Introduction

Replacement of bone marrow by abnormal cells results in unregulated proliferation
of immature white blood cells entering the circulatory system. These leukemic cells
may also enter the liver, spleen, or lymph nodes, causing these areas to enlarge.
Leukemia is classified according to the type of cell it is derived from, lymphocytic
or myelocytic, and as either acute or chronic. Lymphocytic leukemias involve imma-
ture lymphocytes originating in the bone marrow and typically infiltrate the spleen,
lymph nodes, or central nervous system. Myelogenous or myelocytic leukemia
involves the myeloid stem cells in the bone marrow and interferes with the matura-
tion of all blood cell types (granulocytes, erythrocytes, thrombocytes).
The exact cause of leukemia is unknown. There is a higher incidence in people
who have been exposed to high levels of radiation, who have had exposure to ben-
zene, or who have a history of aggressive chemotherapy for a different type of can-
cer. There may be a genetic predisposition to develop acute leukemia. Patients
with Down’s syndrome, Fanconi’s anemia, or a family history of leukemia also
have a higher-than-average incidence of this disease.

SIGNS AND SYMPTOMS

• Acute patients:
• Fatigue and weakness due to anemia
• Fever due to increased susceptibility to infection
• Bleeding, petechiae, ecchymosis (bruising), epistaxis (nosebleed), gingival
(gum) bleeding—due to decreased platelet count
• Bone pain due to bone infiltration and marrow expansion
• Lymph nodes (lymphadenopathy) enlarged as leukemic cells invade nodes
• Liver (hepatomegaly) and spleen (splenomegaly) enlarged as leukemic cells
invade
• Headache, nausea, vomiting, and weight loss
• Papilledema, cranial nerve palsies, seizure if there is central nervous sys-
tem involvement
• Chronic patients:
• Fatigue due to anemia
• Weight loss due to chronic disease process and loss of appetite
• Poor appetite
• Enlarged lymph nodes (lymphadenopathy) due to infiltration of lymph nodes
• Enlarged spleen (splenomegaly) due to involvement of the spleen



TREATMENT
• Acute myelogenous leukemia.
• Administer an anthracycline (idarubicin or daunorubicin) plus cytarabine.

• Combination: Daunorubicin, vincristine, prednisone, asparaginase.
• Administer platelet transfusions.
• Administer Filgrastim for neutropenia.
• Administer antibiotics for infections.
• Bone marrow transplant.
• Administer immunosuppressives to avoid transplant rejection.
• Chronic myelogenous leukemia.
• Administer Signal transduction inhibitor:
• Imatinib
• Interferon-α
• Busulfan
• Hydroxyurea
• Chronic lymphocytic leukemia.
• Administer alkylating agents:
• cyclophosphamide
• chlorambucil
• Administer antienoplastics:
• Vincristine
• Prednisone
• Doxorubicin
• Monoclonal antibody targeted therapy:
• alemtuzumab

• Combination of fludarabine and rituxumab.
• Transfusion if hemolytic anemia or bleeding:
• Packed RBCs.
• Whole blood.
• Platelets.
• Bone marrow transplant and immunosuppression.
• High protein diet.

NURSING DIAGNOSES

• Risk for infection
• Chronic pain
• Imbalanced nutrition, less than what body requires

NURSING INTERVENTION

• Monitor for bleeding—platelet count may be decreased.
• Monitor for infection—patients have increased susceptibility to infection.
• Monitor pain control.
• Small, frequent meals.
• Teach patients about infection control:
• Avoid others with infection.
• Report signs of infection, sore throat, fevers, etc.
• Explain to the patient:
• Use an electric razor.
• Use soft toothbrush.
• Watch for bleeding or bruising.

Introduction

The patient is missing a coagulation factor that is essential for normal blood
clotting and as a result the blood does not clot when the patient bleeds. It is an
X-linked recessive inherited disorder, passed on so that it presents symptoms in
males, and rarely in females. Hemophilia A is the result of missing clotting factor
VIII. Hemophilia B is the result of missing clotting factor IX and is also known as
Christmas disease.

SIGNS AND SYMPTOMS

• Tender joints due to bleeding
• Swelling of knees, ankles, hips, and elbows due to bleeding
• Blood in stool (tarry stool) due to GI blood loss
• Blood in the urine (hematuria)




TREATMENT

• Avoid aspirin.
• For hemophilia A administer factor VIII concentrates.
• Cryoprecipitate.
• DDAVP for patients with mild deficiency.
• For hemophilia B administer factor IX concentrates.

NURSING DIAGNOSES

• Acute pain
• Impaired gas exchange

NURSING INTERVENTION

• No IM injections.
• No aspirin.
• To stop bleeding:
• Elevate site.
• Apply direct pressure to the site.
• Explain to the patient:
• Wear a medical alert identification.
• Contact physician for any injury.
• Avoid situations where injury might occur.

Introduction

The body is unable to absorb Vitamin B12, which is needed to make RBC, result-
ing in a decreased RBC count. More common in people of northern European
descent, the anemia typically develops in adulthood. The intrinsic factor is nor-
mally secreted by the parietal cells of the gastric mucosa and are necessary to
allow intestinal absorption of vitamin B12. Destruction of the gastric mucosa due
to an autoimmune response results in loss of parietal cells within the stomach. The
ability of vitamin B12 to bind with intrinsic factor is lost, decreasing the amount
that is absorbed. Typical onset is between the ages of 40 and 60.

SIGNS AND SYMPTOMS

• Pallor due to anemia
• Weakness and fatigue due to anemia
• Tingling in hands and feet—“stocking-glove paresthesia”—due to bilateral
demyelination of dorsal and lateral columns of spinal cord nerves
• Diminished vibratory and position sense
• Poor balance due to effect on cerebral function
• Dementia appears later in the disease
• Atrophic glossitis—beefy red tongue
• Nausea may lead to anorexia and weight loss
• Premature graying of hair




TREATMENT

Lifelong replacement with vitamin B12 will correct the anemia and improve the neu-
rologic changes that have occurred. Initially the patient is given weekly injections of B12 to combat the deficiency. The injections eventually become monthly for lifelong
maintenance. Oral supplementation is not effective in these patients because they
cannot adequately absorb vitamin B12 due to insufficient intrinsic factor.
• Administer vitamin B12 by IM injection.
• Transfusion of packed RBC if anemia is severe.


NURSING DIAGNOSES

• Impaired gas exchange
• Imbalanced nutrition, less than what body requires
• Risk for injury

NURSING INTERVENTION

• Prevent injuries.
• Explain to the patient:
• Use soft toothbrush due to oral changes.
• Avoid activities that could lead to injury due to paresthesias or changes in
balance.
• Inspect feet each day for injury due to paresthesia.

Introduction

A lower-than-normal amount of iron in blood serum results in decreased formation
of hemoglobin and a decreased ability for the blood to carry oxygen. Iron stores are
typically depleted first, followed by serum iron levels. Iron deficiency may be due
to blood loss, dietary deficiency, or increased demand due to pregnancy or lactation.
As red blood cells age, the body breaks them down and the iron is released. This iron
is reused for the production of new blood cells. A small amount of iron is lost daily
through the GI tract, necessitating dietary replacement. When RBCs are produced
without a sufficient amount of iron, the cells are smaller and paler than usual.

SIGNS AND SYMPTOMS

• Weakness due to anemia and tissue hypoxia
• Pallor due to decreased amount of oxygen getting to surface tissues
• Fatigue due to anemia and hypoxemia
• Koilonychia—thin, concave nails raised at edges, also called spoon nails
• Tachycardia and tachypnea on exertion due to increased demand for oxygen



TREATMENT

Iron replacement therapy is continued to correct the deficiency and replace the lost
stores of iron in the body. The typical timeframe for oral therapy is to continue for
3 to 6 months after the anemia has been corrected. There have been documented
incidents of anaphylactic reactions to iron dextran. Patients new to this treatment
typically have a smaller test dose initially, prior to the initiation of treatments.
• Administer iron to replace what has been lost to return stores to normal levels:
• Oral replacement in split doses (three times a day):
• ferrous sulfate
• ferrous gluconate
• ferrous fumarate

• Parenteral iron replacement for those who cannot tolerate or do not respond
to oral therapy, have gastrointestinal illness, or continued bleeding:
• iron dextran given deep IM or IV
• iron sodium gluconate given IV
• iron sucrose complex given IV
• IM injection of iron using Z-track method.
• Increase dietary intake of iron.


NURSING DIAGNOSES

• Imbalanced nutrition, less than what body requires
• Activity intolerance

NURSING INTERVENTION

• Monitor intake and output.
• Monitor vital signs for tachycardia or tachypnea.
• Monitor for reactions to parenteral iron therapy.
• Explain to the patient:
• Check for bleeding.
• Increase iron in diet.
• Teach dietary sources of iron.

Introduction
The bone marrow stops producing a sufficient amount of RBC, WBC, and platelets,
thereby increasing the risk of infection and hemorrhage. The red cells remaining in
circulation are normal in size and color. This may be due to chemical exposure, high-
dose radiation exposure, or exposure to toxins. Cancer treatments such as radiation
therapy and chemotherapeutic agents may suppress bone marrow function, which
will result in anemia (low RBC), thrombocytopenia (low platelets), and leukopenia
(low WBC). The cause may also be unknown or idiopathic.

