease, 388 Toe infections, in peripheral vascular disease, amputation in, 387–388 case study of, 102–103 Transluminal coronary angioplasty, percutaneous, case study of, 90 Preparation for Class Guidelines in, 90–98 Trauma, case studies of, 377 brain, 496–498 in complex nursing care situation, 581–582 class activities in, 386–387, 590–593 osteomyelitis after, 357 Preparation for Class Guidelines in, 377–385, 582–590 Tumors, brain, case study of, 488 Preparation for Class Guidelines in, 488–496 breast, case study of, 292 pituitary, in acromegaly, 263 skin, basal cell carcinoma as, 570–5723 malignant melanoma as, 561–570 squamous cell carcinoma as, 570–5723 Type 1 diabetes mellitus, chronic renal failure in, 417 class activity in, 238–239 nephrotic syndrome in, 414–415 Type 2 diabetes mellitus, case studies of, 229–230, 581–582 class activities in, 239–240, 590–593 in complex nursing care situation, 581–593 Preparation for Class Guidelines in, 230–238, 582–590

Ulcer disease, case study of, 143–144 in cirrhosis, 192 class activity in, 152–153 Preparation for Class Guidelines in, 144–152 Ulcerative colitis, case study of, 174 class activity in, 182–184 Preparation for Class Guidelines in, 174–182 Ultrasonography, in renal calculi, 428 Universal standards, in Paul’s theoretical framework of critical thinking, 6–7 Upper respiratory infection, in meningitis, 479

Urinalysis, in acute glomerulonephritis, 405 Urinary dysfunction, in benign prostatic hypertrophy, 436–437 class activities in, 448–450 in ovarian cancer, 301–302 Urinary incontinence, case study of, 438 Preparation for Class Guidelines in, 438–446 Urokinase, in peripheral vascular disease, amputation after, 388

Vaginal bleeding, in endometrial cancer, 281 Validation of tentative nursing diagnoses, in Preparation for Class Guidelines, 19–20 Value-belief, in Functional Health Patterns, 11t, 14t Varices, bleeding esophageal, in cirrhosis, 200–201 Vascular disease, peripheral, Preparation for Class Guidelines in, 102–111 Ventricular dysrhythmias, class activities in, 100–102 Verapamil, in atrial fibrillation, 99 Vertigo, in Ménière’s syndrome, 525 Visual impairment, in cataracts, 526 in glaucoma, closed-angle, 505 open-angle, 516 in retinal detachment, 535 Vitamin K, in cirrhosis, 192 Vomiting, in brain tumor, 488 in cholelithiasis, 212 in chronic renal failure, 417 in Ménière’s syndrome, 525 in pancreatitis, 203 in polycystic kidney disease, 415 in renal calculi, 428

Weakness, in adrenocortical disease, 251 in adrenocortical insufficiency, 260–261 in iron deficiency anemia, 137 Weight gain, in adrenocortical disease, 251 in congestive heart failure, 79, 89 Weight loss, in complex nursing care situation, 593–594 in hyperthyroidism, 240 in laryngeal cancer, 64 in testicular cancer, 303 in type 2 diabetes mellitus, 230 urinary incontinence and, 438 Wheezing, in asthma, 53 in burn injury, 550 in myocardial ischemia, 70

Index

633