SIGNS AND SYMPTOMS

• Fatigue due to hypoxemia
• Weakness due to tissue hypoxia
• Pallor due to lack of oxygen reaching superficial tissues due to anemia
• Infections due to low white blood cell production, causing decreased ability
to fight infection
• Bruising (ecchymosis), and tiny subcutaneous (SC) hemorrhages (petechiae)
due to decrease in platelets, altering clotting ability
• Bleeding from mucous membranes (GI tract, mouth, nose, vagina)



TEST RESULTS
• Low hemoglobin.
• Low hematocrit.
• Low RBC count.
• Thrombocytopenia—low platelet count.
• Leukopenia—low WBC.
• Reticulocyte count low.
• Positive fecal occult blood test.
• Decreased cell counts in bone marrow biopsy as body stops producing.

TREATMENT

• Administer hematopoietic growth factor to correct anemia in patients with
low erythropoietin levels:
• erythropoietin, epoetin alfa (recombinant human erythropoietin) by SC
injection or IV
• Administer human granulocyte colony-stimulating factor (G-CSF) to correct
low WBC levels:
• filgrastim by SC injection or IV
• granulocyte-macrophage colony-stimulating factor (GM-CSF) sargram-
ostim by IV infusion
• Packed RBC transfusions when anemia is symptomatic.
• Platelet transfusion for severe bleeding.
• Bone marrow transplant replaces functioning stem cells.
• Administer immunosuppressive drugs, antithymocyte globulin, and cortico-
steroids.
• Splenectomy when spleen is enlarged and destroying RBCs.

NURSING DIAGNOSES

• Risk for infection
• Activity intolerance
• Risk for deficient fluid volume

NURSING INTERVENTION

• Monitor vital signs for changes.
• Record intake and output of fluids.
• Protect patient from falls.
• Avoid IM injections due to altered clotting ability.
• Explain to the patient:
• No aspirin due to effect on platelet aggregation (clotting ability).
• Plan to take rest periods during activities due to fatigue.
• Only use an electric razor to decrease risk of bleeding due to decreased
platelet count.
• Call your physician, nurse practitioner, or physician assistant for signs of
bleeding or bruising.

Introduction
A low hemoglobin or red blood cell (RBC) count results in decreased oxygen-
carrying capability of the blood. This may be due to blood loss, damage to the red
blood cells due to altered hemoglobin or destruction (hemolysis), nutritional defi-
ciency (iron, vitamin B12, folic acid), lack of RBC production, or bone marrow
failure. Some patients have a family history of anemia due to genetic transmission,
such as thalassemia or sickle cell.

SIGNS AND SYMPTOMS

• Fatigue due to hypoxia from less oxygen being available to the tissues of
the body
• Weakness due to hypoxia
• Pallor due to less oxygen being available to the surface tissues
• Tachycardia as the body attempts to compensate for less available oxygen by
beating more rapidly to increase blood supply
• Systolic murmur due to increased turbulence of blood flow
• Dyspnea or shortness of breath due to hypoxia as body attempts to get more
oxygen
• Angina as the myocardium is not getting enough oxygen

• Headache due to hypoxia
• Lightheadedness due to hypoxia
• Bone pain due to increased erythropoiesis as body attempts to correct anemia
• Jaundice in hemolytic anemia due to increased levels of bilirubin as red blood
cells break down

TEST RESULTS

• Hemoglobin level low.
• Hematocrit level low.
• RBC count low.


TREATMENT

Correction of the underlying cause is necessary. Treatment may include dietary
modifications and supplementations. See specific anemias below.

NURSING DIAGNOSIS

• Fatigue
• Activity intolerance

NURSING INTERVENTION

• Check vital signs for changes.
• Monitor CBC—hemoglobin, RBC, MCV, MCH, RDW.
• Plan nursing care based on patient tolerance of activity.
• Monitor for angina.

How the Hematologic System Works
The hematologic system refers to the blood and blood-forming organs. The forma-
tion of red blood cells, white blood cells, and platelets begins in the bone marrow.
Stem cells are produced in the bone marrow. Initially, these cells are not differen-
tiated and may become red blood cells (RBCs), white blood cells (WBCs), or
platelets. In the next stage of development, the stem cell becomes committed to a
particular precursor cell, to become either a myeloid or lymphoid type of cell and
will differentiate into a particular cell type when in the presence of a specific
growth factor.
The spleen is found in the left upper quadrant of the abdomen. The spleen fil-
ters whole blood. It removes old and imperfect white blood cells, lymphocytes and
macrophages, and RBCs. The spleen also breaks down hemoglobin and stores of
RBCs and platelets.

The liver is found in the right upper quadrant of the abdomen and is the main
production site for many of the clotting factors, including prothrombin. Normal
liver function is important for vitamin K production in the intestinal tract. Vitamin
K is necessary for clotting factors VII, IX, X, and prothrombin.

WHAT WENT WRONG?
Infectious pneumonia may be due to a variety of microorganisms and can be
community-acquired or hospital-acquired (nosocomial). Apatient can inhale bacteria,
viruses, parasites, or irritating agents, or a patient can aspirate liquids or foods. He
or she can also develop increased mucous production and thickening alveolar fluid
as a result of impaired gas exchange. All of these can lead to inflammation of the
lower airways.
Organisms commonly associated with infection include Staphylococcus
aureus, Streptococcus pneumoniae, Haemophilus influenza, Mycoplasma pneumo-
niae, Legionella pneumonia, Chlamydia pneumoniae (parasite), and Pseudomonas
aeruginosa.

PROGNOSIS
Prognosis will vary depending on patient’s age, preexisting lung disease, infect-
ing organism and response to antibiotics. Patients at risk for pneumonia are: older
patients; those with respiratory disease; patients with comorbid conditions such
as heart, liver, or kidney disease; and patients who develop complications (such as
atelectasis or pleural effusion). Patients at greater risk for complications from
pneumonia will be treated within the hospital, while those at lower risk may be
treated at home. Patients with respiratory rates over 30, tachycardia, altered men-
tal status, or hypotension also are considered higher-risk.
Patients without other coexisting conditions, who do not appear to have the
higher-risk symptoms listed above, can usually be safely treated as outpatients.
Patients with comorbidities (higher-risk coexisting symptoms) or who appear ill
are usually treated in the hospital. Some require critical care treatments and must
be closely monitored. There is still a significant mortality rate from pneumonia,
despite the recognition of pneumonia and use of antibiotics.


SIGNS AND SYMPTOMS

• Shortness of breath due to inflammation within the lungs, impairing gas
exchange
• Difficulty breathing (dyspnea) due to inflammation and mucus within the
lungs
• Fever due to infectious process
• Chills due to increased temperature
• Cough due to mucous production and irritation of the airways
• Crackles due to fluid within the alveolar space and smaller airways
• Rhonchi due to mucus in airways; wheezing due to inflammation within the
larger airways
• Discolored, possibly blood-tinged, sputum due to irritation in the airways or
microorganisms causing infection
• Tachycardia and tachypnea as the body attempts to meet the demand for
oxygen
• Pain on respiration due to pleuritic inflammation, pleural effusion, or atelec-
tasis development
• Headache, muscle aches (myalgia), joint pains, or nausea may be present
depending on the infecting organism

TEST RESULTS

• Shadows on chest x-ray, indicating infiltration, may be in a lobar or seg-
mental pattern or more scattered.
• Culture and sensitivity of the sputum to identify the infective agent and the
appropriate antibiotics.
• Elevated WBC (leukocytosis) showing sign of infection.
• Low oxygen saturation on pulse oximetry.
• Arterial blood gas may show low oxygen and elevated carbon dioxide levels.

TREATMENT

Supplemental oxygen is given to help meet the body’s needs. Antibiotics
are given for the most likely organism (empirically) until the sputum culture
results are returned. Patients may need bronchodilators to help open the
airways.
• Administer oxygen as needed.
• For bacterial infections, administer antibiotics such as macrolides (azithro-
mycin, clarithromycin), fluoroquinolones (levofloxacin, moxifloxacin),
beta-lactams (amoxicillin/clavulanate, cefotaxime, ceftriaxone, cefuroxime
axetil, cefpodoxime, ampicillin/sulbactam), or ketolide (telithromycin).
• Administer antipyretics when fever >101 for patient comfort:
• acetaminophen, ibuprofen
• Administer brochodilators to keep airways open, enhance airflow if needed:
• albuterol, metaproterenol, levalbuterol via nebulizer or metered dose
inhaler
• Increase fluid intake to help loosen secretions and prevent dehydration.
• Instruct the patient on how to use the incentive spirometer to encourage deep
breathing; monitor progress.

NURSING DIAGNOSES

• Risk for aspiration
• Impaired ventilation
• Ineffective airway clearance

NURSING INTERVENTION

• Monitor respiration for rate, effort, use of accessory muscles, skin color, and
breath sounds.
• Record fluid intake and output for differences, signs of dehydration.
• Record sputum characteristics for changes in color, amount, and consistency.
• Properly dispose of sputum.
• Explain to the patient:
• Take adequate fluids—3 liters per day—to prevent excess fluid loss through
the respiratory system with exhalation.
• Use of incentive spirometer.

WHAT WENT WRONG?
Lung cancer is the abnormal, uncontrolled cell growth in lung tissues, resulting in
a tumor. A tumor in the lung may be primary when it develops in lung tissue. It
may be secondary when it spreads (metastasizes) from cancer in other areas of the
body, such as the liver, brain, or kidneys. There are two major categories of lung
cancer—small cell and non-small cell. Repetitive exposure to inhaled irritants
increases a person’s risk for lung cancer. Cigarette smoke, occupational exposures,
air pollution containing benzopyrenes, and hydrocarbons have all been shown to
increase risk.
• Small cell:
• Oat cell—fast-growing, early metastasis
• Non-small cell:
• Adenocarcinoma—moderate growth rate, early metastasis
• Squamous cell—slow-growing, late metastasis
• Large cell—fast-growing, early metastasis

PROGNOSIS

Lung cancer is the leading cause of cancer death. Many patients with lung cancer
are diagnosed at a later stage, leading to the long-term (5-year) survival rate of less
than 20 percent. Earlier diagnosis is more beneficial for treatment and outcome.
The longer the cancer has been in the lungs, the greater the likelihood of metasta-
sis to other areas.

SIGNS AND SYMPTOMS

• Coughing due to irritation from mass. Presence of mucous or exudate may
not be until later in disease.
• Coughing up blood (hemoptysis).
• Fatigue.
• Weight loss due to the caloric needs of the tumor, taking away from the needs
of the body.
• Anorexia.
• Difficulty breathing (dyspnea) caused by damaged lung tissue. The patient
begins to have respiratory problems later in the disease.
• Chest pains as mass presses on surrounding tissue; may not be until late in
disease.
• Sputum production.
• Pleural effusion.

TEST RESULTS

• Mass in lung shown on chest x-ray.
• CT scan shows mass, lymph node involvement.
• Bronchoscopy may show cancer cells on bronchoscopic washings; may reveal
tumor site.
• Cancer cells seen in sputum.
• Biopsy will show cell type:
• Needle biopsy through chest wall for peripheral tumors.
• Tissue biopsy from lung for deeper tumors.
• Bone scan or CT scans shows metastasis of the disease.

TREATMENT

Treatment is focused on resolution of the tumor. Surgical removal is appropriate
for some patients, but not always necessary. Chemotherapy and radiation are both
methods that are used to destroy the cancerous cells. Oxygen therapy is used to aid
in meeting the current needs of the body, but not all patients will require supple-
the body. Pain control is an integral component of care in any type of cancer treat-
ment. Appropriate pain management needs to be individualized for the patient.
• Surgical removal of affected area of the lung (wedge resection, segmental
resection, lobectomy) or total lung (pneumonectomy).
• Radiation therapy to decrease tumor size.
• Chemotherapy often with a combination of drugs:
• cyclophosphamide, doxorubicin, vincristine, etoposide, cisplatin
• may see relapse after treatment
• Oxygen therapy to supplement the needs of the body.
• High-protein, high-calorie diet to meet the needs of the body.
• Administer antiemetics to combat side effects of chemotherapy:
• ondansetron, prochlorperazine
• Administer analgesics for pain control:
• morphine, fentanyl

NURSING DIAGNOSES

• Anxiety
• Activity intolerance
• Impaired gas exchange

NURSING INTERVENTION

• Monitor respiratory status, looking at rate, effort, use of accessory muscles,
and skin color; auscultate breath sounds.
• Monitor pain and administer analgesics appropriately.
• Monitor vital signs for changes, elevated pulse, elevated respiration, change
in BP, and elevated temperature, which may signal infection.
• Monitor pulse oximetery for decrease in oxygenation levels.
• Assist patient with turning, coughing, and deep-breathing exercises.
• Place patient in semi-Fowler’s position to ease respiratory effort.
• Explain to the patient:
• The importance of taking rest periods.
mental oxygen therapy. Attention to nutrition is important to meet the demands of

WHAT WENT WRONG?
Chronic inflammation reduces the flexibility of the walls of alveoli, resulting in
over-distention of the alveolar walls. This causes air to be trapped in the lungs,
impeding gas exchange. Smoking is often linked to development of emphysema.
A less frequent cause is an inherited alpha1-antitrypsan deficiency.

PROGNOSIS
Symptoms often begin insidiously and are progressive. Shortness of breath is ini-
tially associated with exertion, then presents at rest. These patients are more sus-
ceptible to lung infections. Supplemental oxygen becomes necessary at first for
exacerbations, then for daily use. Periodic exacerbations requiring hospitalization
are not unusual.

SIGNS AND SYMPTOMS

• Difficulty breathing (dyspnea) due to air trapping, which retains carbon
dioxide and reduces alveolar gas exchange.
• Barrel chest develops over time as more air is trapped within the distal air-
ways. The anteroposterior diameter (distance between front and back of the
chest) increases, giving the chest a more barrel-like appearance.
• Use of accessory muscles to breathe as the respiratory effort increases. The
number of muscles used to inhale will increase in an effort to get enough
oxygen into the body.
• Loss of weight as extra calories are needed to maintain respiration. Increased
effort of breathing also detracts from eating.
• Patients prefer a seated position which allows for greater chest expansion.

TEST RESULTS
• Increased residual volume shown in pulmonary function test due to air
trapping.
• Decreased oxygen and increased carbon dioxide in arterial blood gas as gas
exchange is impaired due to air trapping; more pronounced as disease pro-
gresses.

TREATMENT

Treatment will vary depending on the stage of the emphysema. As the disease pro-
gresses the treatment will change. Medications to control symptoms and keep air-
ways open, use of supplemental oxygen, and smoking cessation are the mainstays
of treatment.
• Administer beta2-agonists to bronchodilate by inhaler or nebulizer:
• terbutaline, albuterol, levalbuterol
• Administer long-acting bronchodilating medications by metered dose inhaler
or dry powder inhaler:
• formoterol, salmeterol
• Administer anticholinergics which allow for relaxation of bronchial smooth
muscle:
• ipratropium, tiotropium inhaler
• Administer methylxanthines to dilate the bronchi. These are typically used
in conjunction with other medications, not for acute effect:
• aminophylline
• theophylline
• Administer steroids to decrease inflammation within the airways:
• hydrocortisone, methylprednisolone systemically
• beclomethasone, triamcinolone, fluticasone, budesonide, flunisolide in-
halers
• prednisolone, prednisone orally
• Chest x-ray shows overinflation of lungs and flattening of the diaphragm.

• Administer antacid, H2 blocker, or proton pump inhibitor to decrease the
amount of acid in stomach, reducing possible ulcer formation due to stress
of the disease or medication effects:
• antacids: aluminum hydroxide/magnesium hydroxide, calcium carbonate
• H2 blockers: ranitidine, famotidine, nizatidine, cimetidine
• Proton pump inhibitors: omeprazole, lansoprazole, esomeprazole, rabepra-
zole, pantoprazole
• Administer expectorant—to loosen secretions:
• guaifenesin
• Administer diuretics to decrease fluid retention in patients that are develop-
ing right-sided heart failure secondary to lung disease:
• furosemide, bumetanide
• Administer vaccines—to prevent respiratory infections:
• influenza
• pneumonia
• Administer antibiotics:
• selected based on results of culture and sensitivity study or given empirically
• Administer alpha1-antitrypsin therapy for patients with deficiency.
• Administer oxygen, 2 liters per minute, to help meet body’s oxygen needs
while avoiding CO2 retention.
• Give patient 3 liters of fluids per day to help liquefy secretions.
• Nocturnal negative pressure ventilation for hypercapnic (elevated CO2 levels)
patients.
• Teach patient how to use:
• the incentive spirometer to encourage deep breathing and enhance cough-
ing and expelling of mucous.
• the flutter valve to increase expiration force.

NURSING DIAGNOSES

• Impaired gas exchange
• Fatigue
• Risk for infection

NURSING INTERVENTION

• Monitor the patient’s sputum for color, amount, or changes in characteristics,
which may indicate infection.
• Place patient in high Fowler’s position, which eases respiratory effort.
• Administer low-flow oxygen, which increases oxygen delivered to patient
without compromising respiratory drive.
• Monitor intake and output fluids.
• Explain to the patient:
• The importance of turning, coughing, and deep-breathing exercises.
• How to administer oxygen therapy.
• Avoid exposure to irritants and people with infections.

WHAT WENT WRONG?
Increased mucus production, caused by infection and airborne irritants that block
airways in the lungs, results in the decreased ability to exchange gases. There are
two forms of bronchitis: acute bronchitis, where blockage of the airways is re-
versible, and chronic bronchitis, where blockage is not reversible. Patients with
acute bronchitis are symptomatic typically for 7 to 10 days often due to viral (but
sometimes bacterial) infection. Patients with chronic bronchitis will have symp-
toms of a chronic productive cough for at least 3 consecutive months in 2 consec-
utive years. There is increased mucous production, inflammatory changes, and,
ultimately, fibrosis in the airway walls. The patient with chronic bronchitis has an
increased incidence of respiratory infection.

PROGNOSIS
Patients with acute bronchitis who have a resolution of symptoms and respiratory
status will return to normal condition. Chronic bronchitis is classified as a chronic
obstructive pulmonary disease (COPD), which is often linked to smoking and has
a progressive pattern. Shortness of breath is initially present only with exertion,
and eventually is present even at rest. Patients with chronic bronchitis often develop
right-sided heart failure and peripheral or dependent edema. Patients will have
acute exacerbations of chronic bronchitis.

SIGNS AND SYMPTOMS

• Cough due to mucous production and irritation of airways.
• Shortness of breath.
• Fever in acute episodes due to infection.
• Accessory muscles are used for breathing—as respiratory effort increases,
additional muscles are necessary to assist.
• Productive cough due to irritation of airways. Mucous is a protective reac-
tion of the respiratory system.
• Weight gain secondary to edema in chronic bronchitis is due to right-sided
heart failure.
• Wheezing due to inflammation within the airways.

TEST RESULTS
• Shadows in affected area of the lungs on the chest x-ray during infection.
• Pulmonary function testing shows:
• Forced vital capacity (FVC) changes because more time is needed to
forcibly exhale an amount of air after a maximal inhalation.
• FEV1 is decreased because more time is needed for exhalation.
• Residual volume (RV) is increased due to air trapping.
• Decreased oxygen and increased carbon dioxide in arterial blood gas.

TREATMENT
Acute bronchitis is treated in the short term with symptomatic treatment and
antibiotics when a bacterial infection is present. Chronic bronchitis is treated with
a combination of medications to keep the airways open, reduce inflammation
within airways, and prevent complications or exacerbations.
• Administer beta2-agonists by inhaler or nebulizer to dilate the bronchi:
• terbutaline, albuterol, levalbuterol
• formoterol, salmeterol
• Administer anticholinergics which allow for relaxation of bronchial smooth
muscle:
• ipratropium, tiotropium inhaler
• Administer steroids to decrease inflammation within the airways
• hydrocortisone, methylprednisolone systemically
• beclomethasone, triamcinolone, fluticasone, budesonide, flunisolide inhalers
• prednisolone, prednisone orally
• Administer methylxanthines to enhance bronchodilation:
• aminophylline
• theophylline (Theo-Dur)
• Administer diuretics to reduce fluid retention in patients who develop right-
sided heart failure:
• furosemide, bumetanide
• Administer expectorant to help liquefy secretions:
• guaifenesin
• Administer antibiotics in acute exacerbation of chronic bronchitis:
• selected by culture and sensitivity study or given empirically
• Administer antacid, H2 blocker, or proton pump inhibitor to decrease the
amount of acid in stomach, reducing possible ulcer formation due to stress
of disease or medication effects.
• antacids: aluminum hydroxide/magnesium hydroxide, calcium carbonate
• H2 blockers: ranitidine, famotidine, nizatidine, cimetidine
• proton pump inhibitors: omeprazole, lansoprazole, esomeprazole, rabepra-
zole, pantoprazole
• Administer vaccines—to decrease chances of infection:
• influenza
• pneumonia
• Give 3 liters of fluid per day to help liquefy secretions
• Oxygen: 2 liters per minute via nasal canula to help meet body’s needs; low
flow rates help reduce dyspnea while avoiding CO2 retention.
• Increase protein, calories, and vitamin C in diet to meet body’s needs.
• Administer the incentive spirometer or flutter valve to encourage coughing
and expelling of mucous.
• Nocturnal negative pressure ventilation used for hypercapnic (elevated CO2
levels) patients.

NURSING DIAGNOSES
• Ineffective airway clearance
• Activity intolerance
• Ineffective breathing pattern

NURSING INTERVENTION
• Monitor respirations looking at rate, effort, use of accessory muscles, skin
color; listen to breath sounds.
• Place patient in high Fowler’s position to ease respiration.
• Weigh the patient daily. Excess fluid due to heart failure will increase weight.
Notify physician, NP, or PA of weight gain of 2 pounds in 24 hours.
• Have the patient perform the turning, coughing, and deep-breathing exer-
cises to enhance lung expansion and expel mucous.
• Monitor sputum for changes in color or amount, which may signal infection
in patients with chronic bronchitis.
• Monitor intake and output.
• Increase fluids to keep mucous thinner and easier to expel.
• Explain to the patient:
• How to administer oxygen.

WHAT WENT WRONG?
Bronchi and bronchioles become abnormally and permanently dilated, caused by
infection and inflammation. This results in excessive production of mucous that
obstructs the bronchi. There is some obstruction of the airways and a chronic
infection. The changes within the lung can be localized or generalized. The lung
may develop areas of atelectasis where thick mucous obstructs the smaller air-
ways, making the mucous difficult to expel. This results in inflammation and
infection of the airways and leads to bronchiectasis.

PROGNOSIS
Early diagnosis and appropriate treatment of infections are essential for manage-
ment. Postural drainage and chest physical therapy aid in movement of mucous
from the airways. The difficulty in breathing is caused by excess mucus similar to
patients with Chronic Obstructive Pulmonary Disease (COPD) (emphysema or
chronic bronchitis).

SIGNS AND SYMPTOMS

• Difficult breathing (dyspnea) due to the mucous production and irritation
within the airways.
• Productive, foul-smelling odorous cough, due to thick, difficult-to-expel,
tenacious mucous, often with bacterial colonization.
• Cough may be worse when lying down.
• Recurrent bronchial infections.
• Hemoptysis (blood-tinged or bloody mucous).
• Loss of weight because patients are not eating well, due to respiratory
changes and foul-smelling mucous with cough. Increased respiratory effort
requires more calories to meet normal requirements.
• Crackles or rhonchi on inspiration due to mucous build-up.
• Anemia of chronic disease.
• Cyanosis.
• Clubbing of the fingers.

TEST RESULTS
• Culture and sensitivity of sputum to identify bacteria and appropriate anti-
biotics.
• Shadows in affected area of the lungs on the chest x-ray.
• CT scan or high-resolution CT will show areas of bronchiectasis.
• Decreased lung vital capacity on pulmonary function test.

TREATMENT
Treatment is focused on getting enough oxygen to meet current needs of the patient,
expel mucous, and treat infections.
• Supplemental oxygen to help meet body’s needs.
• Postural drainage to assist with drainage of secretions.
• Chest PT to loosen secretions.
• Remove excessive secretions during a bronchoscopy.
• Administer bronchodilators to help keep airways open:
• albuterol, levalbuterol
• Administer antibiotics to treat infection:
• selected based on the results of a culture and sensitivity study

NURSING DIAGNOSES
• Ineffective airway clearance
• Imbalanced nutrition: less than what the body requires

NURSING INTERVENTION
• Monitor respiratory rate, effort, breath sounds, skin color, and use of acces-
sory muscles.
• Impaired gas exchange
• Perform chest percussion to help loosen secretions.
• Explain to the patient:
• That family member can perform chest PT.
• How to do postural drainage.
• How to administer oxygen.
• How to properly administer medications.

WHAT WENT WRONG?
The airways become obstructed from either inflammation of the lining of the air-
ways or constriction of the bronchial smooth muscles (bronchospasm). A known
allergen, for example, pollen—is inhaled, causing activation of antibodies that rec-
ognize the allergen. Mast cells and histamine are activated, initiating a local inflam-
matory response. Prostaglandins enhance the effect of histamine. Leukotrienes also
respond, enhancing the inflammatory response. White blood cells responding to the
area release inflammatory mediators.
Astimulus causes an inflammatory reaction, increasing the size of the bronchial
linings; this results in restriction of the airways. There may be a bronchial smooth
muscle reaction at the same time. There are two kinds of asthma:
• Extrinsic asthma, also known as atopic, caused by allergens such as pollen,
animal dander, mold, or dust. Often accompanied by allergic rhinitis and
eczema; this may run in families.
• Intrinsic asthma, also known as nonatopic, caused by a nonallergic factor
such as following a respiratory tract infection, exposure to cold air, changes
in air humidity, or respiratory irritants.

PROGNOSIS
Triggers for the asthmatic patient can often be identified and avoided. Patients can
learn to check peak flow levels and manage symptoms in conjunction with their
caregiver. Well controlled asthma typically has temporary, reversible exacerba-
tions that can be controlled with medications, often in an outpatient setting. With

frequent attacks, a mild exposure to a known trigger will often be sufficient to
exacerbate an attack. Patients who do not respond to medications or who use med-
ications improperly may die during an asthma attack.


SIGNS AND SYMPTOMS

• Wheezing initially present on expiration continues throughout respiratory
cycle as inflammation progresses. Air has difficulty moving through the nar-
rowed airways, making noise. Not all asthmatics will have wheezing.
• Asymptomatic between asthma attacks. Symptoms resolve when there is no
inflammation present.
• Difficulty breathing (dyspnea) as airways narrow due to inflammation. This
is typically progressive as inflammation increases.
• Respiration greater than 20 breaths per minute (tachypnea) as the body
attempts to get more oxygen into the lungs to meet physiologic needs.
• Use of accessory muscles to breathe as the body tries harder to get more air
into the lungs.
• Tightness in the chest due to narrowing of the airways (bronchoconstriction).
• Cough.
• Tachycardia—heart rate greater than 100, as the body attempts to get more
oxygen to the tissues.

TEST RESULTS

• Decreased oxygen and increased carbon dioxide present in arterial blood gas
due to inability to move adequate air, which results in inadequate gas exchange.
• Decreased force on expiration [either forced expiratory volume in the first
second (FEV1) or peak expiratory rate flow (PERF)] during attack shown in
pulmonary function test. Narrowed airways make it more difficult for the
patient to exhale, prolonging time of exhalation and decreasing force of exha-
lation. Patients can check expiratory effort at home on a peak flow meter.
• Hyperinflated lungs shown in chest x-ray due to air trapping.
• Pulse oximetry shows diminished oxygen saturation.
• CBC—elevated eosinophils.
• Sputum—positive for eosinophils.

TREATMENT
The focus of treatment is to return the respiratory status to normal, deliver ade-
quate oxygen, and limit the number of recurrences. Patient education should focus
on understanding the disease, its management, and when emergency care may be
necessary.
• Administer supplemental oxygen to help meet body’s needs.
• Identify and remove allergens and known triggers to avoid causing an asthma
attack.
• Give patient 3 liters/day of fluid to help liquefy any secretions.
• Administer short-acting beta2-adrenergic drugs to bronchodilate:
• albuterol, pirbuterol, metaproterenol, terbutaline, levalbuterol
• Administer long-acting beta2-adrenergic drugs to manage symptoms day to
day; keep airways open, not for acute symptoms:
• salmeterol, formoterol
• Administer leukotriene modulators to reduce local inflammatory response in
lung to reduce exacerbations; does not have immediate effect on symptoms:
• zafirlukast, zileuton, montelukast
• Administer anticholinergic drugs
• ipratropium inhaler, tiotropium handihaler
• Administer antacid, H2 blocker, or proton pump inhibitor to decrease the
amount of acid in the stomach, reducing the possibility of ulcers due to stress
of disease or medication effects.
• Antacids: aluminum hydroxide/magnesium hydroxide, calcium carbonate

• H2 blockers: ranitidine, famotidine, nizatidine, cimetidine
• Proton pump inhibitors: omeprazole, lansoprazole, esomeprazole, rabepra-
zole, pantoprazole
• Administer mast cell stabilizer to retain an early component of the initial
response to allergens, which will prevent further reactions from occurring;
this is not for acute symptoms. This is useful for pretreatment for allergen
exposure or chronic use to improve control of symptoms.
• cromolyn, nedocromil
• Administer steroids to decrease inflammation, which will help open airways;
these are not for acute symptoms:
• hydrocortisone, methylprednisolone intravenously
• beclomethasone, triamcinolone, fluticasone, budesonide, flunisolide, mo-
metasone inhalers
• prednisolone, prednisone orally
• Administer methylxanthines to assist with bronchodilation, often used when
other medications not effective:
• aminophylline, theophylline


NURSING DIAGNOSES

• Impaired gas exchange
• Ineffective airway clearance
• Ineffective tissue perfusion

NURSING INTERVENTION
• Monitor respiration: patient’s respiratory status can continue to deteriorate;
look at respiratory rate, effort, use of accessory muscles, skin color, breath
sounds.
• Place patient in high Fowler’s position to ease respirations.
• Monitor vital signs, look for changes in BP, tachycardia, tachypnea.
• Explain to the patient:
• How to use a peak flow meter.
• How to use the metered dose inhaler or dry powder and in which order to
take inhaled medication.
• Avoid exposure to allergen.
• How to recognize the early signs of asthma.
• How to perform coughing and deep-breathing exercises.

WHAT WENT WRONG?
Asbestos fibers enter the lungs, causing inflammation in the bronchioles and in the
walls of the alveoli. After inhalation, the fibers settle into the lung tissue. Fibrosis
develops and ultimately pleural plaques form. The changes within the lung result
in a restrictive lung disease. The damage to the lung causes impairment in breath-
ing and air exchange.
PROGNOSIS
It may take a decade or longer from the time of exposure before symptoms begin
to develop. Some patients have worked in occupations known for asbestosis ex-
posure (mining, shipyards, fireproofing, and construction before the mid-1970s),
for 10 or 15 years prior to symptom development. There is an increased risk of
lung cancer (mesothelioma) in patients with history of asbestosis exposure, espe-
cially if the patient has also smoked. Mesothelioma may develop 2 to 4 decades
postexposure.

SIGNS AND SYMPTOMS
• Difficulty breathing (dyspnea) on exertion and at rest due to changes in the
lung tissue
• Chest pain or tightness due to changes within the lung tissue and restrictive
air movement
• Dry cough due to irritation within the lungs
• Frequent respiratory infections due to changes within the lung, increasing
susceptibility to infection
• Respiration greater than 20 breaths per minute (tachypnea) due to decreased
vital capacity
• Rales or crackles when listening to breath sounds

TEST RESULTS

• Chest x-ray to reduce chance of illness. Lungs show linear opacities, irreg-
ular opacities. Opacities are increased tissue density on the lung indicating
fibrosis or pleural plaque.
• CT scan shows opacities indicating increased tissue density of fibrosis or
pleural plaque.
• Arterial blood gas shows decreased oxygen due to restrictive pattern of
respiration.
• Pulse oximetry shows decreased pattern.
• Pulmonary Function Test (PFT) shows a restrictive pattern, decreased vital
capacity.

TREATMENT
There is no specific treatment for asbestosis, nor is there a cure.
• Flu vaccine and pneumoccocal vaccine to reduce chance of illness.
• Oxygen therapy (1 to 2 liters per minute) to ease breathing discomfort by in-
creasing available oxygen to meet body’s needs.
• Administer antibiotics for exacerbations of respiratory symptoms—to treat
infectious process based on results of culture and sensitivity study or
empirically.

NURSING DIAGNOSES
• Fatigue
• Impaired gas exchange
• Imbalanced nutrition: less than the body requires

NURSING INTERVENTION
• Administer chest percussion and vibration to loosen and expel secretions.
• Explain to patient:
• How to avoid infections (reduced exposure to others with an infection and
vaccines administered according to physician’s orders).
• Proper use of oxygen therapy.

How the Respiratory System Works
The respiratory system has the following basic functions:
• Movement of air in and out of the lungs
• Exchange of oxygen and carbon dioxide
• Helping maintain acid-base balance
Ventilation moves air in (inspiration) and out (expiration) of the lungs. Dur-
ing inspiration, air flows in through the nose and passes into the nasopharynx.
Air is then drawn through the pharynx, larynx, trachea, and bronchi. The bronchi
branches (bifurcates) right and left into smaller tubes called bronchioles that ter-
minate in alveoli. The airways are lined with mucous membranes to add moisture
to the inhaled air. There is a thin layer of mucous in the airways that helps to trap
foreign particles, such as dust, pollen, or bacteria. Cilia—small, hair-like projec-
tions—help to move the mucous with the foreign material upward so it can be
coughed out.
Alveoli are air-filled sacs containing membranes coated with surfactant. The
surfactant helps the alveoli to expand evenly on inspiration and prevents collapse
on exhalation. Carbon dioxide and oxygen are exchanged; a higher concentration
of gas moves to the lower area of concentration. A higher concentration of carbon
dioxide in the hemoglobin moves across the membrane into the alveoli and is
expired by the lung. Higher concentration of oxygen in the alveoli crosses the
membrane and attaches to the hemoglobin which is then distributed by the circu-
latory system throughout the body.
Lungs are contained within a pleural sac in the thoracic cavity and operate on
negative pressure. The visceral pleura is close to the lungs and the parietal pleura
is close to the chest wall. There is a pleural space between these two layers that
contains a small amount of fluid to prevent friction with chest movement on inspi-
ration and expiration.

Gastrointestinal Complications

Following administration of anesthesia or pain medication, patients may experi-
ence nausea, vomiting, constipation, or paralytic ileus.

WHAT WENT WRONG?
Nausea is a common side effect of both anesthesia and pain medications. Apatient’s
reaction to anesthetic agents varies. Some patients have a lot of nausea after anes-
thesia that may last for several hours. Abdominal surgery may cause direct visceral
afferent stimulation, resulting in nausea and vomiting. Medications may act upon
the chemoreceptor trigger zone, located within the medulla outside the blood-brain
barrier. Once the patient begins vomiting, antiemetic medication may be necessary
to break the cycle. Opiod-based medications and decreased activity can both cause
slowing of peristaltic activity, leading to constipation. Patients having abdominal
procedures are at greater risk for paralytic ileus as a postoperative complication.

SIGNS AND SYMPTOMS

• Nausea as a side effect of medication
• Vomiting due to visceral afferent stimulation or activation of chemoreceptor
trigger zone
• Mild, generalized abdominal discomfort and distention with paralytic ileus
due to decreased intestinal motility
• Slow bowel sounds with constipation; absent bowel sounds with paralytic
ileus due to changes in intestinal motility

TEST RESULTS

• Electrolyte abnormality due to vomiting.
• Abdominal flat and upright x-ray shows stool in constipation, gas-filled intes-
tinal loops in paralytic ileus.

TREATMENT
• Monitor abdomen for distention; listen for bowel sounds.
• Assess for dehydration as a result of prolonged vomiting.
• Restrict oral intake in paralytic ileus or if nausea and vomiting are present.
• Nasogastric (NG) tube connected to suction to prevent vomiting in paralytic
ileus.
• Progress diet as tolerated once bowel sounds return and patient is passing
flatus rectally.
• Administer intravenous fluids.
• Administer total parenteral nutrition.
• Administer antiemetics as required.

NURSING DIAGNOSES
• Risk for imbalanced nutrition: less than what body requires
• Risk for imbalanced fluid volume
• Risk for delayed surgical recovery
• Risk for constipation
• Altered bowel elimination
NURSING INTERVENTIONS
• Ask patient about presence of nausea.
• Monitor vital signs for changes.
• Listen to bowel sounds; assess abdomen for distention.
• Monitor intravenous site for signs of infiltration, pain, and redness.
• Monitor intake and output.
• Monitor color and amount of fluid drained from NG tube.
• Ask patient if he or she is passing any flatus rectally or having bowel move-
ment.

The skin is the body’s first line of defense against infection. During surgery this
line of defense is penetrated. Even though the surgical procedure is performed in
as aseptic an environment as possible, the possibility of infection still exists.

WHAT WENT WRONG?
Wound infections can develop in the postoperative period. The wound may be
contaminated before surgery, such as with penetrating trauma, or may become
infected during healing. The surface of the skin has bacteria that are naturally
present, referred to as normal flora. These bacteria may enter the wound and cause
infection. Nosocomial infections can also occur at the surgical site, caused by
bacteria found elsewhere in the hospital. Infection within the surgical wound will
slow approximation of the wound edges, delaying wound healing.

SIGNS AND SYMPTOMS

• Increase in pain at surgical wound due to inflammatory process early in
infection
• Redness at wound edges that spreads if untreated
• Drainage from wound site due to body’s response to bacterial presence (change
in color and odor of drainage)
• Fever due to infection
• Elevated white blood cell count

TEST RESULTS

• Elevated WBC due to body’s response to bacterial presence.
• Elevated erythrocyte sedementation rate due to inflammation.
• Culture of wound area will identify organism.
• Sensitivity test will identify appropriate antibiotic treatment.

TREATMENT
• Obtain culture and sensitivity test of wound.
• Administer appropriate antibiotics intravenously.
• Keep wound site clean and dry.

NURSING DIAGNOSES
• Risk for infection
• Impaired skin integrity
• Impaired tissue integrity
• Delayed surgical recovery

NURSING INTERVENTIONS
• Monitor vital signs; look for fever.
• Assess surgical wound for redness, drainage.
• Ask patient about pain at surgical site.
• When obtaining wound culture, remove surface drainage with gauze, then
obtain specimen from within wound edge (this will ensure that the organism
is actually from the wound and not from the skin).

Patients with preexisting respiratory disorders, obesity, or thoracic or upper abdom-
inal surgical procedures are at greater risk of developing respiratory complications
postoperatively.

WHAT WENT WRONG?
After surgery, patients are not as mobile. This lack of physical activity leads to
diminished chest wall and diaphragmatic movement, resulting in a decreased
amount of air exchange. Alveolar sacs can collapse, leading to areas of atelectasis.

Pain medications can adversely affect respiratory status by decreasing respiratory
drive. Patients at increased risk for respiratory complications may develop pneu-
monia in the postoperative period due to diminished airflow, increased respiratory
secretions, and inflammatory processes. Patients with increased risk for clotting or
DVT, or those with hypercoagulable states are at risk for developing a pulmonary
embolism.

SIGNS AND SYMPTOMS

• Shortness of breath due to diminished airflow and resultant decreased oxy-
genation
• Chest pain in the area of atelectasis due to collapse of the alveolar sacs within
that area of the lung
• Productive cough due to pneumonia
• Fever due to infection in pneumonia
• Sudden onset chest pain and shortness of breath in pulmonary embolism as
clot blocks arterial blood flow within the lung
• Diminished oxygen levels as gas exchange is impaired in atelectasis, pneu-
monia, or pulmonary embolism

TEST RESULTS
• Pulse oximetry shows diminished oxygenation.
• Chest x-ray shows area of collapse in atelectasis, infiltrate in pneumonia,
wedge infiltrate in pulmonary embolism.
• CT scan shows alveolar collapse in atelectasis, area of infiltrate in pneumonia.
• Spiral CT or helical CT shows clot in pulmonary embolism.
• WBC elevated in bacterial pneumonia.

TREATMENT
• Administer supplemental oxygen.
• Administer antibiotics for pneumonia—initially intravenously, then orally:
• macrolides
• fluoroquinolones
• Administer blood-thinning agents to prevent enlarging of clot or developme
of new clots in pulmonary embolism.
• Mechanical ventilation if necessary.

NURSING DIAGNOSES
• Ineffective breathing pattern
• Ineffective airway clearance
• Impaired gas exchange
• Ineffective cardiopulmonary tissue perfusion

NURSING INTERVENTIONS
• Monitor vital signs for changes.
• Monitor respiratory status: check respiratory rate, rhythm, and depth; check
skin color; listen to breath sounds.
• Monitor pulse oximetry level for oxygenation.
• Monitor intravenous site for signs of infiltration.
• Encourage coughing and deep breathing exercises.
• Encourage incentive spirometer use.
• Encourage early ambulation.

WHAT WENT WRONG?
Patients may develop cardiovascular complications due to the physiological stress
of surgery, side effects of the anesthesia or other medications, or comorbidities.
Myocardial infarction (MI), cardiac arrhythmias, or hypotension are likely during
or in the immediate postoperative period. When getting the patient out of bed for
the first time after surgery, it is good practice to have the patient sit on the side of
the bed for a minute or two before standing up to ascertain if the patient feels dizzy
due to a drop in blood pressure associated with position change. Deep vein throm-
bosis (DVT) is a later vascular complication associated with inflammation and
decreased mobility after surgery.

SIGNS AND SYMPTOMS

• Chest pain which may radiate to back, neck, jaw, or arm due to ischemia in MI
• Shortness of breath due to altered cardiac output and tissue perfusion
• Dizziness or lightheadedness due to diminished cardiac output and cerebral
tissue perfusion or cardiac arrhythmia
• Palpitations due to cardiac arrhythmia
• Cardiac arrhythmias due to myocardial irritability—possibly due to ischemia,
medication side effect, or electrolyte imbalance
• Low blood pressure due to diminished cardiac output
• Unilateral calf pain and lower extremity swelling due to DVT

TEST RESULTS

• Cardiac monitor or EKG shows arrhythmia.
• BP below normal level.
• Doppler ultrasound of extremity shows clot within blood vessel.

TREATMENT
• Monitor cardiac rhythm.
• Administer antiarrhythmic medications to stabilize cardiac rhythm.
• Administer intravenous fluids to expand circulating blood volume to raise
blood pressure.
• Administer blood-thinning medications to decrease likelihood of clot enlarg-
ing or additional clots forming:
• heparin
• low–molecular weight heparin
• warfarin

NURSING DIAGNOSES
• Decreased cardiac output
• Ineffective cardiopulmonary tissue perfusion
• Ineffective peripheral tissue perfusion
• Impaired physical mobility

NURSING INTERVENTIONS
• Monitor vital signs for changes.
• Check blood pressure lying down and sitting up for orthostatic change.
• Monitor cardiovascular status for cardiac rhythm, heart sounds, peripheral
pulses, capillary refill, and pulse deficit.
• Assess for peripheral edema.
• Ask patient about calf pain or tenderness.
• Monitor intravenous site for signs of infiltration.
• Encourage ambulation and leg exercises to prevent development of DVT.
• Monitor proper use of elastic stockings or sequential compression devices
postoperatively.

After the surgery, the patient enters the postoperative period. The immediate post-
operative period requires close monitoring as the patient emerges from anesthesia.
The patient will then be transferred to either a same-day surgery area for discharge
home that day or an inpatient surgical unit for care. After discharge from the hospi-
tal, the patient may need home care. Return to full activities may take several weeks.

POSTANESTHESIA CARE
The patient is transferred from the operating room to the postanesthesia care unit
(PACU) for close monitoring in the immediate postoperative period. Initial assess-
ment is focused on ABC: airway, breathing, and circulation. Monitor the patient’s
airway, gas exchange, pulse oximetry, oxygen delivery, accessory muscle use, and
breath sounds. The patient can develop stridor due to edema or bronchospasm. The
cardiovascular status is checked next. Vital signs are checked every 15 minutes
until stabilized; pulse, blood pressure, and cardiac rhythm are monitored.
The surgical wound is checked for signs of drainage or bleeding. The dressing
is checked. The drains are checked for output and patency. Tubes that need to be
connected to suction (such as nasogastric tubes) are connected. Intravenous fluids
are monitored.
Neurologic assessment is performed to check level of consciousness. Following
general anesthesia, the patient follows a predictable progression in the return to
consciousness. Initially there is muscular irritability, and then restlessness followed
by pain recognition and the ability to reason and control behavior. Pupil responses
are monitored, looking for bilaterally equal responses to light. Motor responses are
monitored, looking initially for purposeful response to painful stimuli and later for
response to command. Pain management is begun during this time. As the anes-
thetic agent wears off, it is important to assess the patient’s level of pain. This may
be assessed through subjective information in patients who are conscious, or through
more objective signs in patients who are still in semiconscious states. Monitor for
changes in vital signs (elevated pulse and BP), changes in movement, and moan-
ing. Expected pain levels can be estimated from the type of surgery and give a start-
ing point for those patients as they begin to come out of the anesthesia.
Gastrointestinal status is monitored for presence of nausea or vomiting. This
may be a reaction or side effect to anesthesia. Check for abdominal distention and
presence of bowel sounds. Monitor drainage from nasogastric tube; note amount
and color of drainage.
Monitor laboratory results as indicated. Electrolyte levels, hemoglobin or hema-
tocrit levels, BUN and creatinine, arterial blood gases (ABGs), or other studies may
be necessary in the immediate postoperative period. The diagnostic studies neces-
sary will depend on the patient’s history, the estimated blood loss during surgery,
and the type of procedure performed.
After the initial recovery time, the stable patient who is transferred from the
PACU to the same-day surgical area continues to be monitored. Vital signs are
taken, although not as frequently. Respiratory and cardiovascular functions are
monitored. Cardiac rhythm is no longer monitored. The dressing is checked for
any drainage. Bowel sounds are checked. Clear fluids are given if the patient is not
experiencing nausea. Patients are monitored for urinary output prior to being dis-
charged to home.
Patients who are admitted to the hospital are transferred from the PACU to a
surgical unit. Vital signs, respiration, and cardiovascular status are checked. The
dressing is monitored for drainage; drainage tubes are monitored for output. Intra-
venous lines are monitored for signs of infiltration and proper flow rates. Bowel
sounds are monitored.
Patients who are unstable or who have had extensive procedures are transferred
to intensive care for close monitoring. Nurses who are used to caring for complex,
unstable patients care for these patients. Their vital signs are closely monitored.
Some patients will still be on mechanical ventilation.

POSTOPERATIVE COMPLICATIONS
The focus of care that is common for all of these postoperative patients is identi-
fication of complications. Common complications involve the cardiac, respiratory,
and gastrointestinal areas, and infections.

The intraoperative period is the time involved with the surgical procedure. The
focus during this time is on asepsis and protection of the patient. Within the oper-
ative suite, the staff wears scrub suits. They change into the scrub shirt and pants
when they get to the locker room within the surgical area. A surgical cap covers
hair. Shoe covers are worn to prevent tracking bacteria or dirt from other areas into
the operating rooms.
THE SURGICAL TEAM
Members of the surgical team include the surgeon, a surgical assistant, an anesthesi-
ologist or anesthetist, a circulating nurse, a scrub nurse or surgical tech, and a hold-
ing area nurse. The surgeon is the doctor who will perform the surgery. The surgical
assistant may be another surgeon, a surgical resident, an RN first assist, or a physi-
cian’s assistant. The person providing anesthesia and monitoring the vital signs of
the patient is either an anesthesiologist (a physician) or a certified registered nurse
anesthetist (CRNA). The circulating nurse is a registered nurse who acts as the
patient advocate, obtains the necessary supplies for the procedure, makes sure diag-
nostic studies and blood products are available if necessary, prepares the operative
table, positions the patient (padding bony prominences if necessary), and cleanses
the skin in the operative area before positioning surgical drapes. The scrub nurse or
surgical tech sets up the sterile field, assists with draping the patient, and hands ster-
ile supplies into the operative field and takes used instruments from the surgeon. The
circulating nurse and scrub nurse (or surgical tech) together count all instruments,
sponges, and sharps used in the surgical field. The count is performed before, dur-
ing, and after the procedure. The holding area nurse cares for the patients who have
been brought into the operating room suite but who are not yet ready to go into the
operating room. The holding area nurse may be managing several patients at one
time and can also help to transport and transfer the patient.
Before entering the operating room, the members of the surgical team scrub at
the sink just outside the room in which the surgery will be performed. Prior to start-
ing the scrub, the team member applies a mask with face shield or goggles. The
surgical scrub is usually timed and covers the area from the fingertips to 2 inches
above the elbows. The surgical scrub renders the skin clean, not sterile. After the
scrub, the skin is dried with a sterile towel. A sterile gown, then sterile gloves are
applied. The front of the gown is considered sterile in the front from two inches
below the neck to the waist and from the elbow to the wrist. The circulating nurse
applies the gown and gloves unassisted, and then assists the other members of the
team into their gown and gloves as they enter the room.

RISK FOR INJURY
During the surgery, the patient is anesthetized and cannot tell you if there is pres-
sure anywhere. The patient is positioned to allow for maximal access to the opera-
tive site. This sometimes causes unnatural positioning of the patient or the patient’s
extremities. The operative table is padded to decrease pressure on the patient. There
may be additional padding added to areas of flexion or bony prominences to reduce
the risk of pressure ulcer formation or nerve damage due to positioning.
Heat loss can occur during surgery. The patient is sent to the operating room in
a hospital gown, which may be pulled up or removed depending on the body loca-
tion of the surgery. The body is draped for privacy so that only the surgical area is
exposed. The temperature within the operating room is kept rather cool because
the air exchange rate is higher within the operating room than in other rooms

(to decrease bacterial counts), and the staff are wearing double layers of clothes.
Warmers can be set up for the patients during certain procedures when heat loss is
expected—a large, open operative site or a long duration of surgery.
At the end of the surgical procedure, the wound is closed. The closure is to hold
the wound edges together and to prevent contamination. Closure may be achieved
with sutures (either absorbable or nonabsorbable), staples, glue, or skin closure
tape. Nonabsorbable sutures and staples will have to be removed in the post-
operative period.
Drains may be inserted near the operative site if significant wound drainage is
anticipated. Some drains are attached to suction, some have self-suction, and some
will drain due to gravity. The wound site is covered with a sterile dressing before
the patient is transferred out of the operating room.

ANESTHESIA
Anesthesia can be administered via general or regional routes (for major proce-
dures) or conscious sedation (for minor procedures). General anesthesia renders
the patient unconscious and incapable of breathing on his or her own; pain recep-
tion is also blocked. These patients must be intubated and mechanically ventilated
for the duration of the anesthesia. Regional anesthesia can be achieved through
nerve blocks, or epidural or spinal anesthesia. Nerve blocks occur when an anes-
thetic agent is injected into an area immediately surrounding a particular nerve
or nerve bundle. The nerve tissue becomes anesthetized, effectively causing the
tissue that it supplies to become pain-free. With epidural anesthesia, an anesthetic
agent is injected into the epidural space surrounding the spinal column, usually in
the lower lumbar area. The nerves become anesthetized as they leave the spinal
column, causing the area of the body supplied by these nerves to become pain-free.
This anesthesia is most commonly associated with childbirth but is used for many
surgical procedures. Spinal anesthesia is not commonly used; the anesthetic agent
is injected into the cerebrospinal fluid. Patient positioning is very important, as
gravity will cause the anesthetic agent to travel. The patient must remain flat after
the procedure to prevent leakage of cerebrospinal fluid from the puncture site.

The preoperative period, the time prior to surgery, is used to prepare the patient for
surgery both physically and psychologically. Ideally there is time to correct as many
abnormalities as possible prior to the surgical procedure. For patients having a
scheduled procedure with a significant anticipated blood loss, this is the time to
donate blood to be banked for use in their surgery and begin to take iron, folic acid,
vitamin B12, and vitamin C to aid in red blood cell production. Preoperative clear-
ance is given, informed consent is obtained, and preoperative teaching occurs dur-
ing this time.


PREOPERATIVE CLEARANCE
The patient’s primary care provider typically gives preoperative clearance for sur-
gery. This physician, nurse practitioner, or physician’s assistant is familiar with
the patient’s medical history and current medications and is able to adequately
assess the impending risk of the surgery to the patient. Things to consider when
providing clearance for the patient include the type of surgical intervention planned,
the potential for blood loss during surgery, the patient’s age, general health
and comorbidities, past medical and surgical history, current medications, use of
herbal remedies or supplements, alcohol use, smoking history, substance use,
allergies, family history including problems with surgery, and diagnostic testing
results. Diagnostic studies often include a CBC (to identify anemia or signs of
infection), a chemistry panel (to identify electrolyte imbalance, abnormal glu-
cose, liver or renal function), a urinalysis (to identify infection, protein, glucose),
PT/INR/PTT (to identify blood clotting disorders), an EKG (to identify abnormal
cardiac rhythms or damage to myocardium), chest x-ray (to identify pulmonary
pathology or enlargement of cardiac silhouette), or pulmonary function testing
(for patients with respiratory disorders such as asthma or emphysema). CT scans,
MRIs, PET scans, or stress testing may be ordered for individual patients depend-
ing on their medical history, type of surgical procedure planned, and results
of other diagnostic studies.

INFORMED CONSENT
An informed consent is obtained prior to any invasive or dangerous procedure.
The reason for the surgery, type and extent of surgery to be performed, the risks of
the procedure, the person to perform the procedure, alternative options and their
associated risks, and the risks associated with anesthesia are all explained to the
patient. It is the surgeon’s responsibility to make sure this information is explained
to the patient. The patient must be a competent adult in order for his or her signa-
ture to be valid. If the patient has been given medications that alter his or her abil-
ity to reason or to make judgments, the consent will not be valid. The nurse witnesses
the patient’s signature on the consent form.

PREOPERATIVE TEACHING
Explaining normal preoperative routines to the patient can be very helpful, so the
patient knows what to expect. The nurse needs to be familiar with the types of
surgical procedures and what the expected postoperative course will entail. The
extent of the procedure, type of incision, presence of any tubes or drains, and antic-
ipated pain level after the surgery will help guide the type of teaching necessary
for the patient.
Preoperatively the patient can expect to be NPO, or not allowed to eat or drink
anything for several hours prior to the procedure. The time frame will depend on
the extent and location of procedure, the type of anesthesia, and the scheduled time
of surgery. An exception to this nothing-by-mouth rule would be for patients who
need to take oral medications the morning of surgery. Cardiovascular, diabetic, and
certain other medications may need to be taken even though the patient is not to
eat or drink anything else.
An intravenous access site will be obtained prior to the surgery. Fluids can be
administered to the patient in this way. The access also allows for giving the patient
medications intravenously for rapid action. Fluids are routinely given in the oper-
ating room and in the immediate recovery period. The patient may have continued
intravenous fluids for more extensive procedures.
Skin preparation may only involve washing of the surgical site in the operating
room with an antimicrobial solution. Other patients may need to have removal of
hair from the surgical site. This may be with a razor or a depilatory agent. It is
important not to cut the skin if you are shaving a surgical site; small cuts or abra-
sions on the skin allow for potential sites of infection. Depilatory agents can be
caustic on the skin of some patients, causing irritation or a rash. A small spot test
away from the surgical area is a good idea in a patient with known skin sensitiv-
ity or history of allergies.

For patients having planned surgery involving the intestinal tract, a bowel
preparation will be completed prior to the surgery. This is done to decrease the bac-
terial count within the intestinal tract. Cleansing of the bowel is also completed to
empty the intestine of stool before the surgeon plans on cutting into either the small
or large intestine. Both of these preparations help to reduce the possibility of

infection in the postoperative period. For patients who will have tubes or drains in
place in the postoperative period, a simple explanation of what to expect can help
to alleviate some anxiety.
Availability of pain medication in the postoperative period should be explained
to the patient. In many instances the patient is able to manage his or her own pain
medication. For outpatient procedures, patients may be given a prescription for an
oral pain medication prior to the procedure. This way the medication is available
when the patient gets home from the surgery. For postoperative patients in the
hospital, many patients have an intravenous patient-controlled analgesia, known
as PCA, for pain management, where pain medication is delivered via a pump.
Typically a small basal dose of narcotic is delivered all the time. These patients
also have the ability to press a button whenever they are experiencing pain. The
pump will monitor the amount and timing of each dose of pain medication. If the
patient is due for medication, a dose will be administered; if the patient is not due
for medication, no dose will be administered.

TRANSFER OF THE PATIENT
Most facilities have a preoperative checklist to assist the nurse to make sure tha
all the needed components have been checked prior to sending the patient to the
operating room (OR). All pertinent documentation—the signed consent form
the patient’s chart, and current lab results—accompanies the patient to the OR.

Perioperative Care
The care of the surgical patient ideally begins when the patient is first informed of
the need for surgery. The surgical procedure may be a sudden, unexpected event for
the patient, resulting in stress and anxiety, such as necessary surgery following
trauma, or may be something that the patient has planned, such as a liposuction, far
in advance. The more time the patient has to prepare for surgery, both physically
and emotionally, the better able the patient is to cope with the physiological stresses
of the surgery. Nurses are in a position to care for the patient, provide necessary
education, act as patient advocate, and encourage health promotion behaviors.
Surgical Classifications

The American Society of Anesthesiology categorizes surgical procedures based on
the degree of risk to the patient. The urgency, location, extent, and reason for the
procedure are all considered, as well as the patient’s age; preexisting cardiovascular,

respiratory, and neurologic status; endocrine disorders; malignancies; nutritional,
fluid, and electrolyte status; abnormal laboratory findings; abnormal vital signs; and
presence of infection. The risks of doing the surgery are weighed against the risks of
not doing the surgery. There are some cases in which the risk of surgery is very high,
but the patient may certainly die if the surgery is not performed (patients with uncon-
trolled internal bleeding following a gunshot or stabbing, for example).
The anatomical location of the surgery will affect the degree of risk to the patient.
Surgical procedures performed within the thoracic cavity or skull are a greater risk
to the patient than procedures performed on the extremities. Surgical procedures
involving vital organs such as the heart, lungs, or brain carry a higher risk. The pro-
cedures that involve a greater potential for blood loss, such as vascular surgery, also
involve greater risk.
The degree of urgency of the procedure is described as emergent, urgent, or elec-
tive. Emergent procedures need to be performed immediately after identifying the
need for surgery. Examples include surgery to stop bleeding from trauma, shooting,
or stabbing, or a dissecting aortic aneurysm. Urgent procedures are scheduled after
the determination of surgical need is made. Examples include tumor removal and
removal of kidney stones. Elective procedures are scheduled in advance at a time
that is convenient for both patient and surgeon. Postponement of the surgery for
several weeks or even months will not cause harm to the patient. Examples include
joint replacement procedures and cosmetic procedures.
The extent of the surgery will affect the risk to the patient. The more extensive
the surgical procedure, the greater the potential risk to the patient. More exten-
sive surgical procedures cause more physical insult to the body and typically require
a longer duration of anesthesia. The anesthesia can also cause stress to the patient’s
system, interact with medications in the patient’s system, and must be metabolized
out of the body.

The reason for surgery is another way that surgical procedures are classified. The
purpose may be diagnostic, curative, restorative, palliative, or cosmetic. Diagnostic
procedures are performed to obtain a biopsy for definitive diagnosis of a mass.
Curative procedures are performed to remove a diseased area, such as a lumpec-
tomy for breast cancer or an appendectomy. Restorative procedures are performed
to restore function, such as joint replacements. Palliative procedures are proce-
dures are performed primarily for comfort measures, such as tumor debulking.
Cosmetic procedures are typically performed at the patient’s request; at times
some cosmetic procedures may fall into restorative (repairing damage or a con-
genital defect), curative, or diagnostic (in the setting of skin cancer).
The perioperative period can be broken down into the preoperative (time before
the surgery), intraoperative (time during the surgery), and the postoperative (time
following the surgery until recovery) periods.

WHAT WENT WRONG?
This is a decrease in bone density, making bones more brittle and increasing the
risk of fracture. The body continuously replaces older bone with new bone through
a balance between the osteoblastic and osteoclastic activity. When bone-building
activity does not keep up with bone-resorption activity, the structural integrity of
the bone is compromised.
Increased age, lack of physical activity, poor nutrition, having a small frame,
being Caucasian, Asian, or female all increase the risk of osteoporosis. Osteoporosis
can also occur as a secondary disease, due to another condition. These causes
include use of medications such as corticosteroids or some anticonvulsants, hor-
monal disorders (Cushing’s or thyroid), and prolonged immobilization.



PROGNOSIS
The risk of fracture is significantly increased in patients with osteoporosis. The
most common fracture sites in patients with osteoporosis are hip, vertebrae, pelvis,
and distal radius. Some fractures such as vertebral compression fractures affect
quality of life. There is increased morbidity and mortality in patients who sus-
tain a hip fracture. The cost of healthcare for these patients is significant, and
includes the immediate care of the fracture as well as the necessary rehabilitation.

SIGNS AND SYMPTOMS

• Asymptomatic
• Back pain due to compression fractures in vertebral bodies
• Loss of height
• Excessive forward curvature of the thoracic spine (kyphosis) due to patho-
logic vertebral fractures; collapsing of the anterior portion of the vertebral
bodies in the thoracic area
• Fracture with minor trauma
TEST RESULTS
• X-ray shows demineralization of the bone—not an early sign.
• Dual energy x-ray absorptiometry (DEXA) shows decrease in bone mineral
density in the hip and spine compared to young normal patients, and com-
pared to age-matched, race-matched, sex-matched patients.

TREATMENT
It is much more cost-effective to focus on prevention of osteoporosis. Encourage
adequate exercise and nutrition. Calcium supplementation may be necessary for
patients who are not getting the recommended daily requirement of calcium in the
diet. The body stores calcium in the bones. If there is insufficient dietary intake,
the body will remove the calcium from the bone, further weakening the structural
integrity. Once osteoporosis occurs, proper medical management is important to
prevent fractures and increase bone density.
• Administer bisphosphonate drugs to inhibit osteoclastic bone resorption and
increase bone density:
• alendronate, risedronate, ibandronate sodium orally
• parenteral preparations zoledronic acid, pamidronate
• Administer calcitonin nasal spray to increase bone density, also has analgesic
effect on bone pain after 2 to 4 weeks.
Administer calcium, 1000 to 1500 mg per day in divided doses to enhance
absorption.
Encourage weight-bearing activity.
Perform range-of-motion activities.
Increase vitamins and calcium in diet.
• Administer selective estrogen receptor modulator for postmenopausal women

NURSING DIAGNOSES
• Impaired mobility
• Pain
• Risk for injury
NURSING INTERVENTION
• Pain control if fracture occurs.
• Explain to the patient:
• How to properly take medications.
• Bisphosphonates must be taken first thing in the morning on an empty
stomach, with a full glass of water. The patient can’t lie down for 30 to 60
minutes after taking the medication; this is to reduce risk of esophageal
irritation.
• Monitor for side effects of medications—GI effects with bisphosphonates.
• Encourage weight-bearing activity.
• Encourage appropriate nutrition.
for prevention of osteoporosis:
• raloxifene
• Administer teriparatide to stimulate the production of collagenous bone to
increase bone density.
• Administer vitamin D, which enhances the absorption of calcium; many
patients with osteoporosis are also deficient in vitamin D.

WHAT WENT WRONG?
Osteomyelitis is an infection of the bone. In an adult, it is most commonly due to
direct contamination of the site during trauma, such as an open fracture. Bacteria
that cause infections elsewhere in the body may also enter the bloodstream and
become deposited into the bone, starting a secondary infection site there. This is
more common in children and adolescents. Some of the patients have been treated
with antibiotics previously for the initial infection.
The causative organism is not always identified. More than three-quarters of the
identified organisms are Staphylococcus aureus. Acute infection is associated with
inflammatory changes in the bone and may lead to necrosis. Some patients will
develop chronic osteomyelitis.



PROGNOSIS
The sooner the infected area can be made infection-free, the better the prognosis
for the patient. There is a risk for developing chronic osteomyelitis. This risk is
greater in patients with a compromised immune system or poor blood supply to
the area (such as diabetics).

SIGNS AND SYMPTOMS

• Pain
• Fever, chills
• Malaise

TEST RESULTS

• Elevated white blood count (WBC).
• X-ray osteolytic lesions (localized loss of bone density).

• Bone scan shows area of increased cellular activity—detects site of infection.
• Culture and sensitivity tests to determine the infecting organism and anti-
biotic—may be difficult to determine infecting organism.
• Bone biopsy to identify organism.

TREATMENT
Removal of necrotic bone tissue and local pus or drainage is often necessary to
speed healing. Typically, patients need antibiotics for several weeks to properly
treat the infection.
• Debridement of the area to remove necrotic tissue.
• Drain the infected site.
• Immobilize or stabilize the bone if necessary.
• Administer antibiotics parenterally for 4 to 6 weeks or orally for 6 to 8
weeks:
• nafcillin, vancomycin, penicillin G, piperacillin, ticarcillin/clavulanate,
ampicillin/sulbactam, pipercillin/tazobactam, clindamycin, cefazolin, line-
zolid, ceftazidime, ciprofloxacin
• Administer analgesic to relieve discomfort as needed:
• ibuprofen, naproxen, acetaminophen
• oxycodone, hydrocodone
• If there is vascular insufficiency or gangrene, amputation may be needed.


NURSING DIAGNOSES
• Impaired mobility
• Activity intolerance
NURSING INTERVENTION
• Monitor vital signs, changes in blood pressure, elevated pulse, elevated tem-
perature and respiratory rate.
• Monitor wound site for redness, drainage, and odor.
• Monitor IV access site for patency.
• Explain to the patient:
• When and how to take medications.
• Importance of completing antibiotic medication.
• How to flush venous access device.
• Signs of infiltration, clotting of venous access device.
• When to call for assistance with venous access